Commentary
As in many family cases, the issue here was the cause of the child’s injuries. It includes a distinction to be made between handling in hospital, such as holding of wrists for blood to be drawn, application of masks to assist breathing and holding of head still, to what would be expected in a normal domestic setting. It illustrates how a CMV infection complicated the court’s analysis of the evidence.
Case
When N was 20 weeks old, he was taken to hospital because his parents, M and F, were concerned about marks that that they had seen to his body. That hospital admission and various investigations that followed, led to a number of injuries being discovered to N’s body, including bruising, fractures to his lower legs, vertebra and ribs, soft tissue swelling to his scalp and bilateral subdural effusions.
This was a fact-finding hearing, to determine whether the local authority was able to prove that the injuries were inflicted/caused through rough or inappropriate handling, and if so, by whom.
Expert evidence
The following experts were instructed and reported as independent experts:
a) Dr Johnson (consultant paediatric radiologist)
b) Dr Gupta (Haemato-Oncology consultant)
c) Dr Williams (Neuroradiologist)
d) Dr Allgrove (paediatric endocrinologist)
e) Mr Jalloh (consultant paediatric neurosurgeon)
f) Dr McKiernan (consultant paediatrician specialising in paediatric liver disease)
g) Dr Morrell (Consultant paediatrician)
The court accepted that:
Radiological evidence is not determinative when considering the possibility that a child might have reduced bone strength.
The “normal ranges” for bone biochemistry in blood tests are rough and ready and dependent on the population sampled and so are of limited value.
Bone biochemistry can be “normal” even in children who have conditions disposing them to bone fragility.
There is no scientifically-measured direct relationship between reduced bone density and reduced bone strength
It was submitted that:
A difference had to be drawn between handling in hospital, such as holding of wrists for blood to be drawn, application of masks to assist breathing and holding of head still, to what would be expected in a normal domestic setting.
The degree of force cannot be determined from the degree of soft tissue scalp swelling.
A propensity for easier bruising could be relevant to the question of scalp swelling.
To examine the possibility of a non-traumatic cause such as infection, there is a need to marry up the clinical data to see if there is evidence of ongoing, active intra-cranial infection since that is the way such cases generally present.
Subdural collections in the context of vasculitis are considered rare, although they can occur.
Having considered, and produced, a small number of medical research papers in respect of a suggested association between CMV and subdural effusions, Mr Jalloh maintained his view that the subdural effusions could have either been caused by a traumatic event, or by an inflammatory process related to the CMV infection.
Dr Morrell had the benefit of coming at the end of the other medical expert evidence and considering all that had been said before, as well as being able to consider the various pieces of medical literature that had been produced during the hearing. When asked what the Court was to make of the two different expert views, one that there was no clinical evidence and the other that there appeared to be isolated examples, Dr Morrell said:
It is very difficult. I suppose what the Court can take from the experience of Dr Williams and Dr Jalloh, is that the risk of the [subdural effusions] being caused by a CMV association, is quite low. The evidence base is quite small. Looking at the research papers it is possible that they [subdural effusions] may be caused by something secondary to CMV infection, or it may be due to inflicted injury. The level of evidence is not great to decide one way or the other”
The court found that a number of the child’s injuries were caused by pinching or gripping as a result of rough or inappropriate handling, out with normal handling for a child of N’s age.