The Judge found that neither parent was seeking to cover up matters or to deal other than truthfully to the best of their ability. This company officer is, or was, associated with at least 1 company roles. Email this page You will maintain your access to the resource throughout your 60 day catch-service period too. I note his evidence as to the prevalence of Vitamin D deficiency, particularly in Asian sub-groups, and his view that the absence of radiological evidence does not mean that there is 'no rickets' i.e. UK based, CPD accredited, online courses for doctors in all of the major specialties, Navigation: 17. (5) S's Vitamin D levels, which were on the borderline on 2nd November 2011, were never higher than insufficient. The father recalled that S "cried throughout", crying as soon as the examination started although the doctor carried on. I have noted the reported reactions of T to the birth of S. I have considered S's early developmental history after her birth; also the arrival when S was about 10 days old of the maternal grandmother from Sri Lanka to help the mother look after the children. Upper limb rheumatology/radiology MDT: . I return to consider T and his behaviour later in this judgment.12. (3) It is not known why some patients with rickets become hypocalcaemic, one of the clinical pictures of rickets or Vitamin D deficiency, and why in some patients with rickets patients have fractures, some have two or three, others have none. What has emerged is that none of the adults present could provide any instance of anything done to S by themselves or the other adult members of the family, or which had befallen her, which would explain the fractures. Her special interests include musculoskeletal radiology and trauma, particularly imaging in inflicted injury. Doctors, medical appointments, hospitals, medical staff. It is simply not possible to know where the boundary lies. I never observed either parent react angrily towards each other or either child. All prices include VAT, Viewers will be asked to evaluate each session and will be provided with a CPD certificate upon completion 2018 Karen Johnson Andrea Schnell, a Internist practicing in Madison, WI March 27, . But in the light of all that is known about the parents and from my impression of them in evidence balanced against all that is submitted and produced by the local authority it is not likely, in my judgment, that her injuries were caused by non-accidental force. sub-optimal bones that have not yet developed radiological signs of rickets; (6) I note that she was not in a position to give an expert opinion on metabolic bone disease which she identified as a very complex subject beyond the radiological aspect and that she would defer to a metabolic expert; (7) she accepted that the lack of evidence for fractures occurring in patients with lower than normal levels of Vitamin D (who did not have radiological evidence of rickets) is the current state of research and acknowledged that there is a need for more study to be done; she further accepted that this is a developing and controversial area of medicine; (8) I noted that it is accepted by all medical experts that it is unknown what level of force would be required to cause the injuries in a baby that had a Vitamin D deficiency or insufficiency; understandably it is not possible for experiments to be carried out. In the last week of the last Parliamentary session the judgement was rubber stamped into law. 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. He has extensive experience and a mature knowledge of research done in this field. 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. She was between the 25th and 50th centiles for weight, and maintained the usual track after the usual loss of weight in the first week. (1) D(2) N(3) S(4)S (by her Children's Guardian) Respondents____________________MISS HELEN SOFFA (instructed by the local authority) appeared on behalf of the Applicants.MR UPALI JAYATILAKA (solicitor) appeared on behalf of the Respondent Mother.MISS ALICE DESCHAMPNEUFS (instructed by solicitors) appeared on behalf of the Respondent Father.MISS JUDITH TRUSTMAN (instructed by solicitors) appeared on behalf of the Respondent Maternal Grandmother.MISS SORREL DIXON appeared on behalf of the Children's Guardian.____________________Digital Tape Transcription by:John Larking Verbatim Reporters(Verbatim Reporters and Tape Transcribers)Suite 91, Temple Chambers, 3-7 Temple AvenueLondon EC4Y 0HP.Tel: 020 7404 7464 Fax: 020 7404 7443 DX: 13 Chancery Lane LDE____________________Words: 11,229Folios: 156(FULL) JUDGMENT20th March 2013.01. courses@infomedltd.co.uk+44(0)20 4520 5081. 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. This new, pocket handbook encompasses all aspects of paediatric radiology. The parents agreed to section 20 accommodation on 27.10.11 and on 2.11.11 the local authority issued care proceedings. 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. 