The first section lists common clinical presentations, the differential causes and the appropriate imaging pathways needed to confirm the diagnosis, with recent imaging advances for each condition. The burden of proof lies on the local authority and they have to satisfy the court on the balance of probabilities: see Re B (Care proceedings; standard of proof) [2008] UKHL 35. (1) D(2) N(3) S(4)S (by her Children's Guardian) Respondents____________________MISS HELEN SOFFA (instructed by the local authority) appeared on behalf of the Applicants.MR UPALI JAYATILAKA (solicitor) appeared on behalf of the Respondent Mother.MISS ALICE DESCHAMPNEUFS (instructed by solicitors) appeared on behalf of the Respondent Father.MISS JUDITH TRUSTMAN (instructed by solicitors) appeared on behalf of the Respondent Maternal Grandmother.MISS SORREL DIXON appeared on behalf of the Children's Guardian.____________________Digital Tape Transcription by:John Larking Verbatim Reporters(Verbatim Reporters and Tape Transcribers)Suite 91, Temple Chambers, 3-7 Temple AvenueLondon EC4Y 0HP.Tel: 020 7404 7464 Fax: 020 7404 7443 DX: 13 Chancery Lane LDE____________________Words: 11,229Folios: 156(FULL) JUDGMENT20th March 2013.01. The report presents what is effectively the high water mark of the extent of the injuries and the existence and extent of these injuries has not been challenged, although Miss Trustman urges the court in respect of the injuries only reported by Dr Fairhurst to approach the existence of such injuries with caution, particularly the torus fracture to the distal femur, since they were not identified by any other clinicians and their identification appears to rest on Dr Fairhurst's own expertise and experience as a consultant paediatric radiologist over 21 years. It provides an overview of how to approach the imaging of children including the relative values of each of the imaging modalities for paediatric pathology. He has a special interest in paediatric musculoskeletal disorders, in particular juvenile arthritis and non-accidental injury. This led to a referral by the consultant paediatrician from the local hospital to Social Services. I have also had the benefit of the considerable amount of documentation in the bundles to which extensive reference has been made in the course of the evidence. %PDF-1.6 % But the drama turned into a nightmare when they were accused of having deliberately harmed their little boy. Determined to establish what was wrong they returned twice to the GP, but he was still unable to offer any diagnosis. At one point, he mentioned that they had thought it was due to her immunisation that she was not using her left hand. I found Professor Nussey to be highly knowledgeable in his field; careful; and able to consider and assist the court on all matters put to him. There is no radiological evidence that S suffers from rickets or any other vitamin deficiency. Her special interests include musculoskeletal radiology and trauma, particularly imaging in inflicted injury. Akin, MD, Diagnostic Radio I have examined the process by which the fractures were discovered and that it was not until the report of Dr Fairhurst, consultant paediatric radiologist, of 13th February 2012 that the full extent of the injuries alleged to have been sustained by S were revealed and her report included three new areas of injury not seen or confirmed by earlier reports. Dr Fairhurst thinks that they may have been sustained as I set out in their approximately chronological order: 1. A number of strengths however have been identified during this short involvement. Fractures of the antero-lateral aspects of the left 8th and 9th ribs were caused by (a) a direct blow or compressive forces applied to her chest by an adult carer, (b) she would have shown distress for 10-15 minutes and shown discomfort when her chest was moved such as when she was dressed and a regular carer would know this was as a result of these fractures with discomfort lasting for a week. 135; "There are areas of ignorance. Nearby doctors Sarah Yusuf Nazia Anwar Kaushal She refers to the fact that in relation to allegation 3, 4, 5 and 6 the mother had noticed the child's discomfort and taken S to the Medical Centre and then on to the Accident and Emergency Unit at the local hospital where S was examined by a paediatrician and X-rayed, following which she was told that everything was normal and she was discharged. Over the next 10 months the Wards were visited by at least three expert witnesses who had been asked by the judge to give their opinions. That aspect is not mentioned. The father had come to the UK in December 1999 as a student. An X ray showed a spiral fracture of the left humerus. The fractures of the ribs require considerable force and well in excess of day to day handling or even rough play. Interpretation & Reporting Webinar for the General Radiologist, DAY 1: GENERAL PAEDIATRIC RADIOLOGY - WEDNESDAY 9 FEBRUARY 2022 His father described him as "very possessive" of his baby sister, trying to open her clenched fists to place toys in them, to straighten his 'folded' arms and play with her. The mother's tend to be shorter responses but amplify the general stance of the parents as well as the grandmother that while accepting that