What were the warning signs?
Thank you to the College of Registered Nurses of British Columbia for permission to adapt their case study.
Two-month-old Brandon sees a public health nurse at a child health clinic for his first immunizations. His mom reports he is fussy, spits up frequently and is difficult to feed. She mentions that she tried a different formula without success. The nurse notes that while Brandon’s weight gain is adequate and his development appropriate, the mom is concerned. The nurse advises the mom to take Brandon to see his family doctor. She also discusses strategies for managing fussiness and gives Brandon his immunizations. She arranges to follow up with the mom and Brandon in two weeks.
A follow up visit
At the next visit, the nurse notes that Brandon has a dime-sized bruise on his left cheek. The mom says Brandon’s three-year-old brother hit him with a toy. The mom also says that she and the dad find Brandon’s crying stressful. She admits that yesterday the dad became quite angry and pushed her. When the nurse questions her further, the mom states that the dad gets angry but has never threatened or hurt her. The dad loves Brandon and she’s sure he would never hurt him. They take turns with Brandon when he is crying so they each get a break. The nurse is concerned and gives the mom a domestic violence resource card. They talk about having a safe place to go. Brandon looks well and the mom seems confident. She advises the mom to more closely watch the three-year-old with the baby. She discusses strategies for managing a crying baby. Then, she 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 mom to call. She also calls the mom’s cell phone and leaves a message.
An emergency department visit
Three weeks later, the mom brings Brandon to a nearby emergency department. His mouth is bleeding. He is weighed, briefly assessed by the triage nurse and seen by the physician. Brandon’s upper frenulum is torn. The mom explains that Brandon accidentally bumped heads with the dad while feeding. The physician says this should heal with no problem. Brandon looks well – his bruise has disappeared and the mom doesn’t mention it. Because it is late on a Friday night, a social worker is not available. Brandon is discharged.
A few days later, the public health nurse tries again to follow up with Brandon and his mom. She leaves a message on the mom’s cell phone.
Back in emergency
Brandon is four months old when he arrives at the emergency department by ambulance. His mom says 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. Brandon survives but is left with permanent neurological damage.
What are your thoughts?
- What red flags should give health professionals a “reason to believe” there is a risk of abuse?
- What other questions would you have asked the mom?
- What else could have been done to help Brandon?
Your legal obligation: Early detection and reporting is critical
According to CARNA’s Practice Standards for Regulated Members, practice standard 1.2 states that regulated members are responsible and accountable for following current legislation, standards, and policies relevant to their practice. Your responsibilities and accountabilities for ensuring client safety are also stated within the Canadian Nurses Association’s Code of Ethics for Registered Nurses.
In this situation, the Child, Youth and Family Enhancement Act states that any person who has “reasonable and probable grounds” to believe that a child is being harmed or in danger of being harmed by their parent or guardian has an obligation to report it. If it is known that the child has a case worker involved, then it must be reported to the case worker; if not, it can be reported through the Child Abuse Hotline. This means that if you believe that a child has been abandoned, is being neglected, physically injured, emotionally injured or sexually abused, you need to call to have the situation assessed. You can report a concern any time during the day or night by calling the Child Abuse Hotline at 1-800-387-5437, and you will be directed accordingly. It is also important to ensure you are following your employer’s requirements related to early detection and reporting.
Disclaimer: Our case studies are fictional educational resources. While we strive to make the scenarios as realistic as possible, any resemblance to actual people or events is coincidental.