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A recent Rapid Review in Bury has found that the safeguarding risk of bruising in immobile babies is not always understood and the process is not always followed when bruising is noted.

Bruising is the commonest presenting feature of physical abuse in children. The younger the child the greater the risk that bruising is non-accidental.

Infants who have yet to acquire independent mobility (rolling/crawling) should not have bruises/ marks or other injuries without a clear explanation. Any bruising in an immobile baby should raise child protection concerns and raise suspicion of maltreatment and an immediate referral to Children’s Social Care Services should be made to arrange for an urgent paediatric opinion. Any injuries are unusual in this age group, unless accompanied by a full consistent explanation. Even small injuries may be significant, and they may be a sign that another hidden injury is already present. It is the responsibility of Children's Social Care Services in conjunction with the local acute or community paediatric department to decide whether the circumstances of the case and the explanation for the injury are consistent with an innocent cause or not.



A Health Visitor, during a new birth visit to a 10 day old baby, noted a bruise to the hand. Mother was unable to give an explanation of how it occurred. The baby did have a bruise on the other hand but this was caused by a cannula whilst in hospital. The Heath Visitor, followed the Greater Manchester bruising in non-mobile baby policy and referred the baby to MASH. The MASH were reluctant to take the referral without further exploration by the Health Visitor who then contacted other agencies but still no explanation was established. There was a lack of recording, within the MASH, despite detailed conversations on the day from the Health Visitor.

A strategy meeting took place 3 days later when subsequent safeguarding concerns were identified unrelated to the bruising.


Safeguarding Concern

  • Delays in initial assessment as policy was not followed—the child was not seen for a child protection medical some 48hrs after the incident was reported to Children's social care
  • Lack of professional knowledge over the pathway for bruising in immobile babies and around the understanding of the potential significance of bruising on non-mobile babies
  • Not following the policy around bruising and non-mobile babies to inform decision making made the S47 medical confusing
  • The decision making within the MASH, in respect of the bruising was a single agency decision and not a multi-agency one, by a single professional.


Other safeguarding concerns were subsequently identified and a multi agency Rapid Review was conducted by Bury Integrated Safeguarding Partnership (BISP). The review panel identified that the decision making within the MASH, in respect of the bruising ,was a single agency decision and not a multi-agency one which subsequently delayed a strategy discussion which took place 3 days later after the weekend.

There were elements of multi-agency working around the bruise which, initially did not work well. Policy wasn’t followed, records were incomplete and there was a delay in establishing that the bruise was a cause for concern. A section 47 child protection medical eventually took place and the bruising was established to be as a result of a medical intervention.


Recommendations: Key Areas

  • All staff need to have a sound knowledge of the Greater Manchester Bruising Protocol for Immobile Babies and Young Children and ensure this is embedded within the practice of all safeguarding professionals. Protocols are not effective if they aren’t adhered to by all professionals
  • Practice ‘respectful uncertainty’ - critically evaluate any information you receive and maintain an open mind to ensure that babies and children are not exposed to further harm from a plausible parent
  • The child protection medical protocol needs to be kept up to date and circulated across all agencies to provide greater clarity for professionals following the pathway. This will allow professionals to challenge if there is a deviation from the process.

What to do

  • It is the responsibility of the first professional to learn of or observe the bruising to make the referral
  • A bruise or injury must always be assessed in the context of medical and social history, developmental stage and explanation given. Assessments will be led by Children's Social Care and a lead medical professional (local acute or community Paediatrician) to determine whether bruising is consistent with the explanation provided or is indicative of non-accidental injury
  • As far as possible, parents or carers should be included in the decision-making process, unless to do so would jeopardise information gathering (for example, information could be destroyed) or if it would pose a further risk to the child
  • The importance of signed, timed, dated, accurate, comprehensive and contemporaneous records cannot be over-emphasised - body maps can be used.

Questions to consider

  • Are you familiar with The Greater Manchester Bruising Protocol for Immobile Babies and Children?
  • Would you know what to do if a parent(s) refuse to take their child for a child protection medical?
  • What would you do out of hours? Who would you contact? See: I'm worried about a child
  • As a team, outline the steps you will all take to improve practice in line with the recommendations.