Risk radar

A continuing NSPCC study of under-two-year-olds who were the
victims of serious physical abuse is, believe Peter Dale, Richard
Green and Ron Fellows, making a strong case for more rigorous
assessment procedures.

One of the most challenging situations in child protection work
is the assessment of cases where babies and infants have sustained
serious physical injuries and where parents’ explanations don’t
tally with expert medical opinion. Mistakes can have tragic

In one case, extensive bruising to baby Bianca’s face and body
was noticed when she was two weeks old. She was admitted to the
local children’s hospital that day where the consultant
paediatrician formed a firm view that the bruising was
non-accidental. However, contrary to the advice of the
paediatrician, Bianca was returned to the care of her parents while
criminal and child protection enquiries continued.

During the next few weeks she was seen by professionals to have
further facial bruising. Medical opinion was not sought. At the age
of eight weeks, Bianca was readmitted to hospital by ambulance with
extensive bruising to her body and severe head injuries from which
she died.

It is difficult to understand how, after nearly 30 years of
co-ordinated child protection procedures, the safety of very young
babies can be compromised in such tragic ways. However, the case of
Bianca is by no means unique. Prediction of serious physical abuse
is an inexact science in an area where there are no risk-free
options and the stakes are high. Errors in either direction
(inappropriate permanent separation or re-injuries following
rehabilitation) may have irredeemable negative consequences.

A continuing NSPCC study of the child protection response to 21
cases where babies and infants (0-24 months) were subject to
serious physical abuse – and where there were disputed or
discrepant explanations from parents as to how the injuries
occurred – demonstrates the need for guidelines on effective
professional practice in this critical area of child protection
assessment. Findings highlight concerns about:

– The extent and nature of physical abuse to babies and

– Similar cases being handled in very different ways.

– The challenges for professionals in assessing immediate safety
needs and future risks.

The extent and severity of injuries inflicted on babies and
infants is striking: 21 cases reflect a total of 132 noted injuries
to 34 babies/infants. Forty-two of these were rated as very
serious. Four involved suspicious deaths, including one previously
seriously injured infant who subsequently died in circumstances
that were highly indicative of further maltreatment. In 10 cases,
14 children were subject to further serious physical re-injuries
after the intervention of child protection services.

All of these cases (see below) created significant disagreement
in professional networks. A key factor is that they were all middle
class families who experienced none of the familiar child abuse
indicators of social deprivation, nor the overtly disturbed
personalities and relationships that have come to be seen as
stereotypical of serious child abuse. In the absence of such
characteristics the “normal” appearance of parents in these
circumstances can impede professional recognition of other factors
which may constitute continuing risk of further serious violence to
babies and infants.

In the sample as a whole, with a few notable exceptions, the
initial child protection system intervention was largely effective
in placing a temporary buffer between the baby and the adults who
were thought to have caused the injuries. These effective urgent
safety measures (which however failed Bianca) stem from adherence
to child protection procedures that have been continually refined
over the past 30 years. Initial child protection case management is
largely procedurally driven and this – so long as procedures are
followed – provides a degree of consistency in initial safety

However, soon after the initial safety phase, child protection
systems appear much less consistent in assessing and managing the
risk of further abuse. Cases with similar characteristics can be
handled in very different ways. On occasions child protection
systems become seriously confused by the multiplicity of factors
which generate contradictory opinions, conflicting plans and
heightened emotions. Sometimes incomprehensible decisions are made,
and on other occasions – especially when the injuries have occurred
to a baby in a middle class family – child protection and legal
systems become paralysed.

That this should happen is partly a result of the fact that the
child protection system does not have the benefit of valid
research-based assessment guidelines to weigh the likelihood of
further maltreatment. Unlike the initial safety assessment phase,
there are no generally agreed procedures for the systematic
assessment of the risk of further harm to babies and infants.

“Wait a minute!” we hear you say: is this not exactly what the
new assessment framework1 is supposed to provide? While
we welcome the more rigorous approach it requires, our view is that
the framework will do little to assist with the systematic
assessment of cases of serious injuries to babies and infants where
there are discrepant or disputed explanations.

The framework does not focus on these cases in enough detail to
assist practitioners to recognise the issues that need to be
carefully considered. Influenced by policy principles stemming from
Messages from Research the framework inclines toward the
view of abusing parents as being helpless and poor – doing their
best in difficult circumstances.2

There is undoubted merit to this perspective as a good deal of
relatively minor child abuse occurs in situations where
over-stressed parents suffer social exclusion and the absence of
effective family support services. However, in many cases of
serious physical abuse to babies and infants severe parental
personality disorder, mutual adult domestic violence, substance
misuse and serious mental health problems are to be found and set
these parents apart from the much more common group of
“over-stressed parents”.

To add to the complexity, in this NSPCC sample, records of over
a quarter of the cases did not reveal evidence of stereotypical
indicators of risk. In the middle class families in particular,
covert explosive violence to babies and infants appears to erupt in
the context of otherwise “normal”families where the babies and
infants are developing appropriately and seem well cared for.

In these circumstances, the plausibility of denials of violence
can cause professionals to underestimate the significance of
underlying escalating patterns of violence. This may be
particularly distracting for workers who can be less confident and
astute in child protection work with articulate, resourceful and
middle class parents. It was in this context that Bianca died and
that eight babies in this sample received very serious

This research illustrates the complexity of personalities and
family dynamics which culminate in serious injuries to babies and
infants. The professional challenge is to be better able to
distinguish parents who present risks borne principally of
contextual pressures – from a smaller group where high risk stems
from more inherent, concealed and ominously explosive violent
personalities. Paradoxically, the former group often “score” higher
on traditional risk indicators than the latter.

Practitioners and the courts need more valid guidelines to
systematically assess initial safety and subsequent risks where
babies and infants have received serious suspicious physical
injuries. This research is in progress and aims to contribute to
the development of a structured risk assessment model to help
clinical and legal decision making in these cases.

1 DoH, Framework for the Assessment of
Children in Need and their Families, Stationery Office,

2 Dartington Social Research Unit, Child
Protection; Messages From Research, Stationery Office,

Further information at pdale@nspcc.org.uk

Peter Dale, Richard Green and Ron Fellows are children’s
services managers at the NSPCC.

A catalogue of abuse

– A three-week-old baby girl sustained three separate fractures
to both legs. One week earlier a bruise to her face had been noted.
The explanation given that the fractures must have occurred while
being passed from one parent to the other during the night was
discounted by a consultant paediatrician. Nevertheless, the baby
was discharged home to her parents prior to a child protection case
conference. One week later she was removed from their care when
further bruising was noted.

– An eight-week-old boy received three separate limb fractures
and at least five fractures to his ribs. A retrospective search
through medical records uncovered a pattern of a large number of
injuries to elder siblings including a fracture to one at age six
months. Parents offered a number of explanations involving a
boisterous elder sibling and restraint during a very routine
medical procedure. All children were removed from parental care and
a protracted court battle commenced involving conflicting medical
evidence regarding the plausibility of the parents’

– An eight-week-old baby boy was admitted to hospital with a
tibia fracture. Two weeks prior to this bruising to his abdomen had
been noted by a health visitor on a routine visit. The parents
claimed that the injury was self-inflicted by the baby having been
over-active in his cot. He was returned home to his parents’ care.
At the age of 17 months he was re-admitted to hospital with a
fractured femur. Again, the parents stated that this was
self-inflicted. Six separate specialists concluded that this was an
inflicted non-accidental injury.



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