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Questioning Confessions

Coerced or Nonvoluntary Confessions


Hollida Wakefield, M.A.* and Ralph Underwager, Ph.D.

Police may engage in deceptive and coercive interrogations to obtain confessions.  When a confession is later retracted, judges and juries must assess the totality of the circumstances surrounding the confession, including the interrogation techniques used and the effects of these tactics on the particular defendant.  A suspect who is vulnerable and confused or who is given false evidence by a coercive interrogator may produce a false confession.  Expert testimony may be necessary to help jurors understand the circumstances that lead to nonvoluntary confessions.  © 1998 John Wiley & Sons, Ltd.

A confession is one of the strongest forms of evidence that can be brought into a court of law.  In the United States criminal justice system, prosecutors avidly seek confessions as the most persuasive evidence to win cases.  Eliciting a confession and presenting it to the fact finder easily becomes a primary goal of the justice system.  A confession has a compelling influence on jurors and they are more likely to convict on the basis of a confession than anything else, including eyewitness identification.  This effect persists even when the jury is fully aware that a confession was coerced and likely nonvoluntary (Kassin & McNall, 1991; Kassin & Sukel, 1997; Kassin & Wrightsman, 1985).

However, confessions have also been a source of controversy.  Whether the suspect was of sound mind and whether the confession was voluntary or coerced must be considered by judges and juries.  Kassin (1997) notes that “a confession is typically excluded if it was elicited by brute force; prolonged isolation; deprivation of food or sleep; threats of harm or punishment; promises of immunity or leniency; or, barring exceptional circumstances, without notifying the suspect of his or her constitutional rights” (p.221).

If it is demonstrated that the police lied, fabricated evidence, or otherwise coerced a confession, the fact finder must consider whether the police lies and deception would have made an innocent person confess.  Judges must determine the admissibility of the confession by evaluating whether it was voluntary, but they seldom find police lying so severe that it undermines voluntariness (Young, 1996).  The result is that lying, deception, coercion, and fabrication of evidence may be approved and condoned in court rulings even while such practices are criticized.  Convictions based on coerced confessions may later be upheld through the appellate process.  Huff, Rattner, and Sagarin (1996) observe that a systemic bias exists in the justice system so that lower courts are seldom reversed by higher courts.

When a confession is admitted and later retracted and claimed to have been made under duress, an additional question is whether the jury can understand the pressures that led up to the confession.  Milgram’s (1963, 1964) obedience studies suggest that, although most people may believe they personally would never succumb to pressure, their behavior in a coercive environment is to conform.  Jury members may be unable to perceive how an innocent person could actually confess to something he did not do.  Widespread overconfidence in personal ability to resist coercion may lead jurors to give undue and erroneous weight to a coerced confession.  Expert testimony may be necessary to help jurors understand the circumstances that lead to nonvoluntary confessions, but trial courts have not always admitted such testimony.

JUDGES AS GATEKEEPERS

Whether a questionable confession is admitted as evidence before a fact finder is determined by the trial judge.  The judge also determines whether expert testimony concerning the circumstances of the confession will be admitted.  This is true whether the jurisdiction is operating under the older Frye rule or the more recent U.S. Supreme Court Daubert ruling on the admissibility of scientific evidence.  A judge is the gatekeeper and either opens the gate for expert testimony or closes it.  The result is that testimony about nonvoluntary confessions may or may not be admitted depending upon the particular judge and his or her interpretation of the law.

The problem with judges as gatekeepers is likely that described by Chief Justice Rehnquist in his dissent to the Daubert ruling:

I defer to no one in my confidence in federal judges; but I am at a loss to know what is meant when it is said that the scientific status of a theory depends upon its “falsifiability” and I suspect some of them will be too (Daubert v. Dow Pharmaceuticals, 1993, pp.3-4).

Saks (1989) sees the law as policy analysis without benefit of data and based on guesswork:

The law, and most of the people who enter the law, had their intellectual upbringing in the humanities.  Law students are typically smart people who did not like math.  The quantitative, empirical, social and behavioral sciences exist in another world (p.1115).

Judicial capacity as a gatekeeper may be affected by a number of factors including bias, personality dispositions, cognitive capacity, and social or political pressures (D’Amato, 1990; Imwinkelried; 1996; Landsman & Rakos, 1994; Wesley, 1984).  For the science of psychology, the gatekeeping task of judges is an example of the fundamental tensions and conflicts between the law and psychology that have been discerned in the past (Meehl, 1989).

COERCED CONFESSIONS AND FALSE CONFESSIONS

Coerced or nonvoluntary confessions must be distinguished from false confessions, since not all coerced or nonvoluntary confessions are false and not all false confessions are coerced.  Although it is common for defendants to retract confessions made during police interrogations, this will include both true and false confessions.  Obviously, some nonvoluntary confessions are true.  In this paper, the focus is on coerced and nonvoluntary confessions and is not limited to those that have been demonstrated to be false.

It is sometimes argued that police coercion, including deception and trickery, is necessary to make criminals confess, but such interrogation techniques also risk eliciting false confessions.  The extent to which this happens is unknown since no one knows the actual rate of false confessions (Kassin, 1997).  Several researchers maintain that enough instances have been documented to suggest that a concern over such a risk is justified (i.e., Ayling, 1984; Brandon & Davies, 1973; Kassin & Wrightsman, 1985; Leo, 1996a, 1996b, 1996c; Leo & Ofshe, 1998).  Rattner (1988), in a sample of 205 cases of wrongful convictions, reports that coerced confessions accounted for 8.4%.  In a study of 229 inmates in Icelandic prisons, 27 (12%) of the inmates claimed to have made a false confession in the past during police interviewing (Gudjonsson & Sigurdsson, 1994) and the majority of the subjects (78%) were convicted of the offense to which they had allegedly made a false confession1.

