Non-accidental injuries in infants attending the emergency department

HSIB legacy content

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

Background

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.

Analysis of trust serious incident reports

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 national 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.

Findings

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.

Local-level learning

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.

Safety recommendations

Royal College of Emergency Medicine

HSIB recommends that the Royal College of Emergency Medicine, working with relevant stakeholders, develops guidance to support clinicians in the diagnosis and management of non-accidental injuries.

The Royal College of Emergency Medicine (RCEM) is happy to accept safety recommendation R/2023/227 and is committed to produce a useful guidance for Emergency Medicine clinicians to help with the diagnosis and management of non-accidental injuries.

In order to develop the guideline, the RCEM will form a writing group consisting of clinicians with Paediatric Emergency Medicine (PEM) sub-specialty, doctors in training and Emergency Medicine Consultants without PEM sub-specialty, the latter being of particular importance to make sure that the guideline is useful to those without PEM sub-specialty that have paediatric patients presenting to their Emergency Department (ED).

The guideline will have useful and pragmatic clinical advice for all ED clinicians, aimed highlighting key factors to help identify non-accidental injuries in infants. The RCEM also acknowledges the importance of having the involvement of other services to ensure the best outcome and management of this group of patients and, will endeavour to have this reflected on the guideline. This will help not only to clarify the interface between the ED and key services but, to stress the importance of having a well-structured work relationship with them.

Actions planned to deliver safety recommendation:

First guideline draft to be internally by the RCEM by 30 June 2023.
Recruitment and formation of the writing group by 1 August 2023.
Guidance written and published by the writing group by 31 January 2024.

Response received on 9 May 2023.

NHS England

HSIB recommends that NHS England, working with relevant stakeholders, reviews the utility of the safeguarding data in the Emergency Care Data Set and agrees a process for assuring the quality of any data to be captured.

NHS England welcome this report and will work closely with relevant stakeholders to consider how best to implement the recommendations.

For the Emergency Care Data Set the data fields required to collect the safeguarding information already exist, as conformance Indicators https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/emergency-care-data-set-ecds/emergency-care-data-set-conformance-indicators:

Safeguarding concern
Injury Intent
Injury Mechanism

The ECDS dashboard Emergency Care Data Set (ECDS) Dashboard: Time in department - Tableau Server (england.nhs.uk) is active across 187 systems. Systems can access the ECDS dashboard, and various reports can be generated to self-assess themselves, benchmark against data quality and ensure required fields are being populated adequately.

Guides for healthcare workers have been produced to highlight the importance of vigilance in reporting concerns Information Sharing to Tackle Violence | RCEM

Systems responsibilities are mandated in the ‘Safeguarding children, young people and adults at risk in the NHS Safeguarding accountability and assurance framework’ (england.nhs.uk)

NHS England resource the Child Protection Information System Child Protection - Information Sharing (CP-IS) service - NHS Digital already being stood-up within all NHS urgent care settings which contains children on a child protection and / or looked after children plans and there are Phase 2 plans for CPIS within outpatients for was not brought, primary care, community dental and sexual health to roll out by March 2025.

The NHS and healthcare providers have the statutory multi-agency safeguarding Local Area Designated Officer (LADO) requirements as set out in Working Together to Safeguard Children (2018) (Chapter 2 Paragraph 4) and is governed by the Local Authorities duties under section 11 of the Children Act 20004 and the statutory Child Death Overview Process on the untimely death of children Working Together to Safeguard Children 2018.

Actions taken to deliver safety recommendation:

By December 2023, any Section 17 (child in need), 47 (child protection plan) and CDOP or LADO referrals from emergency departments, PICU or NICU must be shared with Designated Professional at ICB immediately. Progress and assurance: Complete. From November 2023 ICBs began receiving notifications of any NICU / PICU baby with NAI who is also logged on CPIS. In addition, the Child Death Overview Process (CDOP) leads now report directly into Integrated Care Boards (ICBs). This is logged in the NHS Safeguarding Integrated Data Dashboard (NHS SIDD) via the Safeguarding Case Review Tracker (SCRT) since January 2024. Each ICB designated professional is responsible for updating the SCRT.
By April 2024, each ICB will ensure that the ECDS safeguarding (low grade harm) codes and the BadgerNet (system in Paediatrics and Neonatal Intensive Care Unit (PICU/NICU)) safeguarding codes are routinely and securely shared with the lead ICB assurance officer. Progress and assurance: Complete. NHS Head of Safeguarding is working with our lead consultant for Emergency Medicine and the Data & Analytical Services Directorate to support implementation of this recommendation. The Data and Analytical Services Directorate (new) are undertaking their prioritisation plan for ECDS in mid-April 2024. This will enable sharing of ECDS safeguarding codes.
To further ensure the routine and secure sharing of BadgerNet safeguarding codes the NHS Head of Safeguarding is reviewing the approach with the Chief Midwifery Officer. Progress and assurance: In progress and action due by September 2024.

Response received on 14 March 2024 and updated July 2024.

Safety observations

HSIB makes the following safety observations:

It may be beneficial if there was an electronic system available for clinicians to view any safeguarding information to assist in decision making.
It would be beneficial if the safeguarding operating model, to be tested through pathfinders, included a response time for advice when sought by professionals such as emergency department clinicians.
It may be beneficial if safeguarding teams are either physically located near to, or make efforts to promote their visibility in, emergency departments.

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