He also is an expert of considerable renown. Three days: 375 | Two days: 295 | One day: 175 Her expertise within paediatric radiology covers the full range of imaging modalities including plain X-ray, ultrasound, fluoroscopy, CT, MRI, and nuclear medicine. 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 S had only been in the house with the parents, grandmother and T. Investigations were put in hand. DR KARL JOHN JOHNSON is British and resident in England. You will maintain your access to the resource throughout your 60 day catch-service period too. They both appear to value education and a need to promote this ethos with their children. 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. 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. 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. 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. The record confirms the father's account that they had been advised to use Infacol, had done so and that it was not working. In this case the local authority brings proceedings for Public Law orders relating to S, born on 18th July 2011. I found Professor Nussey to be highly knowledgeable in his field; careful; and able to consider and assist the court on all matters put to him. Her responses in the Schedule point out that the allegations are made on the presumption that S did not have any genetic abnormality or bone disease. Angry that parents like themselves could be put through such an ordeal without being able to challenge the credibility of experts called to give evidence against them, the Wards returned to the High Court. 37. I do not form the impression that they could be seen then or with hindsight can be seen now as a family seeking to hide their ill-treatment of S from the authorities. The father's main recollection seemed to be that S was "very quiet" on the Friday, although he had told the police on 24 October 2011 she was "fine" on 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. %PDF-1.6 % While the mother, in oral evidence, did not accept that she had noticed S was "not moving her arm" the previous day, although it is clearly noted by two different clinicians, she was very clear that neither she, her husband or her mother had done anything to S, nor could she remember any episode when she had cried more.27. Excellent peer interaction and collaborative learning. 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 Earlier records that day mention mother and father being present. There was then a further sharp issue over which expert should be instructed in this field which was not brought before the court until 24th May 2012. 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. It is reasonable to conclude that they were lower before then because she was breastfed. I note his view that osteogenesis imperfecta was 'exceptionally unlikely.' (4) He accepts that in relation to injuries such as these some force has to be applied. When Victoria and Jake Ward saw their baby son crying and refusing to feed, they took him to their doctor. At 17.10, the presenting complaint was noted as "swelling and pain in the left upper arm, since yesterday" [Friday] those symptoms noted by the parents "yesterday" with swelling of the left arm and "crying ++" when she was moved. The book is an important revision aid as well as an up-to-date reference. The father's responses set out a general defence to each allegation setting a number of relevant points that formed part of his evidence. Expert evidence from paediatric radiologist (Dr. Karl Johnson) and consultant paediatrician (Dr Russell Croft) was obtained and they were cross examined in Court. 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. Recurrence is not in itself probative;iii. The final section details the imaging findings in a wide variety of clinical conditions. 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. This company officer is, or was, associated with at least 1 company roles. VOIT$=EfPuP^ AiiUw~,JZ%?rG?("S{t }p# y|!W7XQb,{*|p>'A7:#;p`Wnx n&Thb !pA}ifRh0$*W@~n0?Olgj;|TO^,WicR|WV2riRm- At times she appeared to have poor recollection, which to my mind was not surprising given the sort of detail that she was required to remember after some considerable time. Akin, MD, Diagnostic Radio 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. However, the identities of the expert witnesses in the case remained shrouded in secrecy. Left knee is swollen, feels hot and tender. )_______________. 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 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. This further hearing took place on 24th October 2012.08. On 19 August 2011, two days later, there is a record in the GP notes confirming a visit by the mother and father with S. She was seen by the GP. 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. Dr. Johnson is presently the Chair of the British Society of Paediatric Radiology. Injuries to S could not have been caused by a person rolling onto her. 135; "There are areas of ignorance. Mrs K Oestreich 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. There can be no criticism that it has pursued these allegations as vigorously as it has, even if at the end of the day they have failed to satisfy me that the case is proved. Mrs K Oestreich Prof T Southwood Dr Karl Johnson: Tumour Clinic (LTB Clinic) Tuesdays once per month: Ms Baldrighi: The Transition Clinic : Four to six times per year at Queen Elizabeth Hospital on a Tuesday morning : . You can book online your appointment and hire medical insurance online. His claim that William had suffered four fractures on at least two occasions was contradicted by their assertion that he had only two fractures, both of which had probably been caused at the same time. an improved understanding of Paediatric imaging interpretation and reporting skills. Radiologists, Country Fee includes 90 days of access with unlimited playback during this time. 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. It was inevitable, that the local authority had to bring this case to court. 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. 16 the following conclusion was offered, and the parents are referred to as N and D: 'Throughout the assessment period N and D were observed to provide a high level of emotional warmth, mental stimulation and basic care for S and T which they sustained throughout the contact sessions. 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. On 24th October 2011 a skeletal survey detected what appeared to be two left rib fractures. 47. It is positive that Children's Services have no history of involvement with this family and furthermore the family have no history of involvement with the police. It is not possible to know which incidents or movements caused or gave rise to force sufficient to bring about fractures. After the birth it became apparent he had a medical problem with intestinal obstructions and severe constipation, requiring a good deal of medical attention and a surgical procedure at 3 weeks. Wanted a review(Under 'P') Discussed with Mum and Dad possible colic will continue withInfacol and see how she gets on over next week. S would often cry and it was initially believed that this was due to her suffering from colic. 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. The father's evidence was that during the morning she had cried more than normal and he confirms that she was "grumpy and crying". At this point I summarise his evidence by identifying the following features: (1) Professor Nussey has a clear and far-reaching understanding of endocrinology and the systems involved with Vitamin D and bone mineralisation. A number of strengths however have been identified during this short involvement. 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". 