A Dual-site audit into the management of non-accidental head injury in two tertiary children's centres

A Dual-site Auditinto the Managementof Non-AccidentalHead Injury in TwoTertiary Children’sCentres

ShortReportKaren Low*Ruth MixerJames FraserPaediatrics, Bristol Royal Hospital forChildren, Bristol, UK

Russell JonesEmergency Paediatrics andCommunity Child Health, BristolRoyal Hospital for Children, Bristol,UK

Clare DonovanPaediatrics, University HospitalsBristol NHS Trust, Bristol, UK

Jane SchulteBristol & South Gloucester ChildProtection, Southmead Hospital,North Bristol NHS Trust, Bristol, UK

Maria BredowSafeguarding, Southmead Hospital,North Bristol NHS Trust, Bristol, UK

Following the death of Victoria Climbié in London in 2002, inreference to Lord Laming’s report, the House of Commons

Select Committee Sixth Report (2003) stated:

‘The paediatric units throughout the country should be instructed to reviewtheir arrangements for ensuring continuity of care, supervision of juniormedical staff and medical audit.’ (p. 28, recommendation 1)

Similarly, the same report highlighted a ‘failure of communi-cation between different staff and agencies’ (p. 11).

Children with head injury have many differing presentations,and head injury may not initially be suspected. However, it isimperative that when the clinical features of head injury arepresent in young children, non-accidental injury is consideredas part of the differential diagnosis. It is also important that athorough and standardised investigation of other rare causes ofintracranial haemorrhage are excluded. The Royal College ofPaediatrics and Child Health (RCPCH) (2007) has developedguidelines for the assessment of non-accidental head injuries(NAHI). These are found in the Child Protection Companion(Appendix 7), and summarise tests that should be undertaken anda timescale within which they should be achieved. This documenthighlights the need for legible, accurate record keeping within apatient’s medical notes. In the southwest of England, we havedeveloped a local guideline based on the RCPCH guidance, whichhas been in use since 2006. It has been developed by a multi-professional team comprising experts from paediatric intensivecare, child protection, radiology (Royal College of Paediatrics andChild Health, 2008), ophthalmology, haematology, neurosurgery

* Correspondence to: Dr Karen Low, Paediatric Trainee ST2, Bristol Royal Hospital forChildren, Paul O’Gorman Building, Upper Maudlin Street, Bristol BS2 8BJ, UK. E-mail:[email protected]

‘Children withhead injury havemany differingpresentations, andhead injury may notinitially besuspected’

‘We have developeda local guidelinebased on the RCPCHguidance’

Child Abuse Review Vol. 20: 67–74 (2011)Published online 7 December 2010 in Wiley Online Library(wileyonlinelibrary.com) DOI: 10.1002/car.1160

Copyright © 2010 John Wiley & Sons, Ltd.

and metabolic medicine. It follows the RCPCH advice with regardto timelines for investigations, and offers additional advice formore specific haematological and biochemical investigation. Italso collates advice from other specialists with respect to repeat/follow-up investigations and scans. The agreed protocol follows anovel ‘timeline’ that directs the clinical team to specific investi-gations at various intervals following the child’s admission. InBristol, the guideline is used across two hospital sites that areinvolved in the care of children with head injury. One has theregional neurosurgical unit, while the other has the children’shospital and paediatric intensive care unit (PICU). This audit wasprompted following some of the authors’ experience of working inthe neurosurgical unit. We felt that often such children were admit-ted but that the NAHI protocol was not meticulously followed. Wetherefore sought to audit its use to ascertain whether or not it wasbeing used correctly, and if not, where the problems lay andwhether these could be addressed.

Ethical Approval

This work was approved through the recommended audit proce-dures by the audit departments at both University Hospital BristolTrust and North Bristol Hospitals Trust.

Method

A retrospective audit was performed across both hospital sites toreview compliance with our NAHI guideline. The aims of theaudit were:

• Is our documentation thorough and inclusive?• Are we undertaking the appropriate tests within the recommended

timescales?• Are we informing the community paediatricians responsible for the

assessment and multi-agency liaison regarding NAHI and childprotection?

