Thinking the Unthinkable: Child Protection in the Emergency Department

 thinking the unthinkable child protection stemlyns

That people in a position of trust could intentionally injure, abuse or neglect children is almost unthinkable but it is a reality in the day-to-day practice of the Emergency Department1. Unfortunately, not only is it unpleasant to be confronted by the ideas and imagery that child abuse and neglect conjures up, it sometimes feels complicated and labour intensive to do something about it. I’ve put together some thoughts below about looking after children in the ED with child protection (and non-accidental injury, AKA non-accidental trauma, AKA child abuse…) in mind.

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When to Ask for More Information

Deciding what triggers your child protection threshold can be very subjective as cases present along a spectrum, just like every other aspect of Emergency Medicine. Detection is a team responsibility; you may find that the triage nurse flags up a presentation as unusual before you even see the patient.

Some things will always arouse suspicion, such as2:

  • injuries not consistent with the child’s developmental age (for example, long bone fractures in non-mobile children – note that spiral fractures of humerus or femur are not pathognomonic of non-accidental injury in mobile children provided a consistent history is given; for example, the toddler whose foot is trapped under something and they fall while on a twisted leg.)
  • implement marks in injuries, such as hand/finger marks or marks from another solid implement, ligature marks, bite marks
  • burns in certain distributions: scalds are common and usually reflect a child tipping a hot drink onto themselves; cigarette burns and glove-and-stocking distribution scalds (suggesting forced immersion) are suspicious.
  • bruises in unusual places – toddlers fall over a lot but they usually bruise over bony prominences (shins in particular). Bruises on cheeks, buttocks and abdomen are unusual (and concerning in non-mobile children who really shouldn’t have bruises at all) but may be explained by some mechanisms of injury. Circumferential bruising is hard to explain.
  • delayed presentations, particularly after significant injuries where you would expect the child to have made it clear that they were in pain
  • particular radiographic appearances: Radiopaedia3 has an article on radiographic causes for suspicion; note that the commonest skull bone fractured accidentally in paediatric patients is the parietal bone: the commonest non-accidental skull fracture is also the parietal bone.

There are other circumstances you might find yourself extra alert – such as when a child has had multiple previous attendances. As explained in an article on, this alone is not grounds for a child protection assessment in itself but it should probably prompt a referral to the health visitor (for preschool children) or school nurse (for school age children) at a minimum. Often different professionals see slices of the same picture and it’s not until information is shared between them that the full picture is visible.

Some good hard and fast rules for your practice are:

  • make sure that, whatever the reason for attendance, non-verbal children are stripped from head-to-toe including removing the nappy. Not only will this help you spot suspicious wounds, burns and bruises, you might also uncover non-blanching rashes
  • give verbal children a chance to explain what happened before their parents fill in the gaps of the history. They aren’t always reliable historians but don’t be dismissive. Some children will directly disclose non-accidental injuries to you.
  • speak to teenagers with a chaperone but without their parents. This is an ideal opportunity to ask about other important things they may not want to disclose: sex, drugs, smoking, alcohol. This may be appropriate for some younger children too. If a disclosure is made do NOT promise to keep it secret but DO promise to help and DO take it seriously.
  • pay attention to the way parents/carers and the child interact. Give credence to the concerns of your nursing colleagues. Neglect and emotional abuse can be much harder to detect than physical forms.

What to Do When You Suspect Something

Be humble first and foremost – you might be wrong. However, you have a duty to explore further. Your trust should offer some basic child protection training as part of your induction or mandatory training – if you haven’t received any, ask! Even if you are working in an adult-only ED, you may still see children who are accompanying adult patients, so it is important that you are familiar at least with where to get help.

Firstly, you can contact the ED consultant (or PED consultant). If you need guidance about a patient in the department they should be your first point of contact. Senior nursing staff, particularly in a paediatric ED, are usually familiar with the child protection processes for your hospital and should be able to point you in the direction of referral forms etc. You may need to complete a social services “common assessment framework” which contains lots of information about the child and their family.

Secondly there will be a named safeguarding nurse for the hospital but they are sometimes only available in-hours: out-of-hours they may ask for details to be faxed or emailed to them, which you should do, but that’s not much good if you need help right now. There will be a duty safeguarding consultant (usually a general paediatrics consultant) but the paediatric registrar often undertakes child protection medicals as part of their day-to-day workload so they should also be able to help.

