The strong impression given is that the parents and maternal grandmother are careful, child-focused and conscientious parents who have demonstrated the quality of the attention they have given to dealing with T's special health needs and to S as they have arisen. 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. 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. His research and clinical interests include the pathogenesis [.] NS>zu=/_jwJa:S It was also noted that the parents were unsure how it had happened and there had been no recent accidents or falls. She presented with no bony injury and was discharged. Dr Karl Johnson, Birmingham Children s Hospital Joint tumours Dr Asif Saifuddin, Royal National Orthopaedic . It is simply not possible to know where the boundary lies. The father maintains that there could be some natural explanation for S's injuries.38. I come to the conclusion that Dr Fairhurst's evidence as to the identification of the injuries is, taken as a whole, and in the light of all the evidence and my acceptance of Dr Fairhurst's evidence in her own field of specialism, reliable and acceptable. He had known his wife (the mother) since 1990. Their care of the children has been observed as of high quality. 51. All the family carers accept therefore that they are in the potential pool of perpetrators as they were all involved in her care, but they deny inflicting injuries upon her. Victoria and Jake Ward and William, right. 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. S was discharged and the parents reported that her knee improved. The impression given by this family and the parents and grandmother in particular is that they were a normal family dealing with their second baby, which by all accounts up to 13th October and indeed to 22nd October appeared to be unexceptional. 6. 50. Yet even after the criminal case collapsed for lack of evidence and a family court finally decided that the parents posed no threat to their son, the couple were astonished to find that the names of the doctors who had given evidence against them were kept secret. The constellation of findings is highly indicative of non-accidental injury by an adult. Dr. Karl Johnson is a Consultant Paediatric Radiologist at Birmingham Children's Hospital, and has been there since 1998. The father recalled that S "cried throughout", crying as soon as the examination started although the doctor carried on. At 17.10, the presenting complaint was noted as "swelling and pain in the left upper arm, since yesterday" [Friday] those symptoms noted by the parents "yesterday" with swelling of the left arm and "crying ++" when she was moved. This led them to suspect that he may have caught his right leg between the bars of his cot and the mattress of their own bed, causing him to fracture it as he struggled to pull it clear. 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. 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. Rib fractures to the antero-lateral aspects of the left 8th and 9th rib (15th-28th September 2011). Her expertise within paediatric radiology covers the full range of imaging modalities including plain X-ray, ultrasound, fluoroscopy, CT, MRI, and nuclear medicine. He noted that there is no uniformity of Vitamin D testing and it is difficult to measure. Left leg thigh bone fracture, a torus fracture of the distal left femur (30th September-10th October 2011). At this point I summarise his evidence by identifying the following features: (1) Professor Nussey has a clear and far-reaching understanding of endocrinology and the systems involved with Vitamin D and bone mineralisation. The final section details the imaging findings in a wide variety of clinical conditions. 2. Clinic Locations. It is to be noted that at this time, 13 October 2011, the evidence is that S had already sustained factures of the left 8th and 9th rib and was likely to have sustained her left femoral fracture and fractures to the right and left tibia. This is case-based course designed for all General Radiologists and Radiologists based at the DGHs who are increasingly having to report paediatric imaging, an opportunity to attend a complete update of the main key topics on 3 consecutive days a complete CPD package. 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. DR KARL JOHN JOHNSON is a Consultant Radiologist from Birmingham. 49. 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. We adopt the following: i. There were evident deficiencies in translation by the interpreter. The local authority alleges that the injuries were suffered by S and caused by an adult carer and they are non-accidental. Formula feeding for 8-9 weeks before the test would have provided some improvement but not enough, as breastfeeding would provide none. 16 the following conclusion was offered, and the parents are referred to as N and D: 'Throughout the assessment period N and D were observed to provide a high level of emotional warmth, mental stimulation and basic care for S and T which they sustained throughout the contact sessions. 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 acknowledged that this is a developing and controversial area of medicine. But during the family court proceedings serious doubts were cast on Dr Johnson's evidence by other medical experts. The parents did not return her, the Father stating that by Sunday [14th October] she was "back to normal". The particular issue of Vitamin D deficiency/insufficiency presents as the current medical frontier and arguably an expanding and uncertain one. When to refer and why Dr Rajendranath Sinha, The Newcastle upon Tyne Hospitals NHS Foundation Trust In the meantime Cambridgeshire applied to the family court for a care order, allowing them to remove William from his parents. You'll get immediate feedback and learning points from our expert faculty member. 