Recognising and responding to a sentinel injury — OSCE

Candidate instructions (8-minute station)

You are the paediatric registrar. A 3-month-old infant has been brought to the emergency department by the mother with a small bruise on the ear and a small bruise over the cheek, attributed to a feed-bottle knock. The infant, who does not yet roll, is alert and well. Your colleague was about to discharge the family. [8]

Your tasks are: [8]

1. Recognise the presentation as a sentinel injury and explain, to the mother, why you are concerned — in plain, non-accusatory language. [8]
2. Outline the plan you will run (examination, body map and photographs, a skeletal survey and a blood test, involving the child-protection team and a report to child protection) and why these happen now rather than later. [9] [2]
3. Respond to the mother's likely distress, anger and fear, using a trauma-informed, child-centred stance. [2]

You are not expected to confront or accuse the mother, nor to disclose suspicions of a specific perpetrator. [2]

Examiner prompt to the actor (mother)

"I am worried and a bit angry. The other doctor said it was fine. Are you saying I hurt my baby? Will you take my baby away? Why do you need X-rays for a tiny bruise?" [9]

Marking domains

• Recognition (3): identifies the sentinel injury; knows a bruise in a non-mobile infant is never 'normal'; applies the TEN-4-FBCP reasoning (ear and cheek bruising in an infant is positive). [7] [8]
• Communication (4): explains the concern and the plan in plain language without accusing a parent; acknowledges the mother's distress; keeps the child's safety as the explicit frame; avoids confrontation of a specific person. [2]
• Plan (3): names the parallel bundle — trauma-informed top-to-toe examination with a body map and photographs, skeletal survey with dedicated views and a coagulation screen, child-protection team involvement, and a mandatory report now, not after certainty. [9] [2]

Model answer — the explanatory script

"Thank you for bringing your baby in. The bruises are small, and your baby is well, which is reassuring for today. But I am concerned, and I want to be honest with you about why. A baby of three months who is not yet rolling cannot easily bruise their own ear or cheek, and a feed-bottle knock does not usually cause that pattern. We call an injury like this in a baby who is not yet mobile a sentinel injury, and it means we need to look carefully rather than assume it is nothing — because in some babies it is the first sign of a problem, and we do not want to miss that." [8]

"Here is what I would like to do, and why. I would examine your baby from head to toe, measure and photograph the bruises on a body map so we have a careful record, and take a small blood test to check the clotting. I would also arrange a set of X-rays called a skeletal survey to look for any other marks or healing we cannot see. I will involve our child-protection team, who are experienced in this, and I will make a report to child protection — this is something I do whenever I have a concern like this, to make sure your baby is safe. I am not saying you have done anything wrong; my job, and the team's job, is to make sure your baby is protected. None of this waits — we do it now, while your baby is here and well." [9] [2]