(S> $}=I% l S2QBC(*YMhTX^Gf=,HO)t}cg3F 0s/yGUu. X-rays The maternal grandmother had not witnessed T intentionally being rough or boisterous towards S and had not witnessed him attempting to hold S or pick her up. Dr. Foster spent two and a half years working in paediatricsbefore moving into radiology. The parents' first child T was born on 14th February 2008. Dr Karl Johnson, Birmingham Children s Hospital Joint tumours Dr Asif Saifuddin, Royal National Orthopaedic . 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. 52. S would often cry and it was initially believed that this was due to her suffering from colic. As to the grandmother, she gave evidence by Skype from Sri Lanka and as I have earlier said her evidence was subject to unavoidable and unfortunate technical difficulties. 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. The child appears by her children's guardian and has been represented by Miss Dixon. 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. He has extensive experience and a mature knowledge of research done in this field. The parents agreed to section 20 accommodation on 27.10.11 and on 2.11.11 the local authority issued care proceedings. In his report of 25 October 2011 the Consultant Paediatrician confirms that ophthalmological testing showed no evidence ocular trauma with healthy discs and no retinal haemorrhages seen. On the contrary, the evidence appears to demonstrate that the parents had the wellbeing of S in mind and acted to seek medical attention. The Judge found that neither parent was seeking to cover up matters or to deal other than truthfully to the best of their ability. 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. A diagnosis of OI (osteogenesis imperfecta) is exceptionally unlikely. She took the view that the two left leg fractures (3 and 4) could have happened at the same time. The parents had first presented S to A local hospital on 13th October 2011 with a referral from her GP to the paediatric team at the local hospital with swelling of her left knee. However, the medical professionals did not note any problems with S on 20th October 2011 despite Dr Fairhurst's dating of the fracture between 16th October 2011 and 19th October 2011. 3.o-VR;+lZsA30PK#>] FP+irJBp%MU :g I{,8fVn|aQY/,E/sa8Cd8sfhD5wGtkE4*8*q0zW,7(Ic Dr Neil Stoodley, Consultant Neuroradiologist, Bristol Royal Hospital for Children Dr Caren Landes, Consultant Paediatric Radiologist, Alder Hey Children's Hospital, Liverpool Dr Karl Johnson, Consultant Paediatric Radiologist, Birmingham Children's Hospital Dr Sally Old, Medical Defence Union He was earnest, straightforward and did not quibble with the questions although he did not always understand the question. No temperature. Dr Johnson, however, reported "a number of equivocal appearances on radiographs with respect to the left distal femur and proximal left tibia" and suggested further films. View more radiologists birmingham Consultations Consultations Steelhouse Lane, Birmingham, England. Over the next 10 months the Wards were visited by at least three expert witnesses who had been asked by the judge to give their opinions. Lovely baby." England, Population In reviewing the broad canvas of S's family, therefore, I have taken stock of the mother and father's background and employment and the unfortunate medical problems suffered by the couple's first child T with Hirschsprung's Disease and the particular care and attention that this child required. Nothing untoward is reported by the clinician who weighed her and the Health Visitor could not recall S as being unhappy.23. The parents' observations are also a matter of record, as are the consultants' examination. 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. 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. (9) He anticipated that S's level was 30-35 when she was born, not adequate and markedly deficient. The record confirms the father's account that they had been advised to use Infacol, had done so and that it was not working. Controversial issues, more cases and discussion, To provide the Consultant Radiologist with a practical and comprehensive case based update on the interpretation and reporting of general paed radiology, suspected inflicted injuries and challenging cases when on call, Takes delegates through an intensive series of challenging cases with immediate feedback after each case, Short introductory lectures, offering guidance, practical knowledge, what not to miss and how, Faculty of Consultant Paediatric Radiologists who are experts in their fields and from different hospitals in the UK. Country hmk0^g? Dr. Johnson is presently the Chair of the British Society of Paediatric Radiology. When S was born on 18 July 2011, T was 3 years and 5 months old. The mother, father and grandmother all said that Infacol did eventually help for a time before her crying became worse again.15. Wanted a review(Under 'P') Discussed with Mum and Dad possible colic will continue withInfacol and see how she gets on over next week. At no point did I observe either child to be wary of their parents. At 18.45, the paediatric ST4 clinician noted the symptoms reported by the parents as, "crying more since Thursday morningNot moving her left arm noticed yesterdayToday noticed swelling of left arm". He had known his wife (the mother) since 1990. S's early developmental history, after her birth on 18 July 2011, was unremarkable at first sight: more would come to be known about her Vitamin D deficiency later, with ensuing events. On 24th October 2011 a skeletal survey detected what appeared to be two left rib fractures. The local authority relied upon the evidence of the consultant paediatric radiologist who acknowledged what whilst there could be a Vitamin D deficiency