SBS: New Forensic Patholgy Evidence

July 5, 2011,  EMILY BAZELON

Illustration courtesy of Academic Forensic Pathology Incorporated.

When I wrote about shaken baby syndrome last winter for the magazine, a Canadian pathologist named Evan Matshes was working on intriguing new research that hadn’t yet been published. Matshes’s paper is just out, in Academic Forensic Pathology, the journal of the National Association of Medical Examiners. It opens a new avenue of inquiry for this difficult and fraught diagnosis.
In the most contested cases, shaken baby syndrome is diagnosed based on a triad of internal injuries in the brain: subdural bleeding, retinal bleeding and brain swelling. There is no evidence of impact, like a skull fracture. And there’s also no obvious sign of the kind of neck injury that comes with severe whiplash. In the absence of such external injuries, biomechanical engineers have raised doubts about whether it’s even possible to shake a baby to death. Many doctors who treat abused children, on the other hand, say that clinical observations make it clear that this does happen.
Matshes’s research shows how death from shaking could in fact occur — but not because of the traditional triad of injuries to the brain. As NPR notes: “The new findings split a lot of the difference between the warring camps on shaken baby syndrome. For supporters, there’s evidence that shaking alone can lead to a baby’s death. But it also says skeptics were right to suggest it’s not the head injury that causes death and that shaking deaths are likely rare.”
In investigating the deaths of 35 babies, Matshes did autopsies in a new way. The usual practice is to dissect only part of the spinal column. Matshes dissected the spine down through the neck and into the nerve roots. What he found was striking. He looked at the spinal columns of 12 babies whose history showed evidence of injury from hyperflexion — in other words, severe whiplash, from shaking or, for example, from a car accident. In all 12, he found bleeding in the nerve roots of the part of the spinal column called C3, C4 and C5. Matshes also dissected the spinal columns of 23 babies for whom there was not solid evidence of an injury from whiplash. (Most of the babies in this group died of SIDS, or from being smothered by an adult who was sleeping with them.) Only one baby in this group of 23 had bleeding in the same C3, C4, C5 region, and that child’s history, while inconclusive, made shaking a distinct possibility.
The C3, C4 and C5 are the part of the spinal column that controls the diaphragm. Babies depend on their diaphragms to breathe more than older children or adults. So Matshes thinks that damage to these nerve roots is fatal because by paralyzing a baby’s diaphragm, it stops the baby from breathing. This internal neck injury, previously undetected, could be the missing piece of the puzzle: the causal mechanism that the biomechanical experiments haven’t accounted for.
If Matshes proves correct about this, then his work indicates that pathologists should look beyond the traditional triad of injuries in the brain, and into the spinal column, to determine whether a baby was shaken. In other words, the current standard method of establishing that a child had been killed via shaking may not be reliable. Matshes says he’s no longer comfortable relying on subdural and retinal bleeding alone — no matter how extensive — to rule a baby’s death a homicide from shaking, given other explanations that need to be ruled out. “I just don’t know if I don’t look at the neck,” he says.
I sent Matshes’s paper to four doctors, two supporters of the traditional shaken baby diagnosis and two critics. They all said the paper, while based on a small sample, pointed to a new area worthy of more research. “It’s terribly important to direct us to look at the neck,” said Waney Squier, a pediatric neuropathologist in Britain who frequently testifies for the defense in shaken baby cases. “In terms of ideas, it’s a really interesting paper,” agreed Desmond Runyan, a professor of pediatrics on the other side of the debate, who will soon move to the University of Colorado to direct the Kempe Center for the Prevention and Treatment of Child Abuse and Neglect.
At the same time, Squier and Runyan both pointed to a methodological weakness in Matshes study: he knew the histories of the babies he autopsied when he examined their necks. His study was not “double blind” — the scientific gold standard for ensuring that a researcher doesn’t skew his findings in the direction that will confirm his hypothesis. Matshes says that pathologists doing autopsies are ethically bound to know the subject’s history. “In forensic pathology, since we can’t do randomized controlled double-blinded studies, we have to make certain concessions,” he said.
This week, Frontline, NPR and Pro Publica aired a joint investigation into prosecutions for child deaths blamed on abuse that raised questions much like the ones I raised in my article. (Here’s an online chat with the reporters that I participated in.) Runyan brought up this latest wave of coverage while we were talking about Matshes’ new paper. The latest wave of coverage, he said, “just goes to show we need better research,” he said. Amen to that.
http://6thfloor.blogs.nytimes.com/2011/07/05/new-evidence-on-shaken-baby-syndrome/

