ObjectiveEvaluate the quality of the medical opinion and risk analysis in reports of child protection medicals undertaken by paediatricians.MethodsAll child protection medical reports for examinations undertaken (Acute admissions and NAI Clinic), between 1st Jan and 31st Mar 2015, were reviewed (n=86) and assessed against the following quality criterion: Does the report conclude whether it is thought that the injury is accidental or non-accidental?Is there a clear conclusion with a clear statement of the level of concern regarding the risk to the child/young person?Are the presence/absence of additional concerns documented clearly?Was the report subject to peer review? Outcomes11% of the initial proformas did not make a judgment as to whether the injury was felt to be accidental, non-accidental or unclear. A further 29% were recorded as unclear. In the final written reports, 8% did not give a clear conclusion and 10% did not document clearly the presence/absence of additional concerns. 21% of reports were subject to peer review within 2 weeks and 33% within 3 weeks.ConclusionThis quality improvement audit shows that in more than a third of cases the initial conclusion of a child protection medical report is unclear or not documented. There was great clarity in the final written reports however standards regarding peer review and documentation of additional concerns were not met. It is important when writing child protection medical reports that they give a clear conclusion as to whether on balance of probability, the injury is more likely to be accidental or non accidental. Additional concerns should be documented and a risk analysis formulated. Subsequently, a new guideline has been developed on best practice for child protection medical reports, with specific guidance on terminology, impact statements and formulating a risk analysis.

other names eg. 'blackout', 'five-minutes-in-heaven and 'space monkey'. Participants are usually adolescentsa North American study found 68% had heard of the game, 45% knew somebody who played it, 6.6% had tried it and 40% perceived no risk, although this is difficult to quantify. Warning signs include marks on neck, headaches, bloodshot eyes, changes in personality. Social networking sites have enabled millions to watch videos of the choking game, which may normalise the behaviour. Most bunk beds are made using metal tubes or timbers, their design enabling easy attachment of ligatures. Conclusion Adolescents must be made aware of the dangers of this activity and parents and professionals need to recognise the warning signs. There is the potential for bunk beds to be designed to eliminate anchoring points for ligatures.

Aims Over time, demand for paediatric intensive care beds is rising inexorably.1 Most units, operating close to capacity, balance the needs of planned admissions with emergencies. Following cardiothoracic surgery, most children require a period of intensive care. Unplanned admissions may mean a bed is not available and in these cases the operation is often cancelled at short notice, causing significant distress for patients and families. In our institution, ongoing audit showed that around 6 operations were cancelled on the day every month due to lack of capacity in cardiac intensive care. Our aim was to reduce this number by 30%. Methods Following observation and process mapping, the daily planning meeting for staff members from cardiothoracic wards and sub-specialities was selected as the setting for the initial intervention. The primary outcome measure was numbers of, and reasons for, same-day cardiac surgery cancellations and was plotted on a SPC (statistical process control) chart. Results A system of creating a list of all potential admissions (elective and emergency) on a board at the meeting was developed and refined through several Plan-Do-Study-Act (PDSA) cycles. For the four months after the new system was introduced, the number of patients cancelled on the day of operation due to capacity in cardiac intensive care was reduced to a mean of 2.2 per month from 6.1 at baseline (65% reduction). Conclusion Even in the most complex systems, a straightforward low cost idea can deliver a measurable improvement. This simple change created a shared visual resource, promoting more effective multidisciplinary communication and discussion and allowed better balancing of elective and emergency admissions according to priority. When bed availability for the following day was threatened, this information sharing enabled the team either to make alternative arrangements to allow surgery to proceed, or at worst re-book with more notice. As a result, same-day cancellations of cardiac surgery were reduced by almost two thirds allowing the department to better predict their case-load and improving the experience for children and families. Reference Paediatric Intensive Care Audit Network Annual Report 2010–2012 (published September 2013): Universities of Leeds and Leicester.

Aims Abusive head trauma (AHT) is one of the leading causes of death in children. In infants with serious head injury, the high prevalence of non-accidental causes mandates a systematic and thorough approach to its investigation.(1,2) We aimed to study adherence to our hospital protocol and reviewed reasons for any deviation. Methods A multi-source search strategy identified all children admitted to our tertiary paediatric intensive care unit (PICU) between 2011 and 2012 with head injury or abnormal cranial imaging. Those with identified causes were excluded. A retrospective review of the remaining eligible case notes was carried out. Interdisciplinary discussion and analysis of results was then undertaken. Results 33 case records were identified; 24 sets of paper notes and 9 with electronic records. For 15 children, all aged <12 months, the working diagnosis on admission was AHT (no history or reported assault); 9 had alternative explanations for head trauma. 32 survived to discharge. Audit standard Adherence to protocol (%) All admissions Suspected AHT at presentation Social work team informed 92.0 100 Safeguarding documentation in notes 58.3 77.8 Consultant neurologist to see child by the beginning of the next working day 54.2 100 Ophthalmologist examined by 48 h 72.0 90.0 External CT reported by neuroradiologist by next working day 66.7 58.3 MRI by end of day 4 33.3 60.0 Plan for skeletal survey documented 64.0 70.0 Haematological investigations complete 27.3 53.3 Biochemical investigations complete 24.2 40.0 Conclusions Overall adherence to the protocol was poor, and this was consistent with two previous hospital audits (in 2006 and 2009). Subsequent interdisciplinary discussion has identified disagreement about appropriateness of some parts of the protocol – these are being revised to ensure multi-speciality agreement. Other important modifiable factors identified included accessibility and knowledge of the protocol, clarity of wording and layout and practical difficulties in implementation. Technological and process-based solutions have been introduced, and a re-audit is planned. Making a hospital-wide change in practice requires more than just a new guideline – it needs widespread ongoing consultation with stakeholders and a continuous evaluation of processes to ensure achievement of the original objectives. References Jayawant S, Rawlinson A, Gibbon F, Price J, Schulte J, Sharples P, et al. Subdural haemorrhages in infants: population based study. BMJ 1998 Dec 5;317(7172):1558–61 Child Protection Companion 2nd edition. London : RCPCH; 2013