Case 33 An infant with a swollen face
A 9-month-old Chinese boy, Jiang, is taken to the GP by his mother because he has a swollen, bruised left cheek. His mother, Lien, speaks no English but the GP is Chinese speaking. Lien says that Jiang crawls and that he hit the left side of his head on a coffee table the previous day. She says he cried but did not lose consciousness.
On examination there is extensive swelling over the left zygoma which is tender and a red bruise over Jiang’s left upper eyelid.
He is sent to the hospital for a X-ray of the zygoma and Lien is told to return to the GP in 2 days time.
What do you think of the GP’s management?
Lien, does not return to the GP as planned and the GP does not take any further action until he receives the X-ray report a week later. The report states that there is a possible skull fracture and advises that further X-rays be performed. The GP attempts to contact Lien but her mobile phone is switched off and two days later he has still not been able to contact her.
What should the GP do now?
The GP contacts the Health Visitor who visits Lien and tells her to go to hospital. Jiang returns to hospital and is seen by an ED FY2 doctor who is not aware of the details of the case but knows that a full set of skull X-rays is required. These show a long parietal skull fracture (Case Figure 33.1).
What should the ED FY2 doctor do now?
Jiang is admitted to the paediatric ward for a further assessment. A CT brain scan is performed as the NICE Guideline on Head Injuries recommends a CT brain scan in all cases of head injury when there is a clinical suspicion of nonaccidental injury.
Via a Chinese interpreter the following history is obtained. On the day of the fall, Lien, his mother, was in the same room but had her back turned. She heard him fall and thought that he had been pulling himself up to stand and had then fallen, hitting the left side of his face on the edge of the coffee table. He cried for a minute and then seemed to be back to normal. Two hours later his face became swollen. She decided not to go to the doctor that evening as she knew that the Chinese speaking doctor would not be in the surgery until the next morning. That night Jiang was fretful and seemed uncomfortable when lying on his left side. The following day he seemed generally fine but the swelling was more marked.
The boy lives with Lien and his 4-year-old sister. Lien says that her husband ran off with another woman when she was pregnant with the boy and that there has been no further contact. She often leaves the children with a female friend and they had been with her the day before the reported incident.
A full examination is performed and no other signs of injury are detected.
The CT scan is normal apart from the skull fracture. When Lien is told about the skull fracture she becomes upset, worried and concerned. She goes very pale and asks whether this will affect his future development. The paediatric registrar feels that the injury is consistent with the history and that the mother’s affect is appropriate and so Jiang is allowed home the next day with an appointment to return to clinic five days later. The following day the X-rays are reviewed by a consultant paediatric radiologist who contacts the responsible consultant paediatrician to say that the skull fracture is extensive, branching, crosses a suture and involves the occiput and that nonaccidental injury should be strongly considered.
What should the consultant paediatrician do now?
Jiang is readmitted and a skeletal survey is performed which shows a buckle fracture of the left distal radius. Lien is told about this fracture but can offer no explanation for it. Fundoscopy is performed by a consultant ophthalmologist and shows no abnormality. A strategy meeting is held and a Section 47 (child protection) investigation is commenced by Children’s Social Care (CSC).
The police inform CSC that the father is in prison. He was convicted of serious violent crimes and has been sentenced to 10 years imprisonment. Lien is fully aware of this and had attended the trial. She is interviewed by the police and gives a completely different account of the events leading up to her taking the boy to the GP. She admits lying to the doctors about the fall against the coffee table and says that the injury happened when the boy was in the care of her friend. The sister discloses that their mother hit her with a shoe leaving red marks on her body.
Both children are taken into care. Lien is charged with grievous bodily harm to Jiang but is not convicted because the cause of his injuries cannot be established beyond reasonable doubt.
Expert opinion
The GP was concerned that Jiang might have a fractured zygoma. This would be an unusual injury for a child of this age. A detailed history should have been taken to explore all the possible ways in which such an injury could have occurred and to elucidate who had been in contact with the child in the preceding days when the injury might have happened. The extensive swelling was probably serious enough to warrant immediate referral to a paediatrician rather than just sending Jiang for a X-ray. The follow-up arrangements were not robust enough for a young child with a serious injury. When Jiang was not brought back for follow-up, alarm bells should have rung. The GP could also have done a home visit, contacted CSC or contacted the police. He could have sought advice from a consultant paediatrician or the named doctor or nurse for child protection. When things began to go wrong the GP should have contacted a paediatric registrar or consultant so that Jiang was not dealt with by a junior ED doctor who was not in possession of all the relevant information. Good communication is always essential in managing cases of possible deliberate harm.
Legal comment
It is difficult to secure a conviction for child abuse without firm evidence which meets the criminal standard of proof which is ‘beyond reasonable doubt’. In this case, it may be that no-one will ever be convicted for the injury done to Jiang.
We are told that Jiang and his sister have been taken into care. There will now be civil proceedings in the family courts to determine where they should live in the future. The courts are encouraged to deal with matters within a ‘timetable for the child’, ideally 40 weeks, but that may prove difficult to achieve if his mother, Lien, challenges the plans which are put forward. In practice, the proceedings could take a year or so to reach a conclusion.
What are their prospects of being restored to Lien? Much depends on her approach to the enquiries. Although she has lied to the GP, and then to the hospital doctors, she did then admit her lies to the police. The cultural pressures on her will be taken into consideration, but generally, the more cooperative she is in the future, the better the prospects of the family being eventually reunited.
Enquiries will be made into Lien’s circumstances to establish whether it is in her children’s best interests to return to her. If the conclusion is that it is not, the children are young enough to have a prospect of finding adoptive parents.
As for the GP in this case, he is heavily criticized by the expert for not responding quickly enough. In the hospital too there were delays, for example in establishing the extent of the skull fracture and that there was also a fractured arm.
These are matters which should certainly be investigated by the hospital and/or the GP’s PCT. That investigation will hopefully lead to improved communication and to heightened awareness. It is possible that the investigation report will suggest that the failings by individuals are potential disciplinary matters and consideration should be given to reporting them to the GMC.
