At one week she was seen by the Community Nurse and was reported to be "thriving, contented and settling well." The parents needed to be careful over his food, medicine and health. 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.". He identified irregularity in the distal left femur in an earlier X-ray taken on 13th October 2011, but after further scans concluded that there was no fracture of the distal left femur. Full access to the cases to follow alongside with the sessions. He refused to feed and the next day Mrs Ward took him to see her GP. However, on 22nd October 2011 the parents again presented S, this time with swelling to her left arm. 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. When to refer and why Dr Rajendranath Sinha, The Newcastle upon Tyne Hospitals NHS Foundation Trust 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. 8. The x-ray of the left femur had been reported as showing no bony injury on 13 October 2011 and no obvious metaphyseal infraction. Determined to establish what was wrong they returned twice to the GP, but he was still unable to offer any diagnosis. HkBsD R#\#[(!$D(AyLgtJ%{mc8zA&+;*JV [a%4[)Er_'! I note in particular the five times when she was seen at medical appointments when she was said to be suffering fractures. Right wrist fracture, a metaphyseal (bucket-handle) fracture of the distal right radius (difficult to date). endstream endobj 38 0 obj <>stream "ag`|v#+(U)R1Vrg+1TnD G#qOQOGB[ @+v7#ibHd7X ~6?fJq*bk&~GTQH6To-,dh=>!aFd&02uGo(y GCv&_SRbc>N; ^1Qc(:*%Bl#~vczyAa;~tlvY4Y;U: e0| 34Ba7/, h!i"#>!9l^(bl1oUT (R&^I'[V.1e7'}N"e@ZAEY }^gEm1|4_I|Zj>apQvcZreu[OyTqWl({MicALn("#S' Attendance of the course includes access to the database of cases associated to this event on our server at PostDICOM. Left lower leg fracture, a metaphyseal fracture of the left tibia (shin bone) (3rd-10th October 2011). Their most recent appointment, in our records, was to DR K JOHNSON LIMITED on 2015-08-17. Karl John Johnson Radiologist Steelhouse Lane, B4 6Nh, Birmingham, England. 17. 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. 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. 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. In his report of 25 October 2011 the Consultant Paediatrician confirms that ophthalmological testing showed no evidence ocular trauma with healthy discs and no retinal haemorrhages seen. 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. With no help from outside agencies their couple mounted their own investigation into the cause of their son's injuries. 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. I note at p. 3 the following: 'Children's Services have only become involved with this family since 23rd October 2011 therefore there has been limited time to complete any thorough assessment with regards to this family. This person was born in December 1965, which was over 57 years ago. 8. Dr. Johnson is presently the Chair of theBritish Society of Paediatric Radiology. 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. 7. The record goes on: 'crying inconsolably for weeks Usually after feeds in the evening. Full access to each case with a full toolset to open, view and manipulate each case alongside the faculty but on your own screen! 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. an improved understanding of Paediatric imaging interpretation and reporting skills. Ms Baldrighi, Back to top of page I have taken account of the fact that she gave her evidence through an interpreter while having at least a working grasp of English. Only now, three years later, have the Wards managed to draw a line under the affair by forcing the name of the key expert witness to be made public. It was also noted that the parents were unsure how it had happened and there had been no recent accidents or falls. She was born in 1979. I considered that the family members have a very close bond and I did not observe any concerns regarding their attachment. 45. 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. 04. The Wards were arrested and questioned by police on suspicion of grievous bodily harm and child cruelty towards William. Dr. Johnson is presently the Chair of the British Society of Paediatric Radiology. He has a special interest in paediatric musculoskeletal disorders, in particular juvenile arthritis and non-accidental injury. Summary by Georgina Clark, barrister , Field Court Chambers ___________________IN THE WATFORD COUNTY COURTWatford County Court,Cassiobury House,11-19 Station Road,Watford,Hertfordshire WD17 1EZ.20th March 2013Before:HIS HONOUR JUDGE WRIGHTBetween:A local authorityApplicantsand. 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. It is simply not possible to know where the boundary lies. 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. Consistent with this, the father described a happy baby in the first two weeks of her life. Mrs Ward, who at the time worked as a manager for child care strategy for Cambridgeshire, told BBC One's Panorama, in a documentary to be broadcast tomorrow night: "We were absolutely shocked. 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. She took the view that the two left leg fractures (3 and 4) could have happened at the same time. Steelhouse Lane After the immunisation, the parents were advised to give her Calpol. Expert evidence from paediatric radiologist (Dr. Karl Johnson) and consultant paediatrician (Dr Russell Croft) was obtained and they were cross examined in Court. The GP's entry records "crying, excessive ? No local tenderness in leg or hip", S was x-rayed, but nothing abnormal was observed. While T was originally the subject of the local authority's applications at the outset when proceedings were issued on 27th October 2011, I made an order on 13th December 2011 returning him to the care of his parents and no continuing orders were made relating to him. 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. 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. 