Safeguarding, Non Accidental Injury, and Retinal Haemorrhages: What Medical Experts Must Understand

Retinal haemorrhages in infants and young children are among the most scrutinised findings in safeguarding and non-accidental injury (NAI) cases. Courts expect medical experts to provide clear, balanced, and evidence-based interpretation of these findings, recognising the difference between plausible accidental mechanisms and forces more consistent with abusive head trauma.

This blog is written for medical professionals, expert witnesses, and colleagues in safeguarding

. Its purpose is to support accurate, objective assessments that assist the court in its fact finding function while avoiding advocacy or overinterpretation.

1. Why Retinal Haemorrhages Carry Significant Medicolegal Weight

Retinal haemorrhages can be caused by a range of mechanisms, but not all mechanisms produce the same pattern, distribution, or severity. Ophthalmic experts are often asked to comment because:

• the retina can record the magnitude and direction of force

• certain haemorrhage patterns have high specificity for abusive head trauma

• resolution can occur within days, making early assessment crucial

• the court relies on the ophthalmologist to help distinguish accidental from non accidental causes

Medical experts must approach these cases with neutrality, clarity, and careful attention to evidence.

2. Recognising Patterns: What Experts Must Assess

When evaluating retinal haemorrhages, the expert should document and interpret:

• the layers involved (pre retinal, intra retinal, sub retinal)

• extent (posterior pole only or extending to the ora serrata)

• number (few, moderate, or too numerous to count)

• symmetry or asymmetry

• associated retinal findings such as retinoschisis or perimacular folds

• presence of optic nerve sheath haemorrhage

• other ocular or periocular injuries

These features help distinguish between high force mechanisms and low energy events.

3. Alternative Causes: What Must Be Considered

A balanced expert opinion requires active consideration of alternative explanations. These may include:

• birth related trauma (typically limited in extent and resolving quickly)

• accidental short falls (usually producing few, localised haemorrhages)

• severe coagulopathy

• raised intracranial pressure

• severe infection

• CPR (rarely produces extensive retinal haemorrhages)

Experts should be clear about whether these explanations can account for the observed pattern.

4. When the Clinical Story Does Not Match the Science

One of the most important questions for medical experts and the court is whether the reported mechanism can plausibly account for the findings.

Expert witnesses should consider:

• the force required to produce the pattern

• the biomechanical likelihood of the explanation provided

• whether the injuries are consistent with the developmental abilities of the child

• whether additional ocular or systemic injuries support or contradict the account

When discrepancies exist, the expert must explain their reasoning without making factual determinations, which remain for the court.

5. The Role of Timely Examination

Retinal haemorrhages may resolve within days. Delays in assessment can lead to:

• incomplete documentation

• lost opportunities to differentiate between patterns

• uncertainty in timing

• increased risk of contested evidence

Medical professionals and expert witnesses should emphasise the importance of early ophthalmic review in all suspected NAI cases.

6. Safeguarding Responsibilities for Clinical Teams

All clinical professionals involved in paediatric care should:

• document injuries thoroughly

• refer promptly when NAI is suspected

• ensure photographs and imaging are completed where feasible

• communicate clearly with safeguarding teams

• understand local and national escalation pathways

Ophthalmic findings rarely stand alone. They form part of a wider multidisciplinary assessment.

7. Expert Witness Responsibilities in NAI Cases

Expert witnesses must:

• remain impartial and avoid advocacy

• explain the range of possible causes

• clarify which findings are more or less consistent with each mechanism

• ensure conclusions are probability based

• reference accepted scientific evidence

• identify limitations in the available data

• avoid overstatement

The expert’s overriding duty is to the court, not the instructing party.

8. What the Court Typically Needs to Know

The court relies on ophthalmic expert evidence to answer:

• Could the described mechanism reasonably produce these injuries

• Are the findings more consistent with high force or low force trauma

• Is there evidence of repetitive or differing mechanisms

• Are there medical conditions that may mimic abusive head trauma

• What is the significance of the distribution and severity of retinal haemorrhages

• Does the temporal evolution of findings support a particular timeline

Experts must present this information in clear, structured, and neutral language.

9. The Importance of Multidisciplinary Collaboration

In NAI cases, ophthalmic evidence forms only one part of the picture. Collaboration with:

• paediatrics

• neurology

• radiology

• haematology

• forensic teams

• safeguarding specialists

is essential for accurate interpretation and robust medico-legal conclusions.

Conclusion

Retinal haemorrhages in infants and young children carry significant medicolegal implications. For medical professionals and expert witnesses, understanding the patterns, differentials, biomechanics, and clinical context is essential to providing balanced, court compliant evidence.

The expert’s role is not to determine guilt but to provide clear, objective ophthalmic insight that supports the court in reaching an informed conclusion. When approached with rigour and neutrality, ophthalmic testimony becomes an invaluable component of safeguarding justice for children.