44. At 6.20pm on 13 October 2011, S was brought to the local hospital, with the presenting complaint "swollen left knee started yesterday." 4. 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. Full access to the cases to follow alongside with the sessions. S's Vitamin D levels were borderline on 2.11.11 and were never higher than insufficient. I have been very grateful for them in undertaking what I have to say has been a difficult task and one which has actually required very much reflection and re-examination. an improved understanding of Paediatric imaging interpretation and reporting skills. 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. I have in particular noted the GP entry reports and the visits made by the parents for checks or routine appointments. (10) His view was that it was likely that S was Vitamin D deficient in utero and in the early neonatal period. Her case is that she came to the United Kingdom specifically to support her daughter and son-in-law with the day to day care of the children. The Judge surveyed the 'wide canvas' of the case including the manner in which the parents gave their evidence. Dr Karl Johnson, Birmingham Children s Hospital Joint tumours Dr Asif Saifuddin, Royal National Orthopaedic . S could not have been injured when in a bouncy chair from normal use. 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. 36. 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. Three days of this course provides 18 CPD credits in accordance with the CPD Scheme of the Royal College of Radiologists. Her expertise within paediatric radiology covers the full range of imaging modalities including plain X-ray, ultrasound, fluoroscopy, CT, MRI, and nuclear medicine. So the records engage even closer scrutiny. 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. I adjourned the hearing with directions for written submissions but anticipated that the particular difficulties of the case, its subject matter and the possible issues arising over evidence, required a further hearing for the parties to address the court having exchanged their submissions. 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. His research and clinical interests include the pathogenesis [.] 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. I gave a short judgment identifying the difficulties in which the paediatrician found himself in dealing with the analysis of Vitamin D deficiency/insufficiency which was outside his expertise and which presented a substantial difficulty in the case. ,(`df\CT&B6+c! 52. The parents' first child T was born on 14th February 2008. In the absence of an explanation of the injury to S's left arm, the Consultant Paediatrician considered that there was a "high level of suspicion that the humeral and rib fractures may have been sustained as a result of non-accidental injury". The local authority place considerable weight on the evidence of Dr Fairhurst as to the interpretation and significance of the X-rays, the report of 13th February 2012 and the evidence as to the mechanism of injury in relation to spiral fractures, metaphyseal fractures, fractures of the antero-lateral aspects of the ribs and a torus fracture raise very serious implications for the family members. 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. 55. It provides an overview of how to approach the imaging of children including the relative values of each of the imaging modalities for paediatric pathology. Mrs A Jester Dr Landes is radiology trauma lead and has contributed to the Royal College of Radiologists (RCR) guidance on imaging in paediatric trauma. The responses of the parents and the cases which they have put before the court appear in summary form on the Scott Schedule. I have heard the evidence of the experts as follows: (1)Dr Fairhurst, consultant paediatric radiologist, and read her reports, notably that of 13th February 2012; (2) A Consultant Paediatrician and his report of 5th March 2012; (3) I have heard the evidence of Professor Steven Nussey, Professor of Endocrinology, and read his reports of 10th and 22nd July 2012; (4) I have heard the evidence of the mother; the father; and the grandmother, and read their statements filed in this case; (5) I have heard the evidence of the health visitor. 