SBS: New Zealand: Diagnosis Questions

20 May 2011,
A single firm shake has long been thought to be able to cause serious damage to a baby's brain. But an article published in the Journal of Primary Health Care (JPHC) suggests it might not be so clear cut, and that babies thought to have died because of being shaken may have actually died from other causes.
Both sides of the debate are presented. Dr Lucy B Rorke-Adams, who holds numerous neuropathology posts and is the Clinical Professor of Pathology, Neurology and Pediatrics at the University of Pennsylvania School of Medicine, suggests that shaking is indeed why the babies have died.
She points out that there is a "high frequency of association between the [three features that indicate central nervous system trauma] and shaken impact syndrome" before moving on to demonstrate the flaws in possible alternate explanations.
She backs up her argument with reference to the body of knowledge about shaken baby syndrome that has built up over the years.
"The scientific base for shaken impact syndrome has accumulated over a period of at least 150 years, although sporadic writings of physicians, anatomists and writers commenting about effects of CNS trauma, in particular concussion, appeared long before that time."
Dr Rorke-Adams finishes her discussion with a warning that "Those who offer untested hypotheses to defend individuals who have harmed infants do considerable disservice to science and to the victims."

On the other side of the debate is Consultant Paediatric Neuropathologist Dr Waney Squier, from the John Radcliffe Hospital in Oxford, UK.
While stating that "We can all agree that it is never safe to shake a baby", she also points out three major arguments against the shaken baby hypothesis.
In the first, Dr Squier states that, "In nearly 40 years [since the syndrome was recognised], no one has ever witnessed shaking to cause the collapse of a well baby."
Dr Squier describes the second argument as appealing to common sense. Violent shaking would cause neck injuries, which are seldom seen.
A third argument is more complex. To paraphrase Dr Squier, shaking a baby would not cause one of the symptoms seen in shaken baby syndrome. The symptom is "thin-film subdural bleeding"; shaking a baby may well cause bleeding, but because of the anatomy of the central nervous system, it would have a very different pattern.
Like Dr Rorke-Adams, Dr Squier also finishes with a warning.
"Failure to look beyond the simplistic and increasingly untenable shaking hypothesis risks incalculable damage by wrongfully removing children from loving parents or incarcerating innocent people.
"Further, by focusing on shaking or inflicted trauma to the exclusion of accidental and natural causes, we are almost certainly missing opportunities to save babies through prevention, early diagnosis and treatment."

Journal Editor Professor Felicity Goodyear-Smith says, "Both failure to act in cases of genuine child abuse, and unnecessarily separating children from their parents do irrevocable harm, so this is an important debate that needs to be had."

Both sides of the debate can be found in the June 2011 issue of the JPHC, which is a scientific journal published by the Royal New Zealand College of General Practitioners

http://www.nzdoctor.co.nz/un-doctored/2011/may-2011/20/does-shaken-baby-syndrome-really-exist-.aspx

SBS: "Water filled brain cysts" are not necessarily significant

12 May 2011 Andy Coghlan

WATER-FILLED cysts in the brain of a dead baby should not be taken as proof that the infant has been shaken to death. New findings show that cysts are also found in babies known to have died of innocent causes.

If the brain is starved of oxygen - because of a breathing problem or a blood clot caused by trauma, for example - it will swell up. A study of swollen brains in 20 babies who died aged 5 months or less showed that the longer they had survived before dying, the more likely they were to develop water-filled cysts between the cerebral cortex and the inner regions of the brain.

"While these cysts may be seen as a consequence of trauma, they do not appear to be due to mechanical tissue disruption, and may occur after brain swelling from any cause," says Waney Squier at the John Radcliffe Hospital in Oxford, UK Squier's team suggests that the cysts arise because the brains of young babies have yet to fully develop the plumbing needed to drain excess fluid.

The paper is the latest to cast doubt on post-mortem evidence that has till now been taken to show that abuse has taken place. Last year, evidence emerged to challenge the use of the "triad" - the combination of brain swelling, and bleeding on the surface of the brain and at the back of the eyes - as evidence in such cases.