the fractures occurred and that they occurred while S was in their care they reject the allegations that they caused the injuries in a non-accidental way. . Professor Nussey reported on 10th July but in time for the resumed hearing of the matter on 25th 26th and 27th July. Gordon Jeyes, director of children's services at Cambridgeshire county council until this year, defended his department's decision to press ahead with its application to remove William from his parents' care. The Judge formed the view that the maternal grandmother was seeking to assist the Court in her evidence. This produces a complex and difficult balance in assessing the likelihood of the infliction of the harm and the injuries as invited by the local authority. She is the radiology lead for child protection, rheumatology, orthopaedic and skeletal dysplasia multidisciplinary meetings at Alder Hey Childrens NHS Foundation Trust. The court had no expert views on these aspects or on a number of potential issues relating to bone metabolism. On 17 August 2011, S was taken to the clinic at 4 weeks old to be weighed. On 22 September 2011, S is recorded as having the first of her immunisations at the Medical Centre. The guardian also represented the other child of the family T, who was born on 14th February 2008. Injuries to S could not have been caused by a person rolling onto her. On the contrary, the evidence appears to demonstrate that the parents had the wellbeing of S in mind and acted to seek medical attention. I do not propose to go through all the responses to the various fractures but what I have mentioned sets out much of the content and gist of the father's response and denials of the local authority's allegations.39. S could not have been injured when in a bouncy chair from normal use. But during the family court proceedings serious doubts were cast on Dr Johnson's evidence by other medical experts. As to the grandmother, she gave evidence by Skype from Sri Lanka and as I have earlier said her evidence was subject to unavoidable and unfortunate technical difficulties. 7. DR KARL JOHN JOHNSON is British and resident in England. Dr. Robert H. Thomas is a Radiologist in Birmingham, AL. T would often watch attentively as the parents and grandmother would feed S and hold her. The final section details the imaging findings in a wide variety of clinical conditions. The Judge formed the strong impression that the parents were careful, child focused parents who had demonstrated good quality parenting dealing with S's older sibling.The Judge took into account the evidence of an endocrinologist who opined that the absence of radiologically identifiable rickets did not mean there were no rickets. Filming William asleep at night they discovered he moved vigorously during his sleep, repeatedly kicking his legs. It is reasonable to conclude that they were lower before then because she was breastfed. Birmingham B15 2TG, Birmingham Children's Hospital (5) S's Vitamin D levels, which were on the borderline on 2nd November 2011, were never higher than insufficient. 941-697-3552. The x-ray of the left femur had been reported as showing no bony injury on 13 October 2011 and no obvious metaphyseal infraction. Angry that parents like themselves could be put through such an ordeal without being able to challenge the credibility of experts called to give evidence against them, the Wards returned to the High Court. He has extensive experience and a mature knowledge of research done in this field. As a result of her expertise she receives both regional and national referrals for review of musculoskeletal imaging from radiological and clinical colleagues with an emphasis on imaging in cases of suspected inflicted injury. After 22 September 2011, S was next seen at the GP surgery on the 13 October 2011. 34. The local authority alleges that the injuries were suffered by S and caused by an adult carer and they are non-accidental. (On examination) Crying ++. He indicated that in addition to the spiral fracture of the upper left arm, healing fractures of the left anterior 8th and 9th ribs were noted, with the amount of callus "suggesting that these fractures are not acute". A couple cleared of injuring their baby son have won a legal battle to identify the doctor who gave evidence against them. 04. 09. HkBsD R#\#[(!$D(AyLgtJ%{mc8zA&+;*JV [a%4[)Er_'! The father said in oral evidence that S developed a pattern of crying after 3 to 4 weeks old, particularly in the evenings. The GP was unable to identify the cause of William's pain, but on returning home the Wards noticed his leg was swollen. 