About the Family Law Week blog

The Family Law Week Blog is a companion site to Family Law Week. It complements the news, cases and articles published on Family Law Week with additional comment and coverage of the wider aspects of family law.

The Blog is edited by Jacqui Gilliatt, of 4 Brick Court and Lucy Reed, of St Johns Chambers.

Tuesday, 29 July 2008

The hidden untouchables: part 2

A small but powerful group of radiologists believe that certain types of greenstick fracture indicate abuse asserts Camilla Cavendish in the Times: I have not come across this phenomenon in relation to greenstick fractures (again I promise to research this more thoroughly and would be very grateful for feedback from anyone who knows different) although I am aware of it in relation to certain metaphsyeal fractures and rib fractures (particularly posterior in babies), for example. Greenstick fractures are almost exclusive to children. It may be that what the body of opinion believes is that greenstick fractures in babies ie non-mobile children or of a particular bony site (eg the femur) are usually NAI. If there is evidence to support a checklist approach being taken with little valid data to support it then it should be something that is raised with the relevant medical body. I have certainly seen this happen with regard to scalding injuries and certain bony injuries and with points being taken such as any delay in seeking medical attention is indicative of abuse.

One serious difficulty in this is area is that whilst unusual events do happen (see Plunkett / Geddes research) with some injuries the most likely ie more likely than not explanation is always going to be NAI and it can feel like it is then down to the parent to disprove NAI (Charles J is alive to just this point in the recent case of an alleged shaking injury where he rejected the expert evidence). In other words the medical experts assume, for example, that posterior rib fractures in babies are the result of NAI in say 80% of cases. They generally only accept an accidental explanation in the remaining 20% where there is an incident described which could account for the injury coupled with a level of distress being displayed by the child. Firstly, this presupposes that the statistics are accurate (and how much is known about how many children suffer rib fractures (when it depends on incident, presentation to hospital and bony imaging). It is often said that if minor incidents (eg older child throwing toy or stamping on younger child) caused serious injury A & E wards would see them all the time: but they do not necessarily carry out the investigations which would establish whether these injuries do in fact occur with rather less force involved. Secondly, even if a child has been injured by one carer, the other carer may only know that the child is distressed by something. It could be teething, colic, injection reaction, unsettled by environmental change etc. Experts are certainly quick to exonerate other medical professionals who do not spot serious injury (I have experience of a handful of cases where a femur fracture was not observed by a GP, physiotherapist (manipulating just that area) or health visitor (who had removed a nappy). Distress may be obvious but not the cause. A further operating assumption is as to the level of pain being suffered by the pre-verbal child (who may be being treated for some other presenting complaint by the administration of Calpol) and we can really only guess from the pain thresholds of adults and children who can articulate their pain how much complaining about pain would be normal. Often it is said that the child would have screamed the place down for several minutes to half an hour and then been constantly upset on handling in the affected area. Yet, as I have said, I have known a case in which a physiotherapist was manipulating a child's leg at a time when it had suffered a hip fracture, but this was not obvious from the child's reaction.

I absolutely agree that these issues need to be the subject of research and informed discussion. In order to achieve that there needs to be the right forum, maybe a panel of medical & other experts such as have produced numerous RCPCH publications. Case studies need to be made available to such groupings so that the underpinning scientific assumptions can be challenged. Disclosure for research is already provided for by the FPR: no doubt it could be strengthened. But what is really needed, I would argue, is a comprehensive programme of research which is properly funded and representatively scrutinised. I would particularly welcome some input from a philosophical type discipline as to how to assess fairly the possibility / probability of something being a cause when in the majority of cases it is not the cause. Do you get me?


Anonymous said...

A very interesting point about the pain threshold in babies. My family fell foul of this when our baby fractured his arm and NAI was suspected by a paediatrician. The paediatrician would only accept that the only possible reaction to a fracture was for our baby to scream the house down. A straw poll amongst friends and family (including doctors working in A&E) uncovered numerous incidents where the response to pain in children was not as "expected". Luckily for us, an all round investigation in to our family circumstances and history led to no action being taken by social services. However, it does highlight the dangers of certain operational assumptions made by paediatricians

Anonymous said...

I beleive what you said about babies not screaming in pain. We our in an investigation where our son has a fractured coller bone and he has screamed the house down but we were then told he had a healed rib fracture when he didn't make a sound about it but because we cannot explain the rib injury we have a long investigaion ahead of us.