All children under two years of age admitted with head injury toboth hospitals between July 2007 and November 2008 were iden-tified. Children were identified from a variety of sources:

• Department of Community Child Health record of severe headinjuries in the under twos

• PICU database of children admitted with head injuries• A coding search. The coding scores were:

Non-accidentalHead injury

‘The agreed protocolfollows a novel“timeline”’

‘A retrospective auditwas performedacross both hospitalsites to reviewcompliance with ourNAHI guideline’

Low et al.68

Copyright © 2010 John Wiley & Sons, Ltd. Child Abuse Review Vol. 20: 67–74 (2011)DOI: 10.1002/car.1160

Skull fractureExtraduralSubduralSubarachnoidIntracranial bleedRetinal haemorrhages

Using the above searches, 133 sets of notes were identified.Notes were returned if the child was over two years old, if theinjury was deemed by staff to be definitely accidental, or there wasa non-accidental injury (e.g. scald) but there were no concernsabout head injury and the guideline was therefore not applicable.

Each set of notes was then audited for a copy of the guidelineand for important history points taken at the time of admission, asrequested by the guideline. It was also determined whether all theinvestigations were done at the correct timepoint and whether theresults were documented clearly in the notes.

Results

We identified 22 cases at the neurosurgical unit (15 male, 7female). Sixteen cases were identified at the children’s hospital(10 male, 6 female). Children at the neurosurgical hospital werereferred from hospitals across the region, which reflects its statusas a tertiary paediatric neurosurgical centre. The majority of casesin the children’s hospital were admitted directly through the emer-gency department.

Age at Presentation

Figure 1 illustrates the age range seen across the two sites. Thereis a notable difference in the ages of children from the two sites.Most cases seen at the children’s hospital were aged three monthsor less, whilst the neurosurgical unit saw a number of children inthe older age categories. This difference can probably be attributedto the fact that the neurosurgical unit received cases from acrossthe whole region, whereas the children’s hospital admissions camelargely through the emergency department.

Injury Type

Figures 2 and 3 illustrate the injury subtypes found across bothsites. The difference in the types of injury between sites is mostlikely to represent the fact that one of the sites is a tertiary neu-rosurgical site with a higher proportion of serious injury likely torequire neurosurgical intervention. Conversely, there was a higherproportion of minor head injuries at the children’s hospital.

‘Using the abovesearches, 133 sets ofnotes were identified’

‘There is a notabledifference in the agesof children from thetwo sites’

Audit into the Management of Children’s Non-Accidental Head Injury 69


Presenting History

The initial history was documented as being taken from theprimary caregiver in 91per cent (20/22) of cases at the neurosur-gical unit, and in 75 per cent (12/16) at the children’s hospital.Sixty-five per cent (25/38) of historians across both sites reporteda history of trauma preceding the presentation. However, a historyof trauma was denied in 37 per cent (10/27) of cases where asignificant injury was seen on computed tomography (CT) scan.Significant injury included skull fracture, extradural and subduralhaemorrhage, or other intracranial bleed.

Figure 1. Age at presentation at two children’s centres

Figure 2. Neurosurgical unit injury subtypes

‘A history of traumawas denied in 37 percent of cases wherea significant injurywas seen on CTscan’

Low et al.70


Multi-agency Referrals

Eight-four per cent (32/38) of cases across both sites were dis-cussed with the on-call community paediatrician within 24 hours.Ten out of 18 (55%) children at the neurosurgical unit and nine outof 14 (64%) at the children’s hospital were discussed with socialservices within 24 hours. Twelve out of 18 (66%) cases and 11 outof 14 (78%), respectively, had completed chronology paperworkin their notes.

Use of the NAHI Guideline

From the original cohort of children, those with major head injuryon CT and who were discussed with the community paediatricianwere selected for further auditing. It was assumed that this groupshould have had a full investigation and guideline use. This selec-tion produced 14/32 (43%) cases in the neurosurgical hospital andeight out of 16 (50%) cases in the children’s hospital. Two-thirdsof these cases across both sites had evidence of use of the protocolin the notes. However of these, two-thirds of cases at the children’shospital then had a copy included in the notes and this dropped toone-third of cases at the neurosurgical unit.