52. Recurrence is not in itself probative;iii. What followed next led, eventually, to the diagnosis of a fracture in S's left upper arm. All prices include VAT, Viewers will be asked to evaluate each session and will be provided with a CPD certificate upon completion "It was a nightmare which seemed to be spiralling out of control.". I have reviewed the symptoms then reported by the parents and their decision to take S back to the local hospital after seeing that her left arm was swollen and her reaction to being dressed or undressed. 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. Presentations are kept to the minimum and then you'll be into the fully featured cloud based DICOM viewer, looking at cases, feeding back your findings using our interactive tools. 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. It was only fair, in my judgment, to communicate those to the parties as soon as possible with my reasons in a primary judgment with a fuller judgment to follow to bring the period of waiting for the result to an end for the family as well as for other parties. 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. 06. Notwithstanding that, I formed the impression that she was seeking to assist the court. The note records both mother and grandmother as being present. DR KARL JOHN JOHNSON is a Consultant Radiologist from Birmingham. They could offer no explanation as to how the fractures may have happened. Formula feeding for 8-9 weeks before the test would have provided some improvement but not enough, as breastfeeding would provide none. An X ray showed a spiral fracture of the left humerus. General radiologists and senior radiology trainees Radiologists with an interest in Paediatric Radiology The content Ten sessions over two days: Head and Neck Chest Gastrointestinal Genito-urinary MSK: Non-Traumatic Inflicted Injury: Brain MSK 1: Traumatic (inc Inflicted Injury) MSK 2: Differential diagnosis Inflicted Injury: A Medico-Legal Update 05. On 19 August 2011, two days later, there is a record in the GP notes confirming a visit by the mother and father with S. She was seen by the GP. 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. Stream every session from the webinar for up to 90 days. 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. Doctors, medical appointments, hospitals, medical staff. The GP note for 20 October 2011 records "First meningitis vaccination. S's crying was attributed to colic initially and latterly to her having received her vaccination on 20th October 2011. There is no evidence of an incident of any kind suggestive or on which an inference could be drawn that either of the parents was responsible for an injury (other of course than the X-rays of the fractures). 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. I came to the conclusion that I was unable to determine the case without further specialist expert evidence. Take a look at our extensive range of Imaging courses coming up, available virtually, on-demand and in-person, in study . 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. Caroline Coady Specialty: Gastrointestinal Radiology. 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. That aspect is not mentioned. I take note also that the mother and father completed a parenting assessment. 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 Paul Humphries, Consultant Paediatric Radiologist, Great Ormond Street Hospital and University College London 12:15 MSK MRI 2 - bone marrow Dr Karl Johnson, Consultant Paediatric Radiologist, Birmingham Children's Hopsital 13:00 Lunch 14:00 Abdominal MRI - techniques, common applications and The Wards were only allowed to take William home with them when they agreed to be supervised 24 hours a day by Mr Ward's parents, who had to relocate from Devon to move into the couple's home. Wanted a review(Under 'P') Discussed with Mum and Dad possible colic will continue withInfacol and see how she gets on over next week. His research and clinical interests include the pathogenesis [.] The second section discusses the differential diagnosis of radiological features. (On examination) Crying ++. I record at this point in the narrative that an important incidental date occurred on 15 September 2011, namely the starting date when according to Dr Fairhurst, the first fracture may have occurred. The maternal grandmother denied harming S and did not accept that her daughter or son-in-law would not do the same. (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. Displaying companies where the director has shareholdings or significant control. 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. 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. hmk0^g? . I accept the submission that there is a lack of current research on the susceptibility to fracture in babies who are Vitamin D deficient. 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.' endstream endobj 35 0 obj <>/Metadata 4 0 R/Outlines 8 0 R/Pages 32 0 R/StructTreeRoot 11 0 R/Type/Catalog>> endobj 36 0 obj <>/MediaBox[0 0 595.32 841.92]/Parent 32 0 R/Resources<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 37 0 obj <>stream 20. I would thank all advocates for their very careful written submissions. 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. The Court reminded itself of the guidance in Re U: Re B (Serious injury: standard of proof) [2004] 2 FLR 263 and Re L [2011] EWCA Civ 1705 noting that where there is uncertainty in the medical and scientific evidence the Judge's appraisal and confidence in the parents is crucial. Birmingham Women's Hospital Mindelsohn Way Birmingham B15 2TG . Site map, Please rate your experience out of 5 (with 5 being the highest and 1 being the lowest), Birmingham Women's Hospital * Panorama's Please Don't Take Our Child is broadcast on BBC One tomorrow at 8.30pm. This would have involved manipulation of the legs and arms, and the conducting of other tests. As for that visit on the 22 September, the Health Visitor said that S was not distressed as far as she could recall.18. I therefore come to the conclusion that the local authority has not discharged the burden of proof on the balance of probabilities. 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