there was little, if any, supporting evidence of fractures being caused by lower than normal Vitamin D levels where there is no evidence of rickets. The first time a fracture was noticed was on 22nd October despite an X-ray having been taken of S's knee on 13th October.S had been in the care of her parents and maternal grandmother when the fractures occurred. Upper limb rheumatology/radiology MDT: . There is no evidence of drugs or alcohol abuse, of anger or violent outbursts, of short temper, volatility, irritability or dysfunction. Call. 14. Dr. Johnson is presently the Chair of the British Society of Paediatric Radiology. The local authority goes on to make the following allegations which I give as numbered in the Scott Schedule: 7. While T was originally the subject of the local authority's applications at the outset when proceedings were issued on 27th October 2011, I made an order on 13th December 2011 returning him to the care of his parents and no continuing orders were made relating to him. In the light of this observation, the involvement of local Children's Services inevitably followed and the proceedings were commenced, as I have indicated in this judgment.30. She was between the 25th and 50th centiles for weight, and maintained the usual track after the usual loss of weight in the first week. Dr. I make this observation. The paediatric clinicians note records that "yesterday evening the parents noted [her] crying and unsettled, left leg persistently held in a flexed position." I therefore come to the conclusion that the local authority has not discharged the burden of proof on the balance of probabilities. Dr. Thomas' office is located at 2204 Lakeshore Dr, Birmingham . Having reviewed the evidence in detail, and after considering the written submissions of all parties, I had reached a position where I had come to my conclusions on the issues of fact. 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 Lord Justice Munby agreed with their request and in a landmark judgement in January this year ruled that expert witnesses in family courts could now be named. Presentations are kept to the minimum and then you'll be into the fully featured cloud based DICOM viewer, looking at cases, feeding back your findings using our interactive tools. 45. The father accepts that only he, the mother and the grandmother were caring for S during this time. Dr. Karl Johnson is a Consultant Paediatric Radiologist at Birmingham Children's Hospital, and has been there since 1998. Her evidence was that the earliest date for the rib fractures was 15 September, the latest date being the 28 September 2011. As it is, her persistent crying which may well have been her response to the injuries can be considered in the light of the reports of the parents about her crying and the possibility of their misinterpretation of her crying emerges as a very real consideration. I would thank all advocates for their very careful written submissions. When the cause of his pain could not be found, they took him back twice more. Dr. Karl Johnson is a Consultant Paediatric Radiologist at Birmingham Children's Hospital, and has been there since 1998. 55. This led them to suspect that he may have caught his right leg between the bars of his cot and the mattress of their own bed, causing him to fracture it as he struggled to pull it clear. It is not only the appearance of symptoms, and the timing and description of them with a view to dating the occurrences, even approximately, that has raised a perplexing and indistinct picture with differences in the accounts, and nothing obvious or clear to work on. (4) He accepts that in relation to injuries such as these some force has to be applied. 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. Filming William asleep at night they discovered he moved vigorously during his sleep, repeatedly kicking his legs. I note his view that osteogenesis imperfecta was 'exceptionally unlikely.' At that point a number of problems faced the court. As with the mother, that did not mean that there were no instances when they were confused or mistaken.48. Three days of this course provides 18 CPD credits in accordance with the CPD Scheme of the Royal College of Radiologists. 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 She refers to the fact that in relation to allegation 3, 4, 5 and 6 the mother had noticed the child's discomfort and taken S to the Medical Centre and then on to the Accident and Emergency Unit at the local hospital where S was examined by a paediatrician and X-rayed, following which she was told that everything was normal and she was discharged. This would have involved manipulation of the legs and arms, and the conducting of other tests. There is no radiological evidence that S suffers from rickets or any other vitamin deficiency. 10. hb```e``rg OP#0p4 B1 SGVp_Cb&ow!4MlPU The local authority took action on 26th October 2011 after the Consultant Paediatrician concluded that there must be a high level of suspicion in the absence of explanation of the injury to the left arm that the humeral and left rib fractures may have been sustained as a result of a non-accidental injury. In all sections, the value of all imaging modalities are stressed. They both appear to value education and a need to promote this ethos with their children. Their care of the children has been observed as of high quality. T was described as "very attached to his mother" becoming jealous when mother was with S. He was described on examination as very active in clinic, playing with his sister and wanting to hold her. Stream every session from the webinar for up to 90 days. 05. 