The law V Medicine

Another "EXPERT" bites the dust

2008-03-23T07:01:00.000-07:00

How police put their faith in the 'expert' witness who was a fraudJim Bates joined the police database of qualified witnesses and was used in dozens of serious investigations - including into child pornography and a senior Met officer. Now, after revelations that he falsified his background, the CPS is reviewing the cases he handled

Jamie Doward, home affairs editor The Observer, Sunday March 23 2008 This article appeared in the Observer on Sunday March 23 2008 on p8 of the News section. It was last updated at 00:23 on March 23 2008.

Failures in the vetting procedures used for expert witnesses have emerged after a court ruled that a computer analyst who helped train hundreds of police officers and gave evidence in scores of trials is a liar and a fraudster.

The Crown Prosecution Service is now launching a review of a number of serious cases that drew on evidence supplied by Trevor James 'Jim' Bates, 67, a former television repair man, who has been found guilty of making a false written statement claiming he had a degree in electronic engineering, and perjury.

He is to be sentenced on 11 April. A CPS spokeswoman said: 'We intend to take into account anything the judge may say when making sentence.'

Although cases cannot be reopened, Bates's conviction has prompted questions to be asked about the credibility of his evidence in many trials, including at least one rape case, and the police's role in promoting him as an expert witness.

Copies of emails obtained by The Observer show that Bates was still being invited by police to put his CV on the database of expert witnesses in June 2006 - more than two years after they had started to investigate him.

Bates and the CPS confirm he gave evidence as a defence and prosecution witness in scores of cases involving computer crime. But Bates established himself as a key defence witness in trials involving men who claimed that they had been wrongly accused of accessing child pornography websites and also used his reputation to launch attacks on the police for their handling of Operation Ore, the police investigation into British users of a Texas-based sex site that sold images and video clips of child porn. Through his company website, Bates suggested that many of the 4,000-plus men arrested in the UK for accessing the site may have been innocent.

He argued that in many cases the men's credit card details - used to make payments to the site - had been used fraudulently. 'The scale of the fraud, especially hacking, just leapt off the screen,' Bates said at the time.

He also provided defence evidence in the case brought against Detective Constable Brian Stevens, a police officer who was assigned to liaise with the families of the murdered Soham schoolgirls Holly Wells and Jessica Chapman, and who was arrested on charges of possessing child porn. The case was dropped but Stevens was later jailed for concocting an alibi to escape the porn charges.

Bates was also involved in the case of Gurpal Virdi, a Sikh police officer with the Met, who was accused in 2000 of 14 counts of sending racist letters to himself and several colleagues.

The Met alleged Virdi sent the emails to frame other officers because he was angry at being passed over for promotion. During the wide-ranging police investigation, Bates produced evidence that appeared to show that the letters, written using Microsoft Word, had been composed on Virdi's computer at his police station in Ealing, west London.

By checking the size of the letter files, Bates said he could prove when and where they were written. Bates concluded 'it was a mathematical certainty that the documents were printed at the times indicated,' according to an internal Met report into the affair.

But the conclusion - that Virdi had written and sent the letters - was wrong. It later transpired he was nowhere near his computer when the letters were written. But this emerged only after Virdi was thrown out of the Met, following what he described as a 'kangaroo court' verdict.

Virdi believes that Bates's evidence was crucial in leading the Met to draw the wrong conclusion. 'If somebody had looked at the evidence properly, the case wouldn't have gone ahead,' Virdi said. 'But because somebody said they were an expert and they had all these qualifications, people believed them.'

The former police sergeant took the Met to an employment tribunal, which found in his favour after hearing expert witness testimonies that contradicted many of Bates's claims. Virdi was reinstated in 2002, but he believes his career has been blighted by the case.

Despite the trial verdict, Bates continues to maintain his innocence. 'I've always done what I thought was the honourable thing,' he said. Bates alleged he was part of a police conspiracy to put him out of business for undermining Operation Ore. 'I know people are continuing to tell lies, and I will continue to say what I have to say because people have died and families have been ruined because of what I have now decided is police corruption. In due course the truth and the proof will be published.'

And he denied suggestions that the undermining of his credibility raised wider questions about the quality of the evidence he had given at trials. 'My expertise and impartiality have never been questioned,' Bates said. 'There has never been any question that my claim to a degree has made any difference to any case.'

But Bates should have been aware that he was breaking the law each time he took the stand. A copy of his expert witness statement declares: 'I hold a bachelor of science degree in electronic engineering', and that he makes the declaration 'knowing that, if it is tendered in evidence, I shall be liable to prosecution if I have wilfully stated in it anything which I know to be false or do not believe to be true'.

Now questions are being asked about why the police - who used Bates in numerous complex fraud trials in the Nineties and as a lecturer at its Bramshill Training College in Hampshire - failed to check his credentials and have him removed from the National Centre for Policing Excellence Expert Advisers list, the police database of expert witnesses.

Even the most cursory of investigations would have found that Bates was not the impressive-sounding expert he claimed to be on his CV. Indeed, not only did he wrongly claim to have a BSc but he also gave false information about his time in the RAF, in which he claimed to have served for five years. Instead it emerged during his trial that three years after joining the RAF in 1958 Bates was discharged from the force with 'hysterical amnesia' after being judged to have an 'inadequate personality'. He was treated in a Leicester mental hospital where he was one of the first people in the UK to receive LSD for psychiatric purposes.

Later Bates found work as a television repair man for the company that went on to become Dixons and where he quickly developed an interest in computers.

The court heard how Bates's big break came in the Seventies when he wrote an article in a computer magazine about how to tackle a new sort of virus. This attracted widespread attention in the technology world and prompted the police to approach him to be a lecturer at Bramshill.

It was to be the start of a lucrative relationship: Bates went on to sell a number of software packages to the Metropolitan Police. Today he still enjoys a close relationship with some of its senior officers who gave evidence in his support at his trial.

His spectacular fall from grace has raised worrying questions about the way the credentials of expert witnesses are verified by the police and the CPS. No one, it seems, asked to see his qualifications and instead simply took his word as a guarantee.

The scandal is the latest involving expert witnesses who have lied about their professional qualifications. In 2005 Jessica Rees, a lip-reading expert, falsely claimed to have a degree in English from Oxford University, but it transpired she had never finished the course. Gene Morrison was jailed for five years in 2007 for fraudulently passing himself off as a forensic psychologist in hundreds of court cases.

Experts now hope that, as a result of the Bates scandal, lessons will finally be learnt. 'It is critical that those who serve as expert witnesses are credible on an ethical basis and do not have any alternative agendas which may affect their independent status,' said Jim Gamble, chief executive of the Child Exploitation and Online Protection Centre, which brought the case against Bates.

'The expertise of such witnesses is something on which the court decides. However, whether or not they are witnesses of truth is a matter for us all.'

The law and how it fails the parents

2008-03-23T02:49:00.000-07:00

Dr Rodney Gilbert - never interviewed his computer never seized, yet he appears to have perverted the course of justice. More information will be posted on the internet soon - documents proving a conspiracy.

http://davidsouthallexposed.blogspot.com/2008/03/doctor-who-said-mother-killed-her-baby.html

Oh what a wicked web we weave when first we practice to deceive

2008-03-17T14:05:00.000-07:00

Print Document

24 May 2007

IPCC update into complaints against Wiltshire Police in Joshua Taylor case

The IPCC is midway through its managed investigation into a complaint against Wiltshire Police about its investigation into the death of baby Joshua Taylor, whose mother, Marianne Williams, was acquitted in court of his murder.

Joshua's grandmother complained to Wiltshire Police about the searches undertaken by police officers at the home of Marianne Williams and her partner. She also complained about the treatment Joshua received in hospital and the actions of the doctor treating his case.

IPCC commissioner Ian Bynoe said: "Wiltshire Police voluntarily referred the complaint to the IPCC on 12 November 2006. I decided that the IPCC would manage an investigation into the actions of the police officers when they searched Ms William's home.

"Wiltshire Police are carrying out this investigation under our direction and control and are themselves investigating the complaints made against the doctor. The IPCC has no jurisdiction over the medical aspects of the case.

"Six police officers have been served with a Regulation 9 notice informing them of the complaint, which is a requirement under Police regulations. This in no way implies guilt or wrong doing on the part of any officer."
In dealing with the medical aspect of the complaint Wiltshire Police are seeking an expert witness from outside Britain, following objections from the complainant to experts who were involved to some extent in the original investigation. The inquiry is therefore seeking a wholly independent medical opinion from outside the country.

- ENDS -

How the medics can get it so wrong

2008-03-09T03:02:00.000-07:00

--------------------------------------------------------------------------------

From the Los Angeles Times

Maternal care -- or harm?

A Redlands mother of four is accused of Munchausen syndrome by proxy, fabricating or inducing illnesses in her own children.

By Tracy Weber
Los Angeles Times Staff Writer

March 9, 2008

It was lunchtime at Loma Linda Academy when the social workers arrived, escorted by a deputy sheriff.

They were there to collect the Udvardi children. Amid dozens of students munching sandwiches and chips, school officials found 6-year-old Esther, then Abram, 11, and Sam, 14. They got the eldest, Matthew, 16, just as he arrived at his American Lit class.

The children were hustled one by one to a white van in the parking lot, then whisked away even before their father, the school's band teacher, knew what was happening.

Seven miles away in Redlands, the phone rang at the family's modest tract home. Leslie Udvardi found a county social worker on the line.

The woman was blunt: Leslie had been deemed a danger to her children. They would be in the state's care until a court decided differently.

Leslie said the social worker accused her of subjecting the kids to unnecessary and often painful medical treatments. In fact, child welfare officials believed Leslie was the one who was sick, with a syndrome known by a long and forbidding name: Munchausen by proxy.

Leslie had read about it. It was a TV crime drama disease, a mental illness in which a caregiver, usually a mother, fabricates illnesses in a child to gain attention.

Certainly her children had been stricken by an unusual number of ailments, almost from birth, but Leslie told the woman she'd done everything in her power to help, not hurt, them.

The social worker kept talking: Leslie could drop off clothes and books for the children.

Leslie barely registered the details. All she could think was: They've taken my kids.

Leslie hung up and dialed her husband's cellphone.

She was "screaming in a panic," Kirk Udvardi remembered. He was being accused too, she told him, of failing to protect the children from her.

For four days, Kirk said, no one would tell either parent where their children were.

Kirk said a social worker did offer him some unsolicited advice: "You're going to really need to come out strongly against your wife. If you don't come out against your wife, there's a good chance you're not going to see your kids again."

Problems from the start

Though she'd given birth four times, Leslie never felt she'd had the chance to simply "enjoy a baby."

Her first, Matthew, was besieged by illness almost from the start: rashes, respiratory infections, eye problems and difficulties absorbing food, records show. So many complaints, Leslie recalled, that his pediatrician accused her of being a bad mother. She switched doctors.

Then came Sam. He, too, was dogged by ailments. A reflux problem meant she had to feed him formula until he was 4.

In 1994, Leslie was pregnant again. She was certain that God wouldn't give her another difficult child, she said. But Abram had to be fed through a tube in his nose. Later, he suffered seizures.

Playtime had to be juggled with doctors' appointments and tests. There were asthma episodes, allergic reactions and scary moments when the boys stopped breathing in their sleep. There were oxygen tanks, special diets and detailed instructions to playmates' parents.

Leslie, a small, intense woman with thick glasses and a nervous smile, wondered what was going on. Was there something in the couple's genes that was making their kids sick? She had medical problems herself: headaches, allergies. She'd battled attention deficit disorder since college. She was sure at least one of the boys had it too.

"I tried really hard not to panic," said Leslie, now 49. But she became "hyper-alert" to the smallest symptom, looking up each one on the Internet.

When a geneticist the couple consulted saw no pattern to the family's health problems, Leslie said she couldn't believe it. "I really felt in my gut that they had to be related somehow."

But there was little time for research. Kirk, now 43, was teaching music classes at two local colleges and the academy, a Seventh-day Adventist school, while squeezing private lessons in between.

Leslie, a former high school math teacher, had to cut back on tutoring students to manage the boys' care. Money was tight.

Then came a disconcerting surprise: Leslie was pregnant again. Part of her didn't want to risk having another unhealthy child. But this one turned out to be a girl -- finally, after so many boys.

