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/

SIDS: Nebraska to change guidelines for death investigations

 February 14, 2011  SARAH SCHULZ

Death investigations and coroners’ exams in Nebraska are as varied by county as the deaths themselves.
County attorneys serve as coroners in Nebraska, and there aren’t training requirements established in state statute. But all that is changing because of recent statutes that call for the development of guidelines for uniform and quality death investigations statewide.
Hall County Attorney Mark Young said a subcommittee within the County Attorneys Standards Advisory Council is working on guidelines and training.
“It’s becoming more of an issue,” Young said.
His training for his work as county coroner has consisted of what he has received at seminars, including how to fill out death certificates, determining cause and manner of death and how to gather the necessary information. He believes it will be good to have established standards and he’s glad the Legislature didn’t mandate training without providing funding.
In Hall County, as with many other counties in Nebraska, law enforcement personnel are often the first emergency responders on the scene of an unattended death, homicide, suicide or accident. They are trained in collecting evidence, conducting interviews and investigating the cause of the death, he said. Young is called out to scenes where the cause of death could potentially be criminal.
The county attorneys are also allowed to deputize others to assist with coroner duties. In Hall County, that includes the deputy county attorneys working in Young’s office, he said.
The number of cases the county coroner is involved in each month varies “wildly,” Young said, but, as an example, he said his office signed 26 death certificates/cremation permits in January and ordered one autopsy. He is called out on death investigations as a coroner 15 to 20 times a year on average, but he signs a lot more death certificates that are related to natural causes or medical reasons.
The number of autopsies ordered by the Hall County attorney also varies. Young said he must balance the potential result and necessity with the $2,000 cost to the county. The county has a line item in the general fund for coroner-related expenses and he believed it was currently set at about $44,000. For homicide-related cases, Young tries to take the autopsy costs out of the law enforcement line item he has in his budget in order to “protect the other budgets.”
Autopsies are required by law when the deceased is younger than 19 unless the death was readily recognizable as disease or didn’t occur under suspicious circumstances. The cause of death can’t be certified as sudden infant death syndrome unless an autopsy, a death scene investigation and a review of the child’s medical history reveal no other possible cause, according to state statute.
Young said he orders autopsies when foul play is suspected or the cause of death can’t be determined through the investigation of other facts.
People can request a private autopsy if one has been ordered by the county coroner or law enforcement, and they may retain a pathologist to conduct one, if they choose, he said.
According to an interim study report on the standards and oversight of death investigations in Nebraska, compiled in January 2009 under LB276, the state has no oversight of the county coroner system. The control exists at a local level as county coroners develop their own course of action or policies for death investigations.
Coroners may choose to work with law enforcement to investigate a death. According to the interim study, they can perform the following coroner’s duties or have law enforcement do the same:
n Examine the body at the scene of death or the mortuary.
n Photograph, measure and diagram the scene.
n Collect and document potential evidence.
n Contact the physician of the deceased and obtain the person’s medical history.
n Interview witnesses, family, friends and others.
n Conduct tests on bullets and firearms for evidence.
Buffalo County Attorney Shawn Eatherton said that most of those tasks are left to law enforcement because county attorneys can’t be witnesses in cases that are prosecuted.
Eatherton is on the subcommittee that is working on guidelines and training for county coroners. The group hopes to establish procedures that result in consistency in duties while allowing for flexibility by count. Differences in population, demographics and geography will play into how investigations are conducted, he said.
However, there are certain things that must be looked at in every case, such as the examination of the body and the scene, and interviews with the deceased’s physician, he said.
Eatherton added that autopsies aren’t a “magic bullet” and all the facts of a case must be considered when determining the cause of death.
“Autopsies are just part of the whole picture,” he said.
The checklist being developed by the subcommittee will be an “if, then” list, meaning that if the coroner or law enforcement finds a certain fact, it should be followed by a particular course of action. For example, a fatal traffic accident requires blood draws from those involved, he said.
The state has requested that the guidelines include guidance in determining the need for autopsies, deaths of minors, deaths while in custody, suspicious deaths, entering a death scene, documenting the scene, examining the body, and establishing and recording information.
“The checklist is based on the facts,” Eatherton said. “I’ve looked at the coroners system and the medical examiners system in other states — there is no perfect system. I think we need a blended system to use all our expertise.”
http://www.kearneyhub.com/article_2239a238-3869-11e0-9cc4-001cc4c002e0.html