In January the Crown Prosecution Service in England and Wales issued new guidelines stating that the triad would no longer be sufficient to show that a dead infant had suffered "shaken baby syndrome". As well as requiring additional evidence of possible abuse before a prosecution is started, the guidelines also rename "shaken baby syndrome" as "non-accidental head injury".

"Squier has shown that sub-cortical fluid collections are not [always] the result of primary trauma to the cortex," says Julie Mack, a pathologist studying infant brain injury at Pennsylvania State Hershey Medical Center.

One prominent radiologist in the UK who preferred not to be named says he agrees that the cysts can have innocent causes. But he questions the validity of the new study, adding that he seldom sees evidence of cysts in MRI scans of living infants with swollen brains.

http://www.newscientist.com/article/mg21028124.900-new-doubts-over-shakenbaby-evidence.html

At least half of all parents tried over shaken baby syndrome have been wrongly convicted, expert Dr Waney Squier warns

Angela Levin : 1st May 2011

It is a case that haunts Dr Waney Squier and one any parent will find deeply distressing.
Eleven years ago, Lorraine Harris stood trial at Nottingham Crown Court charged with manslaughter. Although described as a woman of good character and a careful and caring mother, she was accused of shaking her four-month-old baby Patrick to death two years earlier.
Neuropathologist Dr Squier wrote a report for the prosecution saying that the child was the victim of shaken baby syndrome (SBS).

Impeccable record: Dr Waney Squier says she is determined not to be silenced

Lorraine, who vehemently protested her innocence, was convicted and jailed for three years.
Her punishment was not limited to incarceration, as tragic consequences rippled out from Patrick’s death. Lorraine wasn’t allowed to go to his funeral; a baby she gave birth to as she was starting her sentence was taken away for adoption; her partner left her and both her parents died while she was in prison. Her life fell apart.
By the time Lorraine’s appeal was heard in 2005, Dr Squier had become convinced the criteria she had used to define whether SBS had taken place were wrong. In a complete U-turn, she now appeared as an expert witness for the defence. Lorraine’s conviction was quashed.
It is difficult to imagine Lorraine’s feelings as she digested this news. Relief, perhaps, but the occasion could hardly be described as joyous. One of her children had died and she had not been allowed to grieve. Another child had been taken from her. And she would possibly never be free from the taint of the original conviction.

Ordeal: Lorraine Harris was accused of killing her baby son

‘Her conviction was overturned but it was a hollow victory because her life had been completely devastated,’ says Dr Squier, who had helped right a wrong but could not erase the pain it had caused.
‘I did and sometimes still do feel terrible about what happened.
‘I now believe that half or even more of those who have been brought to trial in the past for SBS have been wrongly convicted. It is a frightening thought.’
It is indeed, and it is an extraordinary claim but one that should be taken seriously. Dr Squier, 63, is the most experienced paediatric neuropathologist in the country. She has spent 30 years researching baby brains and has a solid international reputation.
She has appeared countless times in court as an expert witness in cases of SBS, when a child is said to have been shaken so violently that it results in brain injury or death.
You would imagine that when such an eminent scientist says recent scientific developments show that, in the past, she and others have been wrong about SBS, she would be listened to.
Instead Dr Squier has been on the receiving end of vicious attacks by some doctors, lawyers and police officers who do not like her views. She has even been referred to as a supporter of child abusers.
‘Why would I want to do that?’ she asks.
‘I have children of my own. I am chilled by the thought of getting it wrong because of the risk of sending babies back to abusive households, or taking them away from families, or putting people in prison.’

About 250 SBS cases go to court each year. Expert witnesses play a pivotal role in trials. Babies often do not have any symptoms other than bleeding to the head and eyes so, unlike most criminal cases, the opinion of the pathologist may be the only evidence to consider.

However, some convictions are controversial. The problem has been that there is no single agreed definition of SBS. Instead, for the past 30 years, the findings of a U.S. radiologist, John Caffey, have been used in courts.
These findings centre on three signs – swelling of the brain, bleeding between the skull and the brain, and bleeding in the retina – known collectively as the triad. If they are present then a conviction is likely.
But Dr Squier is one of a growing number of doctors who believe that relying on the triad alone is no longer enough.
‘Over the past ten years so much more has been discovered about how a baby’s brain develops in its first year and these developments have seriously undermined SBS,’ she explains.