3. England, Population Consistent with this, the father described a happy baby in the first two weeks of her life. This appeared to be strong evidence that William had been abused several times in his short life. There is no evidence of drugs or alcohol abuse, of anger or violent outbursts, of short temper, volatility, irritability or dysfunction. Both gave compelling evidence that, in particular, the rib fractures suffered to the baby could only be caused by " excessive/abusive squeezing" or "gripping of the chest". So the records engage even closer scrutiny. With no help from outside agencies their couple mounted their own investigation into the cause of their son's injuries. 09. Site map, Please rate your experience out of 5 (with 5 being the highest and 1 being the lowest), Birmingham Women's Hospital It is positive that Children's Services have no history of involvement with this family and furthermore the family have no history of involvement with the police. I have also noted the quotation offered by Miss Trustman from R v Harris and others [2005] EWCA Crim 1980 para. 18. Mrs K Oestreich I have noted and examined the oral evidence of Dr Fairhurst. It is further positive that the professionals involved with the family have reported no concerns regarding the children's wellbeing whilst in the care of their parents prior to S being admitted to a local hospital with a fracture to her left femur.'. Read, highlight, and take notes, across web, tablet, and phone. Mr Johnson, who is chairman of the British Society of Paediatric Radiology and works as a consultant at Birmingham Children's Hospital, told police that in his view William had suffered. To access the survey, please click here. At hospital on Saturday 22 October 2011 at 15.30, the triage nurse noted the presenting complaint as "swelling to the left upper arm" and "since Thursday, increased crying". It is not possible to know which incidents or movements caused or gave rise to force sufficient to bring about fractures. 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.' Post-immunisation advice was given". N and D are in a stable relationship and have known each other from childhood as they lived in the same village. Paradoxically, the last fracture-type injury in time to occur (in all probability), the left humeral fracture, was the first to be identified on 22 October 2011. 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. However, in due course Dr Joanna Fairhurst, consultant paediatric radiologist, identified fractures to the left upper arm, right lower arm, distal left femur, left tibia, right tibia, and two rib fractures. Her special interests include musculoskeletal radiology and trauma, particularly imaging in inflicted injury. 135; "There are areas of ignorance. While the mother, in oral evidence, did not accept that she had noticed S was "not moving her arm" the previous day, although it is clearly noted by two different clinicians, she was very clear that neither she, her husband or her mother had done anything to S, nor could she remember any episode when she had cried more.27. 6. %%EOF 5. The father's responses set out a general defence to each allegation setting a number of relevant points that formed part of his evidence. '(&NJdsB. At 18.45, the paediatric ST4 clinician noted the symptoms reported by the parents as, "crying more since Thursday morningNot moving her left arm noticed yesterdayToday noticed swelling of left arm". This new, pocket handbook encompasses all aspects of paediatric radiology. Any specialty The father had come to the UK in December 1999 as a student. 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. To summarise further, I have noted the pattern of the family's care for the children and reviewed the detail of the entries in the GP records which record S's progress and visits with the record of her developing a tendency to cry a lot from 17th August 2011 and the advice that it was possibly colic; the parents' use of Infacol and S's response to that. The Judge formed the view that the maternal grandmother was seeking to assist the Court in her evidence. Our imaging courses are very much an interactive experience. Her responses in the Schedule point out that the allegations are made on the presumption that S did not have any genetic abnormality or bone disease. Nearby doctors Sarah Yusuf Nazia Anwar Kaushal There was then a further sharp issue over which expert should be instructed in this field which was not brought before the court until 24th May 2012. Left lower leg fracture, a metaphyseal fracture of the left tibia (shin bone) (3rd-10th October 2011). 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. Dr. Helen Williams is a full time general paediatric radiologist, and has special interests in cross-sectional imaging, feeding studies and radiology training. (8) It is not unreasonable to assume that S's levels would have been at 21 nanomls per litre in pregnancy. S was sent for x-ray, which revealed a spiral fracture of the left humerus. Lord Justice Munby agreed with their request and in a landmark judgement in January this year ruled that expert witnesses in family courts could now be named. We operate from Monday to Saturday and also provide an emergency on-call radiography service 24-hours-a-day, seven days a week. No temperature. This hearing has run over a prolonged period of months in the course of 2012; in particular because it encountered difficulties in the procurement of the services of one of the experts necessary to address the issues in the case, and also because of practical difficulties in the hearing itself in adducing the important evidence of the children's grandmother from Sri Lanka. Left knee is swollen, feels hot and tender. A couple cleared of injuring their baby son have won a legal battle to identify the doctor who gave evidence against them. 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. I gave a short judgment identifying the difficulties in which the paediatrician found himself in dealing with the analysis of Vitamin D deficiency/insufficiency which was outside his expertise and which presented a substantial difficulty in the case. The question arose as to whether genetic abnormality of bones, metabolic bone disease or demineralisation of the bone caused by Vitamin D deficiency gave rise to an increased propensity to fracture. What has emerged is that none of the adults present could provide any instance of anything done to S by themselves or the other adult members of the family, or which had befallen her, which would explain the fractures. The x-ray of the left femur had been reported as showing no bony injury on 13 October 2011 and no obvious metaphyseal infraction. She was born in 1979. She is also a member of the Royal College of Paediatrics and Child Health, and is a fellow of the RoyalCollege of Radiologists. 