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MS. J. DELAHUNTY QC and MR. R. LITTLEWOOD appeared on behalf of the Mother.
LORD D. BRENNAN QC and MS. A GRIEF appeared on behalf of the Father.
MS. M COVER and MR. P. MOTLEY appeared on behalf of the Guardian.
Crown Copyright ©
MRS. JUSTICE KING:
The family originate from Pakistan. The father has lived in England since 1999 and is a British national. He speaks fluent conversational English, although he has had the assistance of an interpreter throughout these proceedings.
29th October 2007
"I would go further and announce loud and clear that the standard of proof in finding the facts necessary to establish the threshold under section 31(2) or the welfare considerations in section 1 of the 1989 Act is the simple balance of probabilities, neither more nor less. Neither the seriousness of the allegation nor the seriousness of the consequences should make any difference to the standard of proof to be applied in determining the facts. The inherent probabilities are simply something to be taken into account, where relevant, in deciding where the truth lies."
This is a case where the allegation is that Z died as a result of a shake or a shaking/impact injury. The classic features of such a non-accidental injury, it is said were present, namely encephalopathy, subdural haemorrhage and retinal haemorrhage. This combination of injuries is known as "the triad".
"As already stated when the three elements of the triad coincide for some years conventional medical opinion has been that this is diagnostic of NAHI. Typically the brain is found to be encephalopathic; bleeding is found in the subdural space between the dura and the arachnoid subdural haemorrhages; and there are retinal haemorrhages. There may also be other pathological signs such as subarachnoid bleeding and injuries at the cranio-cervical junction. Further, there may be injuries to nerve tissue (axonal injuries) and external signs of broken bones, bruising and other obvious injuries such as extradural oedema (bruising). Determining these findings requires medical experts from a number of different disciplines interpreting often very small signs within the complex structures of an infant's brain and surrounding tissue.
The mechanism for these injuries is said to be the shaking of the infant, with or without impact on a solid surface, which moves the brain within the skull damaging the brain and shearing the bridging veins between the dura and the arachnoid. The shaking may also cause retinal haemorrhages. In the sense that the explanation for the triad is said to be caused by shaking and/or impact it also is a unified hypothesis, albeit that each element is said to be caused individually by trauma.
The triad of injuries becomes central to a diagnosis of NAHI when there are no other signs or symptoms of trauma such as bruises or fractures."
"Dr. Geddes and her colleagues, following research into almost fifty paediatric cases without head injury, proposed that the same triad of injuries could be caused by severe hypoxia (lack of oxygen in the tissues) which in turn led to brain swelling. The hypothesis was that brain swelling combined with raised intracranial pressure (ICP) could cause both subdural haemorrhages and retinal haemorrhages. Thus, it was argued that any incidents of apnoea (cessation of breathing) could set in motion a cascade of events which could cause the same injuries as seen in the triad. It will be appreciated that there are many events which could accidentally cause an episode of apnoea.
'Our observations in the present series indicate that, in the immature brain, hypoxia both alone and in combination with infection is sufficient to activate the pathophysiological cascade which culminates in altered vascular permeability and extravasation of blood within and under the dura. In the presence of brain swelling and raised intracranial pressure, vascular fragility and bleeding would be exacerbated by additional haemodynamic forces such as venous hypertension, and the effects of both sustained systemic arterial hypertension and episodic surges in blood pressure.' Thus, it was suggested that all the injuries constituting the triad could be attributed to a cause other than NAHI. We understand that this paper has been much cited in both criminal and civil trials since its publication. The criticism of Geddes III is that it is not hypoxia and/or brain swelling which causes subdural haemorrhages and retinal haemorrhages, but trauma. As an example of why the hypothesis is not correct Dr. Jaspan, giving evidence in the appeal of Rock, demonstrated that CT scans taken of Heidi's brain showed that there was little or no brain swelling at a time when subdural haemorrhages and retinal haemorrhages were shown to be present. As a result of critical papers published in the medical journals, as we have already stated, Dr. Geddes when cross-examined frankly admitted that the unified hypothesis could no longer credibly be put forward. In cross-examination she accepted that she could no longer support the hypothesis that brain swelling was the cause of subdural haemorrhages and retinal haemorrhages. She did, however, state that she believed that raised intracranial pressure (ICP) might prove to be an independent cause of both lesions. When asked by Mr. Horwell if she had published a paper on this hypothesis she said that she had not and that her research was still incomplete. It was clear from subsequent questions in cross-examination that this work was still in its early stages and that many questions remain, as yet, unresolved. In my judgment, it follows that the unified hypothesis can no longer be regarded as a credible or alternative cause of the triad of injuries. This conclusion, however, is not determinative of the four appeals before us. There are many other medical issues involved in cases of alleged NAHI. Further, there remains a body of medical opinion which does not accept that the triad is an infallible tool for diagnosis. This body of opinion, whilst recognising that the triad is consistent with NAHI, cautions against its use as a certain diagnosis in the absence of other evidence. These four appeals raise different medical issues and do not necessarily fail because the unified hypothesis has not been validated. But it does mean that the triad, itself a hypothesis, has not been undermined in the way envisaged by the authors of Geddes III"
i) The cause of an injury or an episode that cannot be explained scientifically remains equivocal.