SIDS: Nort Carolina, causes of death not pursued

Oct. 12, 2010

N.C. infants die every three to four days, on average, with little understanding of what killed them, you'd think the response would be a lot more urgent and considerably more dramatic.
A team of Observer reporters and editors this summer found that medical examiners often classify N.C. children's deaths as sudden infant death syndrome despite possible unsafe sleep conditions and other questions surrounding their deaths. That frequent diagnosis was likely masking the real cause: suffocation in pillows and blankets or even under an adult. The widespread use of that diagnosis slowed the education of parents about safe sleep habits. Law enforcement agents say a finding of SIDS prevents them from prosecuting neglect or other crimes.
The Observer series looked at 554 SIDS autopies over five years and found that authorities frequently fail to investigate the deaths thoroughly. Only about 25 babies, or five percent, were apparently sleeping safely, on their backs in their own cribs without dangerous bedding.
The diagnosis matters, because too-frequent SIDS findings make it harder to educate parents about safe sleeping. And that means we're not preventing as many deaths as we might.
The Observer series told the story of Autumn Brown, who died Nov. 20, 2007, at the age of 10 weeks in Alamance County. Her death was ruled SIDS, but her grandfather thinks she may have been smothered accidentally.
Makayla Peek was one month old when she died in Gaston County three years ago. Her death was also declared SIDS despite suspicions of foul play.
It's cases like these a legislative task force now hopes to minimize with changes in the state's response to child deaths.
Among the changes that the N.C. Child Fatality Task Force, chief medical examiner Deborah Radisch and others are examining:
All new law enforcement officers would be required to go through specialized training on child death scene investigations.
The state would hire trained investigators for regional offices, so all death scenes can be investigated properly.
Police would be urged to use a six-page, state-issued checklist at death scenes, which is now optional.
Those are important, and fine as far as they go. But why train only new law enforcement officers, and not all current ones? And task force co-chair Tom Vitaglione and N.C. Health Director Jeffrey Engel say state budget woes may delay the hiring of trained investigators for regional offices, something we obviously need. Also, why not require police officers to use the state-issued checklist, instead of just encouraging them to?
As long as meticulous investigations of child death scenes are optional, questions will loom about how N.C. infants are dying. And without information, parents and authorities can't address the problem.
We understand times are beyond tight for the state budget. We also know that taking basic steps that will help save babies' lives is money well spent.
http://www.charlotteobserver.com/2010/10/12/1755649/improvement-slowly-on-child-death.html#ixzz13HNkrgyt

SIDS: North Carolina Child Protection Team

NEW HANOVER COUNTY, NC (WECT) - New Hanover County needs some serious help when it comes to how children are cared and provided for, according to the county's Community Child Protection Team, or CCPT.

In an annual report to county commissioners, presented Monday morning, CCPT identified five major issues with child services in the county.

Major problems noted by the team include, among others, a "dramatic decrease" in the quality of mental health services for children as well as the loss of preventative services in New Hanover County when it comes to child abuse and neglect.

The Community Child Protection Team was formed because of a state law established in 1991.  The CCPT is mandated to find and address problems with child services in the county. 

The team is made up of child advocates, citizens-at-large, and representatives from agencies including the Wilmington Police Department, New Hanover County Sheriff's Office, and the Department of Social Services (DSS).  The team, however, is not a division of DSS, but a separate community entity.

Each year, CCPT submits a report to the county commissioners. This year's report will be discussed at a pre-agenda meeting Thursday afternoon and again at the regular board meeting on Monday morning, September 20.

In the report, the CCPT pointed out five problems with New Hanover County's services for children.

First, the team stated the county does not have enough local therapeutic foster homes able to meet the needs of our children.  The lack of foster homes is also evident in regard to medically fragile kids.