Others disagree that there is a significant problem with false confessions.  Cassell (in press) believes that there is no empirical evidence that false confessions occur frequently and he maintains that the problem is largely confined to persons who are mentally retarded or have serious mental problems.  He states that many reports of wrongful convictions from false confessions are based on media reports and other secondary sources, and that credible evidence shows that the individuals were most likely guilty of the crimes for which they were convicted.  He argues that false confessions are not caused by police interrogation techniques in general but rather by using these techniques with narrow, mentally limited populations.

In another article Cassell (1998) estimates the number of false confessions leading to wrongful convictions using data from a variety of sources, primarily Huff et al. (1996).  He believes that a reasonable estimate is in the range of 10 to 394 wrongful convictions from false confessions in the United States each year.  Cassell stresses that this estimate relies on extensive extrapolations and assumptions and cannot be viewed as a hard number.  It must also be remembered that this estimate is not of all nonvoluntary confessions or even of all false confessions, but only pertains to the subset of false confessions that result in wrongful convictions.

Being interrogated by the police is a highly stressful experience, especially when the individual is isolated and not in contact with familiar individuals.  Isolation and confinement can cause a wide range of behavioral and physiological disturbances including loss of contact with reality (Gudjonsson & MacKeith, 1982).  Foster (1969) notes that police interrogation “can produce a trance-like state of heightened suggestibility” so that “truth and falsehood become hopelessly confused in the suspect’s mind” (pp.690-691).

Stress can also arise from the suspect’s submission to authority.  When the interrogator is perceived as being invested with socially legitimate authority, the suspect may obey instructions and suggestions which would ordinarily be rejected.  The experiments by Milgram (1963, 1964) on obedience to authority illustrate this.  This is apt to be more likely in an individual who generally defers to authority.

If a person has no experience with arrest and interrogation, he is more likely to become upset and stressed by the interrogation.  A study in England (Irving, 1980) reported that anxiety and fear were most commonly observed in first-time offenders and those suspected of sex crimes.  Observations noted included trembling, shivering, sweating, hyperventilation, frequent urination, and verbal incoherence.  A substantial proportion of the suspects were not in a normal mental state during interrogation.

Gudjonsson and MacKeith (1982) note that factors encouraging a suspect to make a genuine confession may be similar to those that cause a person to make a false confession.  They state that “non-psychotic individuals ruminating guiltily about such things as sexual deviation may also have an exceptionally low threshold to confession to things that they have not actually done” (p.259).  The false confessor may be aware he is not telling the truth or his perceptions may be distorted or he might even be deluded for a brief period of time.  The false confession in all of these situations is an interplay between the person’s mental state, basic personality, intelligence, and all of the environmental circumstances of the interrogation.

There are individual differences in the way people react to the stress of an arrest and interrogation. Three types of false confession have been distinguished: (a) voluntary (statements made without external pressure), (b) coerced-compliant (when the suspect confesses to escape an aversive interrogation, secure a promised benefit, or avoid a threatened harm), and (c) coerced-internalized (when suspects actually come to believe they are guilty of the crime (Kassin, 1997; Kassin & Kiechel, 1996; Kassin & Wrightsman, 1985)).

Although the last type of false confession seems less likely, a suspect who is vulnerable and confused (internal factors) and who is given false evidence by a deceptive interrogator (external factors) may confess to the act, internalize the confession, and confabulate details consistent with the newly created belief.  A laboratory test of these two factors demonstrated that they can lead to a coerced-internalized false confession (Kassin & Kiechel, 1996).  The Paul Ingram case is a well known example of this.  Ingram, following months of coercive and misleading interrogation that included hypnosis, not only falsely confessed but recalled false details of crime scenes (Ofshe, 1992).  Gudjonsson and LeBegue (1989) also provide a detailed case report of a coerced-internalized false confession.

A distinction must be made between the generation in an interrogative context of a false belief that a person committed a crime and a false memory for the crime.  They may not go together (Gudjonsson, 1995).  Creating a false belief may be the precursor to developing a false memory.  The false memory may develop when there is some process which reinforces the false belief.  Gudjonsson (1992) explains internalized coerced confessions by suggesting a memory distrust syndrome.  This is thought to be a state of confusion in which people lose confidence in their own recollections of events.  Then when the confusion dissipates and the original memory returns, the person retracts and challenges the confession.

A situation we have observed is when the accusation is made by an intimate or a highly regarded person.  Although initially the accused knows it is false, he may need to explain how it could happen that the accusation was made.  A low tolerance for ambiguity and a high need for closure may cause the person to think about possible explanations.  Source monitoring errors may eventually lead to a confusion between what is thought and what happened.  Across time the possible scenario becomes more and more real and detailed.  For example, in one case, a man began thinking about an ambiguous dream he had.  It then progressed through more dreams, more details, and then moved to possible behaviors suggested by the dreams.  Finally, he admitted the possibility that he may have done something inappropriate.

THE GUDJONSSON SUGGESTIBILITY SCALES

Research indicates that criminal suspects who make confession statements which they later deny differ from subjects who persistently deny any involvement in the crime of which they are accused.  Gudjonsson and his colleagues have developed a scale to assess “interrogative suggestibility” which is intended to be applicable to police interrogations (Gudjonsson 1984a, 1984b, 1991c, 1997; Gudjonsson & Clark, 1986).  Interrogative suggestibility is seen as differing from other types of suggestibility and is defined as “the extent to which, within a closed social interaction, people come to accept messages communicated during formal questioning, as a result of which their behavioral response is affected” (Gudjonsson & Clark, 1986, p.84).

The features of interrogative suggestibility are:

1. It involves a questioning procedure which typically takes place within a closed social interaction.

2. The questions are mainly concerned with past experiences, events, and recollections.  In contrast, other types of suggestibility are typically concerned with the motor and sensory experiences of the immediate situation.

3. Interrogative suggestibility contains a component of uncertainty, which is related to the ability of the person to process information cognitively.

4. Questioning in a police context commonly involves considerable stress with important consequences for the witness, victim, and suspect (Gudjonsson, 1997, pp.1-2).

