Diagnosis of skull fracture
15. Mr H complains the Alder Hey and Sunderland Trust misdiagnosed a skull fracture leading to a safeguarding referral and his son being taken into care for six months.
16. Mr H’s complaint and the imaging in question has already undergone reviews by four separate teams of radiologists, three of which were specialist paediatric radiologists. There are mixed opinion of what the images reflect.
17. Mr H says this shows there is no certainty as to the diagnosis. Therefore, the Trust were wrong to rush the family into safeguarding procedures which have such serious consequences, on the basis of an unclear cause and diagnosis.
18. Mr H says the fact the determination of whether to refer to safeguarding is down to an interpretation, which can clearly differ between several clinicians, is wrong.
19. Mr H says it has since been revealed the diagnosis was incorrect. He says the Trust has still not taken full accountability for the misdiagnosis.
20. Of the three specialist imaging reviews, only the court appointed radiologist outlined some doubt as to the existence of a fracture. They explained the burden of proof was not sufficient to say there was a fracture on the balance of probabilities.
21. Within their report prepared for the court, the radiologist outlined four possible causes of the imaging appearance; two fractures, two accessory sutures (developmental abnormalities in the skull that can look like fractures), a right accessory suture and a left-sided fracture or a left accessory suture and a right-sided fracture. The radiologist stated they were ‘unable to advise that one diagnostic possibility is more likely than the alternative’.
22. The court appointed radiologist also stated ‘clinically, the findings would be concerning for a skull fracture, and the threshold for calling a fracture must be low since a skull fracture is a significant abnormality. I therefore would not criticise the interpretations made by the local treating clinicians in respect of the skull.’… ‘However, in the medico-legal setting, a justified clinico-radiological suspicion of a fracture does not equate to proof that a fracture more likely than not is truly present’.
23. As such, the radiologist who has thrown doubt over the existence of the fracture, has in fact explained he agrees with the approach taken by the treating Trust. However, for the setting in which he was asked to provide his opinion, he did not believe the threshold had been met. Therefore, out of the three paediatric radiologists who reviewed the images, all three agree that proceeding on the basis of a suspected fracture was appropriate.
24. The Ombudsman investigates by balancing evidence and making decisions on the balance of probabilities, that is to say that something is more likely than not to have occurred. As it stands, there are three paediatric radiologists who explain the scan shows a skull fracture. Even if the Ombudsman were to obtain advice from a fourth paediatric radiologist who then contradicted the view of the three other experts, the majority of expert opinions would still be that a skull fracture was the appropriate diagnosis.
25. Any further work by us would therefore not result in us being able to identify clear failings on the part of the Trusts involved. For this reason, we will decline to investigate this part of Mr H’s complaint.
Safeguarding referral
26. Mr H complains Sunderland Trust enacted safeguarding procedures following confirmation from Alder Hey that a CT scan showed his son had a skull fracture.
27. We have reviewed Mr H’s sons medical records with the help of our paediatrician adviser.
28. The Child Protection Companion is national guidance which guides the paediatrician through the child protection process from examination to identification to referral. Chapter nine: recognition of physical abuse states, ‘features that raise suspicion of physical abuse include:
• a significant injury when there is no explanation • an explanation that does not fit the pattern on the injury seen • infants who are not independently mobile rarely have accidental injuries • multiple explanations proposed that do not fit the mechanism seen • history of inappropriate child response (e.g. didn’t cry, felt no pain).’
29. Chapter 2 of The Child Protection Companion states, ‘all paediatricians have a responsibility to take appropriate action (i.e. make a referral to local authority children’s social care) when they believe a child is suffering or may be likely to suffer significant harm.’
30. The Trust’s children’s safeguarding policy states, ‘local arrangements and action is to be taken by all Trust staff where there is knowledge or suspicion that a child is suffering or is likely to suffer significant harm of physical, emotional sexual abuse/exploitation or neglect. The duty to safeguard children applies to any child who has not reached their 18th birthday.’
31. Mr H and his partner took their son to the urgent care centre for children on 25 December 2022 as he had a bump on his head. When asked how the bump happened, Mr H and his partner said they did not know as they had not witnessed any injury occur. When staff asked if they had heard their son cry out in pain Mr H and his partner said they had not heard him cry. Staff discussed with Mr H and his partner this was suspicious of a non-accidental injury without explanation and would need referring to a senior doctor.
32. Mr H’s son was transferred to a children’s ward for monitoring overnight. On 26 December a consultant paediatrician reviewed him. The consultant paediatrician had a discussion with Mr H and his partner and asked how the bump had happened. Mr H’s partner said she was always with their son and there had been no point when he was alone or had cried out. They said he had a ball pit at home and Mr H was worried he moved his hands a lot and maybe hit himself with a toy.
33. The consultant paediatrician requested an MRI scan and based on the appearance of the scan, decided further confirmation was needed to rule out a skull fracture. The consultant paediatrician recommended a CT scan.
34. Mr H and his partner were keen to go home and discharged their son against medical advice agreeing to come back to the hospital at a later date for a CT scan.
35. On 28 December Mr H and his partner brought their son back to the hospital for a CT scan. The CT scan revealed a skull fracture. The consultant paediatrician sought a specialist opinion from a paediatric radiologist at Alder Hey Children’s Hospital. The specialist paediatric radiologist confirmed the presence of a skull fracture.
36. On 29 December after a skull fracture was confirmed by Alder Hey, the consultant paediatrician started the safeguarding process. The consultant paediatrician made a verbal referral to children’s services advising they had identified a skull fracture without a plausible explanation.
37. The consultant paediatrician noted Mr H had suggested his son hit himself on the head when playing with wooden toys. The consultant paediatrician did not think this was likely and asked Mr H to bring the toys to the hospital so he could see them.
38. On 29 December, Mr H brought the toys into the hospital, and the consultant paediatrician looked at them and considered Mr H’s explanation. The paediatrician noted the toys would not produce sufficient force to fracture a skull and therefore ruled this out as a possible cause.
39. On 30 December, Mr H’s partner told the consultant paediatrician she remembered she had been bathing their son in the sink at 10pm on 24 December and he had slipped and likely banged his head on the hard worksurface. She added he had cried for five to ten minutes. The paediatrician noted he was amazed she was only just recalling this event after 5 days and after many opportunities since 25 December to tell staff this.
40. We have seen evidence the consultant paediatrician raised a safeguarding concern due to the presence of four out of five of the features which raise suspicion (as detailed in the Child Protection Companion). A skull fracture with no explanation, lack of plausible explanation, an infant who is not independently mobile and so an accidental injury would be rare and reports by his parents their son did not cry or show any pain.
41. We are satisfied the Trust followed the correct safeguarding procedures in accordance with guidance from the Child Protection Companion and its own Children’s Safeguarding policy. We note that effective safeguarding relies on organisations and individual clinicians being confident to refer concerns to the appropriate authority despite the challenges entailed. Being reticent or overly cautious could mean valid concerns about a child are not acted upon. The Trust had an overriding responsibility to keep Mr H’s son safe and promote his welfare. Having carefully considered all the circumstances, we have seen no indication of a failing here and will take no further action.
42. We were very sorry to learn about the experience Mr H and his family have been through. Our decision is not made without recognition of the impact these events had on them all.