The key issue here is suspected non-accidental injury (NAI) in a vulnerable infant, combined with parental refusal of consent.

A 4-month-old with unexplained bruising is highly concerning (babies this age are non-mobile → bruising is abnormal), so this is a safeguarding emergency.

Best action:

A. Admit the baby, contact social services to arrange for court consent

Why this is correct:

• The baby may be at risk of harm, so cannot be discharged.
• Parental refusal does not override the child’s safety when abuse is suspected.
• You should:
  • Admit the child for protection and further assessment
  • Escalate to safeguarding team/social services immediately
  • If needed, obtain a court order to proceed with investigations

Why others are wrong:

• B. Emergency foster placement → Not done directly by the doctor; requires legal/social services process
• C. Discharge → Unsafe, potential ongoing harm
• D. Call police to authorise consent → Police do not give medical consent
• E. Doctor proceeds without consent → Only justified in immediate life-threatening emergencies, which this is not (yet)

Key principle:

When there is concern for child abuse and refusal of consent, the correct approach is:

Protect the child first → involve safeguarding services → use legal routes if needed

Exam Pearl Bruises
Bruising is the most common physical sign of abuse and various factors must be considered when abuse is suspected. These would include:

• age of child

• explanation of cause

• location of bruising

• pattern of bruising

The age of the child will dictate mobility; it is unusual for a baby or a nonmobile child to have bruising. Bruising is commonly seen in mobile children especially toddlers who are starting to walk. The location of bruises on the shin, knees and elbows are common in a child who is just starting to walk and are usually on the front of the body. Toddlers are likely to injure their foreheads, nose, chin or the back of their head and hence bruises in these locations are not always suspicious.

Unusual areas of bruising that should raise suspicion of abuse are ears, neck, buttocks and back of trunk. Bruises in the upper arm or thigh may represent a forceful grip with small circular ‘fingertip’ bruises evident. Bruises on sites away from bony prominences are of concern and require further assessment usually with the child in a place of safety.

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