The Gudjonsson Suggestibility Scales (GSS 1 and its parallel form, GSS 2) (Gudjonsson, 1997) are intended to help identify people who are particularly susceptible to giving erroneous accounts of events when subjected to questioning.  The scale, which is applicable to questioning of witnesses and alleged victims as well as interrogations of criminal suspects, assesses responses to leading questions and to pressure resulting from negative feedback.

The scale is based on a short, narrative story, which is read out loud to the subject who is then asked to relate everything that can be recalled about it.  After providing both immediate and delayed recall, the subject is asked 20 specific questions, 15 of which are subtly misleading.  Next, the subject is clearly and firmly told that he or she has made a number of errors (even if no errors have been made), that it is necessary to ask all of the questions again, and that the subject should try to be more accurate.  The extent to which the subject gives in to the misleading questions in the first trial is scored as Yield 1, any change in answers between the first and second trials is scored as Shift, and Yield 1 and Shift are added together to make up the Total Suggestibility score.

Many studies have been done on the GSS and the manual (Gudjonsson, 1997) provides normative data from a number of populations.  Intelligence has been found to correlate negatively with GSS suggestibility scores in several studies (Clare & Gudjonsson, 1993; Gudjonsson, 1997; Richardson & Kelly, 1995).  Poor assertiveness, evaluative anxiety, state anxiety, and avoidance coping strategies correlate positively (Gudjonsson, 1997).  Adolescents do not yield to leading questions more than do adults, but they are more responsive to negative feedback (Gudjonsson & Singh, 1984a); but after age 16, there is no relationship between age and suggestibility (Gudjonsson, 1984a).

Most important for the issue of nonvoluntary confessions, research with the GSS indicates that “resisters” (subjects who persistently denied their involvement in the crime they were charged with) score significantly lower than “false confessors” (subjects who retracted confessions they had previously made during police interrogations) (Gudjonsson, 1984b, 1991a, 1991b).  Gudjonsson (1991a) observes that these differences remain when intelligence and memory capacity are controlled for (Gudjonsson, 1991a).  The results also suggest that the confessing behavior is linked to the suspects’ ability to cope with pressure, rather than their tendency to give in to leading questions per se.  Suggestibility also appears to be related to the suspect’s experience with police interrogations in that it is negatively correlated with previous convictions (Gudjonsson & Singh, 1984b; Sharrock & Gudjonsson, 1993).

Gudjonsson (1991 a) observes that it is almost certain that not all of the “false confessors” in his study were innocent of the crime with which they are charged.  However, at least some most likely were and the fact that not all of these people were of low intelligence reinforces the point that people of normal intelligence can and do falsely confess to serious crimes.

POLICE INTERROGATIONS

Police freely admit deceiving suspects and lying to induce confessions.  Police have fabricated evidence, made false claims about witnesses to the crime, and falsely told suspects whatever they thought would succeed in obtaining a confession.  They have lied about the suspect’s culpability, assuring him that his behavior was understandable and not really blameworthy, or telling him that if he described what happened, the victim could be helped.  They have falsely told suspects that they had physical evidence such as footprints, fingerprints, or semen, that a codefendant had confessed, that the weapon used in the crime was found, that the suspect failed a lie detector, and that there was medical proof of sexual molestation (Heavner, 1984; Hrones, 1996; Skolnick & Leo, 1992; Underwager & Wakefield, 1992; Young, 1996).  Lindsay (1991) conducted a series of four experiments which suggest that police deliberately and intentionally construct biased lineups to assure identification of a suspect they believe to be guilty.

Deception is justified by the police as a necessary evil in order to, obtain convictions of guilty persons.  Skolnick (1982) notes that police officers move from investigation, through interrogation, to testimony.  The system, including the training academies and the courts, permit, if not encourage, deception during the investigation phase.  A detective may pose as a consumer, a fellow criminal, a panderer, or use informers and wiretaps.  The line between entrapment and acceptable deceit is vague and unclear.

The actual number of cases where police lie is not known, but, because most criminal cases end with guilty pleas, the reported cases represent only a fraction of the actual cases where police lie (Young, 1996).  Police deception can result in innocent people being convicted; McCloskey (1989) lists police lies on the witness stand, police pressure to coerce false witnesses, suppression of exculpatory evidence, shoddy police work after a conclusion has been reached about guilt, and falsified forensic science reports as major factors in wrongful convictions.

Miranda v. Arizona, decided by the U. S. Supreme Court in 1966, used quotations from Criminal interrogation and confessions by Inbau and Reid (1962) to show that police used deception and psychologically coercive methods in questioning people.  The court concluded that interrogation is now psychologically oriented rather than physical but that the degree of coerciveness inherent in the situation had not diminished.

The court observed that the 16 strategies for interrogation proposed by Inbau and Reid (1962) show three major themes.  The first reattributes the implications of the situation by shifting the blame or minimizing the seriousness of the crime.  The second attempts to frighten the individual by exaggerating the evidence available, telling the person that the interrogator knows he is guilty, or stressing the consequences.  The third makes an emotional appeal through showing sympathy, flattery, and respect, and by appealing to the best interests of the suspect.  The court found such practices inherently coercive.

The most recent edition of this manual, which remains the most popular in the country for teaching interrogation methods, presents different themes for interrogators to use in eliciting confessions (Inbau, Reid, & Buckley, 1986).  This book remains the most widely used text for training police.  For example, in State v. Kelekolio the detective testified that he lied in the interrogation because he had been told to use that technique at a police seminar.  When videotapes or audiotapes of police interrogations are available, it is easy to discover the specific techniques followed in the interrogation.

Leo (1996b) notes that American police have become extremely skilled at the practice of manipulation and deception during interrogation.  Based on hundreds of hours of research as a participant-observer in three police departments, he concludes that modern interrogation techniques can best be understood as a confidence game based on the manipulation and betrayal of trust.  Zimbardo (1967), based on his review of training manuals, believes that the interrogation techniques of the police are sometimes more highly developed, more psychologically sophisticated, and more effective than those that were used by the Chinese Communists in Korea.  The result of such sophisticated and psychologically persuasive interrogation techniques is that many people will confess to crimes, even when it is against their best interests.