‘Over the past ten years so much more has been discovered about how a baby’s brain develops in its first year and these developments have seriously undermined SBS.’

‘We now know, for example, that almost half of babies have a triad at birth, which can be caused by different factors.
‘In the past four years there have been several discoveries about the dura, the membrane covering the brain. It was thought that it was there to protect the brain from shock, but we now know it also has the very important function of controlling blood flow out of the brain.
‘At birth the dura has huge blood channels that can leak – and not always as a result of trauma. They do, however, disappear during the child’s second year of life.
‘These findings are so significant that I now believe that half or even more of those who have been brought to trial in the past for SBS have been wrongly convicted.
'I am also convinced we can virtually exclude shaking as a cause of death in babies unless, as well as bleeding in the brain, we have additional evidence of trauma, such as serious damage to the neck.
‘When a baby is shaken, the head will flop back and forth and the neck becomes the weak point. In other words, if you shake a baby so hard that it dies, it is the neck that is going to show the damage, not the brain.’
Although her view is gathering momentum worldwide, it has ignited an increasingly toxic argument between doctors, lawyers and police.
‘Some pathologists want to remain in an unchallenging comfort zone of an outdated theory,’ Dr Squier explains.
‘Some judges don’t like the fact that new scientific discoveries make convictions more complex, and the police don’t like them because it can prevent them from getting the convictions they want.

Fragile: Blood channels in an infant's brain can leak during the first year of life

‘I think the police are so put-out that they are trying to ban me from court. It’s why I would like Justice Secretary Kenneth Clarke to set up an inquiry into the methods police have used to deter expert witnesses who challenge old mainstream beliefs.
'This raises serious concerns that one side of the argument is not being heard and means there cannot be a fair trial.
‘If I am blocked from giving evidence in court, defendants already having to cope with the tragic death of a baby will not get the benefit of the new science. Equally, if the courts fail to accept that the mainstream view of 30 years ago can no longer be relied upon, there will be serious miscarriages of justice.’
Dr Squier, who is divorced with two grown-up daughters, is devoted to her work and, despite the pressure she is under, she speaks calmly. Born in Surrey, she qualified as a doctor at Leeds Medical School.
After spells in Bristol, Cornwall and London, she moved to Oxford in 1984 and took up a post as consultant pathologist at the John Radcliffe Hospital, where we talked.
‘Once I came here I specialised in baby brains,’ she explains. ‘I have looked at thousands and written more than 100 medical papers on normal brain development and what happens when things go wrong both in pregnancy and after birth. In the past 15 years, I have investigated many unexpected deaths.’
Her change of opinion was triggered ten years ago by pioneering work carried out by Jennian Geddes, a former consultant neuropathologist at the Royal London Hospital.
Geddes argued that, in a small number of cases, injuries associated with the triad can occur naturally; that some babies suffer from a lack of oxygen supply that triggers bleeding; and that there should be some signs that the baby suffered trauma.
‘A light went on in my head,’ Dr Squier says.
‘I became concerned that the whole basis for shaking was poor.’
She began to conduct her own investigations and found similar evidence to Geddes.
‘It made me feel guilty about my previous unquestioning acceptance of the shaking hypothesis.
‘All my cases are now based on a newer understanding of the science. I am happy with rigorous debate but take exception to attacks on my integrity and professionalism. It is intellectual laziness to apply the old triad diagnosis when symptoms can be explained by natural causes.’
Dr Squier has an impeccable professional reputation so she was shocked early last year to receive a letter from the Human Tissue Authority, an organisation which ensures that doctors keep good records and have consent for everything they do.
‘The Metropolitan Police had raised concerns about the way I was handling post-mortem tissue and the possibility that unrecorded material was being stored, used and disposed of without the knowledge of the police. Fortunately, our procedures at John Radcliffe are absolutely robust, we know where every piece of tissue is, and no action was taken.
‘Then last June, I heard that a complaint on the same subject had been lodged against me with the General Medical Council.’
Dr Squier had to face an interim orders panel, which was set up after the conviction of Harold Shipman to protect the public and the profession from dangerous doctors. Her appearance was requested by the National Policing Improvement Agency and Detective Inspector Colin Welsh, lead investigator at Scotland Yard’s child abuse investigation command.
‘I barely slept for six weeks,’ she says.
‘It was a terrible experience but the hearing had barely got under way when it was dismissed and no restrictions were made on my practice.
‘However, the panel couldn’t remove the complaint lodged about me with the GMC and I don’t know whether it will take it forward. It is hanging over me like a dark cloud.
'I know the GMC will not approve of me speaking out but too much is at stake for me to stay silent.’