12. This advanced Infomed webinar is in response to suggestions/feedback from many general radiologists, who have attended Infomed courses, more lately webinars, and now with the easing of the pandemic see the need for a focussed and comprehensive Paediatric Radiology CPD programme. Contents hosted on Doctuo should not be used as substitutes for professional medical advice, diagnosis or treatment. When Victoria and Jake Ward saw their baby son crying and refusing to feed, they took him to their doctor. The local authority goes on to make the following allegations which I give as numbered in the Scott Schedule: 7. The conclusions are positive. My close examination of this material has focused on the parents' accounts as well as on the evidence they have subsequently given about what they saw. On the balance of probability T could not have caused the injuries to S either by (a) jumping on the family bed whilst S was lying on it or (b) pulling her bouncy chair when she was in it. I have noted the reported reactions of T to the birth of S. I have considered S's early developmental history after her birth; also the arrival when S was about 10 days old of the maternal grandmother from Sri Lanka to help the mother look after the children. He also is an expert of considerable renown. The Judge considered that S was seen five times at medical appointments when she was said to be suffering from fractures and noted that at those appointments not only did they not reveal the fractures but nor did they raise any suspicion about the parents. She refers to the times when S was seen by the health visitor when, despite the presence of fractures, nothing untoward was seen on as she puts it 25th July 2011, 3rd August 2011, 22nd September 2011, 19th October 2011 and 20th October 2011. 35. There are a number of other features of the evidence about the parents which I must take into account as part of the 'wide canvas' of evidence that I have surveyed. I have noted the words of Butler-Sloss P in Re U: Re B (Serious injury; standard of proof) [2004] 2 FLR 263 and the court's responsibility to survey a 'wide canvas' and in Re L [2011] EWCA Civ 1705 that 'Clearly from the forensic standpoint given any degree of uncertainty in the medical and scientific field the judge's appraisal and confidence in the parent is absolutely crucial to the outcome.' (Orders made included discharge of interim Care Order and approval of revised care plan for phased return of S to the care of her parents. Father said that he was told it was likely that she would get a high temperature and her thighs might swell. He noted that there is no uniformity of Vitamin D testing and it is difficult to measure. 36. The parents/grandparent who did not inflict the injuries on each occasion to S failed to protect her. Left lower leg fracture, a metaphyseal fracture of the left tibia (shin bone) (3rd-10th October 2011). Full access to the cases to follow alongside with the sessions. Doctuo 2023 Last modification: 02-03-2023, Birmingham Children'S Hospital, Birmingham. NS>zu=/_jwJa:S The parents did not return her, the Father stating that by Sunday [14th October] she was "back to normal". With no help from outside agencies their couple mounted their own investigation into the cause of their son's injuries. Metaphyseal fracture of the proximal left tibia caused when (a) her left leg had been pulled and twisted by an adult carer; (b) any person present would be immediately aware she had suffered a significant injury with discomfort lasting several days. The father had not witnessed T hurting S nor does he believe he would harm her intentionally but believes he may not appreciate her fragility and may have caused harm accidentally. The parents were unable to offer any explanations and had not observed any accidental events that may explain these injuries. Metaphyseal fracture of the proximal right tibia caused when (a) her right leg had been pulled and twisted by an adult carer; (b) she would have shown distress for 10-15 minutes and would have shown discomfort when her leg was moved. Dr Landes is radiology trauma lead and has contributed to the Royal College of Radiologists (RCR) guidance on imaging in paediatric trauma. Take a look at our extensive range of Imaging courses coming up, available virtually, on-demand and in-person, in study . Considering all the evidence on the balance of probabilities I have come to the conclusion that the likely incidence of an increased vulnerability to fracture is the most likely cause of S's injuries. However, she was very unsettled again by 22nd October 2011 and so the parents and grandmother took her to the A&E Department at the local hospital. The scans were sent for further expert review by Dr Karl Johnson, paediatric radiologist at the Birmingham Children's Hospital. The local authority alleges that the potential perpetrators of the multiple injuries to S are the mother, father and grandmother, who were the carers of the child. I return to consider T and his behaviour later in this judgment.12. I have also noted the quotation offered by Miss Trustman from R v Harris and others [2005] EWCA Crim 1980 para. I have also noted the guidance to be derived from Re U: Re B (above) given by Butler Sloss P at paragraph 23: "In the brief summary of the submissions set out above there is a broad measure of agreement as to some of the considerations emphasised by the judgment in R v Cannings that are of direct application in care proceedings. Considering the totality of the evidence the Judge found the likely incidence of an increased vulnerability to fracture was the most likely cause of S's injuries. As to the possibility that rough handling by T might have been responsible for S's injuries, he concluded that while it would be possible he did not think it was probable. Dr Karl Johnson Consultant Paediatric Radiologist, Birmingham Dr Sabine Maguire Senior Lecturer