They named her Esther. They hoped she would be healthier, but by the time she was a toddler she was plagued by sleep apnea, chronic viral infections and a seizure disorder, according to medical and court records.

In some ways, the Udvardis were just like their friends and neighbors: committed to their hobbies and routines, devoted to their faith. The parents, who had converted to Seventh-day Adventism shortly after moving west from Indiana, had close friends in the tight-knit church community that revolves around Loma Linda University. The family attended services whenever they could.

They gathered for board games on Saturday nights. Matthew played saxophone. Sam excelled on the school's Mock Trial team. Abram and Esther were lively grade-schoolers.

"I thought I was normal," recalled Abram recently.

Still, Leslie said, she couldn't stop worrying about the kids, especially Esther. More and more, the little girl had headaches and cried out in the night, complaining of pain in her legs. The doctors at Loma Linda University Medical Center couldn't pinpoint a cause.

But they didn't hear her cries, Leslie recalled thinking. Leslie pushed relentlessly, at times brashly, for answers.

Finally, on an MRI scan, one doctor saw a syrinx, a fluid-filled cavity, in Esther's spinal cord. Leslie Googled "syrinx" and found that it could be caused by a congenital abnormality called a Chiari malformation, in which a small portion of brain tissue at the base of the skull bulges into the spinal canal, blocking the flow of fluid.

She began posting questions online. She discovered that Chiari could be associated with a hereditary connective-tissue disorder called Ehlers-Danlos syndrome, or EDS. Rare and potentially crippling, it is caused by defects in the genes for collagen, the structural protein in skin, organs, tendons and bones. There are several forms of the syndrome, some more damaging than others, some difficult to diagnose.

Leslie was struck by the bizarre and seemingly unconnected array of symptoms.

To Kirk, they seemed to describe the Udvardi children, reading "like a list of their problems."

Leslie began writing to Chiari and EDS experts nationwide, sending them the kids' medical records. To her relief, doctors wrote back: Yes, we see this in our patients.

Encouraged by the response of the Chiari Institute in New York, Leslie said she made plans to take Esther there for an evaluation. Treating the Chiari could mean risky spinal surgery, but Leslie worried that without expert intervention, her daughter might end up in a wheelchair.

Maybe her boys could be checked at the same time, Leslie recalled thinking, although the diagnostic tests -- controversial even among experts -- seemed frightening. The children would have to endure two days of "invasive surgical traction." To check for blockages of spinal fluid characteristic of Chiari, screws would be inserted in their temples, then attached to pulleys and cables that pulled their heads upward.

Because Esther's legs tired easily, Leslie hoped to get a prescription from Esther's pediatrician for a special-needs stroller for the trip.

She couldn't wait to share her news with the doctor: She might have an answer, at last, to her children's suffering.

Suspicious behavior

At loma linda University Medical Center, the Udvardi children's doctors were looking for answers too.

By 2005, the children had had more than 500 doctors' appointments among them, not including sleep studies and numerous other tests. Their medical records filled thick volumes.

The number of illnesses was "alarming," one geneticist later told detectives, adding that she had "never seen four children in the same family so sick."

In time, the doctors were not focusing solely on the children. They were scrutinizing their mother.

Once at the hospital, when Abram threw up after being left alone briefly with his mother, doctors tested him to see if he'd been given the vomit-inducing drug Ipecac, according to medical records. Another time the boys were screened for opiates, amphetamines and other drugs that might have produced their symptoms. Nothing showed up in any of the tests, save an ingredient in an antihistamine Abram had been prescribed for allergies.

Dr. Edward Elmendorf, the children's pediatrician, later told detectives he suspected that a vaginal discharge problem of Esther's might have been caused by Leslie "rubbing soap suds into her privates."

Leslie's behavior was suspicious, the doctors told detectives. Clearly, her children had suffered from some real disorders, including asthma, seizures and reflux problems. But other symptoms she had mentioned seemed vague or overblown.

Anxious, pushy and very smart, Leslie seized on far-fetched diagnoses and demanded tests and assessments, the doctors recalled. If one doctor didn't give her the answer she wanted, they said, she'd look for someone else.But there was never anything concrete, never an explanation for the children's tangle of illnesses or any proof that they were fabricated, according to court records.

Then in August 2005, Leslie took Esther to Elmendorf's office, insisting that Esther probably had Chiari and needed the special stroller to visit doctors in New York.

Elmendorf later told detectives that Esther showed no signs of pain or difficulty walking. He refused to "order the wheelchair for a healthy child."

An argument ensued. "That is when it hit the fan," Elmendorf told detectives in April 2006.

After Leslie left, a doctor-in-training who had been observing the visit gave a name to everyone's suspicions, scrawling into Esther's medical record: "suspected Munchausen by proxy syndrome."

Elmendorf consulted a colleague from the hospital's Children's Assessment Center, which reviews child abuse cases for the county. This mother, he said, is seeking an unnecessary surgery for her daughter that could cripple her.

Sixteen days after Esther's appointment, Elmendorf added a note to Esther's chart: "Esther has been to 3 neurosurgeons and 2 neurologists. She does not have Chiari malformation . . . but has a small syrinx that is not thought to be symptomatic. . . . Unfortunately -- I believe mother is seeking care for her children that is inappropriate and unnecessary."

That same day, he filed a child abuse complaint with the San Bernardino County Department of Children's Services. The complaint automatically was referred to the Sheriff's Department, which began an investigation.

Leslie, Elmendorf later told detectives, "needed to be stopped."

'Mom is dangerous'

In September 2005, when social worker Esmeralda Puente questioned the pediatrician, he gave a chilling assessment.

"Mom is dangerous," Elmendorf told her, according to a report Puente later filed in court. "She is using the kids for whatever means. . . . I think that the inappropriate seeking of medical care has been going on for years."

Dr. Clare Sheridan-Matney, the medical director for the Children's Assessment Center whom Elmendorf already had consulted, was appointed by the county's Department of Children's Services to determine whether the children's medical conditions were genuine. A forensic pediatrician, Sheridan-Matney was trained to recognize and evaluate child abuse and routinely testified as an expert witness.

About two months later, she reached a preliminary conclusion: Leslie, she told Puente, had "fabricated a long list of medical diagnoses for the children."

That was enough for Puente and her bosses. On Dec. 7, 2005, the children were taken from their school. Five days later, a judge placed them in the state's custody.

The case against the Munchausen mom began to build.

In interviews with social workers, doctors recounted Leslie's "belligerent" refusal to believe their diagnoses. The teachers said the kids seemed normal, not fragile or sick. In a letter, the school psychologist described how Leslie had called in September 2005, concerned that Abram was dyslexic, when testing showed reading was his strength. Longtime school nurse Merry Herrmann told detectives she'd suspected Munchausen by proxy all along.

The mother, she said, was trying "to get attention and to be able to continue to stay home and not work," according to the detectives' report.

Back in school, the kids were brought in to be interviewed by Puente, one by one. "It was a little terrifying," Matthew Udvardi recalled. "She was saying, 'Your mom is doing stuff to make you sick.' "

Dr. Sarah Roddy, a pediatric neurologist at Loma Linda, told detectives she didn't believe Esther had a Chiari malformation. The Chiari Institute, she said, was "questionable" and "will do surgery on anyone."

Meanwhile, Sheridan-Matney made her way through the volumes of medical records. "There are some examples of genuine illness for Esther," she wrote in her final report. "However, almost from birth, exaggerations and fabrications began."

The children, all basically healthy, were subjected to "many unnecessary and often painful medical tests, procedures and treatments," Sheridan-Matney wrote.

Leslie, she said, "has a compelling need to see her children in the sick role, and no amount of normal studies or normal reporting will convince her otherwise."

"In my opinion," Sheridan-Matney concluded, "no medical decision should be made on these children based on symptoms described by Mrs. Udvardi."

'Hard to trust anyone'

"I was terrified, completely terrified," Matthew Udvardi said of the day he joined his younger siblings in the white van. Esther was in the corner, crying.

She and Abram, the two youngest, were taken to one foster home, Matthew and Sam to another.

The older boys' foster parents spoke mostly Spanish, and no one would discuss what was going to happen to them.

"Oh, God, what if they take us away from my parents permanently?'" Matthew, now 18, recalled thinking.

As far back as Matthew could remember, he and his siblings had seemed to have more health problems than most kids. But he'd never felt there was anything wrong with his family, including his mother. His ailments -- depression, food allergies -- were real. "I can feel the things happening to me," he said.

Now the social workers were telling him that his mother made it up.

"They were trying to get me to say that my mom wanted to cut into Esther's spine," said Sam Udvardi, now 16. "It was hard to trust anyone at that point."

At home, Leslie and Kirk said, they were panicked. At one point, Kirk said, he wondered if he shouldn't just say Leslie was guilty, then recant once they got the kids back.

The day after the children were removed from school, Kirk broke down in band class when he saw Abram's empty chair in the second row.

Days later, at the first dependency court hearing, the judge allowed the kids to return home, on one condition: Leslie had to move out. She moved in with a friend, sleeping in a bunk bed in her family room.

She sensed suspicious looks from neighbors, even friends. "There's nothing else that could be worse than to be accused of being a mother hurting your child," Leslie said.

For much of the next five months, Leslie was limited to one two-hour visit with her kids each week, monitored by a social worker. She missed Abram's first concert, Matthew's solo at the talent show, Esther's choir performance.

Though Matthew and Sam were teenagers, Kirk felt he could never leave the children even to run to the market, he said. "I was terrified to leave the kids by themselves, that DCS would come by." He barely saw Leslie but said his faith in her innocence never wavered.

To preserve their options, the couple hired separate attorneys, borrowing money to pay them.

"We kept looking at the records and saying there's nothing to this," Kirk said. "Then each court hearing got worse."

At one point, even Leslie's parents thought she should find a way to settle. "They admitted they felt I could be a little aggressive," Leslie said. Her sister and a brother revealed suspicions that the allegation might be true.

"I can be a little obsessive . . . hyper-focused," Leslie acknowledged later. "On the surface, I look like a Munchausen's mom. I went on the Internet and read it and saw it and said, 'Well, that could be me.' "

But it wasn't, she said.

Turning to a stranger

Through people she met on the Internet, Leslie learned of a national EDS expert whose resume ran 33 pages.

"Now I am really afraid," she wrote in a January 2006 e-mail to Dr. Clair Francomano, an associate professor at Johns Hopkins University School of Medicine in Baltimore and director of adult genetics at the Harvey Institute for Human Genetics.

"It looks like they are going to try and prove that I have been poisoning the kids to elicit their symptom. With that comes criminal charges which will be more difficult to prove but I guess circumstantial evidence is all they need to take permanent custody of the kids."

Leslie pleaded for help, thrusting her family's fate into the hands of this busy stranger.

Francomano, who had never testified in a dependency court case before, was intrigued. She agreed to take this one on. The kids couldn't fly out to see her, but she reviewed volumes of their medical records, a task that would eventually take hundreds of hours, much of it at no charge. She also agreed to examine Leslie and her brother, who exhibited many symptoms of EDS.

"I have to say, this is extremely Kafka-esque, and, of course it is very frightening," Francomano wrote in an e-mail to Leslie on Jan. 25.

"I felt like this family's life was at stake," Francomano recalled later.

A judge's dissection

On a sweltering afternoon in June 2006, the Udvardis, her parents, social worker Puente and five attorneys filed into a San Bernardino courtroom. Today, the judge would render his decision.

For 2 1/2 weeks, the couplehad held hands in court as their parenting choices were scrutinized and debated. The kids didn't attend. Kirk wasn't allowed even to talk to them about it.

The Department of Children's Services had dropped the Munchausen by proxy allegation, but that was more of a technicality than a victory for the couple. It relieved the agency of the obligation to prove that Leslie had purposely made her kids ill. She remained accused of falsely reporting medical conditions in search of needless treatments. Kirk still was alleged to have failed to protect the children.

Now, the Udvardis' hopes rose and fell as Judge David Cohn spent nearly three hours dissecting the case.

He acknowledged that Leslie had a tendency "to take a seed of worry and grow it into a massive tree."

He confessed that he found the testimony of Dr. Paolo Bolognese of the Chiari Institute frightening.