Unknown territory:
Doctors are still learning how a baby's brain develops - and discoveries in just the last ten years have 'seriously undermined SBS' according to Dr Squier

The accusations began to make sense following a conference on shaken babies, which took place in Atlanta, Georgia, last September. DI Welsh, in a public lecture, talked disparagingly about prosecution cases that had failed largely due to expert defence witnesses. He described a way of eliminating them from criminal and possibly family court trials, thus precluding alternative views being presented. He believed they confused the jury and possibly the judges with the complexity of science. DI Welsh’s solutions included ‘questioning everything – qualifications, employment history, testimony, research papers presented by these experts, go to their bodies to see if we can turn up anything’.
Among the audience was lawyer Heather Kirkwood, who was so shocked that she took notes and has signed an affidavit that these notes are a true record.
She says: ‘In the past decade, we have learned that much of what we thought we knew about SBS was wrong, and that many of the babies that we thought were shaken were instead suffering from birth injuries, childhood stroke, or metabolic or infectious disease.
‘Now that we know we got it wrong, we need to get it right. Instead, many prominent advocates of shaken baby theory have resorted to attacking researchers such as Dr Squier, who is one of the world’s leading experts on the infant brain.
‘Families and children deserve better. To get it right, we need open, honest debate, not cover-ups or attacks on those identifying the problems and seeking solutions.’
Dr Squier was outraged to learn of DI Welsh’s comments.
‘It proved in my mind that the police have set out to remove me and two other neuropathologists who share the same view from the courts because we have stood in the way of their campaign to improve conviction rates. If an expert witness bases an opinion on reasonable scientific ground, even if the opinion is a minority one, it should not be excluded.
‘I am determined not to be silenced and if I can’t speak out in court, I shall do it in scientific papers. It cannot be fair to gag one body of opinion. The whole thing is a nightmare, not least because instead of researching vital things about babies, I have to spend time trying to clear my name.
‘Meanwhile, the number of court cases I have been asked to attend has plummeted from 30 a year a few years ago to five in the past year.
‘Some lawyers are still willing to instruct me because they believe I will give them an opinion based on the science. Others feel they can’t use me while the complaint is hanging over me.
‘The experience has made me feel like a whistleblower – on the one hand challenging all those who prefer the comfort of old mainstream opinion, and on the other struggling for my professional life.’
DI Welsh was unavailable for comment, but Scotland Yard said in a statement: ‘The Metropolitan Police did register concerns about certain practices of a doctor with the Human Tissue Authority in December 2009. The Metropolitan Police also agreed to provide any relevant information to the GMC following a report registered by the National Policing Improvement Agency with the GMC.’

 http://www.dailymail.co.uk/femail/article-1382290/At-half-parents-tried-shaken-baby-syndrome-wrongly-convicted-expert-warns.html#ixzz1LaM0v4wd

SBS: London Metropolitan Police accused: ''deliberately discredited pathologists''

