A RCPCH START station on MedMock, start to finish

You have had four minutes to read the scenario. As the consultant paediatrician on call, what is your assessment of Leo’s presentation and your immediate priorities?

This five-month-old non-mobile infant has three highly concerning injuries—an acute spiral humeral fracture, bruising to the pinna and a torn upper labial frenulum—that are incompatible with the reported mechanism of a simple roll off a sofa onto carpet. A spiral humeral fracture requires a twisting torsional force, and ear bruising and a frenulum tear in a non-mobile infant are sentinel injuries strongly suggestive of physical abuse. My immediate priorities are first, Leo’s clinical care and analgesia—immobilising the left arm in a collar-and-cuff or splint, giving appropriate analgesia and admitting him to the paediatric ward as a place of safety—and second, initiating urgent statutory child protection procedures for both Leo and his two-year-old sister at home.

How will you speak with the mother and her partner tonight, and what if they ask to take Leo home once his arm is splinted?

I will see Leo and speak to the mother and her partner myself alongside the registrar and a paediatric nurse, recording verbatim who gives the history and checking parental responsibility. I will be open and honest without being accusatory: I will explain that Leo has a broken arm and bruises that need hospital admission for pain relief, further medical investigations to look for any underlying bone or bleeding vulnerability and to check he has no other hidden injuries, and that whenever a baby of five months has a fracture and bruising, hospital policy and national law require us to involve the children’s social care safeguarding team. If they refuse admission or attempt to remove Leo, I will try to de-escalate calmly, involve hospital security, and call the police immediately to exercise Police Protection powers under Section 46 of the Children Act 1989 (up to 72 hours) while Children’s Social Care apply for an Emergency Protection Order under Section 44.

What medical investigations are required for a five-month-old infant with suspected physical abuse?

In a child under one year with suspected physical abuse, RCPCH and RCR Child Protection guidelines mandate a full set of occult injury and medical differential investigations. First, because he is under one year old, an urgent CT head scan today, even though he is neurologically alert, to exclude occult subdural haemorrhage or skull fracture. Second, a full RCR-standard skeletal survey in working hours with oblique rib views, followed by a repeat limited skeletal survey at 11 to 14 days to detect healing callus. Third, a formal paediatric ophthalmology examination by a consultant ophthalmologist within 24 hours using indirect ophthalmoscopy to look for retinal haemorrhages. Fourth, clinical medical photography of the pinna bruise and frenulum tear with written consent, a detailed body map, and blood tests to exclude a bleeding disorder or metabolic bone disease: full blood count, blood film, coagulation screen, von Willebrand screen, bone profile, vitamin D, parathyroid hormone, renal and liver function.

How do you manage the multi-agency safeguarding process, including the two-year-old sister currently at a neighbour’s house?

The two-year-old sister is at immediate potential risk and must be protected tonight. I will make an immediate telephone referral to the Emergency Duty Team of Children’s Social Care and the police Child Abuse Investigation Team, followed up in writing within 24 hours, and check the Child Protection Information Sharing system, midwifery, health visitor and GP records. Through an urgent Section 47 Strategy Discussion under Working Together to Safeguard Children, we will agree immediate safety arrangements for the two-year-old sister—including bringing her into the hospital tonight for a child protection medical examination—and agree supervised contact arrangements on the ward for Leo. I will also brief the Named Doctor for Safeguarding Children first thing in the morning and ensure contemporaneous, factual notes signed and dated by me.

Thank you. That is the end of the station.