"We're here today because everybody who has looked at this case is scared to death about what's going to happen to Esther at the Chiari Institute in New York . . . " Cohn said. "Screws inserted into the child's skull, the child basically suspended with a series of weights. It sounds like something devised by . . . Tomás Torquemada of the Spanish Inquisition."

But, he said, just because Leslie believed in a rare illness, chose an aggressive physician or even sought potentially hurtful or dangerous procedures, was that any reason to take her children away?

In the end, the judge said, the fate of the Udvardi family hung on the testimony of two experts: Sheridan-Matney, San Bernardino County's preeminent child abuse expert, and Francomano, a distinguished East Coast geneticist and researcher.

Sheridan-Matney had spent days cataloging the occasions Leslie had made up or exaggerated illnesses for her children, painting a picture of an attention-mongering mother.

Francomano had spent days countering each assertion, pointing again and again to evidence of actual illness in the children's medical records.

The geneticist testified that many of the children's conditions could be attributed to a form of EDS that she called "EDS-plus," an unusual constellation of ailments that she saidLeslie and her brother also had. (Kirk did not have the disorder.)

As the judge's analysis wound down, the Udvardis could barely stand the suspense. Would the family be ripped apart?

Then Cohn said the words they'd dreamed of:Sheridan-Matney's opinions were "worthless."

"Either Dr. Sheridan's review of these records . . . was careless, or she has an agenda that caused her to disregard intentionally those records which undermine her conclusions," Cohn said.

The Udvardis, Cohn said, were "honest, forthright and believable." Leslie clearly "does not want to harm her children."

Yes, she allowed terror to cloud her understanding of what doctors were telling her. And, yes, she disregarded the opinions of some well-qualified doctors in favor of others who shared her mind-set.

But in the end, he said, none of that mattered. Francomano delivered "a bona fide medical explanation for what happened with this family," Cohn said. "She's not paid to give some opinion to the highest bidder. This is a world-class scientist, and her opinion corroborates the testimony of Mrs. Udvardi and Mr. Udvardi."

The evidence, he concluded, "does not support a finding that these are severely damaged children, let alone a finding that their parents caused it."

A taint -- and no apology

At home, there was a tearful, almost giddy reunion. It was over, family members recalled thinking.

In the months that followed, they realized it wasn't.

The judge's ruling -- emphatic as it was -- didn't wipe the taint from the family. It didn't remove the sting of knowing that trusted school staff, friends and doctors had seen Leslie as a monster, family members said.

No one even told them when the criminal investigation was dropped. And no apology came from the doctors and social workers, Leslie said.

"I would feel better if the doctors would at least admit to something, that they were wrong -- just a little," Sam Udvardi said.

The only acknowledgment from the hospital came from its attorney, in response to a packet of documents Leslie sent as part of a written complaint. At the end of a three-page letter defending the hospital on every point in dense legal prose, E. Nathan Schilt wrote: "I am deeply sorry for the ordeal you and your family have undergone."

Hospital and social service officials, including Sheridan-Matney, declined to discuss any aspect of the case with The Times, citing confidentiality protections in medical and child abuse cases.

From her insurer, Leslie got a letter saying that Loma Linda no longer wished to treat the family "due to reports of repeated noncompliance and disruptive behavior."

A geneticist at UC Irvine Medical Center,recommended by Francomano, is keeping watch over the children's health. All of them have been diagnosed with "EDS-plus." By March 2007, based on new tests less invasive than those previously used by the Chiari Institute, the children had been diagnosed with Chiari as well, Leslie said. How their health will be affected in the long term remains unknown.

Leslie still fears they are not getting all the help they need. Esther could use better braces to keep the joints in her arms from dislocating. She needs a referral to a pediatric pain clinic. Matthew is on a special diet and takes medication for his depression. Sam still suffers seizures and can't get a driver's license.

The three younger children continue to attend Loma Linda Academy. Kirk still teaches there. Every day, he sees colleagues who supported the couple and colleagues who did not.

Saddled with $151,000 in debt from the battle, the Udvardis wanted to sue their accusers. But attorneys told them it would be fruitless: A state law gives absolute immunity to professionals who report suspicions of child abuse, founded or not.

It's hard to imagine forgetting about all this and resuming the life they had before the white van came. It's hard to imagine anyone else forgetting either.

"I still feel when I walk into a room," Leslie said, "people see me and whisper."

tracy.weber@latimes.com

Lucid Intervals and head injury

2008-02-27T08:17:00.000-08:00

Comment in:

Pediatrics. 2005 Dec;116(6):1608; author reply 1608-9.

Initial neurologic presentation in young children sustaining inflicted and unintentional fatal head injuries.
Arbogast KB, Margulies SS, Christian CW.
Division of Emergency Medicine, Department of Pediatrics, University of Pennsylvania, Philadelphia, USA. arbogast@email.chop.edu

BACKGROUND: It remains unclear if fatal brain injuries in young children are characterized by immediate rapid deterioration or can present after an initial period of lucidity. This issue has legal implications in child abuse, for which understanding the clinical course affects perpetrator identification. OBJECTIVE: To determine patterns of neurologic presentation on hospital admission in infants and toddlers who die of inflicted and unintentional injury. DESIGN/METHODS: Data on children <48 months of age who sustained a fatal head injury from 1986-2002 were extracted from the Pennsylvania Trauma Outcomes Study. Only those with external-causes-of-injury codes for inflicted injury, falls, and motor vehicle crashes (MVCs) with a recorded Glasgow Coma Scale (GCS) on admission were included. The GCS was compared across mechanisms and age groups (0-11, 12-23, 24-35, and 36-47 months). RESULTS: Of the 314 fatally injured children, 37% sustained inflicted injury, 13% sustained a fall, and 49% sustained an MVC. At admission, 6.8% of all children had a GCS score of >7, and 1.9% presented with a GCS score of >12 (lucid). The incidence of admission a GCS score of >7 varied by mechanism. Overall, children with inflicted injury were 3 times more likely to present with a GCS score of >7 than those injured in MVCs (odds ratio [OR]: 3.6; 95% confidence interval [CI]: 1.2-10.3), but incidence of a GCS score of >7 did not differ between inflicted injuries and falls. Similarly, when considering only those children >or=24 months old, a GCS score of >7 did not differ by mechanism. In contrast, in those <24 months old, children who died as a result of inflicted injury were >10 times more likely to have a GCS score of >7 than those who died as a result of a MVC (OR: 9.36; 95% CI: 1.3-80.9). CONCLUSIONS: The data suggest an age- and mechanism-dependent presentation of neurologic status in children with fatal head injury. Although infrequent, young victims of fatal head trauma may present as lucid (GCS score: >12) before death. Furthermore, children <48 months old sustaining inflicted injury are 3 times more likely to be assessed with a moderate GCS score (>7) than those in MVCs. This effect is amplified in the youngest children (<24 months old): those with inflicted injury were 10 times more likely to present with moderate GCS scores than those in MVCs. In addition, this youngest age group seems to be overrepresented in those who present as lucid (GCS score: >12 [5 of 6]). It is unclear whether these differences are the result of inadequate tests to evaluate consciousness in younger children or differences in biomechanical mechanisms of inflicted trauma.

PMID: 15995050 [PubMed - indexed for MEDLINE]obit

Colin Kendrick

2008-02-14T11:57:00.000-08:00

Tears of relief as man is cleared of shaking child to death

CLEARED: Colin Kendrick

A RELIEVED man walked free from court after being cleared of murdering his step-daughter.

Colin Kendrick, 31, was accused of losing his temper and violently assaulting 19-month-old Aimee Collins within just 15-minutes of her mother Sarah-Jane Collins leaving the home they shared in Eden Green, South Ockendon.

At Basildon Crown Court today the jury, along with Kendrick and Aimee's family, broke down and wept as the verdict was read out.

Judge Philip Clegg thanked the jury for their efforts during the five week trial and told them: "This has been an extremely difficult case. I have been in law for 40-years and I have seldom come across a case as difficult as this one. I know perfectly well it has been a great strain on you and I know the great care and attention you have paid to this case."

Kendrick maintained his innocence since his arrest in December 2005 and told how he dialled 999 and attempted to revive Aimee after he found her lying unconscious in her cot.

Doctors at Basildon Hospital fought for seven hours to save the child but her life support machine was turned off when she was confirmed brain dead.

Andrew Scott, junior defence barrister, spoke on behalf of the family and said: "There are no winners today. There is no celebration. At the heart of this case is the death of a child Aimee Collins who was loved and cherished by the whole family and her step father.

"There is always a great danger that out in the wings is another danger and that is a conviction of an innocent person but Mr Kendrick and all his family would like to thank the jury for their patience and their hard work in making their way through what was complex medical evidence. Nobody knows what the future holds for the family but they will need some time to gather their thoughts after today's verdict but what everybody can be certain of is that every day they will remember that beautiful little girl of theirs."

Kendrick said he felt "shattered" and was relieved to be going home and spending Valentines day with his partner Sarah-Jane, 22, whom he had been banned from seeing since his arrest up until the restriction was lifted during the trial.

The child's great-grandmother Dolores Collins praised the defence legal team, which included Bill Baches, the solicitor who defended Angela Cannings, the mother wrongly accused of killing her two children.

Mrs Collins added: "The whole family stuck together. We knew he was innocent from the start. We knew he loved the children and he would never hurt them."

6:54pm today

Colin Kendrick

2008-02-14T09:16:00.000-08:00

Not Guilty.

Now we dissect the prosecution evidence and report accordingly.

Bugging Prisoners and Marianne Williams

2008-02-10T11:25:00.000-08:00

Gasp, shock, horror, the police have allegedly been bugging conversations between solcitors and their clients - excuse the sarcasm, however in R-V-Williams, the alleged salt poisoning case upon which I worked, guess what, they bugged her home, they bugged her home at a time when she was having conversations with her lawyers - this has been investigated by the IPCC and we have been told, "nought wrong with that" - well pardon me? Nothing wrong with bugging confidential conversations?

Be warned, any parent/carer arrested and accused of harming a child is likely to have their home bugged.

Further information regarding what the police get up to will be posted on this blog, because of course when the men in white coats state the child was murdered, all common sense goes out of the window, not to mention the law being trampled all over.

God help them if the likes of Humtley are released on a technicality. Oh and just remember all this is being done under the guise of "homeland security"!

Colin Kendrick Shaken Baby Case Basildon Crown Court

2008-02-09T04:08:00.000-08:00

Well the jury go out Monday - they have heard the evidence - I can only pray the jury listen intently to the Judge's summing up in this case - all that's left is the hypothetical triad. Colin is innocent. Rest in peace Aimee, not long to go before you can be laid to rest sweetheart.

My many thanks to the defence team who as ever have done an oustanding job in presenting the lack of evidence supporting an allegation of SBS and showing how Aimee really died.

Bill Bache Solicitor

Andrew Scott Junior

Michael Topolski QC

XX

The prosecution witnesses should be ashamed of themselves, their testimony was an absolute disgrace in relation failing to do their duty to the court and I will not let that go unpunished, they know better.

Clicking on the title of this blog will take readers to the press reports of Colin's case

The Home Office Pathologists turn on each other

2008-02-06T05:54:00.000-08:00

More Mistakes by Pathologist

A consultant pathologist who admitted professional misconduct over two bungled post-mortem examinations is facing new allegations.

Dr Louay Al-Alousi, of the University of Leicester, admitted making serious mistakes in the cases of two teenagers, saying their deaths were due to cannabis use when that was not the case.

He now faces allegations of mistakes in another seven examinations - one of which involved a murder victim - including one of a "grossly inadequate post-mortem examination" and errors while supervising a trainee pathologist.

Dr Al-Alousi denies all the new allegations.

The Home Office pathologist had restrictions imposed on his ability to practice in January last year after he admitted professional misconduct before the General Medical Council (GMC) over the cannabis cases.

He appeared at a review hearing of those restrictions yesterday.

The panel ruled they should remain.

It was also revealed at the hearing that since July, Dr Al-Alousi has been restricted to research and teaching work at the university.

The panel was told he agreed to a proposal to limit his work made by university vice-chancellor Prof Bob Burgess.

The new allegations are being investigated by the university and National Policing Improvement Agency.

Dr Al-Alousi has worked on cases including that of Earl Shilton woman Joanne Butler, who was murdered by a man and his 13-year-old son.

