Analyzing and Preparing Cases Involving Medically-Based Allegations of Child Abuse

Analyzing and Preparing Cases Involving Medically-Based Allegations of Child Abuse

Bruce Boyer, JDDiana Rugh Johnson, JD, CWLS

Melissa Staas, JD

Getting It Right

• Physical abuse cases are among our most serious

• Removal of a child to foster care is sometimes necessary, but always traumatic

• Reunification after an adjudication of physical abuse can be very difficult to achieve

Case Analysis

• No up-front funds• Attorney needs to know how to go over

his/her own case• Attorney needs to read the medical records• Attorney needs to understand the medical

facts on which the diagnosis was based• Attorney needs to decide if experts need to be

consulted

Investigative Time Frame• The hours leading up to the diagnosis are NOT

the most important.• Obtain the child’s entire medical record leading

up to the injury in question– Prenatal clinic– Birth hospital– Pediatrician– Previous injuries– Previous hospitalizations– Urgent care facilities

Gathering Medical Records

• Obtain all medical records related to the injury in question– Medical Records Department– Radiology Department– Pathology Department– Emergency Department– Emergency Transport (ambulance, life flight)

Investigative Time Frame

• Obtain all medical records created after the diagnosis of the injury in question– Continued hospitalization – Subsequent hospitalization– Follow-up radiology– Therapies

Learn the TerminologyAdeno- gland Cerebro- cerebrum (part of brain)

Adreno- adrenal gland Cheilo- lip (mouth)

Angio- vessel Chondro- cartilage

Ano- anus Cilia- hair

Arterio- artery Cleido- collarbone

Arthro- joint Colpo- vagina

Balano- glans penis Coxa- hip

Blepharo- eyelid Cranio head

Broncho- bronchus (windpipe) Cyto- cell

Capit- head Derma- skin

Cardi- or Cardio- heart Emia- blood

Carpo- wrist Entero- intestines

Cephalo- head Gastro- stomach

Cerebello- cerebellum (part of brain) Gingivo- gums

Know the Parts

Know the Directional Words

Build a Reference Library

Utilize on-line resources

Communicate with others who are doing this work

• http://www.ga-innocenceproject.org/SBSSeminarMaterials-10.12.11.htm

http://www.ga-innocenceproject.org/index.html

Don’t be Intimidated by the Medical Records

• Often, the medical facts on which the case turns are written in plain English– Identify potential problems and inconsistencies

before trial– Child abuse consultation report contains a

compilation of information gathered from other sources and other specialists

– Review the reports of each specialist

Example:• Child Abuse Consult: “CT scan shows likely subdural

hematoma.”• Radiology Report: “Hyperdense material along

posterior falx is nonspecific but may represent a small amount of extraaxial blood products. Recommend repeat imaging in 24-48 hours.”

• Radiology Report: Follow-up of previous hyperdensity along posterior falx cerebri. Again demonstrated as a thin area of high density. No significant interval change, with stable thin hyperdensity along the posterior falx, representing either dural thickening or possibly a tiny amount of subdural blood.

Example:“5 day old neonate who was apparently well upon discharge except for having some fussiness with diaper changes that the parents attributed to his recent circumcision, found to have R thigh swelling after dad noticed baby was not moving his one leg when he played with his feet. On x-ray, baby has an oblique, displaced mid-shaft femur fracture with significant swelling. The history of this neonate not being irritable with diaper changes is not consistent with the fracture being present at that point in time…This injury needs to be considered non-accidental in nature, as there is not an accidental mechanism to account for the injury.”

Don’t forget the basics of lawyering

• Investigate the family– Scene investigation– Detailed interview of parents– Criminal history– Social services history– What kind of parents are they?– Interview family members– Interview neighbors & friends– Interview the pediatrician

Case #1Scene Investigation

Case #2Interviewing Family

2/17/10

Case #3Reviewing Post-Injury Records

• CPC report: 3 new rib fxs since discharge– 3/1/10 CHEST XRAY• There is a healed posterior L 7th rib fx once again

identified• There is also a slightly bulbous medial aspect of the L

9th posterior rib• Minimally displaced healing rib fxs of the R 5th, 6th, and

7th posterior ribs

3/1/10

– 3/8/10 CHEST XRAY• There are healing rib fxs noted bilaterally• The L posterior 7th rib fracture is an old one which was

reported previously• The R-sided fractures are most conspicuous at the

posterior aspect of the 5th through 7th ribs• Note is made that there also appear to be possible fxs

on the anterior aspect of the R 7th through 9th ribs

3/8/10

– 3/11/10 CHEST XRAY• Healing rib fxs of the L 5th, 7th, and 9th and R 5th, 6th, and

7th ribs demonstrate continued callous formation

3/11/10

– 3/23/10 SKELETAL SURVEY• Multiple bilateral healing and healed rib fxs are seen• The L 5th, 6th, and 9th ribs posteriorly show callus formation• There is a contour irregularity of the 7th rib medially on

the L, which may represent an old, healed fx• On the R, there are healing fxs of the 5th, 6th, and 7th

posterior ribs• There are also healing fxs seen at the anterior tips of the

8th and 9th ribs, which are more clearly seen on today’s study and were not present on 3/1/10

• A small area of periosteal new bone formation is also seen on the L 5th rib, separate from the healing fx, that was not present previously and could represent a new healing fx