Use of the guideline prompts for additional history. Thisincludes enquiries regarding a family history of bleeding disorderand administration of vitamin K at birth. Enquiries were maderegarding a family history of bleeding disorder in two cases ateach site, and only one case at each site had documentation regard-ing vitamin K administration at birth.

The guideline specifies further investigations. A skeletal surveywas done in nine out of 14 (64%) cases at the neurosurgical unitcompared with eight out of eight (100%) children at the children’shospital. A further injury was found on skeletal survey in one caseat both sites. Fundoscopy is required for all these children and thiswas carried out in 12/14 (86%) and eight out of eight (100%) cases

Figure 3. Children’s hospital injury subtypes

‘Eight-four per cent(32/38) of casesacross both siteswere discussedwith the on-callcommunitypaediatrician within24 hours’

‘Use of the guidelineprompts foradditional history’



at the neurosurgical unit and children’s hospital, respectively.Seven out of 14 (58%) compared with two out of eight (25%)cases were found to have retinal haemorrhages. This difference islikely to represent the nature of the injury.

Documentation was also audited.We specifically looked at use ofbody maps - three out of 14 (21%) and three out of eight (38%)cases had body maps in their notes at the neurosurgical unit andchildren’s hospital, respectively. Retinal photos should be includedin the documentation. These were found in six out of 14 (43%) andtwo out of eight (25%) cases, respectively. Outcome and plannedfollow-up were found to be very poorly reported generally.

Discussion

The importance of multi-disciplinary and multi-agency involve-ment in the management of children with suspected NAHI washighlighted within this audit. Overall, both hospitals had similarresults. The documentation concerning who gives the history ofthe accident is important for medico-legal reasons. This was notdone in 25 per cent of cases at the children’s hospital and ten percent at the neurosurgical unit. It is possible that the caregiver gavethe history in all the cases but it is nevertheless important todocument this fact. Some of the cases in the children’s hospitalpresented as medically unwell, and it was only on investigationand observation that NAHI was suspected, which may explain whythe doctor taking the history did not explain in the notes who gaveit. This highlights the importance that doctors must learn to alwaysdirectly record the identity of the historian in their documentation,for any case can become a child protection case and may need togo before the courts. This audit did not clarify which caregiver wasthe historian, and future audits might want to determine these factsmore carefully and establish who spoke to provide evidence, whosaid what and whether they were actual witnesses or just retellingwhat they had been told. This is important when a doctor has togive evidence in court.

It is an obligation to discuss any suspected NAHI with chil-dren’s services at the earliest opportunity, to ensure that siblingsare safe and to ensure timely police involvement. Sixty-four percent (9/14) of cases from the children’s hospital and 55 per cent(10/18) of cases from the neurosurgical unit were referred appro-priately, but a significant number were not referred within 24hours. The reasons for this are varied - some children may havealready been referred to the local children’s services prior totransfer to the regional unit and staff might not have realisedthat safeguarding issues need to be addressed in eachcentre. Sometimes NAHI was not considered as a differential

‘Documentation wasalso audited’

‘Overall, bothhospitals had similarresults’

‘Future audits mightwant to determinethese facts morecarefully andestablish who spoketo provide evidence’

Low et al.72


diagnosis. Occasionally, nursing staff are better trained to considersafeguarding than junior doctors and there may be a delay whilstthese differences are addressed. Recent intensive safeguardingtraining for all staff in both Trusts should have improved thissituation and highlighted the importance of actively consideringsafeguarding when caring for a child. Where children’s services’input had been sought, there was poor documentation as to thenature of the ongoing multi-agency plan.

It is important to inform the community paediatrician on callwithin 24 hours of admission if NAHI is suspected: 14/16 (87%) ofcases at the children’s hospital and 18/22 (81%) of cases at theneurosurgical unit were discussed within this time frame appropri-ately. Of those that were not informed within 24 hours, this mighthave been because they presented as medical cases initially, andsubsequent investigations caused a change to a safeguarding focus.