Last year's GMC hearing was sparked by the refusal of Paul and Joanne Burgess, of Leicester Forest East, to accept Dr Al-Alousi's finding in relation to their son, James.

The couple enlisted their own pathologist, while a coroner had a third expert examine James. Both agreed his death was due to an unsuspected heart condition.

The same conclusion was reached for the other teenager.

Since restrictions were imposed, Dr Al-Alousi's supervisor, Prof Guy Rutty, has made fresh complaints against him relating to six autopsies, including "incorrect conclusions as to the cause of death". The other complaint followed work at the University of Dundee.

Hugh Lloyd, defending, said Dr Al-Alousi had made a "substantial" complaint against Prof Rutty.

He did not submit that Dr Al-Alousi's fitness to practice was no longer impaired.

Prof Kevin Dalton, chairman of the GMC panel, said: "The panel considers the allegations against you relating to issues of your clinical competence are serious (and) has found your fitness to practice is impaired."

The panel said it was unlikely he would be considered fit to practice without restrictions while the new allegations were investigated.

It ruled the restrictions should remain for two years. Dr Al-Alousi has 28 days to appeal.

Is there a problem within Home Office pathology in the UK?

2008-02-06T05:37:00.000-08:00

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FTP Panel
Home > FTP Panel > FTP Panel > FTP Panel > FTP Panel
Fitness to PractiSe Panel

22- 24 January 2007

7th Floor, St James's Buildings, 79 Oxford Street, Manchester, M1 6FQ

Name of Respondent Doctor: Louay AL-ALOUSI

Registered Qualifications: MB ChB 1976 Baghdad

Registered Address: Leicester

Registration Number: 3438523

Type of Case: New case of impairment by reason of: misconduct

Panel Members: Dr C Winstanley (Lay), Chairman

Dr T Thorburn (Medical)

Mr C Wheeler (Lay)

Mr I Ashraf (Lay)

Legal Assessor: Mr D Mason

Secretary to the Panel: Mrs Zaheda Khan/Ms Laura Pearce (22 January 2007)

Ms Jenny Hazell (23 – 24 January 2007)

Representation:

GMC: Mr Mark Ainsworth, Counsel, instructed by Field Fisher Waterhouse Solicitors

Doctor: Present and represented by Mr Adrian Hopkins, Counsel, instructed by RadcliffesLeBrasseur Solicitors

allegation

“That being registered under the Medical Act 1983

• At all times you were a registered Medical Practitioner;

Admitted and found proved
• Since 1 December 2002 you have worked as a Senior Lecturer/Honorary Consultant in Forensic Pathology at The University of Leicester; Admitted and found proved

• On 30 July 2003 you carried out a post-mortem on the body of Child A; Admitted and found proved

• You revisited the cadaver on 4 September 2003 and took further specimen blocks. You

a. did not take specimen blocks from the right ventricle, Admitted and found proved

b. did not consider a specialised examination of the electrical conducting system of the heart; Admitted and found proved

• You prepared a report for the Coroner dated 22 October 2003; Admitted and found proved

• In your report you concluded that the cause of death was

• myocardial ischaemia, Admitted and found proved

• cannabis abuse; Admitted and found proved

• You did not explain the petechiae; Admitted and found proved

• You did not appreciate the proper significance of the main pathological evidence (the sub-epicardial fibrosis of the heart without evidence of fatty infiltration); Admitted and found proved

• You did not consider arrhythmogenic right ventricular cardiomyopathy (ARVC) as a cause of death; Admitted and found proved

• You improperly considered status lymphaticus; Admitted and found proved

• Your conclusions were significantly flawed and inaccurate in that

a. you relied upon a scientific paper from Forensic Science International 2001 by Bachs and Morland which was annexed to your report, Admitted and found proved

b. there was no toxicological evidence to show that the cannabis was the cause of death, Admitted and found proved

c. you could not prove that cannabis had a role in Child A's death, Admitted and found proved

• your opinions were speculative; Admitted and found proved

• Your actions as detailed in paragraphs 4, 6, 7, 8, 9, 10 and 11 were

a. inappropriate, Admitted and found proved

• unprofessional; Admitted and found proved

• On 12 March 2004 you reviewed the case of Child A and gave a supplementary statement to the Coroner; Admitted and found proved

• You stated that to simplify the Coroner's enquiry into this death and to assist the deceased's parents to come to terms you did not object to re-phrasing the cause of death as

• left ventricular focal myocardial fibrosis, Admitted and found proved

• myocardial ischaemia; Admitted and found proved

• You wrongly stated that left ventricular focal myocardial fibrosis and myocardial ischaemia were synonymous; Admitted and found proved

• You failed to properly reconsider your conclusions; Admitted and found proved

• The Coroner recorded a verdict that Child A died of natural causes and that the cause of death was arrhythmogenic cardiomyopathy; Admitted and found proved

• Your actions as set out in paragraphs 14, 15 and 16 were:

• unprofessional, Admitted and found proved

• misleading, Admitted and found proved

• inappropriate; Admitted and found proved

• likely to bring the reputation of the medical profession into disrepute; Admitted and found proved

• On 29 July 2003 you carried out a post-mortem on the body of Child B.; Admitted and found proved

• You

a. did not consider retaining the heart for examination by a specialist in cardiac pathology, Admitted and found proved

• only took three specimen blocks from the heart; Admitted and found proved

• You prepared a report for the Coroner dated 24 February 2004; Admitted and found proved

• In your report you concluded that the cause of death was

• coronary artery ischaemia, Admitted and found proved

• cannabis abuse; Admitted and found proved

• You wrongly suggested that the death must have been due to cannabis and no other condition; Admitted and found proved

• You did not consider that the scarring of the heart might have been caused by inflammation of the heart muscle (a healed myocarditis); Admitted and found proved

• You did not consider arrhythmogenic cardiomyopathy as a cause of death; Admitted and found proved

• You improperly considered status lymphaticus; Admitted and found proved

• Your conclusions were significantly flawed and inaccurate in that

• you relied upon a scientific paper from Forensic Science International 2001 by Bachs and Morland which was annexed to your report, Admitted and found proved

• you could not prove that cannabis had a role in Child B's death, Admitted and found proved

• your opinions were speculative; Admitted and found proved

• Your actions as detailed in paragraphs 20a, 23, 24, 25, 26 and 27 were

• misleading, Admitted and found proved

• inappropriate, Admitted and found proved

• unprofessional, Admitted and found proved

• likely to bring the reputation of the medical profession into disrepute.” Admitted and found proved

And that by reason of the matters set out above your fitness to practise is impaired because of your misconduct.

Determination on impaired fitness to practise

“Dr Al-Alousi: At the start of these proceedings, Mr Hopkins QC, admitted on your behalf all of the allegations against you. The Panel has recorded that the allegations, having been admitted, were found proved.

Background

In considering whether your fitness to practise is impaired, the Panel has taken into account all of the documentary adduced and the oral evidence of Professor C, the expert witness called on behalf of the General Medical Council (GMC). It has borne in mind the submissions made by Mr Ainsworth on behalf of the GMC and those made by Mr Hopkins on your behalf.

The allegations against you in essence revolve around the conclusions you reached in the reports you prepared for the Coroner in respect of Child A (dated 22 October 2003 and 12 March 2004) and Child B (dated 24 February 2004). The Panel has heard that the Police were treating the deaths of Child A and Child B as suspicious, given that they had both died suddenly and had previously been healthy. You had learned from the police that both children had taken cannabis shortly before their deaths. In its deliberations, the Panel has considered your actions in respect of each child separately.

Child A

At the material time you were working as a Senior Lecturer /Honorary Consultant in Forensic Pathology at The University of Leicester. You were also a Consultant Pathologist to the Home Office.

On 30 July 2003 you carried out a post-mortem on the body of Child A. It has been accepted by both Counsel that you carried out a thorough examination of the body of Child A and that you recorded your findings appropriately. At this stage you were not able to diagnose the cause of Child A's death.

On 4 September 2003 you took further specimen blocks. You have accepted that you did not take specimen blocks from the right ventricle. Professor C's evidence was that it would be best practice to have done so, but the Panel further notes that at that time there were no official guidelines available to pathologists on the checks required at a post-mortem.

You have also accepted that you did not consider a specialised examination of the electrical conducting system of the heart. The Panel has heard from Professor C that this type of test is very demanding, and is carried out in rare circumstances, and by a specialist cardiac pathologist. Through your Counsel, you have accepted that you should have considered cardio-vascular causes of death, if necessary, by seeking the opinion of a specialist cardiac pathologist, and that you did not do so.

In your initial report to the Coroner dated 22 October 2003, you noted the deceased was believed to have smoked about two joints of cannabis within a few hours of his death. You commented on the fact that “apart from myocardial fibrosis, there was no natural disease which could have caused death or contributed to the cause of death.” In your report you concluded by stating that, “having excluded other conditions from the possible causation of death, in my opinion the cause of death should be issued as myocardial ischaemia and cannabis abuse.”

Professor C confirmed that there is some scientific evidence published that supports an association between cannabis use and cardiac ischaemia or infarction. Professor C made clear that this evidence was not sufficient to support a causative link, although it was reasonable to consider the possible role of cannabis use, given the history you had received from the police and the toxicology report.

You did not explain the petechiae, although you referred to its presence. The Panel finds this to be a minor error.

You have accepted that you did not appreciate the proper significance of the main pathological evidence. In addition you did not consider arrhythmogenic right ventricular cardiomyopathy (ARVC) as a cause of death.

In your report, you referred to status lymphaticus. The Panel has heard that this is now a discredited medical finding. Although you dismiss it in your reports, the Panel considers that it was not necessary to mention it at all.

The Panel accepts Professor C's comments in his report that at this stage of proceedings, “The initial impression formed at the autopsy of this being a drugs-related death appears to have maintained and blinkered a more open-minded and critical review of the evidence as it became available.” (sic). The scientific paper from Forensic Science International 2001 by Bachs and Morland did not support your view that cannabis was a cause of death, and did not purport to do so.

Professor C considered that your explanation and interpretation of your findings were “limited in its breadth and may indeed be, in significant parts, erroneous.” He was of the view that your conclusions “are not properly justified on the basis of the published paper” and that you should have “more critically assessed its relevance and scientific merit.” You have admitted that your conclusions were significantly flawed and inaccurate. In addition there was no toxicological evidence to show that the cannabis was the cause of death and you could not prove that cannabis had a role in Child A's death. You have accepted, and the Panel has therefore found proved, that your opinions were therefore speculative and that your actions in this regard were inappropriate and unprofessional.

You were asked to reconsider your report. Dr D and Dr E (both specialist cardiac pathologists) provided reports. The Panel notes that their conclusions differ. Dr D, in her report of 2 December 2003, commented on the left ventricular myocardium, noted symptoms/signs being consistent with arrhythmogenic right ventricular cardiomyopathy (ARVC). Dr D considered that the death of Child A was due to a cardiomyopthathy. She noted that Cannabis can be associated with cardiovascular complications. Dr E, in his report of 2 February 2004, supported the views expressed by Dr D in terms of the findings in the heart. He commented: “A possible role for recent cannabis abuse in precipitating sudden death due to ischoaemic heart disease is at best speculative.” He felt it was inappropriate to exclude the underlying heart disease from the main cause of death, and concluded, by stating the cause of death in this case was “Idiopathic left ventricular fibrosis”.

You reviewed the case of Child A on 12 March 2004. By this time, you had received the reports of Dr E and Dr D. Notwithstanding this, you did not take account of their views in providing a supplementary statement to the Coroner. Professor C noted in his report: “There appears to have been a failure to maintain an open-minded approach to identification of the cause of death and bias, based on police information, has been allowed to colour excessively the conclusions reached, in spite of representations from the family of the deceased to reconsider.”(sic). The Panel is concerned that having reached a flawed conclusion on the cause of death, you did not significantly revise your opinion in the light of the reports from the specialist cardiac pathologists. Despite your report having been reviewed by a senior colleague, Dr F, the Panel considers that this failure to recognise your error and act appropriately is the most serious aspect of this case.