ii) Recurrence is not in itself probative.
iii) Particular caution is necessary in any case where the medical experts disagree, one opinion declining to exclude a reasonable possibility of natural cause.
iv) The court must always be on guard against the over-dogmatic expert, the expert whose reputation or amour propre is at stake, or the expert who has developed a scientific prejudice.
v) The judge in care proceedings must never forget that today's medical certainty may be discarded by the next generation of experts or that scientific research will throw light into corners that are at present dark.
"...involves an examination of the reasons given for his opinions and... the extent to which they are supported by the evidence."
"...the internal consistency and logic of his evidence; his precision and accuracy of thought... the extent to which a witness has conceived an opinion and is reluctant to re-examine it in light of later evidence... whether or not a witness is biased or lacks independence."
"In a child case involving complex and serious injuries, the expert evidence has to be carefully analysed, fitted into the factual matrix and measured against assessments of witness credibility. To achieve justice for parents and for children, medical evidence given in court is tested fully by the advocates and family judges subject to rigorous analysis."
"The court invariably needs and invariably depends upon the help it receives from experts in this field. The expert advises, but the judge decides. The judge decides on the evidence. If there is nothing before the court, no facts or no circumstances shown to the court which throw doubt on the expert evidence, then if that is all with which the court is left, the court must accept it."
"The moral which I draw from this case and will never forget is that a hypothesis in relation to the causation of a child's injuries must not be dismissed only because such causation would be highly unusual and that, where his history contains a demonstrably rare feature, the possible nexus between that feature and his injuries must be the subject of specialist appraisal at an early stage."
The Key Issue
i) Oxygen deprivation for excess of twenty minutes;
ii) CPR for 24 minutes;
iv) Coagulation impairment;
viii) The heart collapsing first as opposed to the liver and kidneys;
ix) The second cardiac arrest with additional CPR;
xi) Ischemic changes following death.
"Such a diagnosis is a correlation of different features and though it is tempting to take each part separately, you have to take them collectively for a proper diagnosis/conclusion."
"Although you cannot see the difference between a re-bleed and trauma, we are looking the subdural haemorrhage down the microscope. If you take everything together, particularly the eyes and the history, you can conclude that, even if the subdural haemorrhage was a re-bleed, then it related to trauma/movement of the brain within the skull."
"This diagnosis is affected by other findings, for example retinal haemorrhages in this case not only exist, but are of a distribution more likely to have been caused by trauma. Then, put all those matters together and the findings take a different interpretation, one that is more likely to be of trauma."
"It is very important to remember that this is not a one-discipline diagnosis. You cannot rely on just what you see in the brain. It is suggestive and, with the other findings, it becomes a probability."
i)a) Dr. Cohen does not regard trauma as a proper diagnosis where the triad is present, but there are no external injuries such as bruises or fractures and /or a witness to the alleged shaking event.b) Dr. Squier regards trauma as very important. She is of the opinion that the triad, in the absence of evidence of trauma, is simply "no evidence of shaken baby syndrome". The triad of injuries may be due to many other factors that are not trauma. She does not accept that the triad is necessarily a strong indicator of shaken baby syndrome. In the opinion of Dr. Squirer, shaking alone may cause the triad, but the level of violence required is such that many people would be incapable of it and it would break the child's neck. She said, in terms, that she would never advise the court that trauma was the probable cause absent external injury, either seen physically with the naked eye or found at post-mortem.
ii) Both Dr. Cohen and Dr. Squier subscribe to the Geddes III hypothesis in one form or another. Put at its simplest, each are of the view that hypoxia in children can lead to subdural haemorrhages and retinal haemorrhages in the absence of trauma.