Second, the members of the CCPT noted a "dramatic decrease" in the quality of mental health services for children.  They indicated a steady decrease in quality since 2004 and blame, in part, constant policy changes that result in inaccessible or inadequate services for children.

Next, the team addressed funding, saying New Hanover County doesn't have enough money to assist income-eligible families that may be struggling to stay employed or trying to complete education goals.

According to the report, there were 981 families on a waiting list for assistance in New Hanover County as of August 31, 2010.

Another issue tackled by the CCPT deals with child fatalities.  The team stated that too many child deaths are classified as Sudden Infant Death Syndrome (SIDS) by a medical examiner before a thorough investigation is conducted.

The CCPT said it has continually expressed serious concerns about the way child fatalities are handled, and it will continue to push for an autopsy to be performed on every child with a questionable or undetermined death.

Finally, the team expressed that it is "tremendously concerned" with the loss of preventative services in New Hanover County when it comes to child abuse and neglect.  The CCPT cited the economic downturn and rising poverty rates as reasons to expect abuse and neglect to get worse in New Hanover County and elsewhere.

"One more burden and it becomes too much," said CCPT Chairperson, Elizabeth Mandel. "It becomes just the catalyst for them to sink. We want to be there to support them. We can't help everybody. We can't do it alone."

The team is asking for more help from the county and especially the state.

"We're asking for your clout," a team member told the commissioners, who wanted firm numbers on what kind of financial help children's programs in the county need.

The team said it will work on getting solid figures for the commissioners, but in the meantime, asked for help in lobbying state lawmakers to stop making cuts to child services and start rebuilding an ailing system.

At the end of the report, the CCPT pointed out that North Carolina ranks 37th of 50 states when it comes to child well-being, according to the new Annie E. Casey Kids Count report.  North Carolina also ranks 36th out of 50 in a measure of children living in poverty.

"That's not a number that any of us should be proud of," said Mandel.

LaVaughn Nesmith, the director of New Hanover County's Department of Social Services agreed, and emphasized that something needs to be done quickly, with both poverty and child abuse on the rise.

"The end result is death," said Nesmith. "That is not acceptable. Not in a society that we live in."

http://www.wect.com/Global/story.asp?S=13166722

SBS: Texas: New Results Of Autopsy Spur Plea

LISE OLSENSept. 14, 2009,

The Harris County Medical Examiner’s office has quietly rewritten the results of a 1998 autopsy, prompting renewed innocence claims on behalf of a baby sitter sent to prison nearly a decade ago for allegedly shaking a 4-month-old infant hard enough to cause fatal injuries.

The original autopsy classified the baby’s death as a homicide and was used by prosecutors as a key piece of evidence against Cynthia Cash, now 53, a former nurse convicted of fatal injury to a child after 4-month-old Abbey Clements died after being rushed to the hospital from Cash’s home.

But the modified autopsy report made public in a new appeal calls the cause of death “undetermined” and found no evidence of “trauma” in the postmortem exam. Those changes came five years after local officials announced a review of problematic autopsies conducted by a former Harris County associate medical examiner, Dr. Patricia Moore. Moore, who declined requests for comment, left Harris County in 2002 but still works for Southeast Texas Forensic Center, a Conroe-based company that provides forensic work for six counties.

It is at least the fourth time Harris County officials have reclassified a child’s autopsy that Moore originally labeled as a homicide. Two women have been cleared in other cases — including Brandy Briggs, who was jailed at 19 after rushing her baby to the hospital and who spent several years in a prison isolation cell before being freed in 2005. Dr. Luis Sanchez, head of the medical examiner’s office, did not respond to Chronicle questions about Cash’s case or whether he has finished an audit he promised to conduct after finding problems in the Briggs case.

After learning about the new autopsy results, Cash’s husband contacted Briggs’ attorney, Charles Portz, to file an innocence claim on her behalf. The pending appeal asks for her release or a new hearing — though Cash now has only six months left to serve on her seven-year sentence for felony injury to a child. The case is being considered by Harris County District Court Judge Mark Ellis, who oversaw the original trial a decade ago.

