Purpose
This briefing aims to provide a concise overview for multi-agency practitioners and team managers, highlighting key areas of good practice and areas for improvement.
The incident
Oliver was a pre-mobile infant who was seen by health professionals on several occasions following concerns about unexplained bruising. Medical investigations were undertaken to explore potential causes and, when no underlying medical explanation was identified, a safeguarding referral was made. Subsequent child protection medical assessments identified fractures at different stages of healing. Oliver and his sibling were later made subject to Interim Care Orders and placed in foster care while further enquiries continue.
Good practice
- Midwifery and Health Visiting services provided consistent support, maintained good records, promoted safe sleep and routinely explored family wellbeing and risk factors.
- Once medical causes had been excluded, agencies responded quickly and effectively through a coordinated multi-agency safeguarding response, including strategy discussions, safety planning, child protection medicals and clear communication with the family.
Messages for practice
- Bruising or unexplained injury in a pre-mobile infant should always prompt immediate safeguarding consideration. Medical investigations and safeguarding processes should run alongside one another rather than sequentially.
- Professional curiosity must remain central to decision-making. Practitioners should be mindful of the influence of plausible explanations, family presentation, perceived social status and other cognitive biases when assessing risk.
- Safeguarding concerns should be escalated quickly and confidently. Where thresholds appear to be met, practitioners should seek advice, challenge decisions where necessary and ensure appropriate referral pathways are followed.
- Effective information gathering supports better decision-making. Timely sharing of information, including photos, clinical observations and multi-agency intelligence can strengthen assessments and improve outcomes.
What can we do next?
- Review and reinforce local multi-agency procedures relating to injuries in pre-mobile infants, ensuring staff understand the expectation for immediate safeguarding referrals where concerns are identified.
- Strengthen training and supervision around professional curiosity, escalation, diagnostic uncertainty and cognitive bias in safeguarding practice.
- Ensure appointment triage, e-consultation and advice systems include safeguarding considerations so that concerns relating to pre-mobile infant injuries receive urgent clinical oversight.
- Continue embedding multi-agency learning from this review through policy development, audits and workforce development activity to promote timely and consistent safeguarding responses.
Practical tip
Ensure any birthmarks, skin markings or injuries present at birth are clearly documented and included in maternity-to-health visiting handovers to support future assessment and decision-making.
Key learning
Unexplained injuries in pre-mobile infants require an immediate safeguarding response. Early information sharing, professional curiosity and coordinated multi-agency working are essential to prevent further harm.
Discuss, reflect and act
Please use this briefing, along with the resources below, within team meetings, safeguarding supervisions and reflective discussions. Consider how the learning from this review applies to your own practice, service and agency procedures and whether you have identified any learning needs.
Download a printable PDF of this learning briefing
Is there anything wrong with this page?
Help us improve
Don’t include personal information.
"*" indicates required fields