You stated that to simplify the Coroner's enquiry into this death and to assist the deceased's parents to come to terms with the death of Child A you did not object to re-phrasing the cause of death as left ventricular focal myocardial fibrosis and myocardial ischaemia. You wrongly stated that left ventricular focal myocardial fibrosis and myocardial ischaemia were synonymous. The Coroner recorded a verdict that Child A died of natural causes and that the cause of death was arrhythmogenic cardiomyopathy.

You have accepted that your actions in relation to your supplementary statement were unprofessional, misleading, inappropriate and likely to bring the reputation of the medical profession into disrepute.

Child B

Many of the criticisms that have been found proved in relation to Child A are repeated in the case of Child B.

On 29 July 2003 you carried out a post-mortem on the body of Child B. You have accepted that you did not consider retaining the heart for examination by a specialist in cardiac pathology and that you only took three specimen blocks from the heart. In the report you prepared for the Coroner, dated 24 February 2004, you concluded that the cause of death was coronary artery ischaemia and cannabis abuse. You wrongly suggested that the death must have been due to cannabis and no other condition.

You have accepted that you did not consider that the scarring of the heart might have been caused by inflammation of the heart muscle (a healed myocarditis), nor did you consider arrhythmogenic cardiomyopathy as a cause of death. You again improperly considered status lymphaticus. Your conclusions were significantly flawed and inaccurate in that you relied upon and misinterpreted a scientific paper of Bachs and Morland and you could not prove that cannabis had a role in Child B's death.

You have accepted that your opinions in relation to Child B were speculative, and your actions were misleading, inappropriate, unprofessional and likely to bring the reputation of the medical profession into disrepute.

Panel's finding on impairment

The Panel accepts that these rare incidents occurred closely in time and have striking similarities. However, the Panel's view is that these were separate incidents and it has considered them individually. Errors were made by you over a period of months. The Panel does not consider the events to be a single incident, or an isolated lapse from the standards expected.

In considering whether your fitness to practise is impaired, the Panel has borne in mind the GMC's Indicative Sanctions Guidance, including the issue of the public interest. The Guidance states that the public interest includes, amongst other things, the protection of patients and the maintenance of public confidence in the profession.

Professional bodies such as the police and coroners place reliance on the information provided by pathologists. The families of the deceased were entitled to an accurate diagnosis of the cause of death. It is therefore important that the conclusions stated in such reports can be verified. Moreover, when reviewing cases, it is important that this is carried out in a professional manner, and the views of other recognised experts are taken into account. You have accepted that the conclusions reached in the report concerning the cause of death of Child A and Child B were significantly flawed and inaccurate and that your opinions were speculative. You have further accepted that your actions were misleading, inappropriate, unprofessional and likely to bring the reputation of the medical profession into disrepute.

In addition, the Panel has also had in mind the GMC's publication Good Medical Practice (May 2001). This refers to a number of requirements in providing care, including the need to recognise and work within the limits of your professional competence and be willing to consult colleagues. The Panel has found that you have breached this guidance.

In all the circumstances, the Panel has found your fitness to practise is impaired by reason of your misconduct.

The Panel will now invite further submissions from both Counsel as to the appropriate sanction, if any, to be imposed on your registration. Submissions on sanction should include reference to the Indicative Sanctions Guidance, using the criteria as set out in the guidance to draw attention to the issues, which appear relevant to this case.”

Determination on sanction

“Dr Al-Alousi: The Panel has considered what action, if any, to take in relation to your registration. In doing so, it has taken into account all the evidence adduced throughout this hearing, and has borne in mind the submissions made by both Counsel. Mr Ainsworth, on behalf of the General Medical Council (GMC), has invited the Panel to consider making a direction suspending your registration; Mr Hopkins has invited the Panel to consider taking no action on your registration.

The Panel has borne in mind that any sanction imposed must be proportionate and appropriate, and that its purpose is not to be punitive, but to protect members of the public and the public interest. The public interest includes, amongst other things, not only the protection of patients, but also the maintenance of public confidence in the profession.

In considering whether to take action against your registration, the Panel has balanced the public interest against your own interests, bearing in mind your personal circumstances, and has taken into account the principle of proportionality. The Panel has had regard to the GMC's Indicative Sanctions Guidance.

The Panel has taken into account the evidence submitted at this stage of the proceedings, including the oral evidence of Detective Superintendent G and Dr H. It is clear from their evidence that you are considered to be a highly respected, reliable and clinically competent Consultant Pathologist, who provides an excellent service, and who is willing to listen to the opinions of others. The Panel has also had regard to the outstanding testimonials submitted on your behalf. These, too, attest to your high clinical standing amongst colleagues.

The Panel has taken into account the mitigation advanced on your behalf by Mr Hopkins. It has been accepted by both Counsel that that the causes of death in respect of Child A and Child B were not “ run of the mill” and that both cases were difficult, requiring expertise greater than your own. In his evidence, Professor C commented that the autopsies in respect of Child A and Child B were carried out to an extremely high standard. The Panel has heard that, apart from your conduct concerning Child A and Child B, there have been no other complaints to the GMC during 24 years of practising in the United Kingdom.

It has been submitted on your behalf that you have demonstrated insight into the seriousness of your actions. At the outset of the hearing you made full admissions to the allegations against you. The Panel has heard that as a result of the errors of judgement you made concerning Child A and Child B, you have now put safeguards in place to prevent such mistakes from recurring. Mr Hopkins has explained that you now take histology samples from the right ventricle and between 4 to 6 histology samples from the left ventricle of all the hearts that you examine for the purposes of a post mortem. In all cases of young people (below the age of 35) where the cause of death is not clear, the heart is sent to Dr I, Consultant Pathologist, specialising in cardiac pathology. He has further explained that in drug related cases, samples are taken from the left and right hand side of the heart and that the heart is retained whilst you are waiting for toxicology reports.

The Panel also notes that of your own volition and at your own expense, from 29 November to 1 December 2006 you attended a Combined Adult and Congenital Cardiovascular Pathology course at the National Heart and Lung Institute.

The Panel first considered whether it would be appropriate and proportionate to conclude your case without imposing any sanction. It has borne in mind the mitigation advanced on your behalf, as well as the circumstances of your case. In view of the serious nature of its findings regarding your misconduct, the Panel is satisfied that it is necessary in the public interest to take action in relation to your registration.

The Panel then went on to consider whether it would be sufficient and appropriate to impose conditions on your registration. In doing so, it has considered the factors set out in the GMC's Indicative Sanctions Guidance in relation to when it may be appropriate to impose conditions on a Doctor's registration. The Panel has concluded that you have learnt from these incidents and you have shown insight into these matters by changing your practice. The Panel considers that it is unlikely that there is a risk of recurrence provided that the changes you have implemented in your practice are sustained.

However, whilst noting the steps you have taken to change your practice, the Panel seeks assurances that these changes are sustainable. The Panel would wish such arrangements to be formalised and to be reviewed after a period of time. In particular, the Panel wishes you to convert the set of procedures already outlined by your Counsel into a formal protocol. This should be done in agreement with a senior colleague. You should make arrangements for evidence to be provided to the GMC of the implementation of the protocol.

Taking these matters into account, the Panel is satisfied that the imposition of conditions on your registration would be sufficient to protect patients and the public interest, and would be a proportionate response to its findings of fact. It considers that a direction suspending your registration would be disproportionate and would be unduly punitive.

Accordingly, the Panel has determined to impose the following conditions on your registration for a period of 12 months:

1. You must formalise a protocol detailing your management of the heart tissue in post mortem cases where the deceased is aged less than 35 and where there is not an immediately apparent non-cardiac cause of death.

2. You must formalise this protocol with the agreement of a senior colleague, who will act as your supervisor solely in relation to your compliance with this protocol. This supervisor should be a qualified pathologist who is on the specialist register of the GMC and who is at least as senior as yourself.

3. a You must maintain a log detailing your compliance with the protocol in all relevant cases.

b. You should make this log freely available to your supervisor and, on request, to the GMC.

4. You must allow the GMC to exchange information with your supervisor, where necessary.

5. You must notify the GMC promptly of any post you accept for which registration with the GMC is required and provide the GMC with the contact details of your employer.

6. You must allow the GMC to exchange information with your employer, or any organisation for which you provide medical services, and any individual involved in your supervision.

7. You must inform the GMC of any formal disciplinary proceedings taken against you, from the date of this determination.

8. You must inform the GMC if you apply for employment outside the UK.

9. You must inform the following parties that your registration is subject to the conditions, listed at 1 to 8 above:

• Any organisation or person employing or contracting with you (including HM Coroner) to undertake medical work;

• Any locum agency or out-of-hours service you are registered with or apply to be registered with (at the time of application);

• Any prospective employer (at the time of application).

In reaching its decision to impose conditions on your registration for a period of 12 months, the Panel considers that this will give you sufficient time in which to demonstrate that you have sustained the changes in your practice.

Before the end of this period of conditional registration a Fitness to Practise Panel will meet to review your case. A letter will be sent to you about the arrangements for the review hearing which you will be expected to attend. At that hearing, the Panel reviewing the case will expect to receive the following:

• An assessment from your supervisor on your protocol and your log

• A copy of the protocol

• A copy of the log

The effect of this direction is that, unless you exercise your right of appeal, your registration will be subject to these conditions for a period of 12 months, beginning 28 days from the date when written notice of this direction has been deemed to have been served upon you.

Having regard to the measures outlined by your Counsel regarding your current practice arrangements, and the Panel's view that there it is unlikely that there is a risk of recurrence of these events, the Panel is not minded to impose these conditions immediately, unless either Counsel wishes to make submissions on this matter.”

Confirmed

25 January 2007 Chairman

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The research the proves the triad theory is unsafe

2008-02-02T02:56:00.000-08:00

The pathophysiology of infant subdural haematomas
Matthew A Howard, B A Bell, and David Utley

Atkinson Morley's Hospital, Cope Hill, Wimbledon, London, SW20 0NE, UK

Abstract
The widely accepted theories concerning the pathophysiology of infant subdural) haematoma (SDH) were formulated in the pre-computed tomographic (CT) scan era. Violent shaking is considered to be a crucial cause of SDH in non-accidentally injured infants. This theory has been re-examined in a clinical and CT scan review, and our findings have been correlated with results of recent head injury research. A retrospective review was conducted of all head injured infants (up to 18 months old) treated at Atkinson Morley's Hospital over a recent 20 year period (n = 100). Twenty-eight infants with a SDH were identified. CT scans were reviewed and each SDH greater than 0.5 cm thick was morphometrically analysed. Seventeen infants were Caucasian, 10 were non-Caucasian and one was of mixed race. A race-dependent pattern of SDH pathophysiology was noted, with non-Caucasian infants with a head injury more likely to have a SDH than Caucasian infants (67 v 21%, p < 0.01 ) All had a history of, or radiographic and clinical findings most consistent with, an impact injury, and non-Caucasian infants were significantly more likely to have a normal scalp examination despite the impact injury (p < 0.05) and to have developed the SDH after a relatively trivial fall (p < 0.01). They were also more likely to have a large ( > 0.5cm thick) SDH (p < 0.05), and to suffer post-traumatic seizures (p < 0.05). Our findings do not support shaking as the only cause of infant SDH formation and also suggest that non-accidental injury is a less common cause of SDH than it is believed to be.

Introduction

Traumatic SDH commonly occurs in infants with serious head injuries. Twenty years ago, Guthkelch expanded on earlier observations and proposed that in cases of non-accidental injury (NAI), vigorous shaking of the infant was often the mechanism underlying the formation of a SDH. The "shaken baby" hypothesis of SDH formation has subsequently gained wide acceptance. In western countries, a SDH and papilloedcma in an infant without external signs of head injury are considered findings highly suggestive of NAI by violent shaking.

Significant advances in knowledge about mechanisms of head injury and in clinical management have occurred since the shaken baby hypothesis was formulated. CT brain imaging, in conjunction with data derived from primate head injury research, have spawned new theories concerning the pathophysiology of traumatic SDH. Although these investigations have largely centred on adults, the methods utilized arc applicable to head-injured infants.

In view of the clinical and medicolegal importance of an infantile SDH, a clear understanding of the pathophysiology is essential. The current study is directed at re-examining this issue in a retrospective review of all infants with a diagnosis of traumatic SDH at Atkinson Morley's Hospital (AMH) over a 20-year period.

