Last week we wrote about the case of baby Effie, a baby diagnosed with the rare Ehler’s Danloss Syndrome IV, who had been returned to the care of her parents following a family court hearing. Our blog post is here :

Baby removed from parents over ‘abuse’ is found to have rare bruising condition

In that post we noted that the parents had been remarkably sanguine about the actions of professionals and the removal of their baby into foster care, recognising that those actions had been necessary from a child protection perspective whilst matters were investigated. The judge said that

1. This was clearly a very difficult episode for all concerned. It is noteworthy that the parents make no criticism of the doctors, social care nor the police for the manner or fact of the investigation. The child’s presentation on admission to hospital required a full and robust investigation but it should never be assumed that the outcome of the investigation is predictable nor that emotional responses of parents under investigation are easily anticipated. Parents respond to intervention and inquiry in very different ways and whilst those responses might inform the manner of an investigation they should not dictate it.

This week news reports have a somewhat different tone :

The Daily Mail run with :

‘Kiss your baby goodbye’: Mother recalls the horrifying moment her daughter was taken away when hospital staff wrongly thought the sick child had been assaulted

with the father quoted as saying “We were treated like monsters” and the report telling us that “the couple…want the court judgement to be made public to stop other parents being falsely accused.”

and The Times with :

Plea to wait before blaming parents over baby injuries

which begins with :

Campaigners are demanding that doctors wait 24 hours before diagnosing shaken baby syndrome to prevent parents being falsely accused of harming their child.

The report goes on to say that “About 250 cases of shaken baby syndrome are brought every year in the UK.”

That report tells us that whilst Effie was in foster care the parents “were allowed to see their daughter only three times a week for an hour and a half each under supervision”. The father is quoted in similar terms to the Mail piece :

“We were treated like monsters, in particular by the hospital staff,” Mr Stillwell said. “There was one point when Effie was having a really bad seizure and they wouldn’t even let us look at her through the glass.”

Contact in cases where a suspected shaking injury is being investigated

The three times a week for 1 ½ hours is pretty typical in this sort of case with a young baby, although it can be more or less depending on the circumstances. See here for a discussion of the issues around the frequency of contact to babies in temporary foster care. In very condensed form, from a high point where it was once suggested for young babies who were waiting for a longer term decision contact at something like 5 times a week might be justified to maintain a bond, it is now more generally acknowledged that travel and change of environment / carer can be detrimental / unsettling for very young children and that therefore contact frequency tends to be less than this, particularly if any real distance is involved that would require a young baby to spend long periods of time in a car seat (particularly a poorly one). However, much will depend on the particular circumstances of the case (health, age, distance, routine). Realistically however decisions about contact frequency are also impacted by resource pressures (room, supervisor, transport all need to be sourced and funded unless perhaps a placement is a family placement).

It would be preferable for some families to have the opportunity of staying together whilst investigations were ongoing in some sort of safe residential unit, but the cost of this is likely to be prohibitive in most cases (and many families would find things like 24 hour monitoring / CCTV unacceptably intrusive or practically impossible for example if they have jobs and pets and other children). Such units when commissioned to assess parents can cost several thousand pounds a week when on a 24 hour monitoring basis, as they would need to be if shaking were suspected.

Plea for change in practice

The “plea” which is the subject of the headline is this :

that any child should be looked at by expert paediatricians within 24 hours and basic tests carried out to determine whether its condition was likely to be caused by abuse or illness.

If abuse was suspected the case should be reported to social services, she said, but if doctors believed that illness was possible the hospital ought to carry out a review within two weeks to determine the cause.

It is made by campaign group Five Percenters, and supported by Dr Waney Squiers (a controversial expert in family proceedings who was skeptical of “shaken baby syndrome” and who was the subject of disciplinary proceedings. She was initially struck off but later successfully appealed and was reinstated, although she was still subject to some criticism and sanctions – see here).

On one level the proposals that are made probably seem like a total no-brainer. We thought it would be useful to put them in the context of what usually happens in practice in this sort of case and why. Because in fact, most of what is recommended sounds to us to be pretty much what does happen in the typical case (although of course there is variation and some cases do go wrong).

Firstly, it’s worth saying that “shaken baby syndrome” is not really something that is “diagnosed” as the article suggests. It is a set of presentations that are thought by most but not all professionals in the field to arise from shaking type injuries. Typically the symptoms that give rise to a suspicion of shaking injury are the “triad” of encephalopathy (brain injury), retinal haemorrhage (bleed in back of eye) and subdural haemorrhage (brain bleed). However, the fact that these three symptoms are present doesn’t necessarily mean a baby has been shaken. It is however, the sort of thing which is likely to cause legitimate concern on the part of medics treating a child that she might have been injured through shaking or some sort of abusive impact. So the first thing to understand is that when the article talks about “diagnosing” a child with shaken baby syndrome within 24 hours, what they really mean is that the medical team trying to work out what has caused a child to collapse will be trying to form a working hypothesis for what has happened so as to best treat the child and to try and protect it either from illness or medical problems or inflicted harm. A treating Doctor doesn’t “diagnose” that a child has been shaken by her parents – their job is to treat the child, and if they have concerns about the possibility the child has been shaken to report that to those whose job it is to investigate.