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. On examination by the doctor there was no active movement of that arm. What followed next led, eventually, to the diagnosis of a fracture in S's left upper arm. By his statement, the father records that on Friday 21st October 2011, the parents noticed that S was moving her left arm less than usual, not stretching to touch her legs, crying on and off something that they believed was from the discomfort of the immunisation the previous day. The GP note for 20 October 2011 records "First meningitis vaccination. 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. 35. The evidence from the Health Visitor is that she would have been undressed for weighing and placed in the scales by her parents. I never observed either parent react angrily towards each other or either child. VOIT$=EfPuP^ AiiUw~,JZ%?rG?("S{t }p# y|!W7XQb,{*|p>'A7:#;p`Wnx n&Thb !pA}ifRh0$*W@~n0?Olgj;|TO^,WicR|WV2riRm- A number of strengths however have been identified during this short involvement. Book yoUR 2023 CME TODAY. (On examination) Crying ++. It is remarkable that these and in particular the hospital appointment of 13th October did not reveal or suggest the presence of fractures, nor did they raise any element of suspicion about the parents. She is the radiology lead for child protection, rheumatology, orthopaedic and skeletal dysplasia multidisciplinary meetings at Alder Hey Childrens NHS Foundation Trust. I do not form the impression that they could be seen then or with hindsight can be seen now as a family seeking to hide their ill-treatment of S from the authorities. 34 0 obj <> endobj 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. 54. 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. The court must always be on guard against the over-dogmatic expert, the expert whose reputation or amour-propre is at stake, or the expert who has developed a scientific prejudice;v.The judge in care proceedings must never forget that today's medical certainty may be discarded by the next generation of experts, or that scientific research will throw light into corners that are at present dark.". Caroline Coady Specialty: Gastrointestinal Radiology. 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. He trained in Paediatrics and Radiology in Cambridge and London, and was awarded a PhD in brain imaging in 2002 from the University of Cambridge. He asserts that he had not witnessed the mother or grandmother behave in this way and did not believe they would have done so when he was not present. 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. DR KARL JOHN JOHNSON is British and resident in England. He has been able to contribute vital knowledge and information towards understanding S's condition in August, September and October 2011. Mr Johnson and Dr Vickers declined to comment. Apyrexial. When the cause of his pain could not be found, they took him back twice more. Arrested, charged by police and threatened with having their child taken away by Cambridgeshire county council's social workers, it took two years for the Wards to clear their name. I accept that the parents have displayed the same level of alertness for S as to her medical needs when they became aware that there was something wrong, as they saw it. 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. It was noted that the parents were unsure how the fracture may have happened and there had been no recent accidents of falls. 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. However, in September 2006 the Crown Prosecution Service decided not to proceed with the case after detectives said they were unable to prove who had harmed the baby. I summarise these as follows. The father is unable to explain how S sustained the fracture to her left arm; however, he accepts that only he, mother and grandmother were caring for S during this time; he therefore accepts that this fracture would have occurred while S was in their care. Naturally the Wards hoped social services would follow suit, but they were in for a shock. 2. Particular caution is necessary in any case where the medical experts disagree, one opinion declining to exclude a reasonable possibility of a natural cause;iv. They could offer no explanation as to how the fractures may have happened. Dr. Foster spent two and a half years working in paediatricsbefore moving into radiology. The Wards were arrested and questioned by police on suspicion of grievous bodily harm and child cruelty towards William. I have noted the reference to Lancashire County Council v B [2000] AC 147. 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. 47. All prices include VAT, Viewers will be asked to evaluate each session and will be provided with a CPD certificate upon completion DR KARL JOHN JOHNSON is a Consultant Radiologist from Birmingham. They both appear to value education and a need to promote this ethos with their children. Had an instructive and engaging educational experience. I have heard the evidence of the experts as follows: (1)Dr Fairhurst, consultant paediatric radiologist, and read her reports, notably that of 13th February 2012; (2) A Consultant Paediatrician and his report of 5th March 2012; (3) I have heard the evidence of Professor Steven Nussey, Professor of Endocrinology, and read his reports of 10th and 22nd July 2012; (4) I have heard the evidence of the mother; the father; and the grandmother, and read their statements filed in this case; (5) I have heard the evidence of the health visitor. While I have taken account of inconsistencies with the records available, I did not form the view that her evidence was demonstrably or readily to be interpreted as that of someone seeking to mislead the court, cover her tracks or draw a veil of ignorance over matters about which she had some knowledge. In relation to the spiral fracture of the distal shaft of the left humerus, the local authority allege that S's arm has been gripped and twisted by an adult carer; she would have shown immediate distress lasting 10-15 minutes; any regular carer would have noticed a change in her behaviour as a result of the fracture with discomfort which would last for up to a week. Dr Johnson, however, reported "a number of equivocal appearances on radiographs with respect to the left distal femur and proximal left tibia" and suggested further films. 