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Judges are baffled by baby’s painless skull fractures

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8703 (Published 28 December 2012) Cite this as: BMJ 2012;345:e8703
  1. Clare Dyer
  1. 1BMJ

The Court of Appeal has quashed a judge’s findings that parents deliberately harmed their baby daughter, in a case described by the expert witnesses who gave evidence as “unique” and “unprecedented.”

The three appeal court judges faced a “conundrum” over the baby, who they said had experienced “spectacular” skull fractures, but had not had the “very serious brain injuries which would be expected to accompany fractures of such severity.”

They overturned the findings of Judge Katharine Marshall in care proceedings at Swindon county court that the baby’s injuries were not accidental but must have been caused by either her mother or her father. Judge Marshall had cited discrepancies in the parents’ evidence and concluded, “I am not persuaded that this is a case where the court should find that there is something unexplained, beyond current medical knowledge.”

Lord Justice Munby, sitting with Lord Justice Kitchin and Sir Stephen Sedley, said Judge Marshall’s conclusion presented “major difficulties” because it was inconsistent with what she had said elsewhere in her judgment and with the expert evidence in the case. In a “fatal” omission, she had not explained how, in the light of the expert evidence, she had reached her final conclusion.

The baby, referred to as “M” was admitted to hospital in August 2011 at the age of five months after what her father said was an accidental fall. She was found to have three, or possibly four, rib fractures, sustained on at least two occasions, and complex bilateral skull fractures.

In her judgment in August 2012, Judge Marshall said, “The skull fractures are spectacular, so complex and extensive that they have been described by the experts as beyond anything they have seen before in a child of M’s age in their considerable collective experience.

“Her clinical presentation, in that she appeared to be reasonably well and suffering no apparent pain or neurological effects, was not just unusual in the circumstances, but inexplicable. This conundrum has perplexed the experts involved and goes to the heart of this case.”

M’s mother said she had squeezed the baby’s ribs on one occasion in July 2011 to avoid dropping her when she fell out of the bath. The following month, the day before she was x rayed, her father said he had dropped her and she had hit her head on a low table before hitting the floor.

The county court heard from four experts—two consultant paediatric radiologists, a consultant paediatric neurosurgeon, and a professor of paediatric bone disease. The professor concluded that M’s bones were normal.

In evidence at the county court the neurosurgeon described the findings as “minimal scalp swelling...no underlying injury to the brain...no pain on presentation...so there is something strange going on in this case.” He added, “Most people that I have seen of all age groups, with that degree of fracturing have either been unconscious in intensive care units or dead.”

Lord Justice Munby said the only research material to which Judge Marshall had been referred was a study in which the bodies of dead babies had been dropped on their heads to see if their skulls fractured. In a case in which it was being asserted that something unprecedented and inexplicable had happened, the judge should surely have been taken to such literature as there was, he said.

The appeal court judges sent the case to be re-tried by a High Court family division judge, after an extensive search of the literature. Lord Justice Munby acknowledged that the search might produce nothing, leaving the new judge with “the same inexplicable mystery as confronted Judge Marshall.”

Notes

Cite this as: BMJ 2012;345:e8703