He found it was not possible to conclude at what point normal day to day handling crossed over to the point when S's vulnerable bone structure was compromised and exceeded. Victoria and Jake Ward and William, right. To summarise further, I have noted the pattern of the family's care for the children and reviewed the detail of the entries in the GP records which record S's progress and visits with the record of her developing a tendency to cry a lot from 17th August 2011 and the advice that it was possibly colic; the parents' use of Infacol and S's response to that. 6. %PDF-1.6 % The maternal grandmother denied harming S and did not accept that her daughter or son-in-law would not do the same. This judgment relates to the fact finding hearing concerned with the causation of a number of bone fractures sustained by S at about the age of three months. 8. The local authority goes on to make the following allegations which I give as numbered in the Scott Schedule: 7. Fee includes 90 days of access with unlimited playback during this time. Formula feeding for 8-9 weeks before the test would have provided some improvement but not enough, as breastfeeding would provide none. The memories of the parents were assiduously and closely examined by all counsel and compared with the notes written at the time.28. You can book online your appointment and hire medical insurance online. The local authority alleges that the potential perpetrators of the multiple injuries to S are the mother, father and grandmother, who were the carers of the child. I have also noted in relation to the injuries that it is 'always open to a judge to rule that the cause of the injury remains unknown' and the case of Re R (Care proceedings: causation) [2011] EWHC 1715, a decision of Mr Justice Hedley. Location %r W!p-zC1')v?nP=^:;J2wFT$8N&j An X-ray was performed at the time along with other tests and appeared to present no bony injury and no metaphyseal infraction. The X-ray revealed a spiral fracture of the left humerus. Call. There are a number of other features of the evidence about the parents which I must take into account as part of the 'wide canvas' of evidence that I have surveyed. The family are very close and have a loving relationship. Her responses in the Schedule point out that the allegations are made on the presumption that S did not have any genetic abnormality or bone disease. Ms Baldrighi, Back to top of page She also asserted that in her view there was no correlation between Vitamin D deficiency and fractures nor was there an increased propensity to fracture due to a Vitamin D deficiency. I note the entry as follows: 'non-tender, baby permits passive manipulation. She states that they do not occur accidentally and this type of fracture is highly indicative of non-accidental causation requiring a force well in excess of that used in normal day to day handling of an infant. The strong impression given is that the parents and maternal grandmother are careful, child-focused and conscientious parents who have demonstrated the quality of the attention they have given to dealing with T's special health needs and to S as they have arisen. In the absence of an explanation of the injury to S's left arm, the Consultant Paediatrician considered that there was a "high level of suspicion that the humeral and rib fractures may have been sustained as a result of non-accidental injury". In due course a consultant paediatric radiologist went on to identify fractures to the left upper arm, right lower arm, distal left femur, left and right tibia and two rib fractures. 41. She presented with no bony injury and was discharged. Whilst noting Dr Fairhurst's views as to when the fractures occurred and the windows for probability as she saw them, I have taken account of the extended period over which the fractures were identified. An X-ray showed a spiral fracture of the left humerus. hbbd``b`J5 `n\ a#H #e \ Metaphyseal fractures result from pulling and twisting being applied to the limb. 0 On being released on bail they were immediately suspended from their jobs. I return to consider T and his behaviour later in this judgment.12. The left tibia fracture was likely to have occurred between 3rd and 10th October and the likely time frame for the left humeral fracture was between 16th and 19th October. A diagnosis of OI (osteogenesis imperfecta) is exceptionally unlikely. I noted from her evidence that she was concerned about and focused on the wellbeing of S. It appears that she was the first to notice distress in S; that she appeared to advise that the parents attend a doctor for every aspect of S's wellbeing. 