We don’t know where the figure of 250 “shaken baby cases” comes from. We guesstimate that far more than 250 such cases go through the family courts each year, and wonder whether this figure is the number of criminal prosecutions, which are likely to be significantly less.

If a child presents at hospital with an unexplained collapse and has bleeding on the brain and in the back of the eyes it is understandable that the doctors will worry about how it has been caused. We would expect that in most cases the treating team WILL have formed a working hypothesis about whether or not an injury is beginning to look like it was caused abusively or not – because until the doctors understand the cause and nature of an injury or symptom they can’t work out the best treatment plan for the child.

The doctors’ child protection duties mean that they need to tell social services and / or the police once they get to this stage. It certainly sounds as if the way things unfolded in this case was very upsetting for all involved, but in some cases discussions will proceed more calmly and arrangements can be made by agreement for the parents to be supervised when with the child, or for the child to stay with extended family whilst things are worked out.

Once social services are aware that a child has suffered very serious injuries of this sort, and when it is unclear whether those are caused by abuse or innocently, it is usually necessary to start care proceedings so that the evidence can be gathered and considered. Unfortunately in some cases social services adopt a “wait and see” approach and wait for evidence to come in, hoping it will clarify the cause so they don’t need to go to court. This is not best practice and can lead to delay in identifying the real cause and an unnecessarily long time for a child in foster care before they can be returned home, or (as appropriate) placed permanently elsewhere. This most often happens where parents without legal advice agree to their child going temporarily into foster care under Section 20 Children Act 1989 in order to demonstrate they are cooperating.

Once proceedings are issued, the family court will begin to gather evidence. That evidence will often include expert evidence from one or more disciplines, and can include (as here) testing for various genetic conditions and disorders which might explain or have contributed to the symptoms – if that has not already happened. Usually it is necessary for this to happen through a trial process, but if the expert evidence is sufficiently clear it may be that it will be agreed for a child to go home without that happening. Unfortunately for all concerned this process takes a number of months in most cases. Here the process seems to have been concluded in around 6 months, which is pretty impressive for a case involving multiple experts and a relatively lengthy trial window. But 6 months is a very long time in the life of a baby, and it is 6 months of separation that can never be got back.

The campaigners don’t identify what “basic tests” should be carried out to determine whether the injury was caused by illness or abuse, but in our experience a range of tests ARE routinely carried out to determine just this, such as CT scans, MRI scans, retinal imaging, xrays, clinical examinations, blood tests, and sometimes genetic tests. With a collapsed baby many of these tests will be carried out as a matter of urgency, and it will be that type of information that is gathered together and considered by treating doctors within a matter of hours or days to form their working hypothesis about whether or not the child looks likely to have been injured by a carer or to be suffering from some other medical condition. There are some tests for some conditions which are not routine however, and are often only picked up when a parent or lawyer insists on them being carried out in the course of care proceedings (but that depends on the lawyer being sufficiently experienced in both law and medical issues to know what to ask about). In this case it was the parents who did the research and raised the flag.

Conditions like EDS are very rare and from a clinical point of view are almost always NOT the explanation for an injury. And the tests can be very expensive. They can also be invasive and painful for a small child. So hospital staff will have to decide in each case whether a test is justified and that will often depend on whether or not there is a known family history of a particular disorder. In this case it sounds as if the family were unaware that the mother suffered from / carried EDS, and it was only later through internet research that the mother raised the issue. However in some cases the possibility of some sort of disorder will be raised earlier through interviews with the parents about any odd history, and tests will be carried out in hospital.

It would certainly be ideal if all relevant tests were carried out as early as possible so that the process of deciding on the cause of injury could be speeded up and innocent parents reunited more quickly with their children. But in most cases it would still be necessary to hold some sort of trial to consider ALL the evidence – including medical evidence, parents own accounts, police evidence, the evidence of others who saw the child around the time etc. As this case illustrates the fact that there was a diagnosis of EDS did not rule out the possibility that the child was injured by one or other of her parents (it is possible for a child who suffers from an unusual medical condition to be the victim of abusive care by a parent) – the judge still had to very carefully consider ALL the evidence very carefully, including conflicting medical evidence from some of the top experts in their field, before concluding that there was not enough evidence to make findings against the parents. In some cases expert medical evidence will say clearly that a diagnosed condition explains a broken bone or a bruise or some other injury, but in many others it will merely be one of many possibilities.

So in truth, whilst there are some cases in which tests could, with hindsight, have been carried out earlier, we are not sure that the requests for a child to be

• seen by a paediatrician in 24 hours
• for basic tests to be carried out to try and determine the cause
• for a report to be made to social services if abuse is suspected

represent anything other than current practice. The campaigners call also for a review by treating doctors after 2 weeks – in certain types of case this also happens, most often with suspected fractures where repeat scans are usually done after 10-14 days. But it could certainly be useful in some cases to have an early review because by the 2 week stage any expert evidence to be obtained through the court proceedings will not even have been commissioned. If even only a few parents can obtain evidence that shows their child to be suffering from a condition that explains the injuries they are suspected of having inflicted this must be a good thing. It could in those cases (probably a minority) lead to a much shorter period of separation and shorter, less expensive care proceedings (indeed if a 2 week review were routine it might also become routine to wait until that review was received before deciding whether to go to court at all).

Feature Pic courtesy of Abhijit Chendvankar on Flickr (via Creative Commons Licence) – thanks!