The local authority issued care proceedings on 2nd November 2011. However, I note the high level of engagement with the medical services throughout T's life and the attention and care that he needed and received, caused by his own particular medical condition. However, the father points out that there were times when S was sleeping in the bedroom; that T would leave the room where he was being supervised to get a toy or use the bathroom; and his case is that it is possible that he may have gone into the bedroom and caused S injury. On being released on bail they were immediately suspended from their jobs. The family are very close and have a loving relationship. 17. The father's evidence was that during the morning she had cried more than normal and he confirms that she was "grumpy and crying". DAY 3: INFLICTED INJURIES IN CHILDREN - FRIDAY 11 FEBRUARY 2022. "It was a nightmare which seemed to be spiralling out of control.". The other parties to the case are S's parents, who are married. On Thursday 20 October 2011 S was brought to the GP surgery by the parents and given her immunisation injections, in each thigh, by the Health Visitor. (5) S's Vitamin D levels, which were on the borderline on 2nd November 2011, were never higher than insufficient. NS>zu=/_jwJa:S It must also raise as a real possibility the potential explanation that T may have brought about one or more fractures, along with the possibility less likely, in my view that S may have been injured when the family slept together in one bed. 54. It is not possible to know which incidents or movements caused or gave rise to force sufficient to bring about fractures. an improved understanding of Paediatric imaging interpretation and reporting skills. She took the view that the two left leg fractures (3 and 4) could have happened at the same time. Torus fractures can result from a fall, from a direct blow, or from indirect forces applied to the limb when the leg is gripped and forcibly bent, a force well in excess of normal day to day handling of an infant. On the contrary, the evidence appears to demonstrate that the parents had the wellbeing of S in mind and acted to seek medical attention. Mr Johnson and Dr Vickers declined to comment. The Wards subsequently won a legal fight in the High Court for the judgement to be made public. If there is some innate contradiction in that sentence it appears that the latter part of that sentence represents the stronger conclusion. So the records engage even closer scrutiny. I derive particular assistance from his evidence and the conclusion that S had a greater vulnerability to fracture, which he described as a reasonable conclusion, and at the times when they are likely to have occurred. The x-ray of the left femur had been reported as showing no bony injury on 13 October 2011 and no obvious metaphyseal infraction. The maternal grandmother ('the grandmother') is also a party, as she was present in the family home at the material time, and has been represented by Miss Trustman. Since the medical centre was closed, they took S to the local hospital.25. So, as I review the evidence of the parents and the grandmother, it appears that there is a strong strain in the evidence that runs counter to the evidence and conclusions of Dr Fairhurst, producing by its weight and nature what I would regard as a substantial likelihood that this family would not perpetrate the sort of violence which according to the medical evidence of Dr Fairhurst and the Consultant Paediatrician must have been inflicted upon her. In the meantime Cambridgeshire applied to the family court for a care order, allowing them to remove William from his parents. On the balance of probability T could not have caused the injuries to S. 16. Aged 20 in December 1999, she had married the father just before he came to England She joined him in this country in October 2003. 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. s Pediatric Diagnostic Imaging textbook is renowned as one of the oldest and most prominent general textbooks in the field of paediatric text consists of two reasonably sized volumes covering all key areas using an intuitive systems-based approach. Whilst noting Dr Fairhurst's views as to when the fractures occurred and the windows for probability as she saw them, I have taken account of the extended period over which the fractures were identified. These are referred to in more detail in her evidence and indeed in the local authority's threshold document, and she has set out fully in her expert report to the court her opinion on the fractures she found, the dating of S's injuries, the mechanism of injury, possible explanations and her conclusions. 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. The father said in evidence that her crying was first mentioned then, although there is no entry about it in the record, but the following record in the GP Notes does suggest that the Health Visitor had "advised giving her Infacol" at this point, so it probably was raised then. There is no radiological evidence that S suffers from rickets or any other vitamin deficiency. 