Non-accidental injury (NAI) and safeguarding concerns
Non-accidental injury (NAI) and safeguarding concerns
Background
The issue of child safeguarding is one that we all struggle with. I hope that this chapter helps to make sense of some of the complexities. Child abuse is very common and takes many forms. It can present in obvious ways but more frequently it is something that we will only pick up on if we have a constant awareness and vigilance. Its prevalence is difficult to assess due to its nature, but studies have put the prevalence of sexual abuse in the UK as high as 11%, which is greater than the prevalence of asthma.
You have to be aware of the barriers to detecting any non-accidental harm to children and be mindful that the obstacles to uncovering abuse are multiple. You do not want to ‘accuse’ parents and this is because you value your relationship with them. You also have to acknowledge that when you assess children, you do so with a clinical eye. That is what makes you a good doctor. You focus on illness and sometimes this is at the cost of missing the social element of the child that you assess. By keeping your antennae up for possible child abuse, you will be an even better doctor.
This is probably the most difficult area of practice for any doctor who has contact with children, including paediatricians. However, it is important to have the courage to raise the issue and the majority of parents will not be offended if you explain the reasons for doing so. This is one area of paediatrics where fear of a thing is much worse than the thing itself. By being more confident when dealing with child protection matters, you will immediately find ourselves dealing with it more comfortably and efficiently.
How to assess
•Consider the possibility that abuse may be a factor in every encounter with children. In most cases you will be able to close that concern immediately, but if you don’t think about it you can’t detect it.
•Ask for details regarding anything that concerns you. Go into depth about the history.
•Be specific about how injuries have happened.
•If the child can communicate, be sure to ask them what happened before you ask the adults.
•Ask about the exact time, place and way that an injury occurred.
•Always ask yourself, does this story fit what I am seeing and with the developmental age of the child?
•Ask about the social circumstances.
•Ask whether there has been previous social services involvement and why.
•Ask about other children or siblings living in the home – have they ever had social services input?
•Consider whether the parents/carers have acted appropriately. Were they late in seeking medical attention? Could they have contributed to injury or ill health through inappropriate parenting?
The ‘must do’s
Consider NAI when seeing a child who attends multiple times for any reason. In many cases of recent years, the children who subsequently died of abuse presented to medical professionals on many occasions with what was potentially identifiable NAI.
Document everything very clearly.
Examine the whole child if you are suspicious – you may find signs of neglect or of other injuries.
Discuss what you are doing with the parents/carers when you explore safeguarding issues. They need to know so that they understand what is happening. If you don’t, they will find out eventually, and that will anger them far more than any perceived accusation.
Share your concerns with someone. When you reach a level of concern where you are uncertain, then tell the carers this and make a phone call. Discuss the situation with the duty social worker, the trust’s safeguarding children’s nurse or on-call paediatric registrar. You can then agree on how to proceed.
When contacting social workers, give them as much information as possible: current address and how long the family have lived there, names and dates of birth of all household members and significant contacts.
Pitfalls to avoid
Don’t forget to keep the child’s health as the priority. For example, don’t forget to give a child with a burn some pain relief, as well as dealing with child protection concerns.
Don’t think of yourself as passing judgement. No professional can take that responsibility. You have a duty to share concerns but something will only come of those concerns if other professionals add weight to your initial assessment. Think of it a bit like referring a child with abdominal pain and tenderness in the right iliac fossa. You haven’t decided to take their appendix out but you wouldn’t dream of sending them home, despite the fact that you know that from time to time, healthy appendices are removed. So you refer for a further assessment by someone who does take out appendices.
If you are thinking to yourself ‘I don’t want to because…’ then you are probably missing an opportunity to detect NAI.
Never refer without telling the parents that this is what you are doing. If you do this and the parents choose not to go through with your referral, then they could legitimately say that they didn’t see the need. If you have told them about your concerns and they still don’t comply with any assessments, then you really are concerned now, aren’t you?
Never think ‘these are such nice people and so they couldn’t have neglected/abused their child.’ Experience shows us that abuse is sadly more easily concealed in families that give an outward appearance of ‘normality’.
Don’t hold back for fear of consequences for the child. Despite reputations to the contrary, the professionals who do child protection work want to support families and only consider removing a child if the balance of risks justifies doing so.
Don’t expect an abused child to be miserable. They may be apparently normal or inappropriately friendly. They may be naughty or they may be subdued.
Never half-document injuries. A lawyer may use this at a later date to claim that the injuries which you did not log either occurred after you saw them or were inconsistent and unreliably documented. The worst thing that could happen is that one inaccurate account of an injury undermines someone else’s accurate description.
A guide to the management of NAI and safeguarding concerns
As a clinician who assesses children, it is extremely important that you should have a good idea of how to proceed when you or a colleague has a child protection concern. The action that you take will depend greatly on the situation and the degree of concern.
In a general practice setting you may know the family from previous contacts and this can be both a help and a hindrance. It is important to recognise that because GPs tend to highly value the patient-doctor relationship, fear of damaging that relationship can be a barrier to considering and raising child protection concerns. On the other hand, as a family doctor you are in an excellent position to make an assessment. You can review the notes of other family members, discuss your concerns with other members of the team (practice nurse, receptionist, health visitor, school nurse, social worker, etc) and even visit the family home. You will also have a feel for what is appropriate health seeking behaviour and should listen to your gut feeling when something seems wrong.
In the emergency department or an acute assessment unit, there is still a desire to maintain good relationships with all patients and relatives or carers. There are additional resources that you can turn to more easily such as safeguarding nurses or consultants.
With regards to level of concern, I would suggest that it is useful to think of each case coming into one of three categories.
1. There are cases where the situation caused you to consider NAI but after consideration you feel that this is very unlikely. One example of this could be a head injury in a three year old which was witnessed by a third party whom you have spoken to. In these cases it is important to document your opinion and its basis. This is essential for two reasons. Firstly, should the child become a victim of abuse at a later date someone will look back at this episode and ask why you did not consider NAI. Secondly, if the child has further accidental injuries and a diligent doctor looks back on previous entries, it is difficult for them to be reassured that any previous injuries were accidental unless someone has dutifully recorded that the possibility of NAI was considered.
i) Every time you discuss safeguarding children, it reinforces the message to children, parents and carers that we consider child protection to be a serious issue. This might help a child to speak up one day either for themselves or someone else. It might even help someone to change their behaviour towards a child.
ii) Each case is an opportunity to improve safety or circumstances for the child even if no harm has been intended.
iii) The more that you get used to discussing child protection issues the better you will become at it. Like everything else in medicine, managing safeguarding issues is something that you will only do well if you take every opportunity to get involved.
So in these cases the best management is information-gathering and sharing. If you are uncertain about whether to refer a case you initially have two options. You can discuss the case with someone (an experienced colleague, a social worker, a safeguarding children’s nurse or a paediatrician). Between you a decision can then be made regarding the next step. If you don’t feel that you have enough information to discuss the case, then you need to gather information from every source necessary until you are able to do so. Having discussed the case you may find that no further action is needed. You then need to document what was discussed and with whom.
Alternatively, following discussion you may agree that there is a significant ongoing concern. You can then discuss who will take that concern forward. Every locality should have a pathway in place for proceeding with child protection concerns. At some point during the process it is important to advise the child and carer what you are doing and why.
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