This guide advises practitioners on how to safety plan to keep infants and young children safe when there is a concern about potential injuries and a skeletal survey or other medical investigations are required.
Perth and Kinross Child Protection Committee thanks Dr Bernard Colvin, Consultant Community Paediatrician with NHS Tayside, for his expertise in creating this guide.
Introduction
This Guide has been produced by Perth and Kinross Child Protection Committee (CPC). It provides clear practice guidance for all practitioners and managers working to support and protect children and families, particularly those who may be involved in Safety Planning for infants and very young children who may have been subjected to physical abuse.
Purpose
This Practitioner's Guide aims to ensure that practitioners are clear about what a skeletal survey is, the circumstances under which it is considered necessary and the actions that must be taken to safeguard the infant or child until medical investigations have been fully completed.
This guidance should complement, not replace, any existing single service and agency guidance relating to this area of work.
What is a skeletal survey?
A skeletal survey is a medical investigation which is primarily used for babies and children under the age of two years. It is a series of X-rays of all the bones in the baby or child's body. The skeletal survey is undertaken in the X-ray department, and the process lasts around one hour for each appointment.
It is very important to note that two separate sets of X-rays are required to complete the skeletal survey. The second set of X-rays is usually scheduled 11 to 14 days later.
This is because recent injuries to the bones of babies and young children are not always visible immediately and may only be seen on later X-rays.
A scan such as CT head scan may be conducted at the same time as the first skeletal survey, particularly in infants aged under one year, or in suspected head trauma. This is to look for skull fractures or brain injury. This usually does not need to be repeated with the second set of X-rays if the first scan is normal. Blood tests are usually performed around the time of the first skeletal survey if not done before.
Two consultant radiologists will review the images from both sets of X-rays and provide an expert medical opinion as to what, if anything, has been discovered. This means that some days can elapse between the second set of X-rays and the medical opinion being available.
Why would a baby or a child need a skeletal survey?
In a child protection context, a baby or child would be referred for a skeletal survey to look for any abnormality or injury to their bones, following an observed or suspected abusive injury. This could include a non-mobile baby having seemingly minor injuries elsewhere, such as bruising, or the child being the twin of a baby with abusive injuries. Skeletal surveys are used because injuries can be difficult to find in babies and young children. Bones can be broken without external bruising and bleeding in the brain can occur without an obvious injury to the outside of the head. Some babies and children may have underlying conditions that mean their bones are abnormal and they are at increased risk of fractures (breaks). This can also show up on a skeletal survey.
Safety planning for babies and young children
Babies and young children are extremely vulnerable as they are entirely dependent on their parents or caregivers for care and attention. Research has indicated that babies under 12 months of age are the age group who are most at risk of serious physical abuse and, when it does occur, the risk of fatality is higher for them than in older age groups. It is therefore extremely important when a skeletal survey is going to be undertaken for a baby or young child that a robust safety plan is in place. It is essential that the safety plan is not terminated prior to the results of the skeletal survey being received, regardless of how long this may take. This is because the skeletal survey may reveal injuries to a child who otherwise appears well and unharmed.
A baby or young child may require a skeletal survey after being admitted to hospital in an emergency situation or following concerns over their condition which have required medical examination. At this point, the baby or child and their family may or may not be known to Police Scotland and/or Children's Social Work. However, multi-agency discussions will be initiated at the earliest opportunity - this may be through Out-of-Hours Services.
If one has not already taken place, an Interagency Referral Discussion (IRD), which is a formal multi-agency child protection meeting, will be convened for a baby or young child where there are concerns about a potential non-accidental injury to share information and make an assessment of risk. IRDs are attended by representatives of Police Scotland, NHS Tayside and Perth and Kinross Children and Families Social Work at minimum. An integral part of the IRD is putting a safety plan in place to ensure the baby or child is protected from any further potential harm.
Each safety plan will be different dependent on the condition of the baby or child - for example, they may require inpatient treatment; they may be able to be cared for by close relatives or may require a foster placement.
Practitioners should also check that there are no other pending medical investigations (such as scans, blood tests, eye examinations) that may impact on safety planning. However, most of these are usually done before discharge from hospital.
It is essential that no safety plan is terminated prior to an expert medical opinion being received regarding set of X-rays from the second skeletal survey appointment.This is because the second set of X-rays may reveal that the baby or child has been significantly harmed, and further action will be required to safeguard them.
What if parents/carers decline to work with the safety plan?
Parents or carers who have an injured infant or child are going to be distressed and may be angry that a safety plan needs to be put in place to protect the infant or child. This is likely to because they may view the need for a safety plan as a direct allegation against themselves, their partner or someone they trust. For the most part, with honest discussion and reassurance, parents and carers will agree to work with practitioners in creating and working within a safety plan. However, if the parent or carers are resistant to working with practitioners in this way, legal advice must be sought at the earliest opportunity to consider whether there are grounds to apply to the Sheriff Court for a Child Protection Order. This emergency order allows for the infant or child to be kept in a place of safety, such as within the hospital, for two working days when it will be reviewed at Children's Hearing who can make a further short-term order. Unless there is a flight risk, parents and carers should be advised that a Child Protection Order is being sought and they should be advised to get legal advice for themselves. If the parents or carers do not have a solicitor, practitioners should direct them to the Scottish Child Law Centre who will be able to give them advice and guidance around choosing a solicitor locally who has expertise in this area of law. In the event that the legal threshold for a Child Protection Order is not met, urgent further discussion must take place with the senior management team to agree other ways of mitigating against the risks.
Working transparently with parents and/or caregivers
When there is a suspicion that an infant or young child may have been deliberately harmed or hurt, parents and caregivers are likely to be very heightened emotionally and under considerable stress. Workers need to be very sensitive to their needs and remember that this is an investigative process; it may be that the parents or caregivers have not been the person or persons who caused the harm or it may be, as mentioned above, that the baby or child has an underlying condition.
To help support parents and their wider family members at this challenging time, it is essential that workers are clear with them about what to expect from the outset of a safety plan being put in place. When a skeletal survey is being conducted, parents and/or caregivers need to know that this process is likely to take around 3 weeks as a minimum, possibly 4 weeks. Parents and caregivers need to be clearly informed that the safety plan requires to be in place for at least that amount of time as it would be unsafe to end the plan prior to the conclusion of medical investigations. Furthermore, the parents or caregivers should always be advised that a safety plan also serves to protect them from further concerns or allegations in this investigatory period.
Parents and caregivers should have been given clear information regarding the skeletal survey process from medical staff. However, people who are under a great deal of stress are likely to struggle to retain information. It is therefore helpful for all practitioners to be aware of why there is a 14-day space between the first set of X-rays and the second, and that two consultant radiologists need to review the images to reach an agreed medical opinion on the results so they may reiterate this information to the parents or caregivers. Following receipt of the results, there may then require to be a professional meeting held to consider next steps.
Arranging support for the parents and/or caregivers during this period is important, as is keeping them updated and maintaining clear and effective communication. Parents and/or caregivers should be signposted to local support and advocacy services and advised of the benefits of engaging a solicitor for their own legal advice.
Managing expectations of parents and/or caregivers in this period will be helpful to them and ensure that decisions which may endanger the child, such as ending the plan early, are avoided.
Links and resources
- A profile of suspected child abuse as a subgroup of major trauma patients
Emergency Medicine Journal 2015; 32:921-925