32. I have examined the evidence as to the appearance of the symptoms of both the leg injury and the arm injury and noted the consistency of evidence that S was holding her leg differently before the hospital visit on 13th October 2011, and a consistency as to there being something wrong with S's arm which prompted the parents to seek medical attention. Book yoUR 2023 CME TODAY. On 24th October 2011 a skeletal survey detected what appeared to be two left rib fractures. It is to be noted that the father accepts the medical evidence that S suffered each of the injuries numbered 1-6. The 30 September 2011 is the earliest date for the left femoral fracture, but Dr Fairhurst took the view that the most likely time of occurrence was between 10 October and the visit to the GP on 13 October.She also thought that the two leg fractures, i.e. (6) It is not possible to say what difference formula feeding might have provided because there is no baseline to measure from. Thank you! 34 0 obj <> endobj 6. He was earnest, straightforward and did not quibble with the questions although he did not always understand the question. 18. 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. He confirmed the presence of the humeral fractures and rib fractures and, following further X-rays, identified what he thought was a healing fracture of the proximal left tibia. 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.' Within each chapter there are three consistent sections. He was able to extrapolate that S's Vitamin D levels at birth were likely to have been markedly deficient having been Vitamin D deficient in utero. The mother refers to her own and her family's appropriate responses to noticing the abnormal characteristics of S in her left arm movement or in her discomfort with her leg as well as taking steps to address her distress and to take her for medical attention. Print this page Opportunity to submit questions by email to the faculty. 135; "There are areas of ignorance. Radiologists, Country Within each chapter there are three consistent sections. At no point did I observe either child to be wary of their parents. Clinic Locations. Right lower leg fracture, a metaphyseal fracture of the proximal right tibia (shin bone) (12th September-10th October 2011). Certificate of attendance upon completion. She moved back to London, to Great Ormond Street Hospital and the Institute of Child Health, where she obtained a PhD for her thesis, Optimisation of the digital radiographic imaging of suspected non-accidental injury, then returned to Sheffield as a HEFCE-funded Clinical Senior Lecturer in the Academic Unit of Child Health. The parents did not return her, the Father stating that by Sunday [14th October] she was "back to normal". . The local authority took action on 26th October 2011 after the Consultant Paediatrician concluded that there must be a high level of suspicion in the absence of explanation of the injury to the left arm that the humeral and left rib fractures may have been sustained as a result of a non-accidental injury. I have also noted the case of Re S-B (Children)(Care proceedings; standard of proof) [2009] UKSC 17 and particularly the passage in which their Lordships confirmed that the simple balance of probability test following the House of Lords decision in Re B (above) should be applied in finding that a person was the perpetrator of an injury, confirming the approach where the evidence falls short of that standard in North Yorkshire County Council v SA [2003] EWCA Civ 839 to the effect that an individual will be found to be a possible perpetrator if the evidence establishes a 'real possibility' that they caused the injury. Hence attendance at A&E.". He has a special interest in paediatric musculoskeletal disorders, in particular juvenile arthritis and non-accidental injury. The fractures to the right lower leg took place between 12th September and 10th October. He appeared to be frank and open in his answers and not devious. BSc, MBBS, MRCP, FRCR, PhD, FHEA I note the entry as follows: 'non-tender, baby permits passive manipulation. Her expertise within paediatric radiology covers the full range of imaging modalities including plain X-ray, ultrasound, fluoroscopy, CT, MRI, and nuclear medicine. Controversial issues, more cases and discussion, To provide the Consultant Radiologist with a practical and comprehensive case based update on the interpretation and reporting of general paed radiology, suspected inflicted injuries and challenging cases when on call, Takes delegates through an intensive series of challenging cases with immediate feedback after each case, Short introductory lectures, offering guidance, practical knowledge, what not to miss and how, Faculty of Consultant Paediatric Radiologists who are experts in their fields and from different hospitals in the UK. The record confirms the father's account that they had been advised to use Infacol, had done so and that it was not working. 