AMENDMENT
In May 2020, this chapter was updated throughout and should be re-read.Bruising is the commonest presenting feature of physical abuse in children. This procedure covers all actual or suspected injuries to non-mobile children.
Any bruising, fractures, bleeding and other injuries such as burns should be taken as a matter of enquiry and concern.
Any bruising, fractures, bleeding and other injuries such as burns should be taken as a matter of enquiry and potential abuse unless otherwise evidenced.
A bruise must never be interpreted in isolation and must always be assessed in the context of medical and social history, developmental stage and explanation given.
Any injuries in non-mobile babies, however minor, are cause for concern.
In non-mobile children, the presence of any injury including bruising, of any size, in any site should initiate an inquiry into its explanation, origin, characteristics and history.
The professional who has learnt of or observed the injury should consult with their agency Safeguarding Lead/Advisor without delay so that decisions are not made in isolation. Any explanations for the bruising or injury provided by the parents/carers should be discussed with the Safeguarding Lead/Advisor where in place within the organisation and Children's Social Care consulted to inform next steps.
Where there are concerns as to the cause or origin of the bruising/injury the Safeguarding Lead/Advisor will report the matter to Children's Social Care or Emergency Duty Service out of hours. In the absence of the Safeguarding Lead/Advisor the professional must report directly to Children's Social Care or the Emergency Duty Service out of hours.
The detail of what has been observed and discussed should be recorded, dated, timed and signed in the child's individual record held by the agency and followed up in writing as part of the referral to Children's Social Care.
In all instances the agency professional should follow the agreed procedures for consulting on, referring and recording child protection concerns.
Professional judgement not to refer or report an injury should only take place where there has been consideration of the following:
Where a child is presented at a hospital Emergency Department or urgent and unscheduled care setting and where there are concerns Children's Social Care/EDS should be notified and the child protection process followed.
Any child who is found to be seriously ill or injured, or in need of urgent treatment or further investigation, should be transported immediately to hospital for assessment and treatment. It is important to ensure that the child's medical needs are treated first. A referral should then be made to Children's Social Care and the child protection procedures followed.
Where the child or siblings are subject of a child protection plan, child protection process must be followed in addition to informing the child's/siblings social worker or manager in their absence.
Where children's social care staff are made aware of or observe the injury/bruise (whether Child Protection, Child in Need, Looked After or Special Educational Needs or Disability) the child protection process will be followed.
Where a child is referred to Children's Social Care or where the child is already known to Children's Social Care in any capacity, the child protection procedures should be followed. This will include gathering information from relevant agencies and speaking to the parents/carers.
In all cases where there is any doubt about the cause of bruising or injuries and concerns that the child may be at risk of suffering significant harm, Children's Social Care will urgently convene a strategy discussion within 24 hours.
If required, a child protection medical assessment, by a suitably qualified Paediatrician, will be arranged, as part of the actions of the strategy discussion, to take place as soon as possible. The decision about the extent of the medical investigations will be proportionate to the circumstances and context of the injury and be made in consultation with colleagues from other agencies (for example, a skeletal survey or CT scan may not be appropriate or in the best interest of the child if there is a very clear and compatible explanation with no other identified concerns). This assessment will then inform the need for any further investigations.
The Strategy Discussion will decide whether enquiries under Section 47 of the Children Act 1989 should be undertaken (S47 Enquiry).
Section 47 Enquiries (S47) will be undertaken where there are concerns that a child may be at risk of suffering significant harm.
In all cases where a bruise or injury is observed an explanation about the cause should be sought and the explanation(s) recorded. This should be considered within the context of:
Not all children subject to non-accidental injury will have a history of involvement with children's social care so an absence of knowledge of a family should not be taken as a reassurance.
Where the medical examination concludes that the injury is non-accidental Children Social Care should be informed by telephone and a full medical report detailing the facts and the opinion created. It is anticipated that the parents/carers or other likely perpetrators will be interviewed further by social workers and police and a place of safety for this child and any other children in the family would need to be considered urgently.
Where the medical examination concludes that the cause of the injury is accidental or consistent with the explanation given or has a clear medical explanation, the Paediatrician will discuss their findings with Children's Social Care. Any further interventions/support required will be considered by Children's Social Care in consultation with partner agencies.
Where medical examination is inconclusive or there are concerns as to how the bruise/injury has been caused Children Social Care, in consultation with police and medical staff, will consider any further investigations/support required. This may include any emergency action required to safeguard the child or any other children.
If a child is admitted to hospital, then a multi-agency decision is required to determine whether the parents can have unsupervised access or how contact with their child will be managed.
Where any professional has concerns about the nature and cause of an injury or bruise they should explain at an early stage why, in cases of bruising or minor injuries in not independently mobile children, additional concern, questioning and examination are required. The decision to refer to Children's Social Care should be explained to the parents or carers frankly and honestly.
Children's Social Care have the prime responsibility to engage with parents and other family members to ascertain the facts of the situation causing concern and to assess the capacity of the family to safeguard the child.
In most cases, parents should be enabled to participate fully in the enquiry and assessment process. Social workers should interview the parents/carers and determine the wider social and environmental factors that might impact on them and their child. The needs and safety of the child will be paramount when determining at what point parents or carers are given information.
Particular attention should be paid to communication with parents who may have difficulty understanding the explanation, for example parents whose first language is not English, suffer with deafness or parents with learning/ processing difficulties.
Where there are any professional disagreements about how to respond to bruising in a non-mobile baby, this should be referred to the relevant senior managers. If the professional differences remain unresolved, please refer to the SWCPP Escalation Policy.