Z's presentation prior to death and the post-mortem findings
"In the presence of subdural haemorrhages, if it was going to be said the primary event was a cardiac event there would have to be an explanation for the subdural haemorrhages."
"Subdural haemorrhages were associated with non-accidental head injuries and seen in any child of this age would make you concerned as to the possibility of a non-accidental head injury."
"Limited view, but there appears to be two haemorrhages in the left fundus close to the disc (pupils only about 3mm dilated)."
"He has extensive bilateral multi-layer haemorrhages. These are most numerous in the posterior pole of each retina.
In excess of 10 deep retinal haemorrhages.
In excess of 50 superficial haemorrhages.
In excess of 5 subhyaloid haemorrhages - each eye pre-retina between the vitreous and the retina.
In the absence of metabolic or clotting, these findings are consistent with raised venous pressure caused by CPR or with shaking injury."
posterior spinal root nerves and in the lumbar region very occasional small
deposits in one or two posterior spinal roots.
pathological findings of the brain are "complex, and may well be difficult to interpret". He sets out the arguments for and against shaking as a causation. He said that the findings have to be carefully considered with the other autopsy findings, the eye examination, clinical presentation and radiological features before any final conclusion is reached.
"I had a brain in front of me with a small story. It would have been irresponsible not to allow for other possibilities. I did not have the eye pathology, only the clinical. If you want to judge my opinion, judge my final report".
"The eyes showed widespread bleeding in, and associated with, the retina and the optic nerve sheath. In particular there were widespread retinal haemorrhages in the eyes, more so in the left than the right. The haemorrhages involved, primarily, nerve fibre layer, ganglion cell layer haemorrhage, especially posteriorly. There were a number of microscopic foci and intra-retinal haemorrhages involving the layers extending up to the periphery of the retinas in both eyes. Posteriorly there were so-called pre-retinal haemorrhage, especially in the left eye and there was vitreous detachment with sub-hyaloid haemorrhage present. In the left eye a small amount of blood was present in the anterior chamber. The haemorrhage was most extensive in the subdural location, although there was bleeding in the sheath and bleeding in the orbital tissues adjacent to the optic nerve. The retinal tissues and the tissue of the optic nerve heads showed secondary oedema."
Conclusions as to pathological findings
(1) Old subdural haemorrhage of some week's duration with superimposed areas of patchy more recent subdural haemorrhage, together with widespread ischemic changes.
(2) Widespread fresh retinal haemorrhages involving all layers and occasionally extending anterior and under the retina, including ophthalmic nerve sheath haemorrhage.
(3) No evidence of resolving grip marks or skeletal injuries to the body.
(1) Hypoxia can affect the readings by shortening QT intervals.
(2) Acidosis can affect it.
(3) Autonomic tone i.e. very sick children have shortening of QT intervals.
(4) High potassium levels, as present here, would also shorten the QT intervals.
(5) The presence of a considerable amount of adrenaline, which comes as a consequence of being extremely ill, which itself shorten the QT intervals.
(6) Administrations of drugs, particularly, in this case, Amioderone, could lengthen the QT intervals.
"The evidence is that there is no recognised association. There is a very small chance that it is Short QT syndrome. I was extremely sceptical anyway on the cardiac evidence and you cannot explain retinal haemorrhage in connection with Short QT, so that makes me even more doubtful...I cannot rule it out, it is very rare and with the other findings at post-mortem, which I cannot explain with it, it would make me doubt very much the presence of this condition."
Choking/Primary Respiratory event
The accounts given by the parents
"The baby was given a feed of powdered milk at about 1700hrs and placed in a bouncer in the living room where he slept. At about 2030hrs the father came home on a break and checked on the baby who was okay. The baby then started to choke whilst asleep in the bouncer. The mother, who does not speak any English, had to call her husband to telephone for an ambulance."
"Was well until now.