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. Extensive high quality images throughout the book, and additional illustrations, aid the reader with diagnosis and detailed referencing points to further reading. The father said in oral evidence that S developed a pattern of crying after 3 to 4 weeks old, particularly in the evenings. 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. Fax 847-678-6286 Tooting whose report is at E76-E 279 and Dr. Karl Johnson, consultant paediatric radiologist at the Birmingham Children's Hospital . Dr Neil Stoodley, Consultant Neuroradiologist, Bristol Royal Hospital for Children Dr Caren Landes, Consultant Paediatric Radiologist, Alder Hey Children's Hospital, Liverpool Dr Karl Johnson, Consultant Paediatric Radiologist, Birmingham Children's Hospital Dr Sally Old, Medical Defence Union . endstream endobj 38 0 obj <>stream This company officer is, or was, associated with at least 1 company roles. There was no active movement of the left upper arm, and she cried a lot on passive movement of the left upper arm which was swollen and showed some inflammation of the left elbow.26. I have been very grateful for them in undertaking what I have to say has been a difficult task and one which has actually required very much reflection and re-examination. Steelhouse Lane This company officer is, or was, associated with at least 1 company roles. I never observed either parent react angrily towards each other or either child. British Society of Paediatric Radiology: Paediatric MRI for general radiologists - tips and tricks 16:50 - 17:10 Musculoskeletal (MSK) imaging Dr Karl Johnson, Birmingham Children's Hospital NHS Foundation Trust Learning points In the maturing child, the marrow signal will alter depending on the amount of haemopoietic and fatty tissue within it. Show number Centro mdico: Birmingham Children'S Hospital, Birmingham Do you wish to correct the information? 6. The parents' observations are also a matter of record, as are the consultants' examination. She was accompanied by both parents. 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. Dealing with the fracture to the left humerus, the father's response was that he cannot say whether or not he was present when the fracture was sustained. She weighed 6lbs 15 ozs (3.15 kg) at birth and was born by emergency Caesarean section. I have taken account of the occasions when S was seen by medical staff. Our Radiology CPD courses offer an exclusive range of clinical imaging seminars, available to support Radiologists, Cardiologists, Registrars and Radiographers from around the world in gaining CME. In the light of this observation, the involvement of local Children's Services inevitably followed and the proceedings were commenced, as I have indicated in this judgment.30. To access the survey, please click here. Their care of the children has been observed as of high quality. Three days: 375 | Two days: 295 | One day: 175 I note his evidence as to the prevalence of Vitamin D deficiency, particularly in Asian sub-groups, and his view that the absence of radiological evidence does not mean that there is 'no rickets' i.e. Mindelsohn Way Book reviewed by Sana Ali, ST5 paediatric radiology, and Dr Karl Johnson, 's Hospital. The parents' first child T was born on 14th February 2008. 55. 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. The local authority relied upon the evidence of the consultant paediatric radiologist who acknowledged what whilst there could be a Vitamin D deficiency there was little, if any, supporting evidence of fractures being caused by lower than normal Vitamin D levels where there is no evidence of rickets. Mindelsohn Way Birmingham B15 2TG 0121 472 1377 Birmingham Children's Hospital Steelhouse Lane Birmingham B4 6NH 0121 333 9999 Quick links Terms and conditions Give us your feedback Publications and reports Staff links AccessAble Freedom of Information Privacy Policy Accessibility statement Join us on social media Support us 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. She said: "How could we celebrate that someone has decided you didn't hurt your child when you know all along you didn't? Ms Baldrighi, Back to top of page He has a special interest in paediatric musculoskeletal. 07. As with the mother, that did not mean that there were no instances when they were confused or mistaken.48. 14. 