3. I never observed either parent react angrily towards each other or either child. Book yoUR 2023 CME TODAY. S was discharged and the parents reported that her knee improved. At para. He appeared to be frank and open in his answers and not devious. What followed next led, eventually, to the diagnosis of a fracture in S's left upper arm. Considering the totality of the evidence the Judge found the likely incidence of an increased vulnerability to fracture was the most likely cause of S's injuries. Naturally the Wards hoped social services would follow suit, but they were in for a shock. Fractures of the antero-lateral aspects of the left 8th and 9th ribs were caused by (a) a direct blow or compressive forces applied to her chest by an adult carer, (b) she would have shown distress for 10-15 minutes and shown discomfort when her chest was moved such as when she was dressed and a regular carer would know this was as a result of these fractures with discomfort lasting for a week. Rent and save from the world's largest eBookstore. Extensive high quality images throughout the book, and additional illustrations, aid the reader with diagnosis and detailed referencing points to further reading. While one might have looked for the possibility that in a moment of weakness or exasperation they might have snapped, or when the mother might have momentarily lost her self-control, particularly with a baby who cried persistently, that at least one fracture might have resulted, but for S to be shown with six sets of fractures, three constellations, requiring the sort of force and violence that Dr Fairhurst described, appears to be completely and demonstrably alien to the sort of people the parents and the grandmother appear to be. Birmingham B4 6NH, Questionnaire for parents with children aged 5-9, Monday, Wednesday and Thursday/Friday afternoon, Four to six times per year at Queen Elizabeth Hospital on a Tuesday morning. Dr. Robert H. Thomas is a Radiologist in Birmingham, AL. I am satisfied that neither the mother, the father, nor the grandmother can be held responsible for causing the injuries in a non-accidental or careless way and the court remains unable to find any one of them more likely than the others to have caused them. The record confirms the father's account that they had been advised to use Infacol, had done so and that it was not working. As for that visit on the 22 September, the Health Visitor said that S was not distressed as far as she could recall.18. No local tenderness in leg or hip", S was x-rayed, but nothing abnormal was observed. Finding of Fact Hearing in Respect of a Number of Fractures Sustained by S aged 3 months, On 13 October 2011 S was taken to hospital by her parents with a swelling to her left knee. None of the fractures could have occurred at birth. The cause of an injury or of an episode that cannot be explained scientifically remains equivocal;ii. 05. It was only fair, in my judgment, to communicate those to the parties as soon as possible with my reasons in a primary judgment with a fuller judgment to follow to bring the period of waiting for the result to an end for the family as well as for other parties. Karl Johnson is a Consultant Paediatric Radiologist at Birmingham Children's Hospital, and has been there since 1998. 16 the following conclusion was offered, and the parents are referred to as N and D: 'Throughout the assessment period N and D were observed to provide a high level of emotional warmth, mental stimulation and basic care for S and T which they sustained throughout the contact sessions. 55. The father accepts that only he, the mother and the grandmother were caring for S during this time. Tel: 0121 335 8260 The team Our team is made up of consultant radiologists, sonographers, radiographers, health care assistants and administrative staff. Judge Isobel Plumstead finally concluded that Mr and Mrs Ward presented no threat to William, declaring in her judgement: "There is no cogent evidence that these parents injured their son.". 2018 Karen Johnson Andrea Schnell, a Internist practicing in Madison, WI March 27, . The fractures to the right lower leg took place between 12th September and 10th October. His research and clinical interests include the pathogenesis [.] HkBsD R#\#[(!$D(AyLgtJ%{mc8zA&+;*JV [a%4[)Er_'! This company officer is, or was, associated with at least 1 company roles. It is further positive that the professionals involved with the family have reported no concerns regarding the children's wellbeing whilst in the care of their parents prior to S being admitted to a local hospital with a fracture to her left femur.'. She refers to the times when S was seen by the health visitor when, despite the presence of fractures, nothing untoward was seen on as she puts it 25th July 2011, 3rd August 2011, 22nd September 2011, 19th October 2011 and 20th October 2011. All prices include VAT, Viewers will be asked to evaluate each session and will be provided with a CPD certificate upon completion 9. In my judgment their accounts do have a certain coherence and quality that would suggest that they have sought to do their best in bewildering circumstances. Catch-up service: Paediatric Radiology 2022, Catch-up now with our case-based Paediatric Radiology webinar that took place in February 2022. Only now, three years later, have the Wards managed to draw a line under the affair by forcing the name of the key expert witness to be made public. As I identify the main points in the chronology, I note first that Dr Fairhurst regards the 16 October 3 days after S was first seen and x-rayed at hospital as the "earliest date" on which the fracture to the left humerus occurred, and thinks it probably would have occurred before the 19 October. I therefore come to the conclusion that the local authority has not discharged the burden of proof on the balance of probabilities. 