Materials and methods

The medical records and radiographic studies of all head injured infants (up to 18 months old at time of injury) admitted to AMH between July 1970 and July 1990 were reviewed. Infant's names and ages were obtained from the hospital register of discharge diagnoses. Infants in this series with a diagnosis of traumatic SDH are the subject of the current report.

Particular attention was directed at identifying the mechanism of injury that resulted in SDH formation. The history of injury in the medical record was supplemented by telephone enquiries and written questionnaires to parents, guardians, social workers, police officers, coroners and the injured infant's current general practitioner, to add any pertinent information that had come to light after discharge from AMH.

A range of pre-injury infant characteristics were examined in order to identify factors which could influence the formation of a SDH. These characteristics included race, nationality, prematurity, presence of a bleeding diathesis, history of seizures, hydrocephalus or other neurological disorder and developmental delay.

Head CT scans were reviewed and scans with a SDH greater than 0.5 cm thick were morphometrically analysed. The presence or absence of the following specific features were recorded: extracranial injuries, scalp soft tissue swelling, skull fracture, intracerebral haematoma or contusion, and intracerebral low density changes. Subdural haematoma volume, maximum haematoma thickness, and the amount of midline shift were quantified with a Colormorph Interactive Image Analyser (Perceptive Instruments Ltd., Halstead, Essex, UK) using a previously reported computerized technique.

The chi square test with Yates' correction for continuity was used to statistically analyse associations between infant subgroups and specific clinical and radiographic findings.

Results

Infant selection

One-hundred-and-thirteen infants were identified with a discharge diagnosis of closed head injury. Six infants older than 18 months were excluded from the study. Two infants were misdiagnosed as head injuries and five infants' medical records could not be located. Of the l00 infants included in the study, 28 had a traumatic SDH. The diagnosis of SDH was confirmed by review of the head CT scan in 23 cases. In five infants, SDH was diagnosed by angiogram (n = 1 ) or exploratory burr holes (n = 4).

Premorbid infant characteristics (Table i)

There were 18 boys and 10 girls with a mean age of 7.8 months (SE = 0.9, range 0.8-18 months). The premorbid histories were unremarkable with the exception of one premature infant, one infant with a cleft palate and one mentally retarded infant with severe gencralised epilepsy. Twenty-seven infants were developmentally normal at the time of injury.

Infant race and nationality

The race and nationality of all infants with a SDH was identified. There were 17 British Caucasian infants with a mean age of 5.9 months (SE = 1 .0, range 0.8-I5 months), and l0 non-Caucasians with a mean age of 9.4 months (SE = 1.4, range 2-18 months). The nationalities of the 10 non-Caucasian infants, all residents in the United Kingdom, were: British (n = 2), Nigerian (n = 2), Somalian (n = I ), Indian (n= 1 ), Egyptian (n = I ), Qatarian (n = 1), Sierra Leone (n = 1), and Iraqi (n = 1 ). One infant was of mixed racial origin (Caucasian father and non-Caucasian mother). In the group of head-injured infants who did not have a SDH (n = 72), 63 were Caucasians, five were non-Caucasians and two were of mixed racial origin. The race of two British infants in this category could not bc determined. The incidence of SDH in head injured Caucasians was 21%, end in head injured non-Caucasians was 67%. The increased incidence of SDH in non-Caucasian vs Caucasian infants is significant. (p < 0.01).

The possibility that this observed difference results from a biased referral pattern was examined. The 100 head injured infants included in the study were referred from 29 different hospitals and 87% of the non-Caucasian infants were referred from hospitals that had also referred Caucasian infants. In the group of head injured infants without a SDH, the severity of neurological injury assessed by the admission Glasgow coma score (GCS) was not significantly different [Caucasian mean GCS = 10.7 (SD 2.0), non-Caucasian mean GCS = 10.8 (SD 2.5)]. The time from injury to neurosurgical evaluation did not differ between the two racial groups and there is no evidence to suggest any racial difference in the criteria used by the infants' guardians to seek medical attention or in the referral practice of clinicians in the 29 referring hospitals.

Head injury history

Falls were the most frequently reported injury (n = 14), and occurred in 8 of the 10 (80%) non-Caucasian infants, and in 6 of the 17 (35"/0) Caucasian infants. All six Caucasian infants fell from a height of over 3 feet (from a high chair, window or the arms of an adult who was standing). Of the eight non Caucasian infants who fell, three were said to have lost their balance while in the sitting (n = 1 ) or standing (n = 2) position and sustained trivial head impact (multiple unbiased witnesses in two cases). Two others were said to have rolled off a low bed onto a carpeted floor and onlywhrce fell from a significant height.

Six infants presented with no history of trauma, three of these had scalp contusions noted on physical examination. One of the three infants without physical signs of an impact injury had a scalp contusion noted at autopsy. The duration of symptoms in the remaining two infants suggested that injury occurred more than a week prior to admission and there was no suspicion of NAI. It was presumed that these infants, sustained a minor accidental head impact resulting in chronic SDH formation. Four infants were unrestrained passengers in road traffic accidents and four infants were reportedly assaulted. The assaulted infants had been beaten or thrown against stationary surfaces and three of these infants had evidence of scalp contusion on physical examination. A history of shaking was obtained in three of the assaulted infants and they showed evidence of a violent impact injury. In each case the carer described shaking the baby with the intention of resuscitation after the infant had developed symptoms from the initial head impact.

Symptoms

Eleven infants (40%) immediately lost consciousness following their head injury. Ten additional infants were noted to have a delayed deterioration in their Ievel of consciousness ( > 1 hour from time of injury). Infants with a decreased level of consciousness were often noted to have abnormal breathing patterns. Vomiting (50%) and irritability (25%) were frequent presenting symptoms. Post-traumatic seizures (5 immediate and 11 delayed) were more common in non-Caucasian (90%) than in Caucasian (41%) infants (p < 0.05). The time interval to neurosurgical evaluation was highly variable (range 2.5 hours to 4 weeks), but 15 infants presented within 24 hours, four infants between 24 and 72 hours, and nine infants more than 72 hours after a head injury was reported or symptoms were first noted.

Physical findings

Scalp Injury. Scalp contusion or bruising was noted on admission to hospital in fourteen infants (50%). In the 14 infants who had no evidence of scalp injury the reported mechanisms of injury were a fall (n = 9), assault (n = 1), road traffic accident (n = l) and no history of trauma (n = 3). Of these 14 infants, evidence supporting an impact mechanism of injury was present in 12 cases. This evidence consisted of unbiased witnesses of the injury (n = 6), skull fracture on skull X-ray (n = 2), scalp contusion on post-mortem examination (n1), and three infants who presented with a chronic SDH. In these three cases there was no suspicion of NAI, and a minor head impact was thought to have occurred more than 1 week prior to admission. An additional infant presented with a chronic SDH 3 weeks after a reported minor fall. In this case, however, the young single mother's history was deemed suspicious and the child was taken into protective custody. A case report of the only infant with a recent history of head impact ( < 72 hours), a normal scalp examination, and no supporting evidence to verify the presenting history is presented below. The incidence of a normal scalp physical examination was 29% for Caucasians and 80% for non-Caucasians. The association of non-Caucasian race with absence of external signs of head injury is significant (p < 0.05).

Retinal haemorrhages. Fundoscopic findings were recorded in 20 cases. Retinal haemorrhages were noted in 11 infants and no abnormalities were found in nine cases. Retinal haemorrhages were noted in infants with (n = 4) and without (n = 7) external signs of an impact injury, as well as infants suspected (n = 9) and not suspected (n = 2) of having a NAI. On further investigation, no evidence to support the suspicion of NAI could be found in two of the infants with retinal haemorrhages.

Extracranial injuries. On physical examination six Caucasian infants (33%) had evidence of extracranial injuries and none of the non Caucasian infants had evidence of such injuries.

Radiological findings: fractures

Eight of the Caucasian infants (47%) had a skull fracture diagnosed on plain skull X-ray or CT and nine (53%) had no skull fracture. Only two of the non-Caucasian infants (20%) had a skull fracture and eight (80%) had no skull fracture. Seven Caucasian infants (4l%) had skeletal survey examinations and an extracranial fracture was found in one. Nine non-Caucasian infants (90%) had skeletal survey examinations and no extracranial fractures were found.

Radiological findings: CT scan (Table ii)

Head CT scans were obtained in 23 infants (82%). A SDH was located over at least one cerebral hemisphere convexity in all 23 infants. Nine infants also had an interhemispheric SDH and six infants had bilateral convexity subdural haematomas. High (n = 14), mixed (n = 7), and low (n = 2) density SDH was observed. A low density SDH was seen exclusively in infants evaluated more than 72 hours from the onset of symptoms, whereas high and mixed density SDH was observed in infants falling within a wide range of time intervals. Maximum SDH thickness varied from less than 0.5-2.7 cm, with 13 infants having a maximum SDH thickness greater than 0.5 cm (mean = l .6cm, SE = 0.2, for infants with thickness > 0.5 cm). In this latter group, SDH volumes ranged from 26 to 269 ml (mean = 122.4 ml, SE = 18.4). A highly significant race dependent pattern in SDH size was observed with all non-Caucasian infants (n = 10) having a large ( > 0.5 cm thick) SDH compared to only three (23%) Caucasian infants (p < 0.01 ).

Three of 13 Caucasian infants with CT examinations (23%) had brain injuries in the form of visible parenchymal contusions, but none of the 10 non-Caucasian infants with CT examinations had contusions.

Treatment and outcome

Sixteen infants required surgical treatment. Thrce infants underwent craniotomy, and 13 infants had their SDH evacuated by burr hole drainage. Six infants died within 1 week of admission to hospital (21% early mortality). There were three late deaths: one infant who was normal prior to injury and was severely disabled as a result of her injury and died of pulmonary complications 8 years later, a second infant was severly disabled with pre-injury generalised epilepsy and died nine years after her injury of pulmonary complications, and one infant who had a good outcome from his head injury died of leukaemia 4 years later. Outcome data were available on 18 of the ninteen survivors. The distribution of Glasgow outcome scores was: nine good recovery, seven moderately disabled and two severely disabled (50, 39, and 11%, respectively, of survivors with available follow up data). Early deaths were more common (40%) in non-Caucasians (12% in Caucasians), and a good recovery occurred in 20% of non-Caucasians and 35% of Caucasians (Table iii).

Non-accidental injuries

Child abuse was initially suspected in 14 cases (50%). Legal action was taken in 10 cases (carer criminally charged or children taken away from their parents). In two cases legal action was not taken and in two cases the legal outcome could not be determined. Of the 10 cases where legal action was taken, three presented with a history of assault and two presented without a history of trauma, but had physical signs of a recent impact injury to the head.

Carers of the remaining five infants claimed their infants had fallen, but had no unbiased witnesses to verify their history. On physical examination all five infants had retinal haemorrhages and minimal (n = 1) or no (n = 4) evidence of a scalp injury. The accepted medical opinion in these cases was that the SDH could not have been caused by the simple falls described. In all five cases children were taken from the custody of their parents by court order. Three of these infants were non-Caucasian.

Case report

A 1 year old Somalian boy was reported by his mother to have fallen from a bed onto a carpeted floor. The child did not immediately lose consciousness, but had a generalised seizure less than a minute after the haed impact. The infant was brought to a local hospital, observed to be neurologically normal and discharged home. A fundoscopic examination was not recorded. At home the infant became irritable, vomited and had another generalised seizure. At the time of neurosurgical evaluation, 48 hours after head injury, the infant was unconscious with signs of uncal herniation and retinal haemorrhages. A large SDH was diagnosed and surgically evacuated, but the infant died soon after. The prevailing medical opinion was that the child had been the victim of a non-accidental shaking injury. The mother was charged with murder and the infant's two surviving siblings were taken from their parents' custody. An exhaustive investigation of both parents and the two siblings revealed no evidence to support a history of abuse or poor care. There was insufficient evidence to proceed with criminal charges and on judicial appeal 5 months later the siblings were returned to their parents.

