Intended for healthcare professionals


Audit of child protection procedures in accident and emergency department to identify children at risk of abuse

BMJ 1997; 315 doi: (Published 04 October 1997) Cite this as: BMJ 1997;315:855
  1. Peter D Sidebotham (p.sidebotham{at}, consultant paediatrician, community child healtha,
  2. Alison V Pearce, lecturer in community child healthb
  1. a Institute of Child Health, Royal Hospital for Sick Children, Bristol BS2 8BJ
  2. b Child Health Department, Bath and West Community NHS Trust, Bath BA1 3QE
  1. Correspondence to:Dr Sidebotham
  • Accepted 11 March 1997


Hospital accident and emergency departments are often the first place where injured children come into contact with the health services. Children who are victims of or at risk of abuse may be passing through these departments unrecognised. Accident and emergency departments must have clear protocols for recognising and handling suspected abuse and for training staff and updating that training.12

Triage by nurses of all children arriving in the accident and emergency department at the Royal United Hospital in Bath includes checking the child protection register and assessing five indicators of risk for child abuse. These indicators are: whether the child has previously been seen at the department, whether there is an inconsistent medical history, whether the findings on examination match the history, whether there was a delay in bringing the child to the department, and whether there is a head injury or fracture in a child younger than 1 year old. The department has a clear and accessible protocol for the management of suspected cases of child abuse.

Methods and results

A two part audit was undertaken in May 1995 and 1996 to determine the extent to which procedures for identifying and referring children at risk of abuse were being followed in the accident and emergency department. During the two-month audits the record cards of all children attending the accident and emergency department were reviewed. After the initial audit, meetings were held with the local area child protection review panel, hospital management, and accident and emergency staff to share the information and stimulate debate. As a result a number of changes were introduced to the protocol including updating the knowledge of the staff in the accident and emergency department, clarifying which children should be discussed, instituting regular training and feedback sessions, and revising the checklist system for risk indicators.

A total of 1357 cards were reviewed in the first audit and 988 in the second. The table summarises the standards that were achieved. During both audits only five children were identified as being on the child protection register. This is fewer than would be expected from the local prevalence (47.1 per 10 000) and may reflect variations in prevalence within the boundaries of the local authority.3 The proportion of children with one positive indicator of risk remained constant at 40% (543 children in the first audit; 392 in the second), as did the proportion of those with two (4%; 50 and 40 children respectively), and more than two (0.1%; 2 and 1).

Table 1

No (%) of times indicator of risk of child abuse marked on checklist duringvisits by children to accident and emergency at first (1995) and second (1996) audit

View this table:


Clarification of protocols for child protection in the accident and emergency department, regular staff training, and increased communication between paediatricians and nurses in the department led to improvements in identification of children thought to be at risk of child abuse. Improvement was seen in all standards but especially in those relating to nurse triage. Time spent in training and feedback resulted in the development of good rapport between nursing staff and paediatricians and a commitment to achieve high standards in the child protection procedures. In contrast, the overall rate of referral of children thought to be at risk remained low. Just 3 out of the 57 children (5.3%) identified as being at risk were discussed with paediatricians in the first audit, this increased to 13 out of 51(25.5%) in the second. Improvements were made in training junior medical staff in issues of child protection; however, with a regular turnover of staff this needs to be sustained and reinforced by close liaison between the accident and emergency and paediatric departments.

This audit showed whether procedures for identifying children thought to be at risk of abuse were being followed. The checklist of indicators of risk does not identify children who have been abused, but merely heightens awareness of those children in whom there are features that might cause concern. What the audit does not show is whether these procedures can accurately identify children who have been abused. Over a longer time it would be possible to review the records of all children identified as having been abused and use any records from visits to the accident and emergency department to determine the predictive value of the indicators of risk.


Funding: None

Conflict of interest: None


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