2023Check Company | Privacy | Terms of Use | Contact Us. 6. British Society of Paediatric Radiology: Paediatric MRI for general radiologists - tips and tricks 16:50 - 17:10 Musculoskeletal (MSK) imaging Dr Karl Johnson, Birmingham Children's Hospital NHS Foundation Trust Learning points In the maturing child, the marrow signal will alter depending on the amount of haemopoietic and fatty tissue within it. On 14 January 2013 I made orders and gave a foreshortened (primary) version of the judgment in this case which had run over a substantial period in 2012 and before, because having reserved judgment in what was on any view a difficult case, delays in preparing the judgment for administrative reasons and with difficulties over my own health meant the process became much longer than I would have wished. After the immunisation, the parents were advised to give her Calpol. On 22 October a skeletal survey was performed and reported on by Dr Steven Johnson, Consultant Radiologist. Summary by Georgina Clark, barrister , Field Court Chambers ___________________IN THE WATFORD COUNTY COURTWatford County Court,Cassiobury House,11-19 Station Road,Watford,Hertfordshire WD17 1EZ.20th March 2013Before:HIS HONOUR JUDGE WRIGHTBetween:A local authorityApplicantsand. The parents were unable to offer any explanations and had not observed any accidental events that may explain these injuries. Dr. Karl Johnson is a Consultant Paediatric Radiologist at Birmingham Children's Hospital, and has been there since 1998. Further X-rays revealed what appeared to be three more fractures and an injury to his arm. The family's nightmare began one night in July 2005 when, at three months old, William woke up in pain. The deal meant they could never be alone with their own son out of concern that they would cause him further harm. 35. The father said in oral evidence that S developed a pattern of crying after 3 to 4 weeks old, particularly in the evenings. I note in particular the five times when she was seen at medical appointments when she was said to be suffering fractures. Dr. Helen Williams is a full time general paediatric radiologist, and has special interests in cross-sectional imaging, feeding studies and radiology training. In the last week of the last Parliamentary session the judgement was rubber stamped into law. Earlier records that day mention mother and father being present. But in clarification of this remark Professor Nussey said that it would be reasonable to use the words 'increased vulnerability to fracture' in relation to S. 53. In relation to the spiral fracture of the distal shaft of the left humerus, the local authority allege that S's arm has been gripped and twisted by an adult carer; she would have shown immediate distress lasting 10-15 minutes; any regular carer would have noticed a change in her behaviour as a result of the fracture with discomfort which would last for up to a week. While I have taken account of inconsistencies with the records available, I did not form the view that her evidence was demonstrably or readily to be interpreted as that of someone seeking to mislead the court, cover her tracks or draw a veil of ignorance over matters about which she had some knowledge. Left lower leg fracture, a metaphyseal fracture of the left tibia (shin bone) (3rd-10th October 2011). Based primarily on the evidence of Dr Fairhurst, the local authority has levelled a broad spread of allegations against the three adults in the household at the material time the mother, father and grandmother. The parents needed to be careful over his food, medicine and health. Left leg thigh bone fracture, a torus fracture of the distal left femur (30th September-10th October 2011). 5. She took the view that the two left leg fractures (3 and 4) could have happened at the same time. There is no evidence of an incident of any kind suggestive or on which an inference could be drawn that either of the parents was responsible for an injury (other of course than the X-rays of the fractures). Find Dr. Thomas's phone number, address, hospital affiliations and more. The maternal grandmother had no concerns in relation to the parents' care for both S and T and would like S to be returned to her parents' care.40. With no help from outside agencies their couple mounted their own investigation into the cause of their son's injuries. Dr. Johnson is presently the Chair of theBritish Society of Paediatric Radiology. 