Tuesday, February 08, 2011

The Metropolitan Police Service (MPS) has been accused of trying to discredit three leading pathologists when they were called in to court to provide their professional opinion in cases where babies are said to have been shaken to death.
The Royal College of Pathologists has demanded an inquiry into claims by Drs Waney Squier, Irene Scheimberg and Marta Cohen that consultants were undermined in many non-accidental head injury (NAHI) cases. And the pathologists reckoned they all had allegations made against them that were initiated by the Met, among others.
A spokesman for the MPS confirmed that police had raised concerns about "certain practices", adding: "We are aware of a report registered by the National Policing Improvement Agency with the General Medical Council regarding two doctors. The MPS has co-operated with a request from the GMC in June 2010 to provide any relevant information."
However, according to the BBC, Detective Inspector Colin Welsh, a lead investigator with Scotland Yard's child abuse investigation command, said in a speech last year at a 'shaken baby' conference that in a meeting involving Met representatives, consultants and the Crown Prosecution Service the "impact and effect of contradictory expert evidence" was talked about.
In particular, Welsh is reported to have said that the main reason cases failed was testimony by expert witnesses for the defence. So their qualifications, employment history and research should be queried. Welsh is also reported to have said "so deal with back door" which has been taken as meaning that concerns could be passed on to judges about the credibility of the expert witnesses.
While confirming that Welsh had given the speech, the Met spokesman said the police were "completely committed to the judicial process and would never seek to improperly influence it".
However, Dr Squier commented: "[A court] should be able to hear evidence for both prosecution and for a defence and that anybody who has a valid and sincere opinion should be given the opportunity to express that opinion in court.
"And it appears to me that there has been an attempt to remove from the courts all of those people who are willing to challenge the mainstream hypothesis, even if those opinions are sincerely held and are based on a lot of day-to-day experience and are based on a thorough grounding in the current evidence available in the scientific literature."
http://www.publicservice.co.uk/news_story.asp?id=15423

SBS: Police accused of bias by defence0oriented pathologists

8 February 2011

Met accused of 'campaign' against shaken baby witnesses

By Andrew Hosken Some 250 so-called Shaken Baby cases go to court each year Three leading pathologists have accused the Metropolitan Police of attempting to discredit them as expert witnesses in so-called Shaken Baby court cases. About 250 Non-Accidental Head Injury (NAHI) cases go to court every year, with the outcome often relying on a expert testimony from pathologists. The Royal College of Pathologists has called for an inquiry into the claims. Responding to the allegations, the Met said the force was "completely committed to the judicial process". The scientific debate over NAHI has grown increasingly acrimonious over the past 10 years.   At first it was played out in select gatherings of pathologists before ending up in courtrooms and inquests up and down the country. That debate turned toxic, with one side accusing the other of proselytising suspect scientific theories. Now, senior consultant pathologists have accused the Metropolitan Police and others of an orchestrated strategy to discredit them as expert witnesses for parents and carers accused of murdering their children. Suzanne Holdsworth was acquitted at a second trial of a 'shaken baby' killing Dr Waney Squier, Dr Irene Scheimberg and Dr Marta Cohen say their evidence is based on a speech made by Detective Inspector Colin Welsh, a lead investigator with the Met's Child Abuse Investigation Command. The BBC has obtained a version of the speech made at the 11th International Shaken Baby conference in Atlanta, September 2010. In this speech, DI Welsh referred to a meeting in 2008 attended by representatives of the police, medical experts and CPS officials at which the "impact and effect of contradictory expert evidence" was discussed. The Met has