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You are an FY1 working in A&E. Han, a 6 year old girl has been brought in by her mother with a painful arm which she was reluctant to move. X ray shows a proximal humeral fracture and your consultant is concerned that this is a non-accidental injury. Please speak to mother, eliciting her ideas, concerns and expectations. This is a communication station. You will then be asked to discuss the case with the examiner.

Name: Martha Age: 27 PC: Meghan fell off her bike and landed on her left side, now it’s very swollen and she’s not moving it. There doesn’t seem to be any other problems than her arm. HPC: She fell off the bike about 6 hours ago and hasn’t been moving it since, but she hasn’t really been complaining about it, in fact she’s been quite quiet since you’ve been home from work. You’re glad she hasn’t been crying because your youngest, 1 month old Harry, hasn’t been sleeping and you don’t want him to be woken up. She’s clutching her arm and when you ask Meghan if it hurts, she just nods and doesn’t say anything. Nothing is helping, even her Elsa doll (she loves Frozen, its on in the house all the time and she wanted Harry to be called Olaf). It’s not cheering her up or making her feel better. She’s got stabilisers on her bike still You’ve not been able to teach her how to ride as you’ve been a single mum for years and have to work a lot, but your new boyfriend Jason said he’ll take her out and teach her. He’s been great at watching the kids while you’re at work, especially since it’s been half term. The fall happened while you were at work, so you didn’t see it. Jason told you about it when you got home, he says she was showing off on her bike and was going too fast and hit the curb. He says she was fine at the time, but things must have gotten worse as the day went on, because now she’s really quiet and obviously in pain. That’s why you brought her in, Jason was going out tonight so he couldn’t come with you. You haven’t noticed any other injuries, other than the usual knocks and bruises you’d expect for a kid her age. She’s a handful and that’s all part of being a kid and growing up. You think she’s maybe had a few more bruises recently, since the baby and then Jason moving in, but Jason thinks she’s just been playing a bit rougher and “showing off” to get attention because she’s jealous of the new baby. You’ve not had a good look at her recently, Jason is often the one to bath Meghan and put her to bed if you’re busy with Harry or working shifts. It’s often after bedtime when you get home. PMH: Meghan was born at term by normal delivery with no complications, and she’s fully vaccinated. She was bottle fed, and is usually a good eater now but has been a bit more picky with food and not eating as well recently. You feel this is probably because of all the changes in the house. She has eczema and very mild hayfever, but doesn’t need any medications. You put cream on her skin before bed but her eczema is usually well controlled. She has no allergies. Development: She hit all of her milestones and is a very bright little girl. She’s very playful and has lots of friends at school. She loves going to school and is doing very well in Year 1.
FH: Her dad had asthma in childhood you think, but it was never a problem for him as an adult. There’s nothing else that runs in the family and, other than being exhausted, your well in yourself. SH: At home there is you, Meghan, Harry and Jason. Jason isn’t dad to either Meghan or Harry, but you’ve known him for a while. You started a relationship about 3 months ago and he wanted to move in and help with the kids, since their dad isn’t really involved much. He moved in about a month ago and you feel very luck that someone would want to take on both you and the kids You wanted to take more time off work when you had Harry, as he’s only a month old, but you work in a care home and they’re short staffed and you need the money so you had to go back to work. Jason doesn’t work at the moment, so it’s easier and cheaper for him to watch the kids than paying for childcare, and you don’t have any relatives close by who could help. Nobody smokes in the house. Jason usually has a couple of cans of lager every night, but you don’t drink. Jason has never been aggressive towards you, and you’ve never been concerned about him or his behaviour. You’re not aware of any previous violence or run-ins with the police but it’s never come up so you’ve never asked! ICE: You weren’t worried, sometimes children go through phases especially when there’s been a big change so the new baby and Jason moving in probably explains the rough play and change in Meghan’s behaviour recently. You trust Jason and don’t think this has anything to do with him. You’re hurt and offended that anyone would dare suggest that you or him might have hurt your daughter. You’re glad he’s not with you to hear this, because he’d be furious and it’d probably drive a wedge between you if something like this happened. You don’t want social workers getting involved because you think they’ll take your kids away from you. You work all the hours you can to be a good mother and how dare anyone say you’re not and threaten to take your kids away. You just want to go home, it’s already late and you had to bring Harry with you, and it’s way past both of their bedtimes. It’s hard enough getting them into a routine as it is and this is going to disrupt everything, especially since you’re at work early tomorrow and Jason is out tonight.

The student should focus on what, why, when, how, witnesses, and social aspects of history with a non-judgemental approach. The student needs to be open and honest with mum at all times. It needs to be clear that safeguarding concerns have been raised and will have to be acted upon. They must not agree to mum taking the children home. They also must not make promises e.g. “we won’t remove the children” or “social services won’t get involved” etc. You should ask the candidate to summarise findings to you. Examples of questions and points for discussion: • What other additional history/investigations/management steps would you do initially this case? - Speak to Meghan - History from Jason or other witness if available - Baseline bloods - Ortho referral – don’t forget the fracture! • What are the concerning features in this history? - Unwitnessed injury and delayed presentation - Background of behavioural change in the child – off food, quieter • What are the risk factors for NAI/neglect in this case? - Lack of social support - Family under pressure/low income household - Difficult social circumstances • What would you do next considering your concerns? - Escalate to your consultant - Follow local safeguarding procedures – safeguarding team/lead paediatric consultant for safeguarding • What may happen next if this is a case of NAI/neglect? - Admission to ward/place of safety for both children - Safeguarding involvement and strategy meeting - Skeletal survey • What are the different types of child abuse? - Physical, emotional, sexual, neglect. - Cyberbullying • Which children are at risk of abuse/neglect?