He may have had a temperature 2/7 ago Calpol.
Today had been okay.
Was in cot – mother in the room.
Heard him making a noise as if to vomit, but nothing came out.
Started to have difficulty breathing sounds like gasping reflexes.
Mother called dad – working nightshift - to say there's a problem, he called brother to call ambulance.
Mother said he gasped for 5-6 minutes.
Changed colour and pale.
Then stopped breathing."
"I have made a lot of statements to a variety of people relating to Z's collapse on 29th October ... I don't think it would help to go through each one in this statement, but I know my account of Z collapsing at home is not accepted so it is important that I am clear about what I say happened and what I reported as happening."
"I am clear that Z seemed generally okay during the day and things went wrong from when he woke up after his nap at 8.15/8.30pm. He had his last feed at 6.30pm and he had gone to sleep in his baby bouncer in the front room with no problems after being winded... Z cried when he awoke, but that was not unusual. However, it was not normal for him to continue crying, as he then did, after being picked up and comforted. His cries got more persistent. I tried the usual things to sooth him. I winded him over my shoulder. I walked around the room with him. I tried to give him milk, but he resisted by moving his mouth from the teat and pushing it out of his mouth. He would not stop crying – not little ones, but big ones with tears in his eyes. He made noises as if he was trying to vomit or bring something up, but nothing did. He was crying and was clearly having difficulty in breathing. His colour changed, it became paler."
(i) The clear impression given by the father was that immediately upon telephoning his brother, he had contacted his control centre to arrange to leave and go home to his wife and children.
(ii) Both were insistent that they had only spoken to each other once.
(iii) Neither spoke of any telephone calls after the father had spoken to his brother and the mother had spoken to her mother-in-law.
(1) Z, in fact, choked;
(2) The choking was capable of causing each element of the triad, as identified at post-mortem.
Conclusions as to choking
(1) The mother gave no description of the baby choking. The word may have been used, but does not tally with her description of the sound effects or her description of Z's presentation.
(2) If Z was crying after he had choked/attempted to vomit, then he had not choked and the gasping/attempt to vomit could not be a precipitating event which led to his collapse. Dr. Peters felt the gasping noises sounded like the classic gasping noises made by a dying child.
"In the presence of chronic subdural membrane, small vessels are damaged by hypoxia and they may bleed, particularly following resuscitation which leads to reperfusion injury. I assume that the vessels of the retina, being similar to the vessels in the brain, should be subject to similar damage by hypoxia and would bleed on reperfusion".
(i) The children are all over six weeks of age, so as to avoid birth retinal haemorrhages;
(iii) respiratory failure;
(iv) clotting that was consequential upon collapse;
(vi) CPR – which represented eight cases.
"What has been seen overall is very occasional and unilateral haemorrhages with a pattern of bilateral haemorrhages in multi-levels only being seen within the cohort which represents unequivocal trauma. So far as CPR is concerned there has been one observation of retinal haemorrhages after CPR, but that was a single isolated unilateral haemorrhage. Similarly cases of hypoxia, following respiratory failure, following infection has only exhibited isolated unilateral retinal haemorrhages."
(1) Dr. Bonshek set out in his report his specific pathological findings. Mr. Lloyd and Professor Luthert agreed with his description. The only slight difference was as between Professor Luthert and Dr. Bonshek was as to what Professor Luthert called "calibration", Dr. Bonshek described the retinal haemorrhages in the left eye as moderate and the right eye as mild to moderate. The left eye he said, was considerably more severe than the right eye; in the moderate/severe range. Professor Luthert for his part referred to the left eye as moderate and the right eye as mild. He said that his categorisation may be influenced by the fact that he tends only to deal with very serious cases. He readily accepted that Dr. Bonshek was in the better position to comment having seen the actual eyes microscopically, as opposed to photographs with all their inherent disadvantages. It seems to me that the shades of description matter not. What is significant is the type, position, depth and distribution, namely that the retinal haemorrhages were bilateral through all layers both posterior and anterior and that there was haemorrhaging at the optic nerve sheath.
(2) There may well have been some progression in the bleeding in the eyes between Dr. Houston's examination in A&E and Dr. Bonshek's after death. This, however, does not detract from the fact that it is more likely that there were already extensive retinal haemorrhages when Z was first seen by Dr. Houston. In respect of their aetiology, it is immaterial whether they evolved or not.