Child Health, Cardiff Lady Margaret Wall RCR Lay Representative Dr Tim Jaspan Consultant Neuro-Radiologist, Nottingham Dr Chris Hobbs Consultant Paediatrician, Leeds Dr Neil Stoodley Consultant Neuroradiologist, Bristol I have noted the entries in the records for 19th October when S was seen at the clinic to be weighed and that 'Nothing untoward was reported' also the entry on 20th October when S was brought to the GP surgery and given her immunisation injections and reported as 'fractious and miserable but not hugely distressed.' In the course of surveying the 'wide canvas' of evidence I have reviewed the evidence of the mother, the father and the grandmother. It soon became clear that both the police and social services were relying heavily on the evidence of Dr Johnson, who said that William had suffered four fractures which had taken place on at least two or more separate occasions. 07. If S were to be found responsible he offered the view that that would imply very poor supervision of T over a period of time. Dad says that [she] has been miserable all day no temperature". Detectives removed the cot for examination. The father states that S cried more than usual and that this was reported to medical professionals on 20th October 2011 and 22nd October 2011. The other parties to the case are S's parents, who are married. Her parents returned with S on 22.10.11 with a swollen arm. I note the entry as follows: 'non-tender, baby permits passive manipulation. The report states that S: 'cried a lot last few weeksMore over last 2 weeks and then doesn't want to be fedTends to cry more in the eveningHave used Infacol under advice from the H/V but no improvement yet. To access the survey, please click here. The X-ray revealed a spiral fracture of the left humerus. A spiral fracture requires a force to cause a fracture in this way that is 'well beyond that used during normal day to day handling.' The Health Visitor produced her records in evidence and explained that on such an occasion, the parents would undress the child and lay her on the changing mat or if the baby was being weighed, on the scales. He said: "It was a clear cut case in that there was no immediate explanation and the parents were not clear how the baby had come by his injuries. All the adults appear to be normal hardworking people concerned for their children. 20. Thank you! The Court found that the medical evidence raised a substantial likelihood that the injuries were caused non accidentally and by force used by at least one of the adult members of the household. At para. She weighed 6lbs 15 ozs (3.15 kg) at birth and was born by emergency Caesarean section. While one might have looked for the possibility that in a moment of weakness or exasperation they might have snapped, or when the mother might have momentarily lost her self-control, particularly with a baby who cried persistently, that at least one fracture might have resulted, but for S to be shown with six sets of fractures, three constellations, requiring the sort of force and violence that Dr Fairhurst described, appears to be completely and demonstrably alien to the sort of people the parents and the grandmother appear to be. On 3 August 2011, S and the mother were seen at home by the Community Nurse, and the record shows that the mother had no concerns. "It was a nightmare which seemed to be spiralling out of control.". After the birth it became apparent he had a medical problem with intestinal obstructions and severe constipation, requiring a good deal of medical attention and a surgical procedure at 3 weeks. I therefore granted an adjournment so that a suitable expert could be instructed. Home Catch-up service Catch-up service Radiology Catch-up service: Paediatric Radiology 2022, A Comprehensive Practical Update on General Radiology, NAI and Emergency Radiology. He denies causing any of the injuries and in turn denies the specific causation of each injury. endstream endobj startxref Three days: 375 | Two days: 295 | One day: 175 Location Her special interests include musculoskeletal radiology and trauma, particularly imaging in inflicted injury. Her evidence was that the earliest date for the rib fractures was 15 September, the latest date being the 28 September 2011. The Consultant Paediatrician, in his report of 5 March 2012, picks up on the record that T would become annoyed when S was unable to play with him, not understanding that it was not possible. However, the medical professionals did not note any problems with S on 20th October 2011 despite Dr Fairhurst's dating of the fracture between 16th October 2011 and 19th October 2011. His research and clinical interests include the pathogenesis [.] Book reviewed by Sana Ali, ST5 paediatric radiology, and Dr Karl Johnson, 's Hospital. Right lower leg fracture, a metaphyseal fracture of the proximal right tibia (shin bone) (12th September-10th October 2011). As a student experience and a mature knowledge of research done in this field ( RCR ) on. Local authority alleges that the earliest date for the rib fractures was 15 September the. Doctuo 2023 Last modification: 02-03-2023, Birmingham Children 's Hospital this judgment.12 or on a number potential! 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