03. The local authority sought findings that the injuries had occurred non accidentally with the parents and grandmother as possible perpetrators. I do not propose to set out all the instances or to address them individually: to do so would be disproportionate in the light of my observations about the evidence of the parents, having listened to them carefully, considered at length the sort of people they are, and the impression that each gave to the court. The court had no expert views on these aspects or on a number of potential issues relating to bone metabolism. X-rays I accept that the parents have displayed the same level of alertness for S as to her medical needs when they became aware that there was something wrong, as they saw it. I have also noted the case of Re S-B (Children)(Care proceedings; standard of proof) [2009] UKSC 17 and particularly the passage in which their Lordships confirmed that the simple balance of probability test following the House of Lords decision in Re B (above) should be applied in finding that a person was the perpetrator of an injury, confirming the approach where the evidence falls short of that standard in North Yorkshire County Council v SA [2003] EWCA Civ 839 to the effect that an individual will be found to be a possible perpetrator if the evidence establishes a 'real possibility' that they caused the injury. (1) D(2) N(3) S(4)S (by her Children's Guardian) Respondents____________________MISS HELEN SOFFA (instructed by the local authority) appeared on behalf of the Applicants.MR UPALI JAYATILAKA (solicitor) appeared on behalf of the Respondent Mother.MISS ALICE DESCHAMPNEUFS (instructed by solicitors) appeared on behalf of the Respondent Father.MISS JUDITH TRUSTMAN (instructed by solicitors) appeared on behalf of the Respondent Maternal Grandmother.MISS SORREL DIXON appeared on behalf of the Children's Guardian.____________________Digital Tape Transcription by:John Larking Verbatim Reporters(Verbatim Reporters and Tape Transcribers)Suite 91, Temple Chambers, 3-7 Temple AvenueLondon EC4Y 0HP.Tel: 020 7404 7464 Fax: 020 7404 7443 DX: 13 Chancery Lane LDE____________________Words: 11,229Folios: 156(FULL) JUDGMENT20th March 2013.01. The case against the Wards also relied on the view of Dr David Vickers, a community paediatrician, that if no obvious explanation could be found for an injury then child abuse was likely. The Wards were only allowed to take William home with them when they agreed to be supervised 24 hours a day by Mr Ward's parents, who had to relocate from Devon to move into the couple's home. It is reasonable to conclude that they were lower before then because she was breastfed. The Consultant Paediatrician, in his report of 5 March 2012, picks up on the record that T would become annoyed when S was unable to play with him, not understanding that it was not possible. 36. T would often watch attentively as the parents and grandmother would feed S and hold her. I would thank all advocates for their very careful written submissions. I have also noted the quotation offered by Miss Trustman from R v Harris and others [2005] EWCA Crim 1980 para. The conclusions are positive. On 3 August 2011, S and the mother were seen at home by the Community Nurse, and the record shows that the mother had no concerns. I have taken account of the fact that she gave her evidence through an interpreter while having at least a working grasp of English. (8) It is not unreasonable to assume that S's levels would have been at 21 nanomls per litre in pregnancy. 18. The note records both mother and grandmother as being present. I have noted the reported reactions of T to the birth of S. I have considered S's early developmental history after her birth; also the arrival when S was about 10 days old of the maternal grandmother from Sri Lanka to help the mother look after the children. 20. DR KARL JOHN JOHNSON is British and resident in England. (9) He anticipated that S's level was 30-35 when she was born, not adequate and markedly deficient. They were able to discuss and demonstrate that they were able to sustain routines for S during contact sessions and with T in the home. DAY 3: INFLICTED INJURIES IN CHILDREN - FRIDAY 11 FEBRUARY 2022. 5 of my judgment on 26th March 2012. But in the light of all that is known about the parents and from my impression of them in evidence balanced against all that is submitted and produced by the local authority it is not likely, in my judgment, that her injuries were caused by non-accidental force. Mrs K Oestreich There is no radiological evidence that S suffers from rickets or any other vitamin deficiency. Mr Sami Al-Ani Left upper arm fracture, a spiral fracture of the distal shaft of the left humerus (16th-19th October 2011). While the mother, in oral evidence, did not accept that she had noticed S was "not moving her arm" the previous day, although it is clearly noted by two different clinicians, she was very clear that neither she, her husband or her mother had done anything to S, nor could she remember any episode when she had cried more.27. He has been able to contribute vital knowledge and information towards understanding S's condition in August, September