Background A&E is a critical entry point for crisis-based health visits with 1 in 6 presentations resulting from injuries, and 1 in 3 abused children presenting with fractures. The role of A&E personnel is therefore crucially impportant in identifying and initiating safeguarding measures.

Aims To analyse the incidence of fractures in children presenting to A&E with any fracture and identify those with suspected non-accidental injury (NAI).

To identify whether appropriate safeguarding measures had been followed and identify potential barriers if not.

To provide recommendations to improve safeguarding procedures.

Methods This analysis took the form of a re-audit of all children under the age of 3 years with an A&E discharge diagnosis of any fracture. Electronic case notes were reviewed along with the minutes of weekly psychosocial safeguarding meetings to ensure that all suspected cases of NAI were identified and analysed. Results of the initial audit carried out over a 6 month period in 2009 were compared to the same 6 month interval in 2014.

Standards of safeguarding procedures were taken from Benger and Pearce (2002).

Following initial audit, safeguarding procedures and education were improved with casualty card checklists and all infants being seen directly by paediatric speciality. A re-audit was undertaken to ascertain whether further improvement was necessary.

Results In 2009, 73 cases were reviewed with an incidence of suspected NAI of 1.3%. No fractures identified in children under 9 months were referred for further paediatric opinion, and there was limited documentation of consideration of NAI.

In 2014, 56 cases were identified. The safeguarding checklist was used in 57%, delay in presentation was documented in 9% and inconsistent history in 14%. 28% of cases were discussed with the paediatric team and 12.5% discussed directly with social services. 80% of fractures identified in under 9 month old children were referred for further safeguarding assessment with social services. Although further multidisciplinary follow up was carried out, no cases of NAI were identified.

Conclusions Whilst there has been improvement in documentation of safeguarding consideration and onward referral through safegarding pathways, documentation is still limited in some cases. Following presentation of these results, funding for an additional liaison health visitor was secured to review all case notes.