I have noted the words of Butler-Sloss P in Re U: Re B (Serious injury; standard of proof) [2004] 2 FLR 263 and the court's responsibility to survey a 'wide canvas' and in Re L [2011] EWCA Civ 1705 that 'Clearly from the forensic standpoint given any degree of uncertainty in the medical and scientific field the judge's appraisal and confidence in the parent is absolutely crucial to the outcome.' It also records the following: "Mother is not able to recall how the fracture might have occurred: S, she advises, was using her arm less and appeared irritable from Thursday a.m. on 19/10/11 [sic 19/10 was a Wednesday] then went with Mum to have immunisations Thursday 1pm, where she was placed on a couch and not, to mother's recollection, held tightly, then seemed intermittently in discomfort with on-going reluctance to use her left arm as much as right, then today arm appeared swollen. Companies associated with this officer had at least 253,361 shareholder value in recent accounts. The Judge considered that S was seen five times at medical appointments when she was said to be suffering from fractures and noted that at those appointments not only did they not reveal the fractures but nor did they raise any suspicion about the parents. ,8KaF"*w!$uOEF!1 42. 22. 5 of my judgment on 26th March 2012. It was noted that the parents were unsure how the fracture may have happened and there had been no recent accidents of falls. . Had an instructive and engaging educational experience. Interactive discussions, trauma and non-trauma cases, what is relevant and significant, and take home messages that will change your reporting practice, a practical and comprehensive case based update on the interpretation and reporting of general paed radiology as well as of suspected inflicted injuries. Injuries to S could not have been caused by a person rolling onto her. T would often watch attentively as the parents and grandmother would feed S and hold her. 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. On being released on bail they were immediately suspended from their jobs. N and D are in a stable relationship and have known each other from childhood as they lived in the same village. In the course of surveying the 'wide canvas' of evidence I have reviewed the evidence of the mother, the father and the grandmother. S had regained and passed her birth weight. 31. The Consultant Paediatrician, as the locum consultant paediatrician at the local NHS trust, described himself as a 'relatively recently qualified paediatric consultant.' This further hearing took place on 24th October 2012.08. The Judge formed the strong impression that the parents were careful, child focused parents who had demonstrated good quality parenting dealing with S's older sibling.The Judge took into account the evidence of an endocrinologist who opined that the absence of radiologically identifiable rickets did not mean there were no rickets. After the immunisation, the parents were advised to give her Calpol. Ms Soffa has gone to considerable lengths and much detail to expose what are submitted as matters on which I should mistrust the evidence of the parents or confer on their evidence only little weight. A revised care plan was approved for the rehabilitation of S to the care of her parents. I have noted the entries in the records for 19th October when S was seen at the clinic to be weighed and that 'Nothing untoward was reported' also the entry on 20th October when S was brought to the GP surgery and given her immunisation injections and reported as 'fractious and miserable but not hugely distressed.' He arrived at the preliminary conclusion that the humeral and rib fractures must give rise to 'a high level of suspicion' for non-accidental injury. Mrs Ward, who at the time worked as a manager for child care strategy for Cambridgeshire, told BBC One's Panorama, in a documentary to be broadcast tomorrow night: "We were absolutely shocked. 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. After 22 September 2011, S was next seen at the GP surgery on the 13 October 2011. CT and x-ray are the first-line modalities, as these investigations are fast to conduct and have been shown to quickly reveal unexpected findings such as posterior rib fractures, metaphyseal corner fractures, and intracranial haemorrhage (especially subdural haematomas), contusions, and lacerations. This appeared to be strong evidence that William had been abused several times in his short life. 11. Left knee is swollen, feels hot and tender. The GP note for 20 October 2011 records "First meningitis vaccination. This could increase bone fragility and give rise to fractures at a lower force than would otherwise be the case. Dealing with the fracture to the left humerus, the father's response was that he cannot say whether or not he was present when the fracture was sustained. On 22 October a skeletal survey was performed and reported on by Dr Steven Johnson, Consultant Radiologist. We adopt the following: i. (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. The Father said in evidence that when the hospital phoned on Monday morning, his wife told them that S was "fine".21. I have taken account of the occasions when S was seen by medical staff. The impression given by this family and the parents and grandmother in particular is that they were a normal family dealing with their second baby, which by all accounts up to 13th October and indeed to 22nd October appeared to be unexceptional. That aspect is not mentioned. 