P3.B036: Slipping Through the Cracks: Reporting Sentinel Injuries Is Not Always Enough

Introduction: A sentinel injury is a minor trauma that is often a precursor to more severe injuries from child physical abuse. Many institutions have protocols in place to catch sentinel injuries and trigger proper safety measures before more severe, inflicted trauma can occur. Sometimes, though, even when sentinel injuries are identified and reported to child protective services (CPS), children with suspected child physical abuse slip through the cracks until significant damage has occurred.

Case Description: Our patient is a 4-year-old girl, previously healthy, with good follow up in our primary care clinic, who presented to the emergency department in May 2023 for dysuria, found to have numerous unexplained bruises. Patient had bruises to her inguinal region, legs, arms, and back, with a torn upper frenulum. MOP disclosed prior CPS involvement, when it was recommended that patient stay with FOP instead of MOP. Social work was consulted, a report was made to CPS, and patient was discharged with safety plan to stay with maternal grandmother.
August 2023 patient presented with bruises to her lower back, right labia majora, left mons pubis, left outer thigh, right inner thigh, and a missing right 4th fingernail. Report was that patient fell out of her bottom bunk bed onto a toy. Social work was consulted and a report made to CPS. Patient was admitted briefly for IV hydration due to elevated CK, then discharged with plan to stay with MOP with no contact with FOP. CPS stated they would follow up with MOP closely.
October 2023 patient presented as a level 1 trauma with scattered burns (abdomen, perineum, forearm, fingers, legs, ear, tongue, lips, nares), wounds (axilla), and bruising after reports of a fall down stairs. During CPS interview MOP disclosed that patient was in the care of FOP despite previous safety plan arrangements. After a 10 day admission patient discharged home to a foster family. She has had routine follow up with good healing since.

Discussion: In this case, not one but two sentinel injury events were appropriately noted and reported, yet due to subsequent misses (delayed follow up, nonadherence to safety plan, etc.) patient still suffered a significant inflicted trauma. The outcome of this child demonstrates that while identifying and acting upon concerns for sentinel injuries can prevent further trauma, at times identifying and reporting is not enough. Following up with children with active CPS cases and safety plans is quite as necessary as involving CPS in the first place.

Conclusion: Identification and reporting of sentinel injuries have the potential to prevent subsequent severe, and even life-threatening, inflicted trauma, though appropriate follow up is essential to continue to ensure the safety of children at risk for child physical abuse.