Leo (1996c) states that one of the most troubling aspects of false confessions resulting from such police interrogations is that the police leaders and trainers deny that their highly manipulative and deceptive interrogation tactics may produce confessions from entirely innocent persons.  He observes that, due to the widely held belief among police officers that virtually all suspects are guilty and will confess only if they are, in fact, guilty, the interrogator may elicit a false confession without realizing it.  Leo believes that many criminal suspects remain incarcerated for crimes they did not commit as a result of such false confessions.

EXAMPLES OF COERCED CONFESSIONS

Example 1: The Mother

Shortly after a fire killed her severely handicapped child, a mother was asked to come to police headquarters to talk with a detective.  The mother knew that her two older children had been questioned by a detective at school that day but she had no idea what they wanted from her.  After she reached the police station, she was questioned by a detective for several hours.  At the conclusion of the interrogation, she was arrested and charged with murdering the child by starting a fire by deliberately throwing an afghan over a space heater that was next to the child’s crib.

The videotape of the interrogation illustrates the recommended coercive psychological techniques of Inbau et al. (1986) — deception, lying about evidence, and threat.  For example, the book suggests asking, “[D]id you ever think about hurting [the victim] even though you did not go through with it?” (p.66).  The interrogator is then instructed to follow up with questions about the kind and frequency of such thoughts.  Throughout the interrogation, the detective asked variations on this question until the mother eventually acknowledged that it “was possible” she may have thought about it.

The detective claimed that he also had a special needs, severely handicapped child and he assured the mother that he and his wife often thought of hurting their child and even had said that he would be better off dead.  Inbau et al. (1986) describe this technique of creating “a perception on the part of the suspect that he is a less reprehensible person, morally speaking, than the bare facts of the case would indicate” (p.97).  Inbau et al. instruct the interrogator to “Sympathize with [the] suspect by saying anyone else under similar conditions or circumstances might have done [the] same thing” (p.97).  The purpose in repeatedly telling the mother that anybody else, including the detective’s wife, would do the same thing (hope their child was dead and, in fact, kill her) was to elicit a confession.

Inbau et al. (1986) say “Reduce [the] suspect’s feeling of guilt by minimizing [the] moral seriousness of [the] offense” (p.99).  The detective said several times that it was understandable to want a special needs child to be with God, in a better life, and not to suffer any longer.  He said repeatedly that he could understand this because he thought this way about his own child.

The detective also threatened to charge the two older children with murder by telling the mother that they were suspects, and that if she did not start the fire, then they must have done it.  When the mother later described her reactions to the interrogation, it is clear that at this point she dissociated and responded to this threat with high anxiety, confusion, and stress.

The detective falsely told the mother that they had conclusive physical evidence that the fire started from the space heater (no tests had been done at that point and none were produced at the trial).  He also falsely told her at the beginning of the interrogation that there was no intention to charge her.  When the interrogation ended hours later she went directly to jail.

The evaluation of the mother indicated that she was most likely dissociating at times during the interrogation.  She also had a very high score on the Gudjonsson Suggestibility Scale.

The mother never admitted purposefully to choosing to throw an afghan on the space heater but only that it might have happened inadvertently without her knowledge.  Later, she specifically denied that she put it there.  She never admitted to wanting the child dead but only to the possibility that part of her may have wanted that to happen.  Nevertheless, selected portions of the videotape were presented to the jury as a confession of murder.

Example 2: The Friend

John Doe was a mentally retarded young man who lived at home with his parents.  He had never held a job but spent his time doing things with friends and working at odd jobs for his father.  He was in special education classes in school and was on social security disability.

Mr. Doe had spent the night on a married friend’s couch after a fishing trip and awakened early the next morning and returned home.  After he left, the three-year-old daughter came into the kitchen with her pajama bottoms off.  The child’s mother questioned her about this and the child eventually said that Mr. Doe had been in her room.  After further questioning, the child allegedly said that Mr. Doe had removed her pajamas and touched her in her genital area.

The authorities were contacted and the child was interviewed several times.  Tapes indicate that these interviews were suggestive and leading.

A few days later, a police officer told Mr. Doe to come to the police station for an interview.  By this time, the child had been interviewed and the police believed that Mr. Doe had abused her.  The Miranda warning was not given because the police officer said that Mr. Doe was not under arrest and was free to leave the interview at any time.

The interrogation of Mr. Doe was not recorded.  Later, Mr. Doe said that he had been confused about what was going on and that he felt “shook up and scared”.  He said that he denied he had touched the child at first and that he repeated his denials several times but that eventually he agreed to what the officer wanted.  He felt he had to do this in order to end the interview.  Despite the fact that the officer later maintained he had been free to leave, Mr. Doe said he believed he would be arrested if he tried to go.  At the end of the interrogation, the officer wrote out the confession and asked Mr. Doe to sign it.

The psychological testing confirmed Mr. Doe’s mental retardation.  He was barely able to read and, in fact, could not read the signed confession out loud accurately.  Mr. Doe’s intellectual limitations are essential in understanding his reaction to the interrogation.  A retarded person learns early on to try to please others, particularly those in authority.  They tend to acquiesce — that is, say yes to yes-no questions — much more than do persons of normal intelligence (Sigelman, Budd, Spanhel, & Schoenrock, 1981). The retarded individual learns to smile, nod, make appropriate short comments that mimic an unexceptional social interaction but which may be incomprehensible to the retarded person.

Mr. Doe’s performance on the Gudjonsson Suggestibility Scale (GSS) is consistent with this.  After he answered the first set of 20 questions and was told he had made a number of errors and should try to be more accurate, his entire demeanor changed.  He became noticeably anxious and uncomfortable and then changed 9 out of the 20 answers.  His score on the GSS was two and one-half standard deviations higher than the mean of the normative sample.

What this means is that Mr. Doe was extremely vulnerable to making a non-voluntary confession in a police interview, even compared to other intellectually disabled persons.  He responded to the interrogation by doing and saying what the police officer wanted and he lacked the cognitive capacity to understand the ramifications of agreeing to sign the confession statement that he was unable to read and understand.