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. 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. I note his conclusion that although this did not render S more likely to injury, it might increase bone fragility and thus give rise to fractures at a lower force than would otherwise be the case. The father completed a course in tourism management and completed a post-graduate degree in business management. He states that S had a tendency to cry and this was discussed with medical professionals on more than one occasion. He denies causing any of the injuries and in turn denies the specific causation of each injury. 13. The other parties to the case are S's parents, who are married. Within each chapter there are three consistent sections. The parents did not mention the previous weekend's symptoms or the trip to the hospital on 13 October 2011.24. Have you had a video or telephone consultation with us? S was sent for x-ray, which revealed a spiral fracture of the left humerus. It was also noted that the parents were unsure how it had happened and there had been no recent accidents or falls. Catch-up service: Paediatric Radiology 2022, Catch-up now with our case-based Paediatric Radiology webinar that took place in February 2022. Birmingham Update in prostate cancer Topics to include: . There is no evidence of an incident of any kind suggestive or on which an inference could be drawn that either of the parents was responsible for an injury (other of course than the X-rays of the fractures). The mother, father and grandmother all said that Infacol did eventually help for a time before her crying became worse again.15. The father's responses set out a general defence to each allegation setting a number of relevant points that formed part of his evidence. 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". The father said in evidence that her crying was first mentioned then, although there is no entry about it in the record, but the following record in the GP Notes does suggest that the Health Visitor had "advised giving her Infacol" at this point, so it probably was raised then. 33. Take a look at our extensive range of Imaging courses coming up, available virtually, on-demand and in-person, in study . 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. 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. An X-ray was performed at the time along with other tests and appeared to present no bony injury and no metaphyseal infraction. 37. 3.o-VR;+lZsA30PK#>] FP+irJBp%MU :g I{,8fVn|aQY/,E/sa8Cd8sfhD5wGtkE4*8*q0zW,7(Ic The conclusions are positive. 57 0 obj <>stream 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. Within each chapter there are three consistent sections. 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. There was an additional right wrist fracture which was difficult to date. She was discharged from hospital on 25 July 2011. 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. 11. The Health Visitor produced her records in evidence and explained that on such an occasion, the parents would undress the child and lay her on the changing mat or if the baby was being weighed, on the scales. Contents hosted on Doctuo should not be used as substitutes for professional medical advice, diagnosis or treatment. AbeBooks.com: Paediatric Radiology (Oxford Specialist Handbooks in Paediatrics) (9780199204793) by Johnson, Karl; Williams, Helen; Foster, Katharine; Miller, Claire and a great selection of similar New, Used and Collectible Books available now at great prices. Dr. Karl Johnson is a Consultant Paediatric Radiologist at Birmingham Children's Hospital, and has been there since 1998. It is simply not possible to know where the boundary lies. No temperature. Aged 20 in December 1999, she had married the father just before he came to England She joined him in this country in October 2003. The concerns of the local authority and the allegations raised against the family members arise from the appearance on X-ray scans first seen on 22nd October 2011 of a significant fracture to S's left upper arm. 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". 52. I therefore granted an adjournment so that a suitable expert could be instructed. Amaka lectures regularly on various radiology, paediatric, genetic, emergency medicine and orthopaedic courses, locally and nationally. 20. @ $ lp-5v|v3+F;%`(E4Di Birmingham Women's Hospital Mindelsohn Way Birmingham B15 2TG . Dr. The father had come to the UK in December 1999 as a student. I then ruled that Professor Nussey, an expert in the narrow and complex field of biochemical analysis coupled with endocrinology and with a particular expertise on questions of Vitamin D sufficiency/deficiency should be instructed to prepare a report by 29th June 2012. Caroline Coady Specialty: Gastrointestinal Radiology. 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. The mother also worked there.10. an improved understanding of Paediatric imaging interpretation and reporting skills. Doctors, medical appointments, hospitals, medical staff. The final section details the imaging findings in a wide variety of clinical conditions. I derive particular assistance from his evidence and the conclusion that S had a greater vulnerability to fracture, which he described as a reasonable conclusion, and at the times when they are likely to have occurred. In this case the local authority brings proceedings for Public Law orders relating to S, born on 18th July 2011. John is a Consultant Endocrinologist at Queen Elizabeth Hospital Birmingham (QEHB) and an Honorary Senior Lecturer at the University of Birmingham. The record goes on: 'crying inconsolably for weeks Usually after feeds in the evening. Dr. Gregory D. Jackson is a Radiologist in Birmingham, AL. It is to be noted that at this time, 13 October 2011, the evidence is that S had already sustained factures of the left 8th and 9th rib and was likely to have sustained her left femoral fracture and fractures to the right and left tibia. DR KARL JOHN JOHNSON is a Consultant Radiologist from Birmingham. 