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. A revised care plan was approved for the rehabilitation of S to the care of her parents. DR KARL JOHN JOHNSON is British and resident in England. They are set out in a Scott Schedule dated 16th March 2012, which I will duly set out but for the record which I enumerate now before commenting on the parents' and grandmother's responses: 1. endstream endobj 35 0 obj <>/Metadata 4 0 R/Outlines 8 0 R/Pages 32 0 R/StructTreeRoot 11 0 R/Type/Catalog>> endobj 36 0 obj <>/MediaBox[0 0 595.32 841.92]/Parent 32 0 R/Resources<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 37 0 obj <>stream A diagnosis of OI (osteogenesis imperfecta) is exceptionally unlikely. The burden of proof lies on the local authority and they have to satisfy the court on the balance of probabilities: see Re B (Care proceedings; standard of proof) [2008] UKHL 35. Nor is it possible to conclude at what point 'normal day to day handling' a vague phrase at best, and which must include the use of reasonable force and pressure at times crosses over to the point where S's vulnerable bone structure was compromised and exceeded. S's early developmental history, after her birth on 18 July 2011, was unremarkable at first sight: more would come to be known about her Vitamin D deficiency later, with ensuing events. Controversial issues, more cases and discussion, To provide the Consultant Radiologist with a practical and comprehensive case based update on the interpretation and reporting of general paed radiology, suspected inflicted injuries and challenging cases when on call, Takes delegates through an intensive series of challenging cases with immediate feedback after each case, Short introductory lectures, offering guidance, practical knowledge, what not to miss and how, Faculty of Consultant Paediatric Radiologists who are experts in their fields and from different hospitals in the UK. (9) He anticipated that S's level was 30-35 when she was born, not adequate and markedly deficient. Erythematous [reddening on the skin]. Several of these fractures are highly specific for non-accidental causation by an adult. Fax 847-678-6286 Tooting whose report is at E76-E 279 and Dr. Karl Johnson, consultant paediatric radiologist at the Birmingham Children's Hospital . 05. The left tibia fracture was likely to have occurred between 3rd and 10th October and the likely time frame for the left humeral fracture was between 16th and 19th October. 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. Stream every session from the webinar for up to 90 days. On the balance of probability T could not have caused the injuries to S. 16. It is not only the appearance of symptoms, and the timing and description of them with a view to dating the occurrences, even approximately, that has raised a perplexing and indistinct picture with differences in the accounts, and nothing obvious or clear to work on. The father maintains that there could be some natural explanation for S's injuries.38. Metaphyseal fractures result from pulling and twisting being applied to the limb. 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. We adopt the following: i. the fractures to the right tibia and the proximal left tibia are likely to have occurred at the same time, and that that is the likely time-frame for them both.19. 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 draw the conclusion that it is reasonable in S's case to assume that a lesser degree of force would be required if her bones were sub-optimal as a result of Vitamin D deficiency, which I am satisfied on the evidence that S's bones probably were, viz., Vitamin D deficient. Consultant Paediatric Radiologist, Chair of Paediatric Musculoskeletal Imaging, Chair, University of Sheffield's Black, Asian, and other Minority Ethnic (BAME) Staff Network, University of Sheffield and Sheffield Children's Hospital. The GP was unable to identify the cause of William's pain, but on returning home the Wards noticed his leg was swollen. T was described as "very attached to his mother" becoming jealous when mother was with S. He was described on examination as very active in clinic, playing with his sister and wanting to hold her. 8. S was referred to hospital as a paediatric emergency, the GP's impression being "?? Her parents returned with S on 22.10.11 with a swollen arm. This, unfortunately, was soon to change. 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. Book reviewed by Sana Ali, ST5 paediatric radiology, and Dr Karl Johnson, 's Hospital. 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. 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. Extensive high quality images throughout the book, and additional illustrations, aid the reader with diagnosis and detailed referencing points to further reading. 35. The local authority issued care proceedings on 2nd November 2011. That aspect is not mentioned. 43. The Wards took their son to Addenbrooke's hospital in Cambridge, where an x-ray revealed he was suffering from a spiral fracture of the lower right leg, an extremely rare condition in children who have not yet begun to walk. 20. However, she was very unsettled again by 22nd October 2011 and so the parents and grandmother took her to the A&E Department at the local hospital. A number of strengths however have been identified during this short involvement. 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. Foster spent two and a half years working in paediatricsbefore moving into radiology. Fee includes 90 days of access with unlimited playback during this time. 5. 