Example 3: The Sergeant

The sergeant was accused of sexually abusing an 11-year-old boy with a history of serious psychiatric problems.  The boy made the accusation several months after the alleged event while in the hospital.  Charges were pursued and the sergeant was interrogated, arrested, and facing a court-martial.  The interrogation was not recorded but information on the circumstances of the confession was obtained from the testimony of various people in the Article 39 hearings.

The interrogation took place in a small windowless interview room with the doors locked.  The agent, according to his hearing testimony, interrogated the sergeant for over an hour until he confessed.  The sergeant did not directly admit to any specific acts, but instead the confession was in the form of agreeing to allegations posed to him by the agent.  The interrogation was not taped and the agent did not begin to take notes until after the confession.  He acknowledged using the interrogation technique of exploring different themes (Inbau et al., 1986) to make the sergeant confess.

After the confession, the sergeant vacillated back and forth between admitting and recanting the allegations.  According to the agent, he started crying and became extremely upset and then withdrawn, quiet, emotional, and hard to talk to, “as if he was mentally not with me anymore”.  After the agent dictated a statement to be signed, he observed the sergeant on his knees, praying and crying.

The chaplain was called who observed the sergeant leaning against the shelf and uttering a prayer.  A supervising officer was called and the chaplain and the officer described the sergeant as “very distraught”, “highly upset”, and “shell shocked”.  The officer took him to the hospital.  On the way to the hospital he told the supervising officer that he really did not know what was going on, but that he was sure he was not guilty.  He said that the agent had wanted him to sign a statement but he was not sure whether he signed the statement or not.  The sergeant met with a psychiatric resident who reported that the sergeant adamantly denied abusing the boy.

While in the hospital, the sergeant called his pastor and asked him to come to the hospital.  When the pastor arrived, the sergeant was frantic, pacing back and forth with a wild look in his eyes, and weeping and incoherent.  He eventually calmed down enough to tell his pastor what happened.  He described the allegations and said that the agent had kept telling him again and again “Let’s get this kid some help”.  He said that he lined everything out in the statement except for a part about exposing himself to the boy under the carport.  He said that this might have happened accidentally when he was wearing gym shorts with no underpants.

He said he remembered very little about the interrogation.  His recollection was that he initially denied the abuse but the agent repeated that he knew it had actually happened and kept saying, “Come on sergeant, Billy is really in bad shape … Billy needs help and you are the key to him getting well”.  The sergeant said that he eventually admitted it so the child could get help but that it really did not happen.

The sergeant had no prior history of psychiatric or psychological treatment.  He was very active in the United Pentecostal church and reported the gift of the Holy Spirit and speaking in tongues.  Psychological testing indicated that he was conforming, conventional, moralistic, immature, naive, and suggestible and had difficulty handling stress and conflict.  He was vulnerable to dissociating if placed in an extremely stressful situation.

The descriptions of the sergeant’s behavior during and following the interrogation indicate that he reacted with unusual distress during and after the time the confession was elicited.  Persons who have no experience with arrest and interrogation and those suspected of sex crimes are especially likely to become upset and stressed by the interrogation and to therefore not be in a normal mental state (Irving, 1980).

The theme approach used in this interrogation is included in the tactics recommended by Inbau et al. (1986).  The agent overwhelmed the sergeant with damaging evidence, asserted a firm belief in his guilt, and then suggested that it would be easier for all concerned if the suspect admitted to his role in the crime.  In addition, the personality characteristics of the sergeant are likely to have made him unusually vulnerable to the interrogation techniques designed to elicit a confession.

Example 4: The Stepfather

The stepfather, who also had several biological children from three different women, had a history of petty infractions of the law and was unemployed.  He was charged with sexually abusing his 8-year-old stepdaughter.  He was interrogated by the police and initially denied the allegations but eventually acknowledged sexually abusing the child on several occasions when he was very drunk.  He then signed a confession which he later retracted.  The interrogation, which lasted two and one-half hours, was not taped.

According to the stepfather, he was arrested at his home by four police officers, handcuffed, and brought to a small interrogation room with a one-way mirror.  The handcuffs were removed during questioning.  He said that he became very frightened when he realized what he was being questioned for.  “I was scared … This was the scariest time in my life.”  He was frightened because he knew how serious the charges were and how much trouble this would cause.  He was afraid that he would go to prison for the rest of his life.

He initially denied the allegations but then the police officer took a five minute break and returned, saying that their investigation had shown that he had, in fact, had intercourse with his stepdaughter.  In the police report, the officer acknowledged he told the stepfather the medical evidence convinced him the stepfather was not being truthful in his denial, that the child would not make up a detailed disclosure such as this, and that the stepfather was ”sick” and needed help.

The stepfather described the officer waving a piece of paper at him while maintaining that they had medical proof of penetration and had found blood and semen on the sheets and the child’s underwear.  He said that the officer screamed, “You’re a good f— liar” and “turned red in the face because he was hollering so bad”.  He said that the interrogator told him he would get over five counts if he refused to sign a confession but only three if he did.  The interrogator kept talking about all of the counts and said that he would go to jail for 160 years.  He said, “I’ve been doing this for 13 years and know when someone is lying”.  During this period, the stepfather described himself as crying and extremely frightened.  He said he finally made the verbal admission and signed the confession because he believed he would be convicted of more counts and be in jail much longer if he did not go along with it.

Psychological testing indicated that the stepfather was of average intelligence but had long-standing and severe personality problems, was easily distracted and confused, and was likely to deteriorate under stress.  His total suggestibility score on the Gudjonsson Suggestibility Scale was two standard deviations above the mean.  His personality made him especially vulnerable to the type of coercive police interrogation he later reported and which is described in the police officer’s report.