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. 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. The parents agreed to section 20 accommodation on 27.10.11 and on 2.11.11 the local authority issued care proceedings. The parents were unable to offer any explanations and had not observed any accidental events that may explain these injuries. I record at this point in the narrative that an important incidental date occurred on 15 September 2011, namely the starting date when according to Dr Fairhurst, the first fracture may have occurred. The 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. I go into detail on the background facts to this case which important in my consideration because they form part of the 'wide canvas' mentioned by the President Lady Butler-Sloss in the case of Re U (Serious injury: standard of proof) [2004] 2 FLR 63. As to the possible involvement of T, he asserts that he had not witnessed T twisting S's arm (or leg or wrists). The Judge formed the view that the maternal grandmother was seeking to assist the Court in her evidence. Her research interests are in the imaging of suspected child abuse and skeletal dysplasias and in methods of determining which children have fragile bones prone to fracture and which do not. greater confidence in managing the imaging of an acutely unwell child. This hearing has run over a prolonged period of months in the course of 2012; in particular because it encountered difficulties in the procurement of the services of one of the experts necessary to address the issues in the case, and also because of practical difficulties in the hearing itself in adducing the important evidence of the children's grandmother from Sri Lanka. Tell us your views in a simple 5 minute survey to help us make the service even better. Dr Caren Landes obtained her medical degree from the University of Birmingham in 1997 and was appointed a Consultant Radiologist at Alder Hey Childrens NHS Foundation Trust in 2006 and has been Clinical Lead for Radiology since 2012. The local authority sought findings that the injuries had occurred non accidentally with the parents and grandmother as possible perpetrators. Dr. Jackson's office is located at 2204 Lakeshore Dr . 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. She was born in 1979. He has extensive experience and a mature knowledge of research done in this field. 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. 41. Call. 2018 Karen Johnson Andrea Schnell, a Internist practicing in Madison, WI March 27, . 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. The X-ray revealed a spiral fracture of the left humerus. Naturally the Wards hoped social services would follow suit, but they were in for a shock. Left upper arm fracture, a spiral fracture of the distal shaft of the left humerus (16th-19th October 2011). The history squares rather more comfortably with the account given by the father in his statement than in his oral evidence. This would have involved manipulation of the legs and arms, and the conducting of other tests. I make this observation. 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. Recurrence is not in itself probative;iii. With Doctuo you can find the doctors you need. 135; "There are areas of ignorance. 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. 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. Dr. Johnson is presently the Chair of the British Society of Paediatric Radiology. 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. S could not have been injured when in a bouncy chair from normal use. On Thursday 20 October 2011 S was brought to the GP surgery by the parents and given her immunisation injections, in each thigh, by the Health Visitor. 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. 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. Rib fractures to the antero-lateral aspects of the left 8th and 9th rib (15th-28th September 2011). I have examined the process by which the fractures were discovered and that it was not until the report of Dr Fairhurst, consultant paediatric radiologist, of 13th February 2012 that the full extent of the injuries alleged to have been sustained by S were revealed and her report included three new areas of injury not seen or confirmed by earlier reports. The paediatric clinicians note records that "yesterday evening the parents noted [her] crying and unsettled, left leg persistently held in a flexed position." Because William's parents were unable to explain the fracture the hospital deemed the case suspicious and called in social services. The question arose as to whether genetic abnormality of bones, metabolic bone disease or demineralisation of the bone caused by Vitamin D deficiency gave rise to an increased propensity to fracture. The Wards were arrested and questioned by police on suspicion of grievous bodily harm and child cruelty towards William. 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