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. The fractures at 2, 3 and 6 above were only identified by Dr Fairhurst. The Consultant Paediatrician, as the locum consultant paediatrician at the local NHS trust, described himself as a 'relatively recently qualified paediatric consultant.' If no better, to review or sooner at any time if concerns'. 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. (6) It is not possible to say what difference formula feeding might have provided because there is no baseline to measure from. 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. On 16 September 2011, S was seen for her 6-week check. 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. Injuries to S could not have been caused by a person rolling onto her. (4) He accepts that in relation to injuries such as these some force has to be applied. 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.' T would often watch attentively as the parents and grandmother would feed S and hold her. hbbd``b`J5 `n\ a#H #e \ S had regained and passed her birth weight. Dr. Johnson is presently the Chair of the British Society of Paediatric Radiology. Nothing untoward is reported by the clinician who weighed her and the Health Visitor could not recall S as being unhappy.23. Mindelsohn Way The earliest date for the left femoral fracture was 30th September but it was most likely to have occurred between 10th and 13th October. The father completed a course in tourism management and completed a post-graduate degree in business management. 07. No plausible explanation has been offered for any of these injuries. Three days: 375 | Two days: 295 | One day: 175 With no help from outside agencies their couple mounted their own investigation into the cause of their son's injuries. In due course a consultant paediatric radiologist went on to identify fractures to the left upper arm, right lower arm, distal left femur, left and right tibia and two rib fractures. 09. Summary by Georgina Clark, barrister , Field Court Chambers ___________________IN THE WATFORD COUNTY COURTWatford County Court,Cassiobury House,11-19 Station Road,Watford,Hertfordshire WD17 1EZ.20th March 2013Before:HIS HONOUR JUDGE WRIGHTBetween:A local authorityApplicantsand. The constellation of findings is highly indicative of non-accidental injury by an adult. The maternal grandmother's position can most usefully be seen as set out in her position statement of 12th March 2012. (S> $}=I% l S2QBC(*YMhTX^Gf=,HO)t}cg3F 0s/yGUu. Paediatric Radiology opens with a chapter devoted to the different imaging modalities, including radiographs, fluroscopy, ultrasoound, CT, MRI and nuclear scintigraphy before moving on to more detailed, systems-based chapters. Dr. Robert H. Thomas is a Radiologist in Birmingham, AL. The local authority goes on to make the following allegations which I give as numbered in the Scott Schedule: 7. 04. It is remarkable that these and in particular the hospital appointment of 13th October did not reveal or suggest the presence of fractures, nor did they raise any element of suspicion about the parents. The first section lists common clinical presentations, the differential causes and the appropriate imaging pathways needed to confirm the diagnosis, with recent imaging advances for each condition. there is a stage of rickets before it is identifiable radiologically. It was inevitable, that the local authority had to bring this case to court. Only now, three years later, have the Wards managed to draw a line under the affair by forcing the name of the key expert witness to be made public. Metaphyseal fracture of the proximal right tibia caused when (a) her right leg had been pulled and twisted by an adult carer; (b) she would have shown distress for 10-15 minutes and would have shown discomfort when her leg was moved. Further X-rays revealed what appeared to be three more fractures and an injury to his arm. He has a special interest in paediatric musculoskeletal disorders, in particular juvenile arthritis and non-accidental injury. It was only fair, in my judgment, to communicate those to the parties as soon as possible with my reasons in a primary judgment with a fuller judgment to follow to bring the period of waiting for the result to an end for the family as well as for other parties. The parents/grandparent who did not inflict the injuries on each occasion to S failed to protect her. 4. Show number 33. The mother, father and grandmother all said that Infacol did eventually help for a time before her crying became worse again.15. I record in relation to the father that I found his evidence and his certain directness in quality with immediate and unhesitating answers suggested a genuine response. Read, highlight, and take notes, across web, tablet, and phone. 45. 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. He refused to feed and the next day Mrs Ward took him to see her GP. 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