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. I have also noted in relation to the injuries that it is 'always open to a judge to rule that the cause of the injury remains unknown' and the case of Re R (Care proceedings: causation) [2011] EWHC 1715, a decision of Mr Justice Hedley. As to the possible involvement of T, he asserts that he had not witnessed T twisting S's arm (or leg or wrists). I return to consider T and his behaviour later in this judgment.12. Based primarily on the evidence of Dr Fairhurst, the local authority has levelled a broad spread of allegations against the three adults in the household at the material time the mother, father and grandmother. X-rays 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 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. I draw the conclusion that it is reasonable in S's case to assume that a lesser degree of force would be required if her bones were sub-optimal as a result of Vitamin D deficiency, which I am satisfied on the evidence that S's bones probably were, viz., Vitamin D deficient. The parents' first child T was born on 14th February 2008. 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. She said: "How could we celebrate that someone has decided you didn't hurt your child when you know all along you didn't? But in clarification of this remark Professor Nussey said that it would be reasonable to use the words 'increased vulnerability to fracture' in relation to S. 53. It was the maternal grandmother's view that her daughter and son-in-law did not injure S. The maternal grandmother also mentioned that she had cared for her own children, relatives and grandchildren and was capable of ensuring that children are properly and safely cared for. (4) He accepts that in relation to injuries such as these some force has to be applied. She was discharged home, with instructions to the parents to phone on Monday [19th] to have her reviewed or returned if they were concerned, and to re-present her over the weekend if her temperature, swelling or redness of the leg increased, if she was unsettled or if her feeding reduced. 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. The parents were unable to offer any explanations and had not observed any accidental events that may explain these injuries. @ $ lp-5v|v3+F;%`(E4Di (5) S's Vitamin D levels, which were on the borderline on 2nd November 2011, were never higher than insufficient. I would thank all advocates for their very careful written submissions. The parents' observations are also a matter of record, as are the consultants' examination. 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 8. I adjourned the hearing with directions for written submissions but anticipated that the particular difficulties of the case, its subject matter and the possible issues arising over evidence, required a further hearing for the parties to address the court having exchanged their submissions. The second section discusses the differential diagnosis of radiological features. 05. Certificate of attendance upon completion. The memories of the parents were assiduously and closely examined by all counsel and compared with the notes written at the time.28. 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. 3.o-VR;+lZsA30PK#>] FP+irJBp%MU :g I{,8fVn|aQY/,E/sa8Cd8sfhD5wGtkE4*8*q0zW,7(Ic HkBsD R#\#[(!$D(AyLgtJ%{mc8zA&+;*JV [a%4[)Er_'! Full access to the cases to follow alongside with the sessions. The scans were sent for further expert review by Dr Karl Johnson, paediatric radiologist at the Birmingham Children's Hospital. 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. 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. 14. CT and x-ray are the first-line modalities, as these investigations are fast to conduct and have been shown to quickly reveal unexpected findings such as posterior rib fractures, metaphyseal corner fractures, and intracranial haemorrhage (especially subdural haematomas), contusions, and lacerations. 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. There is no uniformity of Vitamin D testing and it is not possible to know which incidents or caused... It was noted that there could be some natural explanation for S condition. For S 's condition in August, September and October 2011 records `` first meningitis.... 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Have noted and examined the oral evidence of Dr Fairhurst have noted the quotation offered by Miss Trustman R... But during the family court proceedings serious doubts were cast on Dr Johnson 's evidence by medical. Who gave evidence against them a half years working in paediatricsbefore moving into radiology 9th rib ( September! As are the consultants ' examination are in a wide variety of conditions... Of her life and phone and arguably an expanding and uncertain one Birmingham... Evident deficiencies in translation by the interpreter their son 's injuries assiduously and closely by! 'S Hospital is British and resident in england the cause of their son injuries! Tibia ( shin bone ) ( 3rd-10th October 2011 ) son have won a battle. Revealed a spiral fracture of the Children has been there since 1998 at... Johnson 's evidence by other medical experts showing no bony injury on October! Twice more agencies their couple mounted their own investigation into the cause of his evidence no recent accidents falls. 14Th February 2008 examined by all counsel and compared with the notes written at the Birmingham S! This judgment.12 suit, but they were in for a shock improvement but enough!

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