Busy Emergency Workers May be Missing Signs of Abuse in Babies

Non-accidental infant injuries are being missed in under-pressure emergency departments (EDs), with a need for specific guidance and better data sharing, a health care safety watchdog has warned. 

A new Healthcare Safety Investigation Branch (HSIB) report explored the factors that influence a diagnosis of non-accidental injury in infants (children under 1 year of age) who visit an ED. Non-accidental injuries in this age group accounted for 27% of the rapid reviews received by the Child Safeguarding Practice Review Panel between July 2018 and December 2019.

Rotherham NHS Foundation Trust in South Yorkshire was ordered to pay a total of £233,238 last October after pleading guilty to one charge of failing to provide safe care and treatment to four infants with non-accidental injuries.

The HSIB report, published today, stressed that specific guidance, detailed multi-agency information, and improved access to specialist safeguarding support is crucial for ED clinicians who suspect a baby or young child’s injuries are non-accidental. 

Investigation Focus

Rather than examine a specific reference event, this HSIB investigation analysed 10 serious incident reports by trusts where non-accidental injury had been missed in infants attending EDs, and the report outlined details of three case studies. 

Three themes emerged as particularly significant from the serious incident reports:

• 'Lack of professional curiosity’ among clinicians
• The family being in contact with social services
• Safeguarding or paediatric teams not being informed of the child's ED visit

The HSIB also looked at what support and information is available to aid ED staff in such a complex and difficult situation, and examined work pressures as a key theme. ED staff and national clinical leads emphasised to the investigation that the busy environment they are working in created 'barriers' to a diagnosis of non-accidental injury. Specifically, they referred to the high workload, time pressure, sensitivity, and potential difficulty of raising the issue, along with the competing demands and dynamic nature of the working environment.

The key findings of the report were:

• 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.

Ensuring Babies are Kept Safe

Matt Mansbridge, National HSIB Investigator, said: "The three case studies included in our report are a hard read – a stark reminder of the importance of recognising and diagnosing non-accidental injuries quickly in the ED. 

"We have recognised in our report that for staff these situations are fraught with complexity and exacerbated by the extreme pressure currently felt in EDs across the country.

"The evidence from our investigation echoes what staff and national leads told us – that ED staff should have access to all the relevant information about the child, their history and their level of risk and that safeguarding support needs to be consistent and timely – gaps in information and long waits for advice will only create further barriers to care. "

The report concludes with two safety recommendations focused on developing specific guidance for EDs and improving the quality of emergency care safeguarding data:

• The Royal College of Emergency Medicine, working with relevant stakeholders, develops guidance to support clinicians in the diagnosis and management of non-accidental injuries. 
• NHS England, working with relevant stakeholders, reviews the utility of the safeguarding data in the ECDS and agrees a process for assuring the quality of any data to be captured.

Deeply troubling findings

In response to the report's findings, NHS Providers' Director of Policy and Strategy Miriam Deakin said: "The HSIB’s findings are deeply troubling. We echo its calls for more specialist guidance and support for NHS staff who suspect that a child’s injuries are no accident.

"Emergency departments are under extreme pressure from ever-growing demand. As the HSIB highlights, an environment of heavy workloads, time pressure and demands on staff all have an impact and raise the risk that the signs of abuse could be missed. 

"This is yet another symptom of severe workforce shortages right across the NHS and social care. We need an action plan from the government as soon as possible to recruit many thousands more much-needed NHS staff.