Taping Interrogations of Suspects

Only one of the above examples, that of the mother, was taped.  In the third example (the sergeant), the agent acknowledged in his Article 39 testimony that he used the interrogation technique of exploring different themes to encourage the sergeant to “admit to wrongdoing when he otherwise wouldn’t”.  In the fourth example, the officer’s report corroborated some, but not all, of what the stepfather claimed took place in the interrogation.  But, in the second example (the friend), the police officer insisted that the young mentally retarded man knew he was not under arrest and was free to leave.  The young man was only able to provide limited details of what took place in the interrogation.

We believe that videotaping is extremely helpful in dealing with nonvoluntary and retracted confessions.  Without a tape the issue is likely to come down to a dispute between the suspect and the police about the nature of the interrogation.  Video- or audiotaping provides the only means by which what actually took place can be known for certain.  Requiring all interrogations of suspects to be taped is therefore an important way of responding to the possibility of psychologically coerced interrogations and police deception.

Cassell (1997) notes there is virtual unanimity that videotaping interrogations is an effective solution to the problem of false confessions.  He argues that videotaping provides an excellent protection for false confessions resulting from inappropriate police questioning since it allows judges and juries to see when the police have coerced an innocent person into admitting to a crime he did not commit (Cassell, 1998).  In addition, taping protects the police against false claims of improper questioning.

Leo (1996c) observes that many police stations now routinely tape interrogations of suspects and that the state supreme courts of Minnesota and Alaska have held that statements obtained in the absence of taping are generally inadmissible.  He argues:

The use of audio or videotaping inside the interrogation room creates an objective record of police questioning to which all interested and potentially interested parties may appeal — police, suspects, prosecutors, defense attorneys, and juries — in the determination of truth and in judgments of justice and fairness.  The use of videotaping is thus the most viable legal intervention for resolving many of the antinomies of crime control and due process inherent in police interrogation of the accused in a democratic society (Leo 1996c, p.682).

VOLUNTARINESS AND ADMISSIBILITY
OF CONFESSIONS

Confessions have been problematical for the U.S. justice system.  Fact finders must evaluate the reliability of a confession, first in terms of its admissibility and, if admitted, in terms of its weight.  To do this, they must determine whether the confession was voluntary or was the result of pressure or inducement and whether the defendant was intellectually competent or was anxious, fatigued, mentally retarded, or unusually suggestible.  This is a complex and difficult task.

Young (1996) describes how the standards for the admissibility of confessions have shifted back and forth over the years.  Early in American jurisprudence, a high standard for admissibility of a confession was set so that the slightest deceptive practice in eliciting a confession rendered it inadmissible.  The U.S. Supreme Court first addressed the admissibility of a confession and the test of voluntariness in 1897 in Bram v. United States. In Bram, the Supreme Court analyzed the issues in terms of the Fifth Amendment privilege against self-incrimination and ruled that to be admissible a confession must not be extracted by any sort of threat or violence nor obtained by any direct or implied promises, however slight.

Bram, however, was a federal case and the Supreme Court’s reliance on the Fifth Amendment in this ruling limited it to federal cases.  At the beginning of the 20th century state courts generally admitted confessions obtained by lies and deception, reasoning that such tactics were not apt to produce false confessions.  During this period, there was a shift as the police began to take over the interrogation process and questioning moved from judicial supervision to the back room (Young, 1996).

Young (1996) speculates that the leniency of state courts in admitting confessions obtained by police interrogation may have been due to their responding to the new role of the police and their hope for more efficient and successful law enforcement.  The result was that for many years state police misconduct was unrestrained.  In 1931, the Wickersham Commission Report provided numerous examples of state police misconduct in interrogations and warned of the dangers of false confessions.

In 1936, using the Due Process Clause of the Fourteenth Amendment, the U.S. Supreme Court ruled that confessions could not be obtained by physical violence (Brown v. Mississippi) and a few years later reversed a conviction obtained by persistent questioning and “other ingenious form of entrapment” (Chambers v. Florida, 1940) (Young, 1996, pp. 444-445).  In the 35 confession cases it decided from 1936 and 1964, the Supreme Court employed the due process voluntariness test to evaluate the admissibility of confessions and it also delineated appropriate and inappropriate interrogation techniques, generally by reducing the amount of psychological pressure that could produce a legally voluntary confession (Leo, 1996c).  In these cases, the Supreme Court continued to criticize third degree tactics and, in considering the voluntariness of a confession, looked at the totality of the circumstances, establishing that test as the standard by which it would review police conduct in interrogations (Young, 1996).

The criterion for the admissibility of a confession has thus evolved into the quality of voluntariness.  The aim of admitting into evidence only voluntary confessions is to prevent the introduction of unreliable evidence.  The Supreme Court has kept the definition of voluntariness vague and imprecise and speaks of a comprehensive analysis of the totality of the relevant circumstances (Kassin & Wrightsman, 1985).  But, as currently interpreted, the modern test of voluntariness is so flexible that courts can use it to admit confessions obtained by police lying (Young, 1996).

The result is that judges may exclude confessions where the coercion is blatant and obvious but not exclude confessions where the coercion is subtle and more readily disguised.  Typically, confessions are excluded if they are elicited by physical violence or a threat of harm or punishment, promise of leniency, or without notifying suspects of their Miranda rights (Kassin & Sukel, 1997).

However, although some courts have differentiated between false statements and fabricated evidence (Young, 1996), even clear evidence of police lying and fabrication of evidence may be considered acceptable.  In State v. Jackson (1983), the interrogating officer put blood and fingerprints on a knife that was similar to the murder weapon and then photographed it so it appeared that a fingerprint identification had been made.  In the interrogation, the suspect was shown the knife and the photograph and told that the fingerprint had been identified as his.  Despite the use of this clearly fabricated evidence to obtain a confession along with other false statements, the North Carolina Supreme Court ruled that these techniques were constitutional because they were not likely to make an innocent person confess.