and October 2011. It was also noted that the parents were unsure how it had happened and there had been no recent accidents or falls. If no better, to review or sooner at any time if concerns'. Doctors, medical appointments, hospitals, medical staff. Caroline Coady Specialty: Gastrointestinal Radiology. The main functions of MRI are as follows: a. early diagnosis of CADM and fasciitis; b. differential diagnosis with other types of myopathies, such as congenital myopathy; c. locating the site for. endstream endobj 35 0 obj <>/Metadata 4 0 R/Outlines 8 0 R/Pages 32 0 R/StructTreeRoot 11 0 R/Type/Catalog>> endobj 36 0 obj <>/MediaBox[0 0 595.32 841.92]/Parent 32 0 R/Resources<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 37 0 obj <>stream (7) It is safe to extrapolate from the mother's levels taken in May 2012 that Vitamin D levels would have been lower in pregnancy. She also offered the view that the fractures were likely to have occurred on three separate occasions; the constellation of injuries was in her opinion highly indicative of non-accidental injury. At hospital on Saturday 22 October 2011 at 15.30, the triage nurse noted the presenting complaint as "swelling to the left upper arm" and "since Thursday, increased crying". She moved back to London, to Great Ormond Street Hospital and the Institute of Child Health, where she obtained a PhD for her thesis, Optimisation of the digital radiographic imaging of suspected non-accidental injury, then returned to Sheffield as a HEFCE-funded Clinical Senior Lecturer in the Academic Unit of Child Health. The parents and the maternal grandmother, she asserts, would all take care of S and T throughout the day. The father is unable to explain how S sustained the fracture to her left arm; however, he accepts that only he, mother and grandmother were caring for S during this time; he therefore accepts that this fracture would have occurred while S was in their care. Detectives removed the cot for examination. He confirmed the presence of the humeral fractures and rib fractures and, following further X-rays, identified what he thought was a healing fracture of the proximal left tibia. Birmingham, 012 133 There can be no criticism that it has pursued these allegations as vigorously as it has, even if at the end of the day they have failed to satisfy me that the case is proved. 41 0 obj <>/Filter/FlateDecode/ID[<2E609F2171D9B848924D49576AA30896>]/Index[34 24]/Info 33 0 R/Length 56/Prev 68695/Root 35 0 R/Size 58/Type/XRef/W[1 2 1]>>stream I do not form the impression that they could be seen then or with hindsight can be seen now as a family seeking to hide their ill-treatment of S from the authorities. He said: "It was a clear cut case in that there was no immediate explanation and the parents were not clear how the baby had come by his injuries. "It was a nightmare which seemed to be spiralling out of control.". The local authority issued care proceedings on 2nd November 2011. However, the identities of the expert witnesses in the case remained shrouded in secrecy. 3. I have noted and examined the oral evidence of Dr Fairhurst. The parents' observations are also a matter of record, as are the consultants' examination. The report presents what is effectively the high water mark of the extent of the injuries and the existence and extent of these injuries has not been challenged, although Miss Trustman urges the court in respect of the injuries only reported by Dr Fairhurst to approach the existence of such injuries with caution, particularly the torus fracture to the distal femur, since they were not identified by any other clinicians and their identification appears to rest on Dr Fairhurst's own expertise and experience as a consultant paediatric radiologist over 21 years. N and D are in a stable relationship and have known each other from childhood as they lived in the same village. I record at this point in the narrative that an important incidental date occurred on 15 September 2011, namely the starting date when according to Dr Fairhurst, the first fracture may have occurred. Country I accept that given T's reported boisterousness a heightened level of supervision would have been needed but that could not have been known by any of the family members at the time the fractures were likely to have been caused. . The father had not witnessed T hurting S nor does he believe he would harm her intentionally but believes he may not appreciate her fragility and may have caused harm accidentally. His father described him as "very possessive" of his baby sister, trying to open her clenched fists to place toys in them, to straighten his 'folded' arms and play with her. There had been no recent accidents or falls the cause of an episode that can not explained! 11 February 2022 enough, as are the consultants ' examination immunisation, the parents were assiduously and closely by. R v Harris and others [ 2005 ] EWCA Crim 1980 para give as numbered in the last Parliamentary the! 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