16. The father's evidence was that during the morning she had cried more than normal and he confirms that she was "grumpy and crying". Tel: 0121 335 8260 The team Our team is made up of consultant radiologists, sonographers, radiographers, health care assistants and administrative staff. It was the maternal grandmother's view that her daughter and son-in-law did not injure S. The maternal grandmother also mentioned that she had cared for her own children, relatives and grandchildren and was capable of ensuring that children are properly and safely cared for. I do not propose to go through all the responses to the various fractures but what I have mentioned sets out much of the content and gist of the father's response and denials of the local authority's allegations.39. This new, pocket handbook encompasses all aspects of paediatric radiology. Paediatric Radiology opens with a chapter devoted to the different imaging modalities, including radiographs, fluroscopy, ultrasoound, CT, MRI and nuclear scintigraphy before moving on to more detailed, systems-based chapters. Nearby doctors Sarah Yusuf Nazia Anwar Kaushal courses@infomedltd.co.uk+44(0)20 4520 5081. "It was felt that it was a matter of such complexity and range of opinion that it was a matter for court determination.". The record concludes with the GP's comment "All well. (6) It is not possible to say what difference formula feeding might have provided because there is no baseline to measure from. HkBsD R#\#[(!$D(AyLgtJ%{mc8zA&+;*JV [a%4[)Er_'! Certificate of attendance upon completion. Mr Sami Al-Ani My approach in law to this case has been assisted by the reference made by the advocates to a number of cases in their written submissions. 2. Left upper arm fracture, a spiral fracture of the distal shaft of the left humerus (16th-19th October 2011). Metaphyseal bucket-handle fracture of the distal right radius caused when (a) her right wrist had been pulled and twisted by an adult carer; (b) any person present would be immediately aware she had suffered a significant injury. In the course of surveying the 'wide canvas' of evidence I have reviewed the evidence of the mother, the father and the grandmother. This produces a complex and difficult balance in assessing the likelihood of the infliction of the harm and the injuries as invited by the local authority. Thank you! an improved understanding of Paediatric imaging interpretation and reporting skills. Book yoUR 2023 CME TODAY. After 22 September 2011, S was next seen at the GP surgery on the 13 October 2011. 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. 57 0 obj <>stream Hence attendance at A&E.". I considered that the family members have a very close bond and I did not observe any concerns regarding their attachment. I gave a short judgment identifying the difficulties in which the paediatrician found himself in dealing with the analysis of Vitamin D deficiency/insufficiency which was outside his expertise and which presented a substantial difficulty in the case. So the records engage even closer scrutiny. 11. However, she was very unsettled again by 22nd October 2011 and so the parents and grandmother took her to the A&E Department at the local hospital. 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. Metaphyseal fracture of the proximal right tibia caused when (a) her right leg had been pulled and twisted by an adult carer; (b) she would have shown distress for 10-15 minutes and would have shown discomfort when her leg was moved. We adopt the following: i. 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. However, in due course Dr Joanna Fairhurst, consultant paediatric radiologist, identified fractures to the left upper arm, right lower arm, distal left femur, left tibia, right tibia, and two rib fractures. Mindelsohn Way She was born in 1979. Again I did not get the impression that this was a man seeking to cover up matters or deal other than truthfully to the best of his ability with matters as he remembered them. It must also raise as a real possibility the potential explanation that T may have brought about one or more fractures, along with the possibility less likely, in my view that S may have been injured when the family slept together in one bed. I have also had the benefit of the considerable amount of documentation in the bundles to which extensive reference has been made in the course of the evidence. I have in particular noted the GP entry reports and the visits made by the parents for checks or routine appointments. The parents and the maternal grandmother, she asserts, would all take care of S and T throughout the day. "Unfortunately the job of social workers is to think the unthinkable because sometimes terrible things happen. When S was 10 days old, her maternal grandmother arrived from Sri Lanka to live with the family and to help mother look after the children.13. Nor is it possible to conclude at what point 'normal day to day handling' a vague phrase at best, and which must include the use of reasonable force and pressure at times crosses over to the point where S's vulnerable bone structure was compromised and exceeded. It is simply not possible to know where the boundary lies. DAY 3: INFLICTED INJURIES IN CHILDREN - FRIDAY 11 FEBRUARY 2022. The Court reminded itself of the guidance in Re U: Re B (Serious injury: standard of proof) [2004] 2 FLR 263 and Re L [2011] EWCA Civ 1705 noting that where there is uncertainty in the medical and scientific evidence the Judge's appraisal and confidence in the parents is crucial. A week later William was placed on the council's child protection register. That theory has to overcome the difficulty that observations of S were made when she was seen at the clinic for weighing on the 19 October and for immunisations on 20 October, and the earliest reported symptom in the arm not moving her arm was on Thursday 20 October or Friday 21 October, which