Not making a referral after bruising to non-mobile babies
Practice issues from serious case reviews – learning into practice
What is the issue?
Professionals do not refer to children’s social care after observing bruising in non-mobile babies.
There is national guidance from the National Institute for Health and Care Excellence (NICE)1 that clinicians should suspect maltreatment if they observe bruising in a child who is not independently mobile, and should refer the child to children’s social care (CSC), following LSCB procedures.
Our SCR analysis identified several instances in which identification of bruising did not result in a referral. For example, in one case a child was taken to an out of hours GP after refusing food. The GP noticed bruising to the child’s face and asked the parents for an explanation. A referral to CSC was not made, although the family’s usual GP was notified.
This is one of a set of 14 briefings on difficult issues in inter-professional communication identified from Serious Case Reviews, with added information gathered from three multi-agency ‘summits’. The briefings are intended to support managers, senior managers and practitioners to consider if these issues exist in their local area, and how they might tackle them. They were produced as part of Learning into Practice, a one-year DfE-funded project conducted by the NSPCC and SCIE.
Why does this occur?
The analysis within the SCR reports highlights a number of reasons for failing to make a referral to CSC in response to bruising in non-mobile babies including:
- a lack of understanding of child protection procedures, particularly among those working in out of hours GP surgeries
- a lack of professional curiosity and ‘respectful scepticism’ about explanations for bruising
- second opinions not sought from more experienced clinicians.
Participants at the three summits also identified a number of underlying reasons for this issue including the following:
Knowledge about bruising and awareness of guidance
Participants commented that not all staff know about the NICE guideline which recommends referral following bruising to non-mobile babies. Participants noted that health professionals have to be familiar with a wide range of guidance, meaning that it can be difficult to keep one particular piece of guidance at the ‘forefront of your mind’. It was also noted that some professionals may not receive specific training on bruising, or on wider child development.
Influence of care settings and staffing
Participants in the summits noted that vulnerable families are more likely to use out of hours services, but conversely these were less likely to have safeguarding expertise and knowledge of local systems, and were also less likely to build sustained relationships with families which would support them. Participants also highlighted that locum doctors may be reluctant to make safeguarding referrals, on the grounds that they may not return to that practice for some time.
Influence of structure of consultations and resource constraints
The structure of GP consultations was seen as a barrier to making necessary referrals. GPs are under pressure to see patients quickly and may not feel comfortable questioning the origin of a bruise if the child is brought in for another complaint. One participant said:
Every consultation is a sieving out of serious cases and you know that a bruise resulting in a MASH [multi-agency safeguarding hub] referral is going to be a lot of work.Named GP
Influence of the relationship with the family
Professionals discussed the problem of questioning explanations, particularly from families who seem ‘plausible’, or are professionals themselves. One participant said:
‘There’s a fear of getting it wrong, there’s the relationship with the parents, [the GP] knows what to do but they don’t carry it through.Designated Nurse
Solutions suggested by summit participants
Participants at the summits suggested the following possible solutions:
- improving out of hours safeguarding practices
- training and encouraging professional curiosity
- development of advice resources or protocols which allow babies with bruising to be assessed by a more experienced professional.
Questions for you to consider
Unpicking the issue
- Is this issue familiar to you?
- Locally, is the issue exactly the same as described above? If not, what does this issue ‘look like’ for you?
What good practice is there in relation to this issue? Are there weaknesses you are
aware of and how would you describe them?
Why do you think this happens in your local area?
- Do some or all of the reasons described above apply in your area?
- Is it an issue that has been identified in local SCRs, audits or inspection feedback? What light have these activities shed on the issue?
- What knowledge do you have from your own experience about why this happens?
- What organisational factors are involved locally?
How does local culture, custom and practice, within and between agencies,
contribute to this?
Thinking through the solutions
- Have there been previous efforts locally to address this issue? What was the result?
- Given your understanding of the reasons for this issue, what further actions do you think would be helpful in addressing it?
- What strengths can you build on, and what are the areas of difficulty?
- What action would need to be taken at a strategic or leadership level?
- Who would need to be involved to achieve improvement?
- Are there any unintended consequences you anticipate for the different agencies and professions involved?
- How will you know whether any actions have had an impact?