Glaring Gaps in Medical Knowledge
Published by the Portia Campaign
There are still glaring gaps in medical knowledge about subdural haemorrhages in infants. All the more reason to avoid jumping to conclusions and convicting parents or minders of infanticide/manslaughter/murder when there is no proof of guilt.
Pathologists making forensic examination cannot rule out infection, clotting disorder or metabolic disorder. Baby Joe Mackin, allegedly murdered by Mrs Helen Stacey, of North Walsham, Norfolk, was not tested for these possibilities. We doubt if there is more than 50 percent likelihood that she is guilty. We suggest that courts, without revision, are incapable of reaching a safe conviction.
INFECTION: Not enough is known about post-infective subdural haemorrhages, as three Newcastle medical students Thomas Beckingsale, Nicholas Ohly and Stephen Land and their tutor Richard Edwards have pointed out. Infection may be a provoking factor more often than we realise.
CLOTTING DISORDER: A recent article in the BMJ states that a clotting screen should be done in all cases. That information concerning the Mackin child is missing.
METABOLIC DISORDER: Writing to the BMJ from Germany, Johannes Zschocke, Georg Hoffman and Ania Muntau said: "We were surprised that neither the authors [of a population-based study of subdural haemorrhages in infants, by S Jayawant and others, BMJ 1998; 317; 1558-1561] nor the accompanying editorial considered the possibility of metabolic disorders in their differential diagnosis.
“It is now well established that subdural haematomata after minor head trauma may be caused by disorders such as glutaric aciduria type I (GA1). We personally experienced four children with GA1 who after mild head trauma suffered intracranial bleeds, in one case even retinal haemorrhages. One child had had apparently normal development in the first months of life but during the episode suffered an acute encephalopathic crisis……The parents were accused of child abuse, and the correct diagnosis was only made four years after the event.
“Several other children with GA1 and subdural haematomata have been reported in the literature. Careful evaluation of neuroradiological findings and a good metabolic work-up including the analysis of urinary organic acids should be part of routine investigations in children with subdural haemorrhages".
[Sources: British Medical Journal and electronic responses (eBMJ 11 December 1998).
Torn blood vessels can cause clots which, over months, build pressure on the brain, according to Dr Chris Hobbs, paediatrician, leading a year-long study into this syndrome for the Royal College of Paediatrics and Child Health.
Laibe Kessler, Professor and Chief Emeritus Surgery (Neurosurgery), at Allegheny
University of the Health Sciences, said “it is a well-known surgical principle that
subdural haematomas are not, as a rule, rapidly occurring events. The usual anamnesis
is that the patient has had a bump on the head which they have forgot and hours,
days or weeks later, depending on how profuse the bleeding, they begin to have symptoms
of headache and, depending again on severity of bleeding, will deteriorate neurologically.
After a primary injury, rebleeding can occur with little provocation.”
Baby Joe Mackin could have suffered an acute encephalopathic crisis due to a metabolic disorder. An encephalopathic crisis would cause a deterioration in level of consciousness probably accompanied by a fit (which need not necessarily have been witnessed or noticed unless observed closely. This could have provoked haemorrhage in his brain and retinae, and then his general condition would have deteriorated quickly. There would have been breathing difficulties and probable vomiting; even inhalation of vomit.
There is a possibility that subdural haemorrhage may arise from a cut by the pathologist’s scalpel.
“No imaging or clinical investigations can differentiate with certainty between accidental
and inflicted injury,” said the Lancet (editorial, August 1, 1998), advising caution
against over-diagnosis of Shaken Baby Syndrome. It says there has been disagreement
about which features comprise the syndrome and how shaking might cause them. There
may be no external sign of injury to the head, or, according to Duhaime and colleagues,
writing in the New England Journal of Medicine, because the majority of infants who
are injured or killed in this way also have evidence of blunt impact to the head,
the syndrome should be called “Shaken-Impact Syndrome.”
The Lancet editorial cites “one UK paediatrician” Dr David Southall as arguing that
“it’s quite clear there is a consensus on this……with regard to subdural haemorrhage
in babies, if there are retinal haemorrhages and other injuries, then this is child
abuse. This accounts for 95 percent of cases.”
His claim was made on a TV discussion programme, to be immediately refuted by Professor
Bernard Knight; he denied there was any such consensus and added: “There are medically
witnessed cases, not many of them, of kids rolling off a settee or a chair and getting
a subdural. And saying 95% are due to NAI (non-accidental injury) still leaves you
with 5% that are not. How do we know in any particular case whether it’s the 95%
or the 5%?”
The Newsnight programme was concerned with an infant whose subdural haematoma was mistakenly attributed to non-accidental injury.
All this is described in the Lancet editorial, which concludes: “Injuries to the
head pose special difficulties, especially in the absence of any external signs of
violence. No imaging or clinical investigations can differentiate with certainty
between accidental and inflicted injury……The difficulties faced by experts in presenting
medical evidence in court, and by the judge and jury in making sense of it, are readily
imaginable. Recent successful murder prosecutions of women said to have caused an
infant’s death by shaking have increased public and professional awareness of the
‘shaken-baby syndrome.’ Let us hope that such increased awareness is tempered with
caution against over-diagnosis.”
The editorial, written with specific mention of the deaths of Matthew Eappen and Joseph Mackin, makes it evident that the Lancet believes Louise Woodward and Helen Stacey are merely said to be guilty.
Tom Watkins, of the Portia Campaign, picked up his baby daughter; her arms knocked off his spectacles; in trying to catch them the child fell, hitting her head on a concrete path. His wife could find no sign of injury. Half-an-hour later, unsatisfied, he took the baby to a doctor; an X-ray showed a fractured skull. After eight days they took her home, with a warning that if the child bumped her head again during the next six weeks it might prove fatal. Did something like this happen to Joseph Mackin or Matthew Eappen? Was there a fall from a settee on to carpeted floor? Did an elder sibling try to lift their baby brother and fail? Was there an accident with a baby-walker or a bouncer?
Jurors may wish to convict however inconclusive the evidence, and there is this factor when a minder or parent stands trial following the death of an infant. Decisions crucial for the defendant (that the damage may or may not have been incurred hours, days or weeks earlier, perhaps by accident and unnoticed at the time) are made by jurors likely to be lacking in all ability to understand the evidence, perhaps even illiterate.
For a verdict to be beyond reasonable doubt, juries in this type of trial should consist of General Practitioners or others with doctorates in medicine.
Several senior judges have made known their belief that cases involving complex financial detail should be heard without juries, in the belief that the evidence may be beyond their understanding. These issues concern mere money, and the penalties at most will be a few years in open prison. Here we are talking of murder convictions involving life sentences, shame and suffering and if the defendant continues to deny guilt there may never be release on parole.
The prosecution, by process of supposition, argues that a baby, alive and apparently well when the period of care began, died mysteriously, and therefore the child-minder must have lost her temper and shaken the baby with intent to kill. There is no evidence of this loss of temper, but it can be guessed at. The jury does just that.
At the Portia Campaign we believe that advances in medical science over the next decade will reveal more and more grounds for reasonable doubt concerning convictions for causing brain damage to infants.
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