Discussion

Head CT scan data and the results of recent primate head injury research demonstrate that in adults the formation of a SDH is highly dependent on two factors: the mechanics of the injury sustained and the cerebral anatomy of the victim. A clear relationship has been shown between mechanism of injry and the type of cerebral pathology that results. The strain rate or duration of head deceleration is a critical variable in this respect. High strain rate injuries are characterised by very abrupt deceleration. A head impacting on an immovable surface alter a fall is an example of high strain rate injury. Low strain rate injuries are those where the head decelerates over a longer period of time. Non-impact shaking of the head is a low strain rate mechanical insult. Cerebral bridging veins are particularly susceptible to disruption following high strain rate head injuries; low energy, high strain rate impact injuries can cause vascular disruption without causing significant direct damage to the brain parenchyma. In contrast, low strain rate injuries are more likely to result in direct injury to the brain and begin to cause significant vascular disruption only at high levels.

Age-dependent changes in cerebral anatomy strongly influence the pathophysiology of a SDH. The combination of cortical atrophy and degeneration of the walls of bridging veins in older adults is an ideal setting for the formation of a SDH. Thus, older adults who sustain high strain rate injuries from a simple fall can develop a large, lethal acute SDH.

Falls are the most frequently reported cause of infant and toddler closed head injury, Hendrick and his colleagues report falls as the mechanism of injury in 52.8% of head injured Canadian infants, while Ivan and his colleagues reported that 66% of childhood head injuries in Canada result from falls. Although the specific relationship between falls and a SDH was not addressed in these two large studies, they concluded that simple falls infrequently caused serious neurological injury in the Canadian populations studied.

In a smaller American study of infants with acute SDH, falling from a height was a common mechanism of injury." Another American report on infants with acute SDH elicits falls as the presenting cause in 33% of the infants, but the details of the falls (whether from a height or not) are not provided. In America it is a widely held view that simple falls from the sitting or standing position cannot cause an acute SDH in an infant. This view is consistent with our findings in Caucasian infants, where none fell from a height of less than 3 feet, and the 33% incidence of falls from a greater height in this series is identical to the incidence of falls in an earlier American infant SDH study.

In striking contrast, simple falls from the sitting or standing position are often reported as the cause of acute SDH in Japanese infants. This pattern of low energy, but high strain rate injury was also frequently found in the non-Caucasian infants in our study. The possibility that these infants did not sustain a simple fall, but were deliberately shaken is unlikely for several reasons. The circumstances of the simple nature of a number of the falls were corroborated by unbiased witnesses and the 80% incidence of falls found in our non-Caucasian infants with SDH is at variance with the 30% incidence of falls reported in children known to have developed SDH as a result of child abuse. The mechanical forces of a fall are more effective in causing a SDH than shaking, and subdural haematomas resulting from accidental simple falls and from child abuse in Japanese infants are distinctly different.

If the carers of the non-Caucasian infants in our series had caused non-accidental injuries, it is unlikely that they would, as a group, show such a difference in the injury history pattern from that reported in earlier non-accidental infant head injury series. This is particularly unlikely when simple falls are so over represented, as this is a mechanism of injury that would be viewed with considerable scepticism by western medical attendants.

Head-injured infants represent a unique population in terms of their cerebral anatomy and the types of injuries they sustain. In the current study, the clinical history, physical examination or radiographic findings in infants with SDH were most consistent with a direct impact injury to the head. Fourteen vf these infants (50%), however, showed no external signs of head injury, a finding consistent with earlier reports. Thirteen of the fourteen infants with a normal scalp examination either sustained a fall observed by multiple unbiased witnesses (n = 6), had an underlying skull fracture (n = 2) or scalp contusion on post-mortem examination (n = 1 ) or presented mth a chronic SDH which is most likely to have been caused by an impact injury sustained more than 1 week prior to evaluation (n = 4).

What exactly is the evidence for the "triad" of SBS

2008-02-02T02:47:00.000-08:00

Expert says baby death evidence is 'remarkably thin'

A MEDICAL expert at the trial of a Thurrock man accused of killing a 19-month-old tot said the evidence that shaking a baby caused severe head injuries was "remarkably thin."

Colin Kendrick, 31, denies killing Aimee Collins at the home he shared with the child's mother Sarah-Jane Collins in Eden Green, South Ockendon, on December 6 2005.

Dr Philip Anslow, a neuro radiologist, said it was clear when he reviewed the CT scan taken on the night Aimee Collins was admitted to Basildon Hospital, that she was already "brain dead."

Dr Anslow told the jury at Basildon Crown Court today he believed the brain died due to lack of oxygen and blood but he could not say what had caused this to happen.

He said while Professor Rupert Risdon, the UK's only paediatric forensic pathologist, was confident the 19-month-old toddler's injuries and death were caused by her being shaken, that was only "one differential diagnosis."

Dr Anslow raised his concerns about the research that has gone into what has been called "shaken baby syndrome", saying: "As time has gone on and I have read more and more about this subject, I am less and less convinced that simply shaking a child causes subdural bleeding. The evidence is remarkably thin. I have been shocked at how thin the literature was to support that shaking can cause a subdural."

He said doctors are unable to carry out experiments on children to discover whether shaking actually causes bleeding around the brain but in studies conducted on animals, shaking did not result in head injuries.

Dr Anslow said the shaken baby syndrome theory came about as doctors searched for a reason why a child could have suffered brain damage and bleeding to the eyes and brain without there being any external sign of injury.

Dr Anslow also said that following the case of the British au pair Louise Woodward, who was convicted of killing a child she was caring for in America, a number of nannies were secretly filmed shaking children and in none of those cases did the child suffer any head injury.

On the day Colin Kendrick alleges he found Aimee lying unconscious in her cot, she suffered a fall in which she hit her head against a door before landing on a solid floor.

Dr Anslow said a fall from 3ft would cause a "significant impact to the head" and this could possibly have triggered off the child's later collapse.

He said: "Very fortunately most children get away with it the vast majority of the time but just once in a while they do not."

He also said it was possible Aimee's collapse was linked to an incident a few months before her death when she briefly lost consciousness for no apparent reason.

The trial continues.

American flies in to tell court of doubts over tragic tot's injuries

From the archive, first published Tuesday 29th Jan 2008.

AN AMERICAN pathologist said there was "no convincing evidence" that a toddler who suffered severe head and body injuries had been shaken to death.

Dr John Plunkett, a specialist in general and forensic pathology, said although the brain, spinal cord and abdominal injuries discovered during a post mortem on Aimee Collins could have been caused by an assault there were other explanations that could not be ruled out.

Dr Plunkett said the findings of Professor Rupert Risdon, the UKs only paediatric forensic pathologist, that the 19-month-old child was shaken, punched, kicked or stamped on during an attack, which occurred within 15-minutes of her mother Sarah-Jane Collins leaving the flat she shared with Colin Kendrick in Eden Green, South Ockendon, were "possible" but "extremely unlikely."

And he said there was no "convincing" evidence that Aimee's head and internal injuries were caused by shaking.

Dr Plunkett, who travelled from Minnesota, USA, to give evidence at Basildon Crown Court today, said: "If shaking were to have caused Aimee's injuries, she would have had to have been subjected to a force that was in excess of 2100lbs and in addition she most likely would have suffered major structural neck damage."

He also said the internal bleeding to her stomach walls were not a feature of "shaken baby syndrome" and were not consistent with an assault but he said it was possible the injuries, along with her three fractured ribs, were caused by the medical staff at Basildon Hospital as they battled to save the child's life.

Professor Philip Luthert, who has a special interest in the pathology of the eye, also gave evidence and told how he found bleeding at the back of Aimee's eyes and around the optic nerves.

Professor Luthert said he couldn't say with certainly what had caused the bleeding but he accepted some kind of trauma was "very closely related."

He also said that while it was "very unlikely" the injury was the result of an accident in which Kendrick tripped while carrying Aimee a few days before her death and landed on top of her, he could not "exclude" it as a possibility.

He added: "The main reason for that belief is that it is my understanding that falls in young children are not uncommon. Fortunately it is relatively rare that we see young children dying with a combination of retinal haemorrhage, sub dural haemorrhage and a slightly swollen brain."

Kendrick, 31, denies murdering Aimee on December 6 2005.

The trial continues.

Baby may have died after fall - trial told
From the archive, first published Friday 25th Jan 2008.

A BABY may have died from an accidental fall rather than being shaken to death, a murder trial has been told.

Colin Kendrick, 31, denies killing his girlfriend's 19-month-old daughter, Aimee Collins, at their home in Eden Green, South Ockendon.

The child was taken to Basildon Hospital on December 6, 2005, and her life support machine was switched off at 2am the following day after she was declared brain-dead.

Judge Phillip Clegg, speaking at Basildon Crown Court, said: "The scenario that has been put forward by the defence is that in a fall in the early afternoon of the sixth, the child spun round and hit the right side of her head against the door and went down.

"You know the type of surface - it was a concrete floor with a very thin carpet covering it."

Neuro-pathologist Dr Waney Squire said Amy had suffered bleeding to the right side of her brain, which could have been caused by the accident.

She said: "I think the brain was swelling from the morning of the collapse."

The trial continues.

Top doctor concedes possibility of other causes in baby death murder trial
From the archive, first published Tuesday 22nd Jan 2008.

AN eminent professor, called to given evidence in the trial of a Thurrock man alleged to have killed a baby, accepted medicine did not have all the answers and there were conditions that remained "unexplained."

Professor Rupert Risdon gave evidence for the second successive day at the trial of Colin Kendrick, who is accused of shaking 19-month-old Aimee Collins to death, at the home he shared with her mother Sarah-Jane Collins in Eden Green, South Ockendon.

On cross examination by Michael Topolski QC, defence counsel for Kendrick, Professor Risdon said while there were conditions that medicine could not explain he believed he knew what caused Aimee to collapse on December 6 2005.

He accepted that bleeding to the brain could be caused by an "impact injury" but said there would normally be a wound or a fracture to the skull.

Professor Risdon, the UK's only paediatric forensic pathologist, said: "With impact injuries serious enough to cause inter cranial damage there is usually some marks outside the head."

He said it was "excessively rare" for bleeding to back of the eyes to be caused by accidental injury and he did not accept that the internal bleeding to the stomach wall was the result of a belly button infection Aimee had been suffering.

Professor Risdon said an accident four days before her death in which Kendrick tripped over while carrying Aimee and the child fell on a Hoover part before the defendant landed on top of her, would not have caused the three fractures to her ribs or the internal bleeding to the stomach wall.

He also accepted that head injuries could be caused by a sudden jolt when a child was strapped into a car seat but said Aimee's injuries were not the result of "seat belt injuries."

Kendrick, 31 denies murder.

The trial at Basildon Crown Court continues.

Court ordera retrial in Edmunds case SBS

2008-01-31T09:22:00.000-08:00

Court orders new trial in Wis. 'shaken baby syndrome' case

By RYAN J. FOLEY

Thursday, January 31, 2008 10:46 AM CST

MADISON, Wis. - An appeals court granted a new trial Thursday to a woman imprisoned for shaking a baby to death, saying new research into "shaken baby syndrome" might prove her innocence.

Audrey Edmunds was charged with first-degree reckless homicide following the 1995 death of a 7-month-old girl, Natalie Beard, that she was baby-sitting. She was convicted in 1996 and later sentenced to 18 years in prison.

Edmunds, a 46-year-old former housewife, has always professed her innocence. In her appeal, she argued that recent developments in medical research into "shaken baby syndrome" cast doubt on her conviction.

The District 4 Court of Appeals agreed Edmunds has presented enough new evidence to win a new trial.

A "significant and legitimate debate" has developed over issues such as whether infants can die through shaking alone and whether other causes can create symptoms similar to those associated with shaken baby syndrome, the court said.

"The main issue at trial was the cause of Natalie's injuries, and new medical testimony presents an alternate theory for the source of those injuries," Judge Charles Dykman wrote for the three-judge panel.

A jury should weigh the competing opinions of medical experts in deciding the case, Dykman said.

"There is a reasonable probability that a jury, looking at both the new medical testimony and the old medical testimony, would have a reasonable doubt as to Edmunds's guilt," he wrote.

Keith Findley, a Wisconsin Innocence Project lawyer who is representing Edmunds, called on prosecutors to drop the case and release his client from a state prison in Waupun.

"I would hope they would, after all this time and given there really is no evidence against Audrey Edmunds other than this now very dubious scientific evidence," he said.

Dane County District Attorney Brian Blanchard said the state first has to decide whether to appeal to the Wisconsin Supreme Court. He said prosecutors weren't ready to say whether they would retry the case or drop it.