confirmed the meeting took place but said it was standard procedure following an acquittal in a court case. According to a note by a Seattle-based lawyer called Heather Kirkwood, DI Welsh talked about the failure of a number of high profile Shaken Baby prosecutions and stated the number one problem as "defence expert testimony". He suggested as tactics to question everything about them -qualifications, employment history, testimony research papers presented by these experts, and even going to their expert bodies "to see if we turn up anything". DI Welsh is also reported to have referred to "judicial inexperience", using the term "so deal with back door" apparently in reference to relaying concern to judges about expert witnesses. A police spokesman confirmed that DI Welsh had given the speech but added that The Metropolitan Police Service "is completely committed to the judicial process and would never seek to improperly influence it". Complaints The pathologists, however, say they were all the subject of inquiries by outside bodies initiated by the Metropolitan Police and others. Dr Squier, who works at the John Radcliffe Hospital in Oxford, was the subject of two separate inquiries last year. The Human Tissue Authority investigated a complaint that Dr Squier may have retained human tissue, a criminal act if true. The accusation was found to be without foundation. The complainant was identified as an officer with the Met. It appears to me that there has been an attempt to remove from the courts all of those people who are willing to challenge the mainstream hypothesis Dr Waney Squier DI Welsh appeared as an "interested party" in a second inquiry by the General Medical Council into Dr Squier and Dr Cohen. The GMC inquiries resulted in both doctors being brought before emergency Interim Orders Panels, but proved inconclusive. The Human Tissue Authority also conducted an inquiry into Dr Scheimberg following a complaint from a colleague based at Great Ormond Street Hospital. She was also cleared. Professor Tony Risdon often acts for prosecution teams and made his complaint about Dr Scheimberg based on information from a third party but which he personally could not verify. He declined to comment when approached by the BBC. Investigation call Dr Squier defends the evidence she gives, saying a court "should be able to hear evidence for both prosecution and for a defence and that anybody who has a valid and sincere opinion should be given the opportunity to express that opinion in court". "And it appears to me that there has been an attempt to remove from the courts all of those people who are willing to challenge the mainstream hypothesis, even if those opinions are sincerely held and are based on a lot of day-to-day experience and are based on a thorough grounding in the current evidence available in the scientific literature." A spokesman said the Metropolitan Police Service had registered concerns "about certain practices of a doctor in December 2009" but declined to comment on the reasons. "We are aware of a report registered by the National Policing Improvement Agency with the General Medical Council regarding two doctors. The MPS has co-operated with a request from the GMC in June 2010 to provide any relevant information," the spokesman added. Professor Peter Furness, President of the Royal College of Pathologists, expressed concern about the allegations of a campaign. "The allegations that there has been a systematic attempt to intimidate people from presenting their honestly held views to a court should be investigated," he says. "I would normally suggest that should be investigated by the police, in this case at least some of the allegations it appears the police have been involved in it. "There are processes for conducting investigations into police activity. It sounds to me from what I've been told that those mechanisms should probably be used. "My concerns about this are as a private citizen not as president of the Royal College of Pathologists. I think anybody who feels the process of justice is being illegitimately subverted ought to feel concerned and ought to try to do something about it." The BBC approached a significant number of pathologists who act for prosecution teams. They all declined a request for an interview, some saying they too had been the subject of threats and complaints.