Thirdly, social services often “know” about some children, particularly if there have been previously documented child protection concerns. This used to be referred to as “being on the child protection register” but this term is outdated. Lots of children have social work involvement for a variety of reasons which have nothing to do with intentional injury (like parental illness or vulnerable housing status). Sharing information between agencies is key to ensuring that children are protected.

Finally, suspected sexual assault is often handled differently. Ideally these patients are seen in a sexual assault referral centre (SARC) like the one in Manchester. The centre in Manchester takes referrals from the police or from patients themselves and will usually handle all of the medical care and examination and as with adults your ED role is usually to ensure there is no life-threatening injury (which can happen). I would suggest that you should also complete a referral to social services as it is better that they receive two than none.

Thinking the Unthinkable

Sensitivity is the embodiment of Emergency Medicine – we exist to consider the worst case scenario for our patients and to convince ourselves that it isn’t the case. The same thing is true of child protection. By the very nature of sensitivity, we have to be over suspicious: if every single case we act upon turns out to have been a safeguarding issue, then we are clearly missing some. I’ve seen Mongolian blue spots mistaken for buttock bruising, osteomyelitis mistaken for a non-accidental fracture, and impetigo mistaken for cigarette burns. Things are often not cut-and-dried in the ED but we should still think – and act.

Being oversensitive means, then, that we are going to be asking more questions of families when actually no intentional inflicted harm has occurred. It is important that we understand that there may still be feelings associated with going through the process of a child protection investigation (at any level); it is perfectly natural for parents, who have done nothing wrong, to feel under scrutiny. Think about the way that you feel on edge and self-conscious after making a clinical mistake. The principle is the same here.

Remember that even if you are fairly certain that an injury has been intentionally inflicted, the parents are not necessarily the perpetrators. Keep an open mind and be non-accusatory, focusing instead on protecting the child.

What to Say to Parents

That’s why it is so important that you approach “the conversation” with parents with humility and understanding. You will be wrong – at least some, hopefully most – of the time. But you are acting with oversensitivity in order to protect the children who need it and if you explain this, most parents will completely understand.

Here is what I say to parents:

“I am absolutely not accusing you of anything. We do know that sometimes children are hurt and it isn’t an accident. There are some things about the injury your child has which we can’t explain (or: which don’t completely add up) and when that happens we have a duty to ask some more questions – and that is so that we can make sure we are helping those children who really need it. For you it’s going to mean some waiting around and quite a lot more questions, but it’s really important that you help us with that because it helps us to protect the most vulnerable children we see.”

No parent has ever refused after I’ve said this!

But What if They Do?

If the parents insist they are leaving the Emergency Department and all attempts to calmly explain the situation to them (including engaging your wise senior nursing colleagues), you might need to call the Police. The Police in England and Wales have powers under the Children Act 19894 to remove a child or prevent removal of a child from hospital for up to 72h during which a child protection evaluation will usually be carried out (commonly known as a Police Protection Order).


Dealing with child protection cases can be very unpleasant. It might be worth talking the case over with an educational supervisor or senior colleague and it’s always worth trying to follow-up what happened. Be sure to get help if you need it.

If you want to know more about child protection (particularly if you are interested in Paediatric EM as a subspecialty), ALSG runs two courses: Child Protection Recognition and Response5 and Child Protection in Practice6 – click the links to find out more.



Before you go…

Recognition of Child Abuse in the ED. Published 2015. Accessed September 30, 2016.
Speight N. ABC of child abuse. Non-accidental injury. BMJ. 1989;298(6677):879-881. doi: 10.1136/bmj.298.6677.879
Non-Accidental Injuries. Radiopaedia. Accessed 9, 2016.
Children Act 1989. Accessed September 30, 2016. [Source]
Child Protection Recognition. Published 2016. Accessed October 1, 2016.
Child Protection in Practice. Published 2016. Accessed October 1, 2016.

Cite this article as: Natalie May, "Thinking the Unthinkable: Child Protection in the Emergency Department," in St.Emlyn's, October 1, 2016,

4 thoughts on “Thinking the Unthinkable: Child Protection in the Emergency Department”

  1. Pingback: Thinking the Unthinkable: Child Protection in the Emergency Department – Global Intensive Care

    1. A very important point. Always suspect trauma (NAI) in young children with altered mental status. Often not obvious at the time of first assessment, i.e. there may not be any blindingly obvious signs of external injury. Always important to take examine these children carefully for signs of NAI.



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