arguably places the timing of that fracture later than 19 October, as the Health Visitor and clinic staff could have been expected to notice or pick up symptoms and appearances that were (reportedly) evident to the parents on the Friday, and very apparent to the hospital doctors on Saturday 22 October 2011.29. He also is an expert of considerable renown. The Wards subsequently won a legal fight in the High Court for the judgement to be made public. Both gave compelling evidence that, in particular, the rib fractures suffered to the baby could only be caused by " excessive/abusive squeezing" or "gripping of the chest". He trained in Paediatrics and Radiology in Cambridge and London, and was awarded a PhD in brain imaging in 2002 from the University of Cambridge. On Wednesday 19 October 2011, S was seen at the clinic to be weighed. The parents did not mention the previous weekend's symptoms or the trip to the hospital on 13 October 2011.24. Metaphyseal fractures result from pulling and twisting being applied to the limb. In this case the local authority brings proceedings for Public Law orders relating to S, born on 18th July 2011. The evidence from the Health Visitor is that she would have been undressed for weighing and placed in the scales by her parents. S's father is represented by Miss Deschampneufs. He appeared to be frank and open in his answers and not devious. 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. They are, in my survey of the evidence, more likely to have a genuinely accidental cause, but because of the evidence of Professor Nussey taken with the evidence of the parents and from the records available it is not possible to reach a view that is more than speculative as to the timing of the injuries. 12. 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. 33. Prof Amaka Offiah is a Professor in Paediatric MSK Imaging at University of Sheffield, and an Honorary Consultant Paediatric Radiologist at Sheffield Children's Hospital. The 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. The other parties to the case are S's parents, who are married. . 4. On 22 September 2011, S is recorded as having the first of her immunisations at the Medical Centre. However, on 22nd October 2011 the parents again presented S, this time with swelling to her left arm. Now the Local authority has promptly and appropriately put into effect a revised Care Plan to give effect to the orders made that day. The appearance and identification of the fractures themselves has only emerged after the examination of the x-rays by a number of clinicians. However, the identities of the expert witnesses in the case remained shrouded in secrecy. 012 133. None of the fractures could have occurred at birth. Read, highlight, and take notes, across web, tablet, and phone. Dr. Helen Williams is a full time general paediatric radiologist, and has special interests in cross-sectional imaging, feeding studies and radiology training. 9. I note in particular the five times when she was seen at medical appointments when she was said to be suffering fractures. 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. The final section details the imaging findings in a wide variety of clinical conditions. Full access to the cases to follow alongside with the sessions. However, I note the high level of engagement with the medical services throughout T's life and the attention and care that he needed and received, caused by his own particular medical condition. 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 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 maternal grandmother's position can most usefully be seen as set out in her position statement of 12th March 2012. Metaphyseal fracture of the proximal left tibia caused when (a) her left leg had been pulled and twisted by an adult carer; (b) any person present would be immediately aware she had suffered a significant injury with discomfort lasting several days. At 22.30, a further medical clinician's note was written, although the authorship is not clear. 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. Dr Neil Stoodley, Consultant Neuroradiologist, Bristol Royal Hospital for Children Dr Musa Kaleem, Consultant Paediatric Radiologist, Alder Hey Children's Hospital, Liverpool Dr Karl Johnson, Consultant Paediatric Radiologist, Birmingham Children's Hospital Dr Sally Old, Medical Defence Union 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. Paediatric Radiology opens with a chapter devoted to the different imaging modalities, including radiographs, fluroscopy, ultrasound, CT, MRI and nuclear scintigraphy before moving on to more detailed, systems-based chapters. 3. You can book online your appointment and hire medical insurance online. On being released on bail they were immediately suspended from their jobs. Dr. Jackson's office is located at 2204 Lakeshore Dr . Added to this was the unfortunate position of counsel for the grandmother, who was not present and who had sent a message to the court that her client's public funding certificate had been embargoed for the reasons and with the consequences set out in para. The family's nightmare began one night in July 2005 when, at three months old, William woke up in pain. Yet even after the criminal case collapsed for lack of evidence and a family court finally decided that the parents posed no threat to their son, the couple were astonished to find that the names of the doctors who had given evidence against them were kept secret. Mrs A Jester She presented with no bony injury and was discharged. Paradoxically, the last fracture-type injury in time to occur (in all probability), the left humeral fracture, was the first to be identified on 22 October 2011. 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