Pre-mobile infant bruising should not automatically prompt section 47s, say government advisers

Panel says cases should be reviewed by health professionals first, as research finds increasing number of council policies require strategy discussions or child protection enquiries

Baby being seen by a doctor
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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In a yet unpublished paper, considered by the panel, social work academic Andy Bilson and mental health researcher Alessandro Talia, challenged the RCPCH’s view that accidental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.”

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5 Responses to Pre-mobile infant bruising should not automatically prompt section 47s, say government advisers

  1. Tom J October 6, 2022 at 3:05 pm #

    Well done to Andy Bilson and others on this who have been shouting about this for years and it has taken so long for the science to be given a fair hearing.

    I recall the repeated phrase used by all health and other professionals for years was ‘‘those that don’t cruise, don’t bruise’’ which led to a nuclear response each and every single time any bruise was seen.

  2. Beverley grant October 6, 2022 at 10:09 pm #

    We are going through hell since March 2022
    The social worker did not support us in any way. Now in October and still no further with the case. Our lives have been turned upside down. We never see the social worker, nobody ever contacts us until a week before court and then everyone appears wanting paperwork in order for court. Nobody seems to care until court is due. We love our granddaughter and would never harm her. We have never been investigated by social services EVER Until now. I am 55 and have brought my children up in a loving family-orientated environment and I have cared for all my grandchildren in the same way. I feel violated and guilty before even proven guilty. We have been treated unfairly and like criminals

  3. dk October 9, 2022 at 2:58 pm #

    Two responses to this article about the injustices perpetrated by social workers, over six times as many to the more recent article about injustices perpetrated against them (i.e. the NQSW’s awful financial struggles on a franky crap wage). A blunt comparison, one I’m sure many would feel is unfair, but from where I stand one that says a great deal about the trajectory and mindset of the average child protection social worker.

    This is incredibly important guidance. We have to be better at accepting that many of interventions cause harms unseen to us and be brave enough to challenge moralising and thoughtless orthodoxies. Too much of our risk assessment is of risk to our own reputations, not to children.

  4. Dr. Tony Spinks October 10, 2022 at 8:06 pm #

    Let’s not forget that brusiing is bleeding under the skin not just a ‘mark” – If a non-ambulatory infant sustains a bleed under the skin this should rightly trigger professional concern. Time and time again we are reminded of the critical need for a multi-agency approach and effective information sharing amonggst involved professionals in such cases and this is excatly what a strategy meeting and S47 investigation are designed to achieve. Whether that S47 investigation results in a child protection coference rests on the outcome of that S47 investigation. These are necesssary and important safeguards to ensure that physical abuse and/or neglect is not missed.

  5. Mazla October 16, 2022 at 2:45 am #

    I agree with Tony Spinks as above.

    The whole idea of section 47 enquiries is to primarily investigate and safeguard concerns raised regarding vulnerable children. Section 47 sets a parameter of actions that are required to safeguard children and young people. What is required is skill, knowledge and substantial experience. Each event or situation should be addressed in relation to individual circumstances. That’s good practice.

    The government has severely compromised NQSWs by re wording the Working Together Document , thus allowing LAs to use newly qualified and inexperienced staff to undertake child protection investigations, promoting staff far too early and growing a work force whereby experience is severely lacking. I do not believe any NQSW or inexperienced member of staff should ever, ever undertake a child protection \ section 47 enquiry until they have had a minimum of 2/3 years experience of actual front line field work practice. The promotion of staff to higher ranks is also a feature of the failings when decision making is required. It’s an abuse of staff and an abuse to children and their families. You get what you pay for.

    Watering down what is deemed a section 47 investigation is not only ridiculous it’s down right dangerous. Grow your staff in a safe and productive manner. Good practice and outcomes will follow. It’s not bloody rocket science. This is so ridiculously frustrating yet easily rectified. The role and ability to be a good sound and knowledgeable social worker is not and will never be taught in a classroom. It is complimented by skill, knowledge and overall experience and humility.

    Please please take it back to basics