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. 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 memories of the parents were assiduously and closely examined by all counsel and compared with the notes written at the time.28. General radiologists and senior radiology trainees Radiologists with an interest in Paediatric Radiology The content Ten sessions over two days: Head and Neck Chest Gastrointestinal Genito-urinary MSK: Non-Traumatic Inflicted Injury: Brain MSK 1: Traumatic (inc Inflicted Injury) MSK 2: Differential diagnosis Inflicted Injury: A Medico-Legal Update He found it was not possible to conclude at what point normal day to day handling crossed over to the point when S's vulnerable bone structure was compromised and exceeded. Dr. Helen Williams is a full time general paediatric radiologist, and has special interests in cross-sectional imaging, feeding studies and radiology training. Mindelsohn Way He stated that on the Saturday morning, at bath time, the grandmother noticed her left arm was swollen and tender and she cried when being dressed or undressed. courses@infomedltd.co.uk+44(0)20 4520 5081. She was described as remaining "settled in A&E, observations in normal range, apyrexial." 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. 6. 6. Specialties The paediatric clinicians note records that "yesterday evening the parents noted [her] crying and unsettled, left leg persistently held in a flexed position." DR KARL JOHN JOHNSON is a Consultant Radiologist from Birmingham. She weighed 6lbs 15 ozs (3.15 kg) at birth and was born by emergency Caesarean section. The Consultant Paediatrician, as the locum consultant paediatrician at the local NHS trust, described himself as a 'relatively recently qualified paediatric consultant.' 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. 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. The particular issue of Vitamin D deficiency/insufficiency presents as the current medical frontier and arguably an expanding and uncertain one. 5. To summarise further, I have noted the pattern of the family's care for the children and reviewed the detail of the entries in the GP records which record S's progress and visits with the record of her developing a tendency to cry a lot from 17th August 2011 and the advice that it was possibly colic; the parents' use of Infacol and S's response to that. 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. Mr Johnson, who is chairman of the British Society of Paediatric Radiology and works as a consultant at Birmingham Children's Hospital, told police that in his view William had suffered repeated fractures and had a history of being abused. 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. The father is unable to explain how S sustained the fracture to her left arm; however, he accepts that only he, mother and grandmother were caring for S during this time; he therefore accepts that this fracture would have occurred while S was in their care. 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. While one might have looked for the possibility that in a moment of weakness or exasperation they might have snapped, or when the mother might have momentarily lost her self-control, particularly with a baby who cried persistently, that at least one fracture might have resulted, but for S to be shown with six sets of fractures, three constellations, requiring the sort of force and violence that Dr Fairhurst described, appears to be completely and demonstrably alien to the sort of people the parents and the grandmother appear to be. Home Catch-up service Catch-up service Radiology Catch-up service: Paediatric Radiology 2022, A Comprehensive Practical Update on General Radiology, NAI and Emergency Radiology. I noted from her evidence that she was concerned about and focused on the wellbeing of S. It appears that she was the first to notice distress in S; that she appeared to advise that the parents attend a doctor for every aspect of S's wellbeing. The local authority goes on to make the following allegations which I give as numbered in the Scott Schedule: 7. A diagnosis of OI (osteogenesis imperfecta) is exceptionally unlikely. Stream every session from the webinar for up to 90 days. 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. He has a special interest in paediatric musculoskeletal disorders, in particular juvenile arthritis and non-accidental injury. The maternal grandmother had no concerns in relation to the parents' care for both S and T and would like S to be returned to her parents' care.40. Rib fractures to the antero-lateral aspects of the left 8th and 9th rib (15th-28th September 2011). At no point did I observe either child to be wary of their parents. "Unfortunately the job of social workers is to think the unthinkable because sometimes terrible things happen. 20. Three days of this course provides 18 CPD credits in accordance with the CPD Scheme of the Royal College of Radiologists. 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. 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. He has co-authored over 35 peer reviewed papers. 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. The family are very close and have a loving relationship. (S> $}=I% l S2QBC(*YMhTX^Gf=,HO)t}cg3F 0s/yGUu. He had known his wife (the mother) since 1990. (5) S's Vitamin D levels, which were on the borderline on 2nd November 2011, were never higher than insufficient. 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. The mother and/or the father and/or the grandmother is the perpetrator of the injuries to S.19. 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. 5. 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. I have also noted the quotation offered by Miss Trustman from R v Harris and others [2005] EWCA Crim 1980 para. Particular difficulties were encountered with receiving the evidence of the grandmother by Skype from Sri Lanka with the connection frequently being lost and with further doubts arising over the correctness of the interpretation of her evidence. As a result of her expertise she receives both regional and national referrals for review of musculoskeletal imaging from radiological and clinical colleagues with an emphasis on imaging in cases of suspected inflicted injury. s Pediatric Diagnostic Imaging textbook is renowned as one of the oldest and most prominent general textbooks in the field of paediatric text consists of two reasonably sized volumes covering all key areas using an intuitive systems-based approach. 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. Tel: 0121 335 8260 The team Our team is made up of consultant radiologists, sonographers, radiographers, health care assistants and administrative staff. 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. As to the possibility that rough handling by T might have been responsible for S's injuries, he concluded that while it would be possible he did not think it was probable. The other parties to the case are S's parents, who are married. 17. Ms Baldrighi, Back to top of page 06. Location An X ray showed a spiral fracture of the left humerus. She moved back to London, to Great Ormond Street Hospital and the Institute of Child Health, where she obtained a PhD for her thesis, Optimisation of the digital radiographic imaging of suspected non-accidental injury, then returned to Sheffield as a HEFCE-funded Clinical Senior Lecturer in the Academic Unit of Child Health. The responses of the parents and the cases which they have put before the court appear in summary form on the Scott Schedule. England, Population There was an additional right wrist fracture which was difficult to date. 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". 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