A judge denied her request last year after hearing from experts from both sides. He said the case against Edmunds remained convincing.

The baby appeared healthy when dropped off at Edmunds' in-home day care on Oct. 16, 1995. The baby began gasping and choking after drinking formula. After emergency personnel arrived, her pulse and respiration stopped.

A pathologist testified at Edmunds' trial that Natalie died of shaken baby syndrome. Prosecution experts at last year's hearing said the baby's injuries indicate she suffered severe trauma.

But Edmunds' lawyers claim she could have died from a number of other causes, such as choking on formula, seizures or an infection.

Findley said the ruling was among the first from a state appellate court to recognize the new research and reverse a conviction. At the time of Edmunds' 1996 trial, doctors who raised such questions were viewed as extremists, he said. Now, they are in the mainstream.

"It's an enormous decision for Audrey, but I also think it's absolutely the right decision," Findley said. "It's the just outcome in this case."

A service of the Associated Press(AP)

Professor Rupert Anthony Risdon

2008-01-31T03:46:00.000-08:00

We've had the Southall and Meadow debacle, however at least they did conduct research into the areas they alleged to have expertise. However Risdon came out of nowhere. On checking pubmed, I can only find one paper that relates to child abuse and it isn't a research paper it is a commentary paper. Risdon's expertise was nephrology - check it out yourselves. Yet he states to the press he has 20 years of experience researching sudden death of infants - if that is the case, how is it then that he has never published the findings of that research?

Risdon also went the academic route which calls into question his experience and training in pathology.

It's beginning to look more like the Charles Smith debacle by the day.

Dr Charles Smith disgraced paediatric pathologist Canada

2008-01-30T12:20:00.000-08:00

In Canada there is a public inquiry underway into Charles Smith a self taught paediatric pathologist and the very person who established the triad in shaken baby cases as being the definitive for the diagnosis.

Clicking on the title of this posting will take you to the transcripts of the hearing and below is the abstract of what Smith and his now disgraced team published in 2002 and forms the basis upon which accusations are made against parents and carers when infants die of alleged SBS - the triad is junk science admitted by one of the authors themselves. Dr Charles Smith. It is considered to be the most comprehensive paper on SBS ever written.

What is truly frightening about this chain of events is how Smith rose to the dizzy heights he did without anyone challenging him and it makes you wonder just how many "experts" worldwide are cut from the same cloth.

Fatal child abuse-maltreatment syndrome. A retrospective study in Ontario, Canada, 1990-1995.

Type ARTICLE, 2002, IRL, ENG

Auteurs POLLANEN (Michael-S), SMITH (Charles-R) : USA. Pediatric Forensic Pathology Unit. Hospital for Sick Children. Toronto. ON., CHIASSON (David-A), CAIRNS (James-T), YOUNG (James)

Auteurs moraux Department of Laboratory Medicine and Pathobiology. University of Toronto. Toronto. ON. CAN, Forensic Pathology Unit. Office of the Chief Coroner for Ontario. Toronto. ON. CAN, Forensic Science Programme. University of Toronto. Toronto. ON. CAN

Titre Fatal child abuse-maltreatment syndrome. A retrospective study in Ontario, Canada, 1990-1995.

Périodique FORENSIC SCIENCE INTERNATIONAL
Volume, fascicule 126, 2
ISSN 0379-0738

Pages 101-104, 12 réf.

Résumé(s) Child death due to repeated episodes of physical assault or neglect has been termed the child abuse-maltreatment syndrome (CAMS).

We characterized the injuries in a series of fatally abused or maltreated child to delineate objective diagnostic criteria for the CAMS for use by clinicians and pathologists.

All deaths (age<17 years) investigated by the Office of the Chief Coroner for Ontario, Canada during the time period 1990-1995 were reviewed.

Cases of CAMS were defined as death due to lethal recent injury or malnutrition in the presence of significant old (healing or healed) injuries indicative of repeated episode of inllicted trauma.

The nature and frequency of the various injuries was determined.
The frequency of the shaken baby syndrome and the types and frequency of ano-genital injuries were also studied.

Twenty-one cases of fatal CAMS were found in the study period.

Most cases had significant recent head injury with intra-cranial hemorrhage (71%)).
Other significant recent injuries commonly observed included blunt injuries of the skin and soft tissues (67%) blunt abdominal trauma with visceral injuries (14%), and fractures (18%).

Eight cases (38%) fulfilled accepted criteria for the shaken baby syndrome.
Many children with fatal head injuries had evidence of older head trauma (38% of all cases).

A significant minority of cases had evidence of malnutrition due to neglect (10%) or ongoing ano-genital injuries (10%).

Most cases of child homicides due to repeated episodes of abuse or maltreatment involve head trauma including shaken baby syndrome.

Fractures of long bone and ribs, the classical markers of child abuse, were relatively infrequent compared with head injury.

A proportion of cases had ano-genital injuries due to repeated sexual abuse or punitive maltreatment.

All clinicians and pathologists must recognize the wide spectrum of injuries in child abuse to ultimate protect the victim or other children in an at-risk situation.

Mots-clés BDSP Mortalité, Epidémiologie, Canada, Amérique, Enfance maltraitée, Abus sexuel, Homicide, Médecine légale, Enfant, Homme, Maltraitance, Amérique du Nord
Mots-clés PASCAL Mortalité, Epidémiologie, Ontario, Canada, Amérique du Nord, Amérique, Enfant maltraité, Abus sexuel, Meurtre, Négligence, Médecine légale, Rétrospective, Enfant, Homme, Victimologie
Mortality, Epidemiology, Ontario, Canada, North America, America, Child abuse, Sexual abuse, Murder, Neglect, Legal medicine, Retrospective, Child, Human, Victimology
Référence BDSP : 263861
Notice produite par INIST-CNRS : 02-0426944
Code INIST-CNRS 002B30A11

Controversial doctor admitted his knowledge of forensic pathology was 'woefully inadequate'

Tom Blackwell , Canwest News Service

Published: Monday, January 28, 2008

TORONTO - Dr. Charles Smith apologized for his mistakes again Monday and admitted his knowledge of forensic pathology was "woefully" inadequate during his years as head of Ontario's pediatric forensic pathology unit.

Smith began his much-anticipated testimony at the inquiry examining his discredited work by acknowledging and voicing regret for his well-documented failings.

As several of the people wrongly prosecuted for homicide in his cases looked on, he conceded he had little training in the forensic field or in courtroom testimony and sometimes behaved unprofessionally.

"I have come to appreciate mistakes I have made and I am sorry for them," a solemn-looking Smith told the inquiry. "I also recognize that at times my conduct was not professional and I deeply regret that.

"I do accept full responsibility for my work and for my opinions and for my actions."

The inquiry was called last year after a panel of international experts found he had made serious errors in 20 of 45 criminally suspicious deaths he helped investigate between 1991 and 2001. Parents or other caregivers were charged in most of the cases, though many have since been cleared.

The outside experts told the inquiry Smith came to conclusions that were clearly unjustified, gave speculative and misleading testimony and seemed to have no training in forensic pathology.

Top officials of the coroner's office said they generally overlooked the mistakes for more than a decade.

Colleagues testified to Smith's disorganized, tardy work habits.

Though he was certified as a pediatric pathologist, he conceded Monday he received virtually no formal training in forensic pathology - dealing with cases that have a legal aspect.

"It was self taught, it was minimal," he said of his knowledge of the field. "In retrospect, I realize it was woefully inadequate."

He also confessed to receiving little training in being an expert witness at criminal trials, apart from a two-day course he took in the United States.

"I thought I knew it, but I realize now just how profoundly ignorant I was."

Sherry Sherret, convicted of infanticide in the 1996 in the death of her four-month-old son Joshua, said she has many questions she wants to hear answered by the pathologist, whose evidence was key in her case.

"I would want to ask him . . . why did he do it, how does he feel, does he regret anything that he did," she said, but conceded that others bear some of the blame for what happened, too.

"In the long run, it's not 100 per cent his fault, because obviously, someone wasn't watching him."

National Post

Roy Meadow moving into SBS

2008-01-29T13:15:00.000-08:00

International Advisory Board

Vancouver 2008 Conference

Seventh North American Conference on

Shaken Baby Syndrome (Abusive Head Trauma)

October 5, 6 and 7, 2008

Vancouver, BC Canada

Opening of Conference Sunday, October, 5, 2008

8:00 - 12:00 p.m. (Investigation)

A Guide to the Investigation of Shaken Baby (Abusive Head Trauma) Cases:

Michel Pilon, Investigator, Professor of Criminology (Montreal, Canada) The Canadian Perspective.
Randy Watt, Assistant Chief of Police (Ogden, UT, USA) The United States Perspective.
Philip Wheeler, DCI (Abbots Langley, Herts, United Kingdom) The United Kingdom Perspective.
James Lauridson, MD, Pathologist and Medical Examiner, (Alabama, USA) Making Sense of an Autopsy Report.
Brian Holmgren, JD, (Nashville, TN, USA) What the Prosecutor Needs from the Investigator.

8:00 - 12:00 p.m. (Prevention)

Addressing Issues of Implementation and Sustaining Prevention Programs:

Evidence Based Programs and Tested Materials
Mark Dias, MD, FAAP, (Hershey, PA, USA)

Ronald G. Barr, MDCM, (Vancouver, BC, CA)

National Legislation: Opportunities and Challenges
Shared Stories of Program Directors from Canada and the United States

1:00 - 5:00 p.m. (Medical)

Other Theories: Is it Shaken Baby Syndrome (Abusive Head Trauma) or Something Else?

Randy Alexander, MD, PhD, FAAP (Jacksonville, FL, USA), Pediatrician
David Chadwick, MD, (La Mesa, CA, USA), Short Falls
Mary Case, MD, (St Louis, MO, USA), Pathology
Brian Holmgren, JD, (Nashville, TN, USA), Legal
Carole Jenny, MD, MBA (Providence, RI, USA), Biomechanics
Alex Levin, MD, MHSc, FAAP, FAAO, FRCSC (Toronto, ON, Canada), Ophthalmology
Wilbur Smith, MD, FAAP, (Detroit, MI, USA), Radiology

Keynote Address

Sunday Evening 6:00 - 8:00 p.m. October 5, 2008

Preserving Reason in the Debate about Inflicted Injuries

Sir Roy Meadow, MD (Leeds, United Kingdom)

Sunday Evening 8:00 - 10:00

Reception for all Participants

Keynote Addresses

Monday - Wednesday, October 6, 7, 8 2008

What are the Three Most Significant Developments as an Expert in your Field?

(Two Hour Presentation)

Moderator: Carole Jenny, MD, (Providence, RI, USA) Each Panel Member will describe the 3 most important developments in their field in the past three years.

Ophthalmology
Alex Levin, MD, MHSc, FAAP, FAAO, FRCSC (Toronto, ON, Canada)

Biomarkers to Detect SBS/AHT
Rachel Berger, MD, MPH (Pittsburgh, PA, USA)

Biomechanical Modeling
Susan Margulies, MD, Professor of Engineering (Philadelphia, PA, USA)

Overview of Field
Cindy Christian, MD (Philadelphia, PA, USA)

What is in a Name SBS/AHT?
Robert Block, MD, (Tulsa, OK, USA)

Surveillance and Prevention
Ronald Barr, MDCM, FRCPC (Vancouver, BC, Canada)

Workshops on Prevention, family Issues, Medical and Legal will occur throughout the day on Monday and Tuesday. Workshops will be selected by the program planning committee.

Monday October 6, 1:30 pm

Keynote Address:

Abusive Head Trauma: Where Have We Been and Where Are We Going

Ann-Christine Duhaime, MD, (Philadelphia, PA, USA)

Tuesday October 7, 8:00 am

Keynote Address:

SBS/AHT Cases: Circumstances and the Stressors of Military Life

Captain Barbara Craig, MD, FAAP (Bethesda, MD, USA);

Major Shelly Martin, MD, USAF, MC (Bethesda, MD, USA);

Kenneth Palmer, HM3 (Portsmouth, VA, USA) Father of a victim of SBS.

Mother of victim of SBS. (TBD)

Tuesday October, 1:30 pm

Keynote Address:

The Case for Shaking in Shaken Baby Syndrome

Mark Dias, MD, FAAP (Hershey, PA, USA)