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Learning briefing: Infant B – Non-accidental injury

The Incident

  • Infant B was a 3-week-old baby living at home with family.
  • Infant B’s parents were both under 18 when baby was born and had vulnerabilities.
  • Infant B was not registered with a GP at the time of the incident and therefore there was no primary care health record.
  • Infant B was taken to a local Urgent Care Centre by family members. Infant B was unwell and had a small bruise on their cheek and an abrasion on their jaw.
  • Infant B was subsequently taken to hospital where a child protection medical was undertaken identifying that they had experienced serious injuries.
  • Infant B was subject to an assessment by Children’s Social Care at the time of the incident.

Good Practice

  • There was evidence of good communication between nurses on the neonatal unit (NNU) and the Social Worker. Good observation of the parents and their ability to care for Infant B. The NNU staff engaged with Dad well and as an equal parent.
  • Staff from the Neonatal Unit shared valuable information with Children’s Social Care, which prompted a safeguarding enquiry and a discharge planning meeting.
  • The Health Visitor was active in sourcing information from the Midwife and the Social Worker.
  • The assessing doctor at the urgent care centre informed the hospital paediatric team to expect Infant B at the hospital and then check that they had arrived.
  • The midwife recognised the vulnerability of Infant B’s mother and made appropriate and timely referrals.

Messages for Practitioners

  • Practitioners should consider the needs of young parents who are children themselves and make sure they are offered the appropriate support.
  • Where the parents of a baby are children themselves, there should be clear protocols about the allocation of social workers to both mothers and fathers, and their child.
  • Fathers must be visible within pre-birth assessments and receive the support, education and interventions offered to mothers, for example advice about safe sleep and coping with crying.
  • School and college representatives should be invited to the Vulnerable Pregnancy Panel meetings when parents are still on roll in those settings.
  • Relationships and communication routes between health visitors and midwives should be strengthened to ensure robust handovers between the services, antenatally and postnatally.

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.