(3) Dr. Houston's observations, or the full extent of them at that point in time, are highly unlikely to have been as a result of CPR or reperfusion.
(4) Whilst the time frame for retinal haemorrhages is 1-8 days prior to Ms. Allen's examination on 31st October, it was likely to be nearer the one day end.
(5) There is a very strong association between retinal haemorrhage and optic nerve sheath haemorrhage and cases of trauma. Resuscitation following cardio-respiratory arrest and cerebral oedema is a possible cause, but not a probable cause. Such retinal haemorrhages are usually extremely mild, even if there has been prolonged and unskilled CPR. In particular, Mr. Lloyd said that the majority of retinal haemorrhages in infants of this age are due to birth, and are very minor and clear quickly.
(6) Choking/aspiration of milk is outside of probable cause. A simple choking aspiration would not cause optical manifestations of any kind. None of the experts are aware of any instances where an episode of choking or aspiration has led to collapse where the classic triad have been evidenced.
(7) Raised intracranial pressure can cause retinal haemorrhages and optic nerve sheath haemorrhaging. The experts' meeting did not favour it as a likely cause of retinal haemorrhage in Z's case.
"I think it is generally agreed that from the overall body of published literature (subject to selection bias) is that trauma outside of the birth related haemorrhage period is the most commonly seen cause of extensive retinal haemorrhages and combined optic nerve haemorrhages...In my experience, in most instances where there is retinal haemorrhages, I see optic nerve haemorrhage so I think the two are closely linked together in this syndrome with swollen brain, subdural haemorrhage within the intracranial cavity and retinal haemorrhages."
(i) CPR alone is very unlikely to cause retinal haemorrhages, even if carried out by unskilled individuals.
(ii) Acute hypoxia, resulting from transient apnoea, has not been shown to result in the SBS picture (in particular subdural haemorrhage and retinal haemorrhage.)
The Old Subdural Haemorrhage
(i) the old subdural was at least a number of weeks old;
(ii) there was fresh blood at the location of the old subdural haemorrhage;
(iii) it is possible that the fresh blood was a consequence of a re-bleed at the site of the old subdural haemorrhage (although this is not the favoured explanation of all the experts).
"The history is the most important information from which to form a diagnosis and mother's description of Z trying to vomit was a very reasonable description of what could happen in a choke. Baby becomes hypoxic, starts to bleed, becomes coagulopathic and the bleeding gets worse."
Spinal Nerve Root Damage
"To examine the brain and spinal cord is very complex and you have to look at all areas and correlate very carefully. So an out of focus photograph of an area I cannot properly identify is wholly unacceptable. I would need to see the brain, the cord and the cranial nerves."
"However, the pathology of the triad is identical in cases where you do see grip-like bruising and the cases in which you don't".
The Expert evidence
(i) That the court must be on guard against the dogmatic expert... who has developed a scientific prejudice and:
(ii) A judge in care proceedings must never forget that today's medical certainty may be discarded by the next generation of experts.
"They come in all the defence cases, so you do not realise that they are in such a minority."
Dr. Cohen and Dr. Squier
"The triad of injuries becomes central to a diagnosis of non-accidental injury where there are no other signs or symptoms of trauma, such as bruises or fractures."
"Throw light into corners that were then dark and that the hypothesis of Dr. Geddes may yet be proven to be in all, or in part, correct."
(i) Geddes III
(ii) That trauma may only be regarded as likely causation where there is a triad plus additional external injury (or alternatively a witness) has led to their conviction in respect of SBS overwhelming their forensic analysis of the case.
(i) Their use of research material;
(ii) Their willingness to defer to the experts in another field and as part of that their acceptance of the importance of confining their respective opinion to their own expertise and;
(iii) The importance in any forensic examination of factual accuracy and in this case, in particular:(a) head circumference;(b) matter in the airways and;(c) evidence of heart failure at post mortem.
