A four-month-old baby died after medical professionals failed to refer unexplained bruising the child suffered for further investigation, a Serious Case Review has found.
The child, named only as ‘Baby V,’ died last year after being transferred to hospital where three bruises were found on the child’s face, one on its collarbone and a fifth on the baby’s chest.
There was a healed rib fracture and bleeding in the back of her eyes.
It was later discovered that there were three skull fractures, brain haemorrhages, three rib fractures, and multiple bruising, covering up to four separate incidents.
An independent probe found that on two occasions professionals were told about marks on Baby V, prior to the child’s death, by a parent and the explanation was accepted and not pursued further.
This is despite the report stating that on one occasion there should have been a referral for further investigation.
On the day before Baby V’s last admission to hospital, an out-of-hours GP saw two bruises on each of the child’s cheeks.
The baby’s parents said their child had been pinching her cheeks in anger.
However in what was described in the report as a ‘missed opportunity,’ despite asking for an explanation and being suspicious, no referral for further investigation was made.
The report stated that it is ‘reasonably certain’ that had there been an onward referral, the child would have been admitted and not at home to have received the final injuries.
It said the implications of unexplained bruising to very young babies were not fully understood, and led to the insufficient curiosity and one occasion, action.
It found two staff definitely known to have heard about or seen bruising, were not aware of the bruising policy for ‘non-mobile’ children and neither had previous training or experience that could have helped them.
An out-of-hours GP employer was unaware of any lack of training and the baby’s nursery school was described as being ‘overlooked’ in formal training plans.
However the Hampshire Safeguarding Children’s Board (HSCB) report revealed the family was not known to social services and there were no indications from the background of either parent, or Baby V’s older sibling, that V would be at any risk of violence.
The report states that there were ‘some indications’ during during Baby V’s lifetime that ‘might have been explored further at the time.’
The HSCB has now updated and promoted its protocol for professionals called ‘Bruising in Children’ (who are not independently mobile) which it has said ‘gives clear criteria and guidance on what to look out for and how to report concerns.’
The HSCB is also working with other agencies to ensure the protocol is better used in local training for health, early years and education professionals and fully understood.
The independent author made recommendations for the Safeguarding Board and nine organisations ranging from school governors to general practice and NHS Trusts.
They include ensuring the bruising policy is widely understood and implemented, that staff are helped to be more challenging, and that out of hours GP services have the best safeguarding arrangements.
The organisations are Frimley Park Hospital NHS Foundation Trust, South Central Ambulance Service NHS Foundation Trust, Hampshire County Council, HSCB, school governors, Southern Health NHS Foundation Trust, GPs, North Hampshire Urgent Care and University Hospitals Southampton NHS Foundation Trust.
Maggie Blyth, independent chairman of the Hampshire Safeguarding Children Board said: ‘The death of this baby was deeply tragic. Naturally, our thoughts and sympathies go to the relatives coming to terms with their loss.
‘Serious case reviews will always find areas for improvement in practice and we are confident that the partner agencies will take forward the recommendations, particularly with regard to ensuring frontline staff are clear about the implications of reported bruising on a child, especially when that child is not yet old enough to crawl or walk.
‘The report makes it clear that the family was not known to social services and most dealings with professionals were unexceptional.
‘Health professionals, educationalists, the police and children’s services staff in Hampshire take the welfare and safety of children extremely seriously and work together to keep children safe from harm. A lot has been learned from this review.’