ADMISSIBILITY OF EXPERT TESTIMONY
ON COERCED CONFESSIONS

The effect of the more subtle coercive interrogation methods on jurors is extremely powerful.  Although jurors may discount confessions when it is evident they were obtained by blatant coercion, when it appears to be the more subtle interrogation techniques that elicit a confession jurors accept it and discount any coercion (Kassin & McNall, 1991).  In a laboratory experiment, Kassin and Sukel (1997) demonstrated that, even when a confession was recognized as coerced, when it was stricken from the record, and when mock jurors said it had no influence, the confession increased the conviction rate.

In Arizona v. Fulminante (1991), the U.S. Supreme Court found that Fulminante’s confession that he had murdered his stepdaughter was coerced and that it was “prejudicial error” to admit it.  But the court also ruled that in certain circumstances, such as when a confession is cumulative or when there is sufficient corroborating evidence, a wrongly admitted coerced confession may constitute ”harmless error.”  That is, the court said that admission of a nonvoluntary confession is a “trial error” similar to the erroneous admission of other types of evidence.  The Fulminante opinion therefore places great faith in the ability of a jury to properly evaluate a confession and the evidence about how it was obtained (Kassin & Sukel, 1997).

When a coerced confession is admitted into evidence, the jury will be required to evaluate the testimony about the circumstances surrounding the confession.  Unfortunately, research indicates that jurors may have difficulty correctly performing this task (Kassin & Sukel, 1997).  It can be extremely helpful to have testimony from an expert concerning the social psychology of interrogation tactics, the circumstances surrounding false or coerced confessions, interrogation tactics used in the particular case, and the characteristics of the defendant that may have made him or her unusually susceptible to a coercive interrogation.  This type of testimony makes it possible for the finder of fact to properly evaluate the confession.

In United States v. Hall (1996), the Seventh Circuit Court of Appeals reversed Hall’s kidnapping conviction on the grounds that expert testimony relating to the police interviews of the defendant and the defendant’s susceptibility to giving false confession was erroneously excluded.  One of the experts was social psychologist Richard Ofshe, a recognized expert in coercive police interrogation techniques and coerced confessions.  The court held that the district court’s “failure to undertake full Daubert inquiry regarding admissibility, as scientific evidence, of psychologist’s testimony on false confessions was not harmless” (p.1338) and it said that the district court had erred in excluding the evidence related to the police interview techniques because “it saw no potential usefulness in the evidence, because it was within the jury’s knowledge” (p.1341).  The court stated:

This ruling overlooked the utility of valid social science.  Even though the jury may have had beliefs about the subject, the question is whether those beliefs were correct.  Properly conducted social science research often shows that commonly held beliefs are in error.  Dr. Ofshe’s testimony, assuming its scientific validity, would have let the jury know that a phenomenon known as false confessions exists, how to recognize it, and how to decide whether it fit the facts of the case being tried (p.1345).

The court noted that:

[O]nce the trial judge decided that Hall’s confession was voluntary, the jury was entitled “to hear the relevant evidence on the issue of voluntariness and [the trial judge was to] instruct the jury to give such weight to the confession as the jury feels it deserves under all the circumstances” (p.1344).

The court addressed the fact that some of the knowledge to which the experts would have testified was within the jurors’ experience, since the district court had concluded that the expert testimony would usurp the jury’s role:

If the expert testimony would be helpful and relevant with respect to an issue in the case, the trial court is not compelled to exclude the expert just because the testimony may, to a greater or lesser degree, cover matters that are within the average juror’s comprehension (p.1342).

In its ruling, the court summarized the approach a judge must take under Daubert when faced with a proffer of expert scientific testimony and stated that “we cannot be confident that the district court applied the Daubert framework” (p.1342).  The court concluded that the failure of the district court to conduct a full Daubert inquiry was not harmless error, since Dr. Ofshe’s proffered testimony went to the heart of Hall’s defense.  It also concluded that the other psychologist should have been permitted to testify about Hall’s susceptibility to interrogation techniques and his propensity to give a false confession.

Following the Seventh Circuit ruling remanding a new trial, a Daubert hearing was held in the district court (United States v. Hall, 1997) to determine the admissibility of Dr. Ofshe’s expert testimony.  At this hearing, the district court judge determined that the proffered testimony relating to false and coerced confessions was properly understood to be scientific knowledge.  The basis for this determination was the testimony that there is a large body of scientific research dealing with coercion, false confessions, and interrogation methods.

CONCLUSIONS

Psychological coercion appears to be common in the interrogations of suspects.  The structure and nature of law enforcement is a powerful influence that may produce police misbehavior.  An indeterminate number of nonvoluntary confessions may be attributed to the coercive nature of police interrogation during which deceptive and deceitful practices may be used.  A psychologist who relates to the justice system needs to understand the extent, nature, and impact of these practices.  However, in order to have testimony about this scientific knowledge admitted, the psychologist must be prepared to deal with efforts to preclude such testimony.  The gatekeeping function of judges must be understood and responded to with a careful, valid, and reliable presentation of the relevant scientific research.

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1 Cassell (1998) reevaluates this data and argues that the actual frequency of false confessions is about 0.6%.  [Back]

didn’t harm my baby
by EMINE SANER, Evening Standard

o Harris knows how close she came to losing her children. She looks
on happily as her two eldest sons race around in excitement. Because
of the snow, there is no school today where they live in
Hertfordshire and Sam, nine, and Ryan, seven, are jumping up and down
and looking out of the window.

Her youngest son, Connor, two, is gurgling contentedly on the floor,
playing with his toys. Jo knows how lucky she is to still have them
around her because, when Connor was just four months old, she was
accused of shaking her little boy so violently that she could have
killed him.

In April 2002, Jo, now 29, a full-time mum, put Connor to bed while
she had a bath. When she came out some 20 minutes later, she went in
to check on him and found, to her horror, that he had stopped
breathing. He was blue and lifeless.

“I just freaked out,” she says. “I was in a complete panic. I picked
him up and shook him very gently and he started breathing again, but
he still wasn’t normal, his breaths were really shallow.”

She called her husband, Dale, who works for a haulage firm and was at
a nearby friend’s house, and they rushed Connor to the local
hospital.

