Lack of agreement on colour description between clinicians examining childhood bruising

Abstract

Introduction. In child protection cases clinicians are often asked to describe and age bruises. This paper looks at both intra- and inter-observer variability in the description of childhood bruising. Methods. Fifty-eight bruises on 44 children were described by three observers, the bruises were then photographed and the same observers described the bruises at a later date. The descriptions were compared and classified in terms of complete, partial, or no agreement, both between observers and between the in vivo and photographic descriptions. Results. Complete agreement on colour description between two observers in vivo occurred in 27% of descriptions in vivo and 24% of photographs. Only 31% of descriptions completely agreed with the later description of a photograph of the same bruise. Conclusions. This marked variability in colour description, severely questions the practice of estimating the age of bruises especially from clinical photographs as evidence in child protection proceedings.

Introduction

Discrepancies between physical findings and the history given by carers are hallmarks of child abuse. Clinicians may therefore be asked by child protection and law enforcement agencies, as well as the court, to comment on the age of any bruise found during the examination of a child. To do this, the clinician must relate the colour of the bruise seen to that described in a recognised sequence of colour changes.¹ Many clinicians will then use clinical photographs as part of the medical record to aid in the documentation of such injuries. Expert witnesses for the defence have only these photographs from which to give their opinion on the age of the bruise.

This study aims to identify how health professionals describe the colour of a bruise and to determine variations that may exist between the descriptions of different observers. It also examines intra-observer consistency in describing the colour of the same bruise in real life and then from a clinical photograph at a later date. Particular attention was paid to the colour yellow as the lack of yellow colouration in fresh bruises is a particularly consistent finding.[1], [2]