Use of research – Dr. Cohen
(i) Personal clinical experience:Dr. Al-Sarraj has carried out research into this area specifically and presented his findings to the British Neuropathology Society meeting in 2002. He took a group with hypoxic and ischemia injury only and a group with definite trauma. In twenty cases of hypoxic ischemic encephalopathy, not one single subdural haemorrhage was found. In a group of presumed shaking, the pathology was such that trauma was seen i.e. damage to the brain itself and damage to the spinal cord. (As yet this work as not been published and therefore has not been subject to peer review);
(ii) Byard's paper:Dr. Al-Sarraj felt that Byard was valuable, as it covered many centres. He too emphasised the fact that in eighty-two cases of hypoxic ischemic encephalopathy there was not one subdural haemorrhage. The importance of this paper, he said, was that all the contributors were forensic pathologists so they had medical and legal experience. It was in his view a very credible paper from a number of forensic departments. He commented that it was not clear what proportion of foetuses were used, but commented that Dr. Cohen had complained in her article that an insufficient number of foetuses made up the cohort in the Byard paper
(iii) Discussions with fellow experts:"We talk", he said, "to paediatric pathologists and the neuro-radiologists and in real life we simply just do not see subdural haemorrhages in hypoxic ischemic injuries".
(1) There was no Beta APP stain taken in order to see if there was any axonal damage;
(2) there was no examination of the spinal cord;
(3) there was no examination of the eyes and;
(4) there was no information as to the gestation of the newborn or their weight.
her oral evidence in a way which was highly technical and difficult to follow. As it was not anticipated that this hypothesis would be a key part of the evidence of Dr Cohen it had not been dealt with by any of the other experts in any detail. It does not in my judgment impact upon the overall analysis of the
(1) It is disingenuous to present the paper as a basis for providing "confirmation" of Geddes III on the basis that thirty children had subdural haemorrhages following hypoxia, where (as the Tables in the article reveal) thirteen of those children died at a day old or less.
(2) The results are entirely at odds with the work of Byard. That in itself is not fatal, there is always room for academic disagreement. It has already been noted that Byard included some foetuses in his cohort (although it would not seem many as that was a cause of complaint by Dr. Cohen). The Byard cohort however represented 82 children, including infants and toddlers, from a number of countries. Every case which fitted the entry criteria was included in the study. There were no significant underlying diseases which might have confounded the neurological interpretation.
(3) The findings are at odds with the experience of all the clinicians who gave evidence.
(4) It reaches its conclusions without the babies having been examined for retinal haemorrhages.
(5) It not only accepts Geddes III, but builds upon it.
(6) Dr. Cohen accepted in evidence that for the purposes of her study the eyes of the foetuses or neonates were not examined. She said there were research papers confirming that hypoxia leads to retinal haemorrhages. That evidence is without exception at odds with the combined view of all the ophthalmic expertise.
Use of research – Dr. Squier
"It is my opinion that the presence of the chronic subdural haemorrhage is also very significant. It is possible that this caused a seizure and collapse, or caused this baby to choke and impaired the baby's normal protective reflexes. There are well described cases in the literature of babies who have choked and presented with subdural and retinal haemorrhages (Hilton 2004, Martinez-Lage 2006)."
227. It has to be said that, within the decorous confines of maintaining professional courtesy and respect, the proposition put by Dr. Squier that these two papers provided evidence that choking can lead to subdural haemorrhage and retinal haemorrhage caused considerable professional disquiet amongst her colleagues. Dr. Bonshek said that in referring to these two articles, Dr. Squier was being "disingenuous". When this was put to Dr. Squier she said she was rather upset by such a comment and, indeed, she looked distressed.
"Circumpapillary retinal ridge in the shaken baby syndrome" by Camille Hylton and Morton Goldberg.
of the "shaken baby syndrome" diagnosis. "The clinical history was not
accepted," she said, "so there is a danger of a circular argument here,
shaking and choking". She said:
"I am not given enough evidence to know which was more important. We know shaking needs to be extremely violent and it is probably beyond the ability of a human, so it is unlikely to have been shaking. So we have to work on the basis that it is the choking that was responsible. "When one steps back and is logical", Dr. Squier went on to say "we must assume that the parent was trying to rescue from a choking episode and that that may be the basis of the subdural haemorrhages and retinal haemorrhages…… I think it was a wrong decision placing the child in foster care and an unfair decision was probably made, as the result in this case of sweeping aside an explanation of choking"
above. It was put to Dr Squier that had any third party who read her report but had not had access to the paper itself y would not have known that shaking was an essential element of the case. Dr. Squier, seemed oblivious to significance of the fact that any reader of her report would have been without that key fact; namely that it was common ground that the child had been shaken rather she replied "I try to present this evidence that subdural haemorrhages results from choking, a shake is noted but on any logical analysis that shake could not have caused it".
