Baby being seen by a doctor

Government advisors say infant bruises prior to moving should not automatically invoke Section 47S

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Government advisers said councils should automatically stop making inquiries about child protection under Section 47 of the 1989 Children’s Act in response to bruising of children who are not on the move.

The Committee to Review Child Protection Practices made the call in a briefing published last weekResearch has found that an increasing number of authorities have policies that require an inquiry in Section 47 or a strategic discussion to decide whether, in these cases, such an investigation should be conducted.

This was even though researchers found that accidental bruising of non-mobile infants was not uncommon.

The committee, whose role is to review and learn from serious cases, said it does not support policies that require Section 47s or other interventions “without a preliminary assessment of the circumstances of the presentation.”

She said children should be examined by an appropriately qualified health professional, including to check whether a medical condition could have contributed to the bruising. Also, a multi-agency discussion, involving the examiner health professional and consideration of any other information about the family, should be undertaken to determine whether any assessment or interventions for family support or child protection should be followed.

The Committee urged the councils and their protection partners to review their policies to ensure their alignment with the national evidence base and guidelines.

Spread of accidental bruising

Cited Committee Briefing for 2020 Evidence review by the Royal College of Paediatrics and Child Health (RCPCH) which found that the rate of accidental bruising among children before hopping ranged between 0 and 1.3%.

But the research papers that fed this review found that rates among babies who weren’t yet rolling or crawling ranged from 0.6% to 5.3%, based on a single observation of them.

This means that the accidents, while uncommon, are not known, the commission said.

In an as-yet-unpublished research paper considered by the committee, academic social work academic Andy Bilson and mental health researcher Alessandro Talia challenge the RCPCH’s view that accidental bruising was rare in immobile children.

They said that one of the studies that RCPCH looked at (Kemp et al., 2015) found that 27% of infants had bruising in excess of 7.6 observations per week on average.

“This challenges the idea that bruises in general are reliable indicators of future damage,” they said.

More boards automatically lead to child protections

Despite this, Bilson and Talia have found that an increasing number of boards are automatically leading to child protection operations where bruises have been identified in an infant prior to mobility.

Their analysis of published policies on bruising, covering 148 of 152 English local authorities, found that seven councils automatically initiated Section 47 while another 28 required a needed strategic discussion.

under We work together to protect children, Strategy discussions should take place when there is reasonable cause to suspect that a child is, or is likely to suffer, significant harm, and a determination should be made as to whether an investigation should be conducted under Section 47.

The 35 who followed one or more routes were higher than the 13 identified as doing so in 2016, based on an analysis of 91 available bruising policies (Bilson, 2018).

Bilson and Talia found that, as in 2016, most policies required immediate referral to child welfare and assessment of contusions by a pediatrician, with police being called if parents refused to have their child seen by a health professional.

They also found that 18 policies said that accidental bruising was very rare and highly predictable for non-accidental injury, with 35 saying that critical case reviews showed employees underestimated the severity of bruising, resulting in more serious injuries being missed.

They said this showed that concerns about “staff underestimating the seriousness of infant bruises appear to have led to an exaggeration of the risks in these procedures and an underestimation of front-line staff, with the potential for a harmful overreaction”.

Their research also found wide differences in how protocols define a child before moving, with half of the authorities — including the seven who enforced Section 47 — defining this by age (less than six months) and a quarter having no definition. The rest diverged between those who saw the rolling babies as immobile and those who said the opposite.

Policies should help build relationships, not suspicion

They added, “Policies should be based more strongly on research evidence and make appropriate recommendations to support frontline employees in making better judgments, allowing them to build relationships rather than develop skepticism.”

National Institute for Health and Care Excellence (NICE) guidelines, last updated in 2017states that health professionals should suspect child abuse in traumatic infants who have not been able to move independently.

In such cases, specialists should refer cases to child welfare, following local multi-agency protection arrangements.

In its briefing, the Child Protection Practices Review Committee said it was broadly supportive of the NICE guidance, but recommended that it be extended to other professionals, including in child social care, and should define what is meant by no mobility independently.

The commission said this should include children who could not crawl, sail or shuffle the bottom, without excluding those who were able to roll over. However, he said special attention should be paid to the risks of those who cannot roll.

Action recommended by the team

She opposed policies that raised Section 47 inquiries or other interventions without evaluation, and suggested instead that there should be:

  • a review by a health professional with appropriate experience to assess the nature and presentation of the bruise and any associated injuries, and whether there is any evidence of a medical condition that could have caused or contributed to the bruise, or a reasonable explanation for the bruise; And the
  • A multi-agency discussion, always including the health professional who examined the child, to consider any other information about the child and family, including known risks, and to jointly decide whether any further assessment, investigation or action is needed for family support or child protection.

In addition to recommending that all protection partners review their existing policies for consistency with the evidence base and national guidelines, it called on the Department of Health and Social Care, NICE and RCPCH to review the evidence base and consider how to strengthen it.

It should “consider whether existing guidance can be updated to deliver a more consistent and clear message, avoiding the risks of excessive interference while maintaining a critical attitude.”

complex work area

In response to the committee’s briefing, Steve Crocker, president of the Association of Child Services Directors, said: “Our work with infants and very young children is especially challenging because they are unable to tell us what has happened to them or how they feel. Well-being is always our paramount concern.

“This is a complex field of work that requires all agencies to work together to assess the available evidence to determine whether a situation is causing or at risk of causing significant harm. While research in this area is limited, professionals work in accordance with nationally recognized legal guidelines supplemented by specific guidelines Published by NICE and the Royal College of Pediatrics.

“This briefing provides an opportunity for local partnerships to reflect on their own processes and procedures, and at the same time, the committee has usefully asked the Department of Health and Social Care to make an assessment of the resources available to help protect practitioners to do their part.”

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