The following is a fictitious story, which serves to illustrate the importance of early detection and action by health-care providers when child abuse is suspected. This story was provided to the College by Dr. Jean Hlady, FRCPC, Clinical Professor, Department of Pediatrics, UBC and Ms. Barbara Willson, RN, Nursing Practice Consultant, College of Registered Nurses of British Columbia.
Reporting a child in need of protection
A young mother brings her two-month-old infant to a child health clinic for his first checkup and immunizations. The infant’s mother reports to the public health nurse that he is fussy, spits up frequently and is difficult to feed. She mentions that she has tried a different formula without success. The nurse notes that while the infant’s weight gain is adequate and his development appropriate, the mother is concerned. The nurse suggests that the mother take her infant to their family physician. She also discusses strategies for managing fussiness and proceeds with the immunizations. The nurse arranges to follow up with the mother in two weeks.
A follow-up visit
At the next visit, the nurse notes that the infant has a dime-sized bruise on his left cheek. The mother says the infant’s three-year-old brother hit him with a toy. She also says that she and the infant’s father find the infant’s crying stressful. She admits that yesterday the children’s father became quite angry and pushed her. When the nurse questions her further, the mother states that the father does get angry but has never threatened or hurt her or the children. The nurse is concerned and gives the mother a domestic violence resource card. They talk about having a safe place to go. While the infant looks well, the nurse advises the mother to more closely watch the infant in the presence of the three-year-old. She discusses strategies for managing a crying infant and arranges a home visit in two weeks.
When the nurse arrives for the scheduled visit, no one is home. The nurse leaves her card with a note for the mother to call. She also calls the mother’s cell phone and leaves a message.
An emergency department visit
Three weeks later the child presents to a nearby emergency department with bleeding from the mouth and is found to have a torn upper frenulum. The mother explains that the infant accidentally bumped heads with his father during feeding. The physician says this should heal with no problem. The infant looks well—his bruise has disappeared and the mother does not mention it. It is late on a Friday night and a social worker is not available. The infant is discharged.
Note to physicians: Bruising or oral injury in pre-cruising infants should be taken very seriously as they are commonly seen in abused infants and exceedingly rare in well infants.
Back in emergency
At age four months, the infant returns to the emergency department by ambulance. His mother claims she found him unresponsive and seizing earlier that morning. His condition is serious. He has severe abusive head trauma, including bilateral subdural hematomas, retinal hemorrhages and four old rib fractures of two different ages.
The infant survives but is left with permanent neurological damage.
Questions to consider?
- What red flags should have alerted health professionals to the potential for abuse?
- What other questions should the health professionals have asked the infant’s mother?
- What else could have been done to prevent this tragic outcome?
Your legal obligation—early detection and reporting is critical
All health professionals have a legal obligation to report a child in need of protection to a local child protection social worker with the Ministry of Children and Family Development (Helpline for Children 310-1234—no area code is required). If in doubt, consult with someone who has experience in this area.
There are five specialty teams across the province that offer additional support and guidance. Note: Contacting them does not replace the obligation to report concerns to a child protection social worker.
- Child Protection Service Unit, BC Children's Hospital 604-875-3270
- Northern Health SCAN Clinic, Prince George 250-565-2120
- Health Evaluation, Assessment and Liaison (HEAL) Team, Surrey Memorial Hospital 604-585-5634
- Vancouver Island Suspected Child Abuse and Neglect Team, Nanaimo 250-755-7945
- Kamloops Suspected Child Abuse and Neglect Clinic, Royal Inland Hospital 250-314-2775
What does “reason to believe” mean?
In British Columbia, anyone with reason to believe that a child has been or is likely to be abused or neglected—and the child’s parent is unwilling or unable to protect them—has a legal duty to report that concern to a child protection social worker. Reason to believe simply means that, based on what you have seen or information you have received, you believe a child has been or is likely to be at risk. You do not need to be certain. It is the child protection social worker’s job to determine whether abuse or neglect has occurred or is likely to occur.
British Columbia, Ministry of Children and Family Development. The B.C. handbook for action on child abuse and neglect: for service providers [Internet]. [Victoria, BC: Ministry of Children and Family Development; 2007]. [cited 2014 Aug 6]. 64 p.
Sheets LK, Leach ME, Koszewski IJ, Lessmeier AM, Nugent M, Simpson P. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013 Apr;131(4):701-7.
Professional Standards and Guidelines
Physicians should be aware of their reporting obligations as described in the new standard Reporting a Child in Need of Protection.