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Training and resources for professionals

Learning Briefing: Ed – Non-accidental injury to infant

The Incident

  • Date: 2020
  • Event: Ed, a 17-week old infant, was admitted to hospital following a Child Protection Medical that found unexplained bruising on the forehead, cheek and thigh. Further examination found healing fractures in the ribs and elbow joint.
  • Consequence: The incident was assessed as non-accidental and indicative of physical abuse.
  • Outcome: A police investigation is underway. The two older siblings were placed in the care of the Local Authority after Ed’s fractures were discovered.


Ed is the youngest of 3 siblings, all under five years old. Children’s Social Care have been involved in assessing and supporting the family since the birth of the older sibling. A pre-birth assessment was undertaken followed by a period of support under the child in need framework, which was closed to Children’s Social Care in September 2018. All three children were subject to child protection plans under the category of neglect with multi-agency professionals involved.

Safeguarding Concerns

  • Ed’s mother was known to Children’s Social Care due to past incidents, including a domestically violent relationship with a previous partner and poor mental health after an adverse childhood. Three older children had been removed from her care due to neglect.
  • Both parents are misusing alcohol as evidenced by each police call out for domestic disputes.
  • The home environment and children’s developmental delays are a concern.

The Review

  • Despite having previous children removed due to neglect, there is no evidence of how this prior removal was assessed. Additionally, any evidence that was collected did not appear to be used to predict future harm to Ed and his siblings.
  • Alcohol misuse was identified on every police callout and should be considered a factor in increased risk for domestic abuse.
  • Barriers for information sharing need to be addressed to safeguard at-risk children.
  • The risk of harm to Ed, who is under one year old, was not adequately categorised despite being in a domestically abusive household.
  • A high support and high challenge approach should be taken to work restoratively with parents while keeping children safe.

Learning from the Review

  • Child protection plans must be individual to each sibling, and physical abuse categories must be considered in households with domestic abuse issues.
  • Assessments must explore parents’ own experience of being parented. Where parents are unable to share information about adverse childhood, consent should be gained and a request made through the Local Authority.
  • Where children present significant signs of physical neglect, a Child Protection (CP) medical must be considered. If a CP medical is not performed, the rationale for this must be recorded on the child’s electronic record.
  • Potential disguised compliance must be identified, particularly if previous safeguarding concerns have been raised.
  • Where there are significant medical implications for children within the context of neglect, a paediatrician should be invited to a strategy discussion, or urgent advice should be obtained from a paediatrician.
  • Safeguarding concerns raised by partner agencies should be routinely referred into Children’s Social Care.
  • Risk assessments must be evidence-based and focused on the child’s needs. Substance or alcohol misuse should lead to consideration of hair strand and alcohol testing as part of initial child protection processes.

Outcome of the Review

Multi-agency professionals have agreed to take forward the below as a priority:

  • The Restorative Practice Learning and Development programme will be reviewed, and its impact on practice, management and supervision of neglect cases will be assessed.
  • A thematic audit of neglect cases will be undertaken to review practice of health involvement in strategy discussions and consideration for CP medicals.
  • Colleagues in Public Health Nursing will review the safeguarding process within their organisation including supervision of staff and escalation processes.

Evidence of good practice

  • Joint visits between health and Children’s Social Care highlights a good multi-agency response.
  • The Single Assessment included previous history of children being removed and patterns of harm. Mentioned the need for legal advice should there be no improvement.
  • The conference chair acted swiftly following the absence of CP medicals after the first strategy discussion.


If you are worried about the safety or wellbeing of a child or young person in Devon,
please complete the request for support online form.


If you think that the child is at risk of significant harm,
contact our Front Door directly by calling 0345 155 1071.


In an emergency call 999.