3/23/10

At Trial

• Make an opening statement– Introduce your theory of the case– Give the judge a road map to the verdict you want

• Know the medical records and the timeline of the case like the back of your hand

• Prepare exhibits– X-rays make great Power Point slides– If dates are important, use a calendar

Example:• Wrist fracture

DATE TIME .pdf PAGE MED RECORDS PAGE

LOCATION DESCRIPTION

2/8/10 1854 1728817368

1653616616

NO BRUISES NO BRUISES

2/8/10 2300 1729217373

1654016621


2/9/10 0023 18168 17416 Right side of neck No description

2/9/10 2330 18168 17416 Right side of neck No description

2/10/10 0023 1775117807

1699917055

Right side of neck No description

2/10/10 0121 1775617814

1700417062


2/11/10 0153 1777217833

1702017081

Groin, neck, chest Purple

2/11/10 0918 1778417848

1703217096


2/11/10 1224 1778917854

1703717102


2/12/10 2212 1818318212

1743117460

No description No description

2/13/10 2125 1819218223

1744017471

Left hand Purple

2/14/10 0827 1819618227

1744417475

Left hand Purple

2/14/10 2135 1820218235

1745017483

Left hand Purple

2/15/10 0821 1847218505

1772017753

Left hand Purple

2/15/10 1949 1847718510

1772517758

Right arm Black

2/15/10 2211 1848118515

1772917763

Right arm Purple

Example:

February 2010Monday Tuesday Wednesday Thursday Friday Saturday Sunday

1No bruises noted in chart








9Right side of neckNo description

10Right side of neckNo description

11Groin, neck, chestPurple

12No location givenNo description

13Left handPurple

14Left handPurple

15Left handRight armBlack & purple

16No data

17No data

18No data


20No data

21No data

22HOME

23HOME

24HOME

25HOME

26HOME

27HOME

28HOME

Example:

Head InjuriesExploring Potential Differential Diagnoses, and Consulting the

Relevant Sub-specialists

Subdural Hematoma

• Treated immediately as a case suspicious for abuse

• Child abuse pediatricians may conclude “likely abuse” (i.e., “shaken baby syndrome” or “abusive head trauma”) based solely on the existence of a subdural hematoma

• However, subspecialists agree that an isolated subdural hematoma is NOT pathognomonic (i.e., diagnostic) for non-accidental trauma

Subdural Hematoma

• For the moment – let’s remove retinal hemorrhages from the equation

• Isolated subdural hematoma could be due to:– birth trauma, – pre-existing medical condition, – short-distance fall, or – some combination of the above

Benign External Hydrocephalus

• Diagnosed via macrocephaly (head circumference exceeding 90th percentile) and radiological findings of enlarged extra-axial/subarachnoid spaces

• Pediatric neurosurgeons and pediatric neurologists agree:

INFANTS WITH BEH ARE SUSCEPTIBLE TO SUBDURAL HEMATOMAS FROM MINOR TRAUMA, OR EVEN SPONTANEOUS BLEEDS

2 Examples of Peer-Reviewed, Evidence-Based Studies

• Papasian & Frim, A Theoretical Model of Benign External Hydrocephalus that Predicts a Predisposition Towards Extra-Axial Hemorrhage After Minor Head Trauma, Pediatric Neurosurgery, 2000

• McNeely et al., Subdural Hematomas in Infants with Benign Enlargement of the Subarachnoid Spaces Are Not Pathognomonic for Child Abuse, AmericaN Journal of Neuroradiology, 2006

How Do We Know that BEH May Be at Play?

• May have been missed or overlooked by the child abuse/child protection pediatrician

• Investigate:– Pediatric records for increasing head

circumference– Radiological findings and impressions– Speak with the pediatric

neurosurgeon/neurologist

Translating the Radiological Jargon

These all mean the same thing:• Benign enlargement of the subarachnoid space

(BESS)• Extra axial spaces of infancy• Benign enlargements of the extra-axial spaces• Benign subdural collections of infancy• Prominence of bilateral frontal extra-axial spaces• Benign extra cerebral fluid collections• Benign subdural effusions of infancy

Significance of the Presence of BEH

• It is a pre-existing medical condition that predisposes infants to intracranial bleeding from minor trauma, or even spontaneously

• Enlargement of the cerebrospinal fluid spaces causes stretching of the bridging veins in the subdural space, making them more vulnerable

• Subdural collections associated with BEH mimics chronic subdural hematomas due to non-accidental trauma

But What About Retinal Hemorrhages?

Non-accidental trauma is still not necessarily the most likely explanation, particularly when there has been:

• Incidental detection of subdural hematomas and retinal hemorrhaging

• Minimal or complete absence of symptoms• Absence of structural damage to the brain

Wading through the murky waters of retinal hemorrhages

• Conflicting views regarding causation, generally, and as to the role of morphology and location

• Vigorous forces ≠ violent/abusive forces• Need for photos and/or diagrams

What do the neurosurgeons say about RHs?

In various specific cases, treating pediatric neurosurgeons have opined and/or testified that the RH in that specific case were consistent with:

• Intracranial pressure• Blood travelling up the optic nerve• Birth trauma

Other explanations for subdural hematomas

• Other medical conditions (blood disorders)• Short-distance falls without pre-existing

conditions

Skull Fractures

Important to rule out a mis-reading of the suture lines, which are prominent in infants

Documents

Analyzing and Preparing Cases Involving Medically-Based Allegations of Child Abuse