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Think laterally!
  1. I Bagchi
  1. Walsall Manor Hospital, UK;

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I wish to emphasise the importance of thinking laterally while looking at skin marks in at-risk children in the setting of a child protection medical, especially under the present medicopolitical climate where paediatricians are being blamed for “doing too little” and “doing too much”.

I was asked to see a 6 year old child with learning disabilities for a child protection medical by Social Services. He was under a care order because of issues regarding neglect. He was, however, living unsupervised with his parents.

The alarm was raised by his school teacher who noted a large red mark on the back of his neck and shoulder for which apparently he could not give a logical explanation.

On examination he indeed had a geographical area of redness on his skin from the back of his neck down to the right armpit. There were drip marks. I did not get a coherent explanation for the mark from the little boy. I initially interviewed him without his parents being present on Social Services’ request. However, because of the child’s obvious learning difficulties I asked mum to come in towards the end of the interview and went through the history with her. She denied all knowledge of him having sustained an injury in the last few days.

I tried to wash off the skin mark with water and tissue, in front of the mother and the social worker, with no effect.

I therefore told mum and the social worker that I was not sure as to the origin of the mark. It did not have any characteristics of any particular injury nor was it something that could be washed off. I told them that I needed to observe him overnight to see if it evolved into anything (there was a significant amount of pressure from the social worker not to let him go home that night as well).

I documented my thoughts in the notes very clearly and never suggested that I suspected non-accidental injury.

The next morning the entire skin discolouration washed off with soap and a scrub! Mum was extremely upset with the whole situation and wanted to talk to me. She at that point disclosed that he was drinking a soft drink called “Vimto” which was quite dark red in colour. She was also upset that we had kept him in on suspicion of “abuse”.

I was able to placate her by reading out my documentation that clearly said that I was not sure of the origin of the mark and I could not draw any firm conclusions from it.

This just highlights the sort of pressures that can be brought to bear from various quarters on a consultant paediatrician dealing with child protection medicals. It also highlights the need for us to be vigilant about simple things which can give rise to very suspicious looking skin marks. And lastly, perhaps most importantly, it highlights the extreme importance of honest, clear, unequivocal, contemporaneous notes, as this is what stopped this situation from becoming a risk management and complaint issue.