http://news.bbc.co.uk/today/hi/today/newsid_9389000/9389553.stm

Shaken Baby Syndrome’ – a response by Dr Waney Squier

Shaken Baby Syndrome’ – a response by Dr Waney Squier

Dr Waney Squier responds to a recent article in Family Law Week.

On 25 February 2010, Family Law Week published an article by John Tughan which referred to the judgment in Re S [2009] EWHC 2115. We have received a letter from Dr Waney Squier, who is mentioned in the article and judgment.

Dr Squier has offered to write an article on this subject. The editors of Family Law Week do not consider that it is an appropriate forum in which to debate matters of complex medical disagreement. Instead we publish the following letter by Dr Squier. Family Law Week itself does not hold a view on matters of medical expertise, and so the views expressed are those of Dr Squier.

Department of Neuropathology
Level One West Wing
John Radcliffe Hospital
Oxford OX2 6QY

April 9th 2010

Dear Sir,
In February 2010 Family Law Week published a review by Mr Tughan of the judgment of Mrs Justice King in Re S [2009] EWHC 2115, (Family Law Week: February 2010). I appreciate the opportunity to respond.
The remarks of Dr Al-Sarraj cited in the article are both inaccurate and unrepresentative.
I do not believe that hypoxia alone causes subdural bleeding as I have pointed out on many occasions, both in reports for the Court and in my academic publications; it's a bit more complicated than that. This was put to me in the course of the trial; my response was that I have never stated this and do not believe this.
These issues are far too serious to be matters of faith; medical opinion must be based not on belief, but on empirical observation and peer-reviewed, objective, scientific evidence. 
It is a matter of objective evidence that the blood vessels of the infant dura are immature and far more extensive than in later life.
It is a matter of objective evidence that bleeding into the young infant dura is common.
It is a matter of objective evidence that sick, hypoxic ventilated infants may develop impaired blood clotting. This predisposes to, or exacerbates, bleeding. 
Only by considering the entirety of the evidence and the highly complex physiopathology specific to the young infant brain and its blood supply can a valid opinion be reached. 
Central to so many of these cases, and so frequently trivialised, is a prolonged period of hypoxia with subsequent resuscitation and brain swelling. It is these features which set babies with the "triad" (of retinal and subdural bleeding and encephalopathy) apart from cot deaths. A study presented last month to the American Academy of Forensic Science indicates that these are the critical factors associated with retinal haemorrhage (1). The same study has not been undertaken with respect to subdural bleeding, although multicentre studies, comparing in-hospital with out-of-hospital cardiac arrest, have confirmed the devastating effects on the brain of prolonged collapse followed by resuscitation (2).
I also challenge the statement that I am the only one of 40-44 neuropathologists in this country who holds this belief. Not only, as noted above, do I not hold this belief, but the statistic is misleading. To my knowledge, there are only 5 neuropathologists who regularly become involved with the study of infant brains in the forensic setting; this is reflected in their attendance at a meeting at the College of Pathologists in December 2009 (3). Among these 5 only two of us devote a significant part of our daily diagnostic practice to the study of brains of infants dying from the whole spectrum of natural diseases. This has been my majority practice for 30 years. The others have no such daily experience. It was clear from the meeting at the College that there is considerable divergence of opinion and that I am by no means alone in my views. The other 35 or so neuropathologists have not to my knowledge been canvassed, nor would they have sufficient experience of paediatric brain injury and the rapidly evolving literature to form an objective opinion.
I am accused of clinging to a hypothesis; on the contrary my views, shared by hundreds around the world, continue to evolve. They are based on the incontrovertible evidence provided by the tissue I see daily on the microscope slides and informed by research and critical examination of the scientific literature. What is staggering is that "mainstream medical opinion" has remained just that, opinion; supported not by evidence but by forty years of repetition.
Shaking as a cause of subdural bleeding has not been supported by biomechanical research; as long ago as 1988 Duhaime wrote ""shaken baby syndrome" is a misnomer, implying a mechanism of injury which does not account mechanically for the radiographic or pathological findings"(4). It is inconsistent with the anatomy of the infant head and, despite an estimated 70,000 cases diagnosed in the UK and USA, has never been independently witnessed to cause the collapse of a previously well baby. The mainstay of the hypothesis is confession evidence (5). 
If not shaking, then impact must be considered. If there is no evidence of impact or violence (autopsy means seeing for oneself), then this consideration must be ranked, pragmatically, with all the other potential causes of collapse and according to the facts of the specific case.
Any attempt by the courts to simplify these issues will lead to misunderstanding.  The difficulties of presenting scientific evidence in the courts have been discussed by Tuerckheimer (6), who stresses "the tensions which thrive where science and criminal justice meet" and specifically that ""Because it is fully constructed by and dependent on medical expertise, Shaken Baby Syndrome (SBS) raises in stark form the problems that arise when science outpaces law..."
Progress has been made over the past decade.  Today, as Mr. Tughan correctly observes, the "triad" is no longer accepted as diagnostic of non-accidental injury but is instead viewed "as a mere hypothesis."  Mrs. Justice King is equally correct in recognising that we do not yet know the full range of natural and accidental causes for the triad.
Meanwhile, I will continue to strive to "[t]hrow light into corners that were . . . dark." 
If lawyers are unwilling to question opinion that is validated only by repetition, or to delve beneath the legal issues and explore the science, there will be miscarriages of justice. And slings and arrows will continue to be directed at the messengers.
Yours faithfully
Dr Waney Squier
Consultant Neuropathologist

Reference List

(1)  Matshes E. Retinal and Optic Nerve Sheath Hemorrhages are not Pathognomonic of Abusive Head Injury. 10 A.D. Feb 24; 2010.
(2)  Moler FW, Meert K, Donaldson AE, Nadkarni V, Brilli RJ, Dalton HJ, et al. In-hospital versus out-of-hospital pediatric cardiac arrest: a multicenter cohort study. Crit Care Med 2009 Jul;37(7):2259-67.
(3)  Royal College of Pathologists. Report of a Meeting on the Pathology of Traumatic Head Injury in Children.  2009.
(4)  Duhaime AC, ennarelli TA, Sutton LE, Schutt L. The "Shaken Baby Syndrome" : a misnomer? J Paediatric Neurosciences 1988;4(2):77-86.
(5)  Christian CW, Block R. Abusive head trauma in infants and children. Pediatrics 2009 May;123(5):1409-11.
(6)  Tuerckheimer D. Criminal Justice at a Crossroads: Science-Dependent Prosecution and the Problem of Epistemic Contingency. Alabama Law Review 62. 2010. 1-8-2010.

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