44.1 Unexplained Injuries to Young Children

Click here to view Flowchart on Injuries to Young Children.

Physical injuries in young children may be life threatening and/or cause permanent neurological damage. Research and child safeguarding practice reviews (formally serious case reviews) highlight that children under 1 year old are especially vulnerable.

Please refer to Evidence & reviews – RCPCH Child Protection Portal for key learning on a range of physical abuse injuries.

Any suspicious (unexplained) injury in a pre or non-mobile and/or pre or non-verbal child must be regarded with extreme concern including:

• Minor injuries with an inconsistent explanation;
• Bruising, especially on the face, ears, eyes (including subconjunctival haemorrhages- A subconjunctival haemorrhage occurs when a tiny blood vessel breaks just underneath the clear surface of your eye (conjunctiva). A subconjunctival haemorrhage appears as a bright red or dark red dot or mark/patch on the white of the eye.There are a number of possible causes of SCHs that need to be considered, including non-accidental causes)
• head, neck and genitalia
• Any fractures;
• Any major injury.

Any injury and its explanation must be assessed in relation to the infant's/child's developmental abilities and the likelihood of the occurrence. The designation of the term “unexplained” should not influence staff into making assumptions that the injury is either accidental or non-accidental. All efforts must be made to establish an explanation for the injury which in turn may assist in determining whether or not the injury is accidental or non-accidental, and if a crime has been committed.

Young children and infants are highly vulnerable and may have a serious injury without obvious physical signs e.g. shaking and/or impact injuries may result in internal head and other injuries. Nevertheless significant internal injuries may be caused and result in:

• Lethargy, poor feeding, apnoea or irregular breathing;
• Vomiting
• Fits;
• Variable levels of consciousness (irritability & drowsiness)
• Intra-cranial bleeding and retinal haemorrhages- (a retinal hemorrhage is bleeding from the blood vessels in the retina at the back of the eye);
• Skull and rib fractures;
• Death.

Serious Unexplained Injury Strategy Discussion

If at the outset or before the conclusion of initial S47 Enquiries the mechanism for an injury to an infant or young child remains unknown, a serious unexplained injury strategy discussion should be convened. This Strategy Discussion should be undertaken as outlined in  Strategy Discussion but must include additional considerations and the attendance of key staff.

To review the current investigation and enquiries made to date;

• Ensure all medical investigations have been undertaken (refer to local/internal and national AHT protocols/guidance).
• Identify additional enquiries that will assist in determining the mechanism of any unexplained injury, who will undertake these enquiries and time scale for completion;
• Identify any specialist advice that may assist in determining the mechanism of any unexplained injury;
• To consider all possible hypotheses and differential diagnoses relating to any injury and for each either determine the extent to which they might explain the injury or exclude them where possible;
• In light of the information gathered at the time, consider whether the threshold for legal intervention has been reached;
• Identify and clearly formulate an interim safety plan for the child. (e.g. remain in hospital, EPO etc);

Participants

Guidance as to who should attend strategy discussions is detailed in Strategy Discussions.  In order for the serious unexplained injury Strategy Discussion to be effective the following personnel must be in attendance:

• Children’s Social Care Service Manager (Chair);
• Social Work Manager;
• Investigating Social Worker;
• Safeguarding Investigations Unit Investigating Officer;
• Safeguarding Investigations Unit Detective Sergeant;
• Paediatrician who undertook Paediatric Assessment;
• Named Doctor;
• Named Nurse;
• Local Authority Solicitor;
• Other specialists who have been involved in the assessment of the injury;
• Other relevant professionals, health professionals and specialists may be required
• Note taker to attend and take full minutes in addition to completion of Record of Strategy Discussion form.

It may be necessary to hold more than one serious unexplained injury Strategy Discussion to finalise enquiries into an unexplained injury to an infant or young child.

Where the S47 investigation is unable to determine how an injury was caused, the minutes of the final serious unexplained injury Strategy Discussion must record how each hypotheses/differential diagnosis was investigated and finalised or excluded. Participants to the final serious unexplained injury Strategy Discussion must all agree that all opportunities to determine the causation of an injury have been examined, and at the time of the serious unexplained injury Strategy Discussion there are no outstanding enquiries that can be undertaken.

Such cases may require a fact finding.

Should there be any professional disagreement during the course of the above procedure, reference must be made to the Resolution of Professional Disagreements

Bruising/injuries in Children who are Not Independently Mobile (NIM) Guidance (Reviewed November 2022)

Body Maps

Leaflet for parents -My non-independently mobile child has a bruise, unexplained skin mark or possible eye injury - what next?