Councils should stop automatically triggering child protection enquiries under section 47 of the Children Act 1989 in response to bruising in pre-mobile infants, government advisers have said.
The Child Safeguarding Practice Review Panel made the call in a briefing published last week, as research found increasing numbers of authorities had policies that required a section 47 enquiry or a strategy discussion to decide whether such an enquiry should take place, in these cases.
This was despite researchers finding that accidental bruising of pre-mobile infants was not rare.
The panel, whose role is to review and learn from serious cases, said it did not support policies that required section 47s or other interventions “without an initial appraisal of the circumstances of the presentation”.
It 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 examining health professional and considering any other information on the family, should be held to determine whether any assessment or interventions to support the family or protect the child should follow.
The panel urged councils and their safeguarding partners to review their policies to ensure they were consistent with the evidence base and national guidelines.
Prevalence of accidental bruising
The panel’s briefing cited a 2020 evidence review by the Royal College of Paediatrics and Child Health (RCPCH) that found that the rate of accidental bruising among pre-mobile infants ranged from 0 to 1.3%.
But research papers that fed into this review found that rates among infants who were not yet rolling or crawling ranged from 0.6% to 5.3%, based on a single observation of them.
The panel said this meant that incidents were, though uncommon, not unknown.
In a yet unpublished paper, considered by the panel, social work academic Andy Bilson and mental health researcher Alessandro Talia, challenged the RCPCH’s view that accidental bruising was rare in pre-mobile infants.
They said one of the studies considered by the RCPCH (Kemp et al, 2015) found 27% of pre-mobile infants had a bruise over an average of 7.6 weekly observations.
“This challenges the idea that bruises in general are reliable indicators of future harm,” they said.
More councils automatically triggering child protection processes
Despite this, Bilson and Talia found that increasing numbers of councils were automatically triggering child protection processes where bruising was identified in a pre-mobile infant.
An analysis they conducted of published policies on bruising, covering 148 of the 152 English local authorities, found seven councils automatically initiated a section 47 enquiry while a further 28 required a required a strategy discussion to be held.
Under Working Together to Safeguard Children, strategy discussions should take place when there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm, and should determine whether a section 47 enquiry should take place.
The 35 who followed one or other route was up from 13 identified as doing so in 2016, based on analysis of 91 available policies on bruising (Bilson, 2018).
Bilson and Talia found that, as in 2016, most policies required an immediate referral to children’s social care and an assessment of the bruising by a paediatrician, with the police called if parents refused for their child to be seen by a health professional.
They also found that 18 policies said that accidental bruising was very rare and highly predictive of non-accidental injury, with 35 saying that serious case reviews had shown that staff had underestimated the seriousness of bruising, leading to more significant injuries being missed.
They said this showed that concerns about “staff underestimating the seriousness of bruising in infants seems to have led to an exaggeration of risk in these procedures and diminution in discretion for front-line staff, with the potential for harmful over-reaction”.
Their research also found widespread differences in how protocols defined a pre-mobile child, with half of authorities – including the seven who mandated a section 47 – defining this by age (under six months) and a quarter having no definition. The rest diverged between those who saw rolling children as pre-mobile and those that said the opposite.
Policies ‘should help build relationships not suspicion’
They added: “Policies need to be more strongly based on research evidence and make appropriate recommendations to support front line staff to make better judgments, allowing them to build relationships rather than develop suspicion.”
National Institute for Health and Care Excellence (NICE) guidance, last updated in 2017, states that health professionals should suspect child maltreatment in cases of bruising in infants who were not independently mobile.
In such cases, professionals should refer cases to children’s social care, following local multi-agency safeguarding arrangements.
In its briefing, the Child Safeguarding Practice Review Panel said it was broadly supportive of the NICE guidance, but recommended it be extended beyond health, to other professionals, including in children’s social care, and should define what is meant by not independently mobile.
The panel said this should encompass children who were not able to crawl, cruise or bottom shuffle, without excluding those able to roll. However, it said particular attention should be paid to the risks of those unable to roll.
Panel’s recommended procedure
It opposed policies that triggered section 47 enquiries or other interventions without assessment, and instead proposed that there should be:
- a review by a health professional with appropriate expertise 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 bruising, or a plausible explanation for the bruising; and
- a multi-agency discussion, always including the health professional who examined the child, to consider any other information on the child and family, including known risks, and to jointly decide whether any further assessment, investigation or action is needed to support the family or protect the child.
As well as recommending that all safeguarding partners reviewing their existing policies to check for consistency with the evidence base and national guidelines, it called for the Department of Health and Social Care, NICE and RCPCH to review the evidence base and consider how it could be strengthened.
This should “consider whether the current guidance could be updated to present a more consistent and clearer message, avoiding the dangers of over-intervention while retaining a critical stance”.
‘Complex area of work’
In response to the panel’s briefing, Association of Directors of Children’s Services president Steve Crocker said: “Our work with babies and very young children is particularly challenging as they are unable to tell us what has happened to them or how they feel so their safety and welfare is always our paramount concern.
“This is a complex area of work requiring all agencies to work together to assess the available evidence to determine whether a situation is causing or at risk of causing significant harm. Whilst research in this area is limited, professionals do work in accordance with nationally recognised statutory guidance supplemented with specific guidance published by NICE and the Royal College of Paediatrics.
“This briefing offers an opportunity for local partnerships to reflect on their processes and procedures, at the same time the panel has helpfully called on the Department of Health and Social Care to do a stocktake of available resources to help safeguarding practitioners undertake their role.”