Non-accidental injuries in infants attending the emergency department

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Clinicians in emergency departments (EDs) will see babies and young children with injuries that may be non-accidental. If the cause of such injuries is missed, there is a risk of further harm to the child. However, making a judgement about whether an injury might be accidental or not is complex and difficult.

This investigation explores the issues that influence the diagnosis of non-accidental injuries in infants (children under 1 year of age) who visit an ED.

Specifically, it explores the information and support available to ED clinicians to help them to make such a diagnosis. Because of the nature of these types of injuries, and the different ways in which incidents that do come to light may be recorded, it is difficult to understand the full scale of this issue.

In 2020 the Office for National Statistics published a report of collated data on child abuse which showed that 4,170 children in England were the subject of a child protection plan because they had experienced or were at risk of physical abuse.

Non-accidental injuries in children under 1 year old accounted for 27% of the rapid reviews received by the Child Safeguarding Practice Review Panel between July 2018 and December 2019.

The investigation’s findings and safety recommendations aim to help clinicians in considering non-accidental injuries as a potential diagnosis.

Due to the nature of the subject matter no specific incident was used to explore this area of care. Instead, the investigation analysed 10 serious incident reports (reports written by NHS trusts when a serious patient safety incident occurs) to identify the factors that contribute to non-accidental injuries not being diagnosed. These factors were grouped into themes, which informed the terms of reference for the investigation.

The investigation engaged with national stakeholders to sense-check the themes which had been developed to ensure that they were meaningful. The stakeholders also provided insights which helped to contextualise some of the themes.

The investigation engaged with national stakeholders to sense-check the themes which had been developed to ensure that they were meaningful. The stakeholders also provided insights which helped to contextualise some of the themes.

• There is no specific guidance for ED clinicians on the identification of suspected non-accidental injuries and what to do if they suspect an infant has a non-accidental injury.
• There may be barriers to routinely escalating cases of children with a potential non-accidental injury to paediatric (child specialist) and safeguarding teams.
• Delays in the availability of information about potential safeguarding concerns add to the pressures on ED staff when making decisions about infants with potential non-accidental injuries.
• There remain concerns about, and an inconsistent approach to, sharing safeguarding information between organisations.
• The Emergency Care Data Set (ECDS) gathers information about ED attendances and includes a field for when such attendances are related to safeguarding.
• The ECDS safeguarding information collected is not currently utilised within the NHS and there is minimal quality assurance in place to ensure that it is reliable.
• Risk factors for non-accidental injuries which do not meet the criteria to be included on the Child Protection – Information Sharing system (the electronic system designed for information sharing between the NHS and social services) are not included in a patient’s summary care record and may therefore remain unknown to clinicians.
• The investigation identified mechanisms which could enable safeguarding information that is not currently available to ED clinicians, to be made available through existing national and regional digital systems.
• Safeguarding teams are often located physically distant from EDs. This can create a barrier to communication and liaison with the team.

During discussions with trust staff, the investigation learned of actions that had been implemented locally to embed child safeguarding into the culture of EDs:

• Induction training: Benefits were seen where relevant staff had undergone a training session during which adult and child safeguarding was discussed, with a focus on how and when sharing of information between organisations is appropriate for safeguarding.
• Simulation training: The regular inclusion of a safeguarding element within simulation training has been seen to increase the confidence of staff to deal with safeguarding issues.
• Psychosocial multidisciplinary team (MDT) meetings: These meetings were held to discuss children (under 18 years) who had attended the ED and about whom there were safeguarding concerns. It was attended by various safeguarding stakeholders, including the police, violence reduction team and the probation service, as well as members of the local mental health team, ED clinicians and paediatricians. The MDT acted as a proactive step in sharing relevant multiagency information to identify children who may be at risk of harm.