"Benign shaken baby syndrome. Case report" by Martinez-Lage.
taken the choke "sufficiently seriously" and she did not think that the parents would have shaken the baby hard enough to cause subdural haemorrhages.
and, if the hypoxia was leading to subdural haemorrhages, he would expect
to do so. He gave an example from the previous night when he had been
on call. During the course of the night he had dealt with two cases, one
was an accidental strangulation with a wire where the child had suffered
cardiac arrest followed by CPR and the second concerned a child who had
drowned in the bath, also leading to cardiac arrest and CPR. In each case,
Dr. Peters said the children had suffered profound hypoxia and neither had
is being carried out at Great Ormond St. where one hundred cases of fatal
hypoxia in a newborn have been recorded. The entry criteria is that the
child or infant should have died, that there should have been hypoxia or
cardiac arrest. The control samples are cases of unequivocal trauma. The
research was run between 2001 and 2006; out of the hundred children,
fourteen of the children were less than 6 months of age.
All agree that much remains unknown about SBS and the triad. It is essential, however, that Dr. Squier and others engaged on such research avoid becoming a zealots with the consequence that scientific rigour is lost or sacrificed.
(ii) Deferral to experts and keeping within one's own expertise
"Dr. Till addressed this issue very well and she was convinced upon recovery that this QT interval remained short, and she actually raised this issue. The only thing that obviously discouraged her was the presence of a retinal haemorrhage."
"It (the note of the experts meeting) says I was convinced. I am not convinced. There is a very small chance that it is QT syndrome. I was extremely sceptical anyway on the cardiac evidence and cannot explain retinal haemorrhage in conjunction with the QT."
"I'm leaving it to her, I cannot go against her."
"He (Dr Peters) is a paediatrician and if he has more information I accept it, but there is not much a paediatrician can see or hear after the event."
(iii) Factual accuracy
"It appears from the statement of Mr. Richards that this baby may have had a pre-existing intracranial bleed because the head circumference was growing abnormally fast in the first few months of life. This must be considered as a factor in considering the cause for collapse and the baby's response to hypoxia."
"The clinical history of Z's's case [sic] indicates that his head circumference was growing faster than expected; it rose from the 25th to the 91st and then returned to the 75th centile by two months of life. This may be an indication that a chronic subdural bleeding was present and was a fluid collection of fluctuating volume during this time."
"It is my opinion that the presence of the chronic subdural haemorrhage is also very significant. It is possible that this caused a seizure and collapse which caused this baby to choke and impaired the baby's normal protective reflexes."
"There are well described cases in the literature of babies who have choked and presented with subdural and retinal haemorrhages."
"In the presence of chronic subdural membrane, small vessels are damaged by hypoxia and they may bleed particularly following resuscitation which leads to reperfusion injury. I assume that the vessels of the retina, being similar to the vessels of the brain, would be subject to similar damage by hypoxia and would also bleed on reperfusion."
"Chronic subdurals cause some babies to be unwell, clearly irritable and there may be an association between old subdural haemorrhages and vulnerability to choking. The physical signs? no evidence just a reflux that did not work. The sound effect I think is consistent."
Pink frothy sputum
"The child was found with milk and vomit in his airways by the ambulance man."
c) Heart abnormality
Conclusions as to subdural haemorrhage and hypoxia.
in particular Dr. Peters. Each and every clinician is clear in their evidence, that they simply do not see subdural haemorrhages following hypoxia where there has been no trauma. Dr. Cary and Dr. Al-Sarraj, from a pathological view, agree and Dr. Cary reminds the Court that the pathology he sees, as a Home Office Pathologist, in cases of trauma is identical regardless of whether there are additional injuries such as grip marks.
"You need to be very careful. The triad is only diagnostic when it is properly worked up. The finding of subdural and retinal haemorrhages and encephalopathy are not diagnostic. When I express my view at the experts' meeting, I am making my assumption that, by the time of the meeting, each element has been worked through. I hope what I have done is tested against the science."