Assistant District Attorney Lynn Hardaway said prosecutors remain confident about their case based on other “evidence presented at trial from doctors who thought she was a victim of shaken baby syndrome.”

Conflicting opinions

Abbey Clements received three vaccinations at a checkup a few hours before Cash, her baby sitter, claimed to have found the baby blue in her crib after a nap. Cash had kept Abbey and her brother along with her own son and five other children.

Abbey died at Texas Children’s Hospital. Doctors there later testified that though she did not have any external injuries, she suffered swelling of the brain and retinal hemorrhages — injuries they described as consistent with so-called shaken baby syndrome.

A neurologist expert for the defense testified at trial that he found none of the broken bones, external bruises or other injuries considered to be classic signs of shaken baby syndrome and the girl likely suffered an extremely rare fatal reaction to vaccines. Dr. Richard M. Hirshberg also reviewed the new autopsy and repeated his argument for Cash’s appeal: “It’s my firm belief now as it was during the Feb., 5, 1999, trial that this defendant is innocent.”

The modified autopsy issued in February 2008 says “a diagnosis of trauma cannot be substantiated,” though no other cause of death was determined. The report also says that doctors who testified in Cash’s trial made some “erroneous” conclusions, wrongly describing bleeding patterns found in the examination of the child’s brain as evidence of trauma.

The revised autopsy, however, also says it could not substantiate claims made by defense experts that the baby likely died from anaphylactic shock — a severe allergic reaction to vaccines. Such rare reactions are well documented in medical literature but generally occur soon after a vaccination is administered.

Paul Clements, Abbey’s father, said he had been briefed on the new results but said “one ME changing an autopsy still doesn’t change what we think happened because of all the other evidence presented at the trial.”

Clements said he also bases his conviction that Cash was guilty on his experience of seeing his daughter “right after it happened and discussing it with the doctors in the hospital. They had never seen a baby shaken as badly as Abbey.”

Cash’s husband, Ken Cash, and her attorney, Portz, both claim that Cash never would have been indicted if the autopsy had been conducted correctly in the first place.

“All I want for her is justice,” said Cash, who sold his house to help pay legal fees and raised their young son on his own after his wife was imprisoned. “They railroaded her in that autopsy report. She is innocent.”

The Harris County District Attorney’s office, however, opposes the appeal.

“The Court of Criminal Appeals held that a claim of actual innocence based upon newly discovered evidence should not be overturned lightly and the burden on the defendant who has had error-free proceedings is exceedingly heavy,” the prosecutor’s answer in the case says, later continuing: “There is considerable evidence in the record to support the … conviction.”

lise.olsen@chron.com

MOORE AUTOPSY PROBLEMS:

Dr. Patricia Moore, a former associate medical examiner in Harris County, was repeatedly disciplined for failing to follow procedures and for favoring the prosecution in 1998 and 1999, Harris County personnel records show. She left Harris County in 2002 for personal reasons, but her work on children’s autopsies here continues to be challenged:

• New innocence claim: After a baby’s 1998 death was reclassified from homicide to undermined causes last year, family and an attorney for 53-year-old former baby-sitter Cynthia Cash recently filed an appeal claiming innocence and seeking her release.

• Mother freed in 2005: Moore’s original autopsy called 2-month-old Brandon Lemons’ 1999 death a homicide, but it was reclassified years later as “undetermined.” The new report suggested that the baby may have died from lack of oxygen because of a medical error. Lemons’ mother, Brandy Briggs, was subsequently freed.

• Mother cleared in 2004: Prosecutors dropped charges against another woman originally accused of reckless injury to her newborn after Moore’s autopsy was challenged and the baby’s cause of death was changed to undetermined.

• Other cases questioned: Trenda Kemmerer, a woman convicted in 1997 in another child’s death remains in prison, though the child’s autopsy was changed and Moore reprimanded for failing to show objectivity in the case. And Moore herself changed the results of a Montgomery County child’s autopsy in 2007.

Source:

http://www.chron.com/disp/story.mpl/metropolitan/6617198.html

 

http://medicalmisdiagnosisresearch.wordpress.com/2010/09/18/new-results-of-autopsy-spur-plea/