In cases of suspected NAHI, the use of the guideline did notprompt further questioning about a family history of bleeding orvitamin K administration at birth. The questions that should havebeen asked are important questions in protecting the child andfamily from both abuse and false accusation of abuse. Legally, allalternative causes need to be considered, and as healthcare staff wemust be seen to have considered and asked the relevant questions.Additionally, it should be noted that this information is relevantclinically, not just for medico-legal purposes, and yet this was stillrecorded poorly. Other questions also not completed were thoseregarding family background: parental occupation, smokers andfamily tree. Again, these questions are imperative for building acomplete picture of the social background.

The audit demonstrated a problem with documenting bloodresults. Although these are available through the hospital intranet,there is currently no way of confirming that results have beenreviewed by a doctor other than writing them into the notes. Bodymaps and growth charts were not completed and attached to thenotes where indicated. The results of all tests should be docu-mented in such a manner to indicate that they have been positivelyinterpreted. It would also be best practice to document if a specificdecision had been taken not to do a certain test.

Consensus should be obtained regarding all additional investi-gations (e.g. metabolic investigations). All potential tests shouldbe identified but all cases should be considered on an individualbasis and clinical judgement applied. Every child’s measurementsshould be plotted on a growth chart. Although we did not audit thisdirectly, it was noted that very few charts appeared in the notes.This should be standard paediatric practice.

All hospital discharge plans should be clearly described in thenotes. Follow-up arrangements, either by the admitting or localhospital, should be planned and the relevant children’s services’

‘Occasionally,nursing staff arebetter trainedto considersafeguarding thanjunior doctors’

‘The questions thatshould have beenasked are importantquestions inprotecting the childand family from bothabuse and falseaccusation’

‘Very few chartsappeared in thenotes. This should bestandard paediatricpractice’



departments informed. Repeat investigations, booked for a laterdate, should be recorded to ensure that the reviewing doctor knowsto chase the results. This is evidence of good care, and is essentialto prevent children being lost in the ‘system’. In this audit, docu-mentation was generally poor. Many cases proceed to either thecriminal or civil courts, and healthcare staff will be called upon togive evidence. If documentation is not complete and the guidanceis not seen to have been followed, this evidence will not be goodand may not be credible. Compliance with the protocol is there-fore key. The consultant community paediatrician is required toprovide an overview report to address the recent injury and widercare of the child and also to contribute to the multi-agency futurerisk assessment. If the protocol is not adhered to, the subsequentreport may be less helpful to the multi-agency process.

Conclusions

In these complex cases, it is essential that documentation is opti-mised for both clinical and safeguarding reasons. This audit hashighlighted that one of the key improvements that could be made inmanaging these children is improving our documentation process.We have therefore recommended that an integrated care record beimplemented across both Trusts. This would act as a reminder to allstaff to consider child protection and to document investigationsand results simultaneously. This should include body map, retinalphotos, blood and radiology results and should link in with thegreen child protection paperwork without duplication. Completingpaperwork in this way makes a referral far easier and multi-agencywork can begin with all the necessary information.

This audit highlighted certain training requirements for juniorstaff and also a lack of awareness of existing guidance and proto-cols. This includes knowledge and understanding regarding refer-ral pathways and multi-agency working. Training has alreadybeen put in place since the time of this audit in order to address this.For such protocols to work they must be highlighted to medical andnursing staff alike, preferably at the time of induction into thedepartment. Re-audit will identify whether this has been addressed.

Ultimately, a multi-agency referral is made with the child’s bestinterest in mind. If a thorough and complete report is submitted,this can be at the forefront of ongoing multi-agency involvement.

References

Royal College of Paediatrics and Child Health. 2007. Child Protection Readerand Companion. RCPCH: London.

Royal College of Paediatrics and Child Health. 2008. Standards for RadiologicalInvestigations of Suspected Non-accidental Injury. RCPCH: London.

‘One of the keyimprovements thatcould be made inmanaging thesechildren is improvingour documentationprocess’

‘If a thorough andcomplete report issubmitted, this canbe at the forefront ofongoing multi-agencyinvolvement’

Low et al.74


Documents

A Dual-site audit into the management of non-accidental head injury in two tertiary children's centres