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What were the warning signs?

Case study about a nurse's legal obligation to disclose
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Two-month-old Brandon sees a public health nurse at a child health clinic for his first immunizations​​​.

His mom reports he is fussy, spits up frequently and is difficult to feed.

She mentions that she tried a different formula without success. The nurse notes that while Brandon’s weight gain is adequate and his development appropriate, the mom is concerned. The nurse advises the mom to take Brandon to see his family doctor. She also discusses strategies for managing fussiness and gives Brandon his immunizations. She arranges to follow up with the mom and Brandon in two weeks.​

A follow up visit

At the next visit, the nurse notes that Brandon has a dime-sized bruise on his left cheek. The mom says Brandon's three-year-old brother hit him with a toy. The mom also says that she and the dad find Brandon's crying stressful. She admits that yesterday the dad became quite angry and pushed her. When the nurse questions her further, the mom states that the dad gets angry but has never threatened or hurt her. The dad loves Brandon and she's sure he would never hurt him. They take turns with Brandon when he is crying so they each get a break. The nurse is concerned and gives the mom a domestic violence resource card. They talk about having a safe place to go. Brandon looks well and the mom seems confident. She advises the mom to more closely watch the three-year-old with the baby. She discusses strategies for managing a crying baby. Then she arranges a home visit in two weeks.

When the nurse arrives for the scheduled visit, no one is home. The nurse leaves her card with a note for the mom to call. She also calls the mom's cell phone and leaves a message.​

An emergency department visit

Three weeks later, the mom brings Brandon to a nearby emergency department. His mouth is bleeding. He is weighed, briefly assessed by the triage nurse and seen by the physician. Brandon's upper frenulum is torn. The mom explains that Brandon accidentally bumped heads with the dad while feeding. The physician says this should heal with no problem. Brandon looks well – his bruise has disappeared and the mom doesn't mention it. Because it is late on a Friday night, a social worker is not available. Brandon is discharged.

A few days later, the public health nurse tries again to follow up with Brandon and his mom. She leaves a message on the mom's cell phone.

Back in emergency

Brandon is four months old when he arrives at the emergency department by ambulance. His mom says she found him unresponsive and seizing earlier that morning. His condition is serious. He has severe abusive head trauma, including bilateral subdural hematomas, retinal hemorrhages and four old rib fractures of two different ages.

Brandon survives but is left with permanent neurological damage. ​

What are your thoughts?

  • What red flags should give health professionals “reason to believe” there is a risk of abuse?
  • What other questions would you have asked the mom?
  • What else could have been done to help Brandon?

Your legal obligation: Early detection and reporting is critical

If you have reason to believe a child or youth is (or is likely to be) at risk of being abused or neglected, you must promptly report your concern to a child welfare worker.

To make a report, call 1 800 663-9122 at any time of the day or night. The person who answers will make sure your concerns are directed to the right place.

If you're in doubt about whether to report, consult with someone who has experience in this area.

What does "reason to believe" mean?

Source: The BC Handbook for Action on Child Abuse and Neglect for service providers

In British Columbia, anyone with reason to believe a child has been or is likely to be abused or neglected – and the child's parent is unwilling or unable to protect them – has a legal duty to report that concern to a child welfare worker.

"Reason to believe" simply means that, based on what you have seen or information you have received, you believe a child has been or is likely to be at risk.

You do not need to be certain. It is the child welfare worker's job to determine whether abuse or neglect has occurred or is likely to occur. ​

Additional support

​There are five specialty teams across the province that offer additional support and guidance. Note that contacting them does not replace reporting to a child welfare worker.

  • Child Protection Service Unit, BC Children's Hospital, 604-875-3270

  • Health Evaluation, Assessment and Liaison (HEAL) Team, Surrey Memorial Hospital, 694-585-5634

  • Kamloops Suspected Child Abuse and Neglect Clinic, Royal Inland Hospital, 250-314-2775

  • Northern Health SCAN Clinic, Prince George, 250-565-2120

  • Vancouver Island Suspected Child Abuse and Neglect Team, Nanaimo, 250-755-7945 ​

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  • Telephone 604.736.7331 ext. 332
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  • Email practice@crnbc.ca
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