36. The left tibia fracture was likely to have occurred between 3rd and 10th October and the likely time frame for the left humeral fracture was between 16th and 19th October. Dr Karl Johnson, Birmingham Children s Hospital Joint tumours Dr Asif Saifuddin, Royal National Orthopaedic . The record concludes with the GP's comment "All well. The cause of an injury or of an episode that cannot be explained scientifically remains equivocal;ii. Interactive discussions, trauma and non-trauma cases, what is relevant and significant, and take home messages that will change your reporting practice, a practical and comprehensive case based update on the interpretation and reporting of general paed radiology as well as of suspected inflicted injuries. My approach in law to this case has been assisted by the reference made by the advocates to a number of cases in their written submissions. sub-optimal bones that have not yet developed radiological signs of rickets; (6) I note that she was not in a position to give an expert opinion on metabolic bone disease which she identified as a very complex subject beyond the radiological aspect and that she would defer to a metabolic expert; (7) she accepted that the lack of evidence for fractures occurring in patients with lower than normal levels of Vitamin D (who did not have radiological evidence of rickets) is the current state of research and acknowledged that there is a need for more study to be done; she further accepted that this is a developing and controversial area of medicine; (8) I noted that it is accepted by all medical experts that it is unknown what level of force would be required to cause the injuries in a baby that had a Vitamin D deficiency or insufficiency; understandably it is not possible for experiments to be carried out. The X-ray revealed a spiral fracture of the left humerus. His claim that William had suffered four fractures on at least two occasions was contradicted by their assertion that he had only two fractures, both of which had probably been caused at the same time. The maternal grandmother denied harming S and did not accept that her daughter or son-in-law would not do the same. The main functions of MRI are as follows: a. early diagnosis of CADM and fasciitis; b. differential diagnosis with other types of myopathies, such as congenital myopathy; c. locating the site for. Dr. Robert H. Thomas is a Radiologist in Birmingham, AL. Metaphyseal fractures result from pulling and twisting being applied to the limb. An X ray showed a spiral fracture of the left humerus. (4) He accepts that in relation to injuries such as these some force has to be applied. He states that S had a tendency to cry and this was discussed with medical professionals on more than one occasion. Excellent peer interaction and collaborative learning. Prof Amaka Offiah is a Professor in Paediatric MSK Imaging at University of Sheffield, and an Honorary Consultant Paediatric Radiologist at Sheffield Children's Hospital. The Father said in evidence that when the hospital phoned on Monday morning, his wife told them that S was "fine".21. He found it was not possible to conclude at what point normal day to day handling crossed over to the point when S's vulnerable bone structure was compromised and exceeded. Her special interests include musculoskeletal radiology and trauma, particularly imaging in inflicted injury. Her research interests are in the imaging of suspected child abuse and skeletal dysplasias and in methods of determining which children have fragile bones prone to fracture and which do not. I accept that given T's reported boisterousness a heightened level of supervision would have been needed but that could not have been known by any of the family members at the time the fractures were likely to have been caused. His research and clinical interests include the pathogenesis [.] 03. Karl Johnson is a Consultant Paediatric Radiologist at Birmingham Children's Hospital, and has been there since 1998. In his second report after reviewing the outcome of the medical investigations after his original report he held to the view that there was a high suspicion for a non-accidental causation. The record goes on: 'crying inconsolably for weeks Usually after feeds in the evening. 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. Added to this was the unfortunate position of counsel for the grandmother, who was not present and who had sent a message to the court that her client's public funding certificate had been embargoed for the reasons and with the consequences set out in para. Catch-up service: Paediatric Radiology 2022, Catch-up now with our case-based Paediatric Radiology webinar that took place in February 2022. It was inevitable, that the local authority had to bring this case to court. Recurrence is not in itself probative;iii. 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. 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. With at least 1 company roles ; ii loving relationship discussed with medical professionals on more than one.. 'S comment `` All well mindelsohn Way book reviewed by Sana Ali, ST5 Paediatric radiology webinar that took between! At birth and was born by emergency Caesarean section to normal '' the,... Bail they were immediately suspended from their jobs it was inevitable, that did not quibble with the 's! 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