“The doctors examined him and said he was stable,” says Jo. “They did
some blood tests and I told them I had shaken him to get him
breathing again. They didn’t say anything, they seemed fine about it.
He was kept in for a couple of days but they couldn’t seem to find
anything wrong. They just said he had some sort of virus.”

Swelling on baby’s head

The Harrises took their son home but Jo noticed that Connor still
wasn’t quite right. “He was sleeping more than usual and not feeding
well. About a week later, I noticed a swelling on the top of his
head. I took him straight back to hospital.”

Jo spent a fraught night by her baby’s bedside, fearing the worst.
The next morning, one of the doctors said Connor needed to have a
brain scan. “The doctor came back and told me the scan showed blood
clots on Connor’s brain,” says Jo. “She asked if he’d had a bad birth
or been in a car accident.

“When I told her he hadn’t, she said the only other explanation was
shaken baby syndrome, which I had never heard of before.

“She said he had signs of being shaken violently on a regular basis.
I told her I’d shaken him the week before, but it had only been very
gently and only the once.

“By this point I was in tears. It hadn’t really sunk in that I was
being accused. All I could think about was Connor and what would
happen to him. I thought he was going to die.”

Doctors contacted social services

The doctor told Jo that Connor would need another brain scan and,
because of her suspicion of shaken baby syndrome, of which some 200
cases are reported every year, that she had contacted social
services.

“I couldn’t believe it,” says Jo. “I asked her if she thought I’d
harmed my baby and she said she couldn’t say. I phoned my husband in
tears and he rushed over. When he got to the hospital he demanded to
see a doctor and was told that I had shaken our baby.”

********”The traumatic experience of two years ago came flooding back
to Jo this week when Lord Goldsmith, the Attorney-General, announced
that dozens of parents jailed for shaken baby syndrome are to have
their cases reviewed.

The ruling came after Angela Cannings was acquitted of killing two of
her children. She had been convicted largely on the evidence of
discredited paediatrician professor Sir Roy Meadow. “******

Thousands of cases – of infanticide, or where children were removed
from their families – are to be re-examined.

From the moment the finger of suspicion was pointed at Jo, she wasn’t
allowed to be alone with her baby.

“One of the doctors told me that if I even tried to take Connor out
of the room, he would call the police. There was one very kind nurse
but the rest of the staff just made me feel guilty.”

The second scan seemed to confirm the presence of blood clots; worse,
when Connor was X-rayed, he was found to have a suspected broken
wrist and fractured ribs.

“When the hospital told me I just broke down,” says Jo. “I knew I
hadn’t hurt him but I started to think someone else had. I went
through everyone I had left him with in my mind.

“I never doubted my husband. I demanded a second opinion and the
scans and X-ray were sent to Great Ormond Street hospital.”

When Connor had been in hospital for two days, a social worker and a
child protection officer arrived to tell Jo and her husband that they
weren’t allowed to take him home.

Instead, he had to be placed with a member of the family or a close
friend. “I was crying and saying, ‘He’s mine, you can’t do this’ over
and over again.”

Baby handed to sisterin-law

After he had been in hospital for four days, the doctors, who were
still waiting for the results from Great Ormond Street, said Connor
was stable enough to be discharged.

Weeping, Jo handed him over to her sister-in-law, a lawyer, who lived
nearby. “She doesn’t have any children and she had no idea how to
look after a baby,” says Jo.

“I gave her long lists of instructions, his cot, bottles, baby
monitor. I made sure he had his favourite green blanket and dummy.”

Jo’s eldest son, Sam, suffers from attention-deficit hyperactivity
disorder – diagnosed a month before Connor’s birth – and because this
makes him boisterous, Jo couldn’t help wondering if he could have
hurt his younger brother.

“It did go through my mind,” she says. “But I had always been careful
not to leave Connor alone with Sam.” The effect on the children was
severe. “I sat them down and explained that I had been accused of
hurting Connor. Sam said, ‘Tell them I did it and then he can come
home’ and Ryan said, ‘You’ve never hurt any of us’.

“My husband was a big support. He never asked me if I had hurt Connor
and I don’t think he suspected me, but when doctors and the social
worker were saying it had to be the only explanation, I would have
understood if he had.”

Accusation impossible to deal with

For Jo, being accused of harming her child was almost impossible to
deal with. “I felt that I was having a breakdown,” she says. “Losing
Connor was hell. I couldn’t sleep, I would just read medical
textbooks every night to see if I could find any other explanation
for his injuries.

“Most of the time, though, I just sat and cried. The idea that I
could have hurt my baby so was alien to me. I was all ready to take
Sam and Ryan to my sister-in-law’s house to get Connor and just drive
anywhere. I thought that if I was found guilty, all three boys would
be taken away.”

Later that week, Jo and her husband had to go to the police
station. “They questioned each of us for two hours. They kept asking
me if I’d shaken Connor. I told the truth – that I had, but only
gently, because he wasn’t breathing – but I felt like a criminal. It
was so traumatic. I was in tears for the whole time.”

Jo and her husband were allowed to visit Connor, but not to be alone
with him. “He was waking up in the middle of the night for feeds and
I simply couldn’t get to him. It was so hard to leave him there.”

Just over a week after Connor had been placed with her sister-in-law,
Jo went along for her routine visit. Her husband was already
there. “He opened the door and he had a huge smile on his face,” she
remembers.

“He said the hospital had just called and they had the results back
from Great Ormond Street – there were no blood clots, no broken
bones – and that the hospital had made a mistake. We were allowed to
take him home.”

Stigma and emotional strain remain

But the stigma and the emotional strain of being falsely accused -
the family have never had an apology from the child protection unit,
and a mooted inquiry has never materialised – still haunts them.

“I am so over-protective of Connor,” says Jo. “He didn’t start
walking until late because I would wrap cushions around him so he
wouldn’t hurt himself when he fell. I watch him constantly.

“On the one hand, I keep wanting to take him to the doctor in case
there’s something wrong, but on the other I’m scared of doing that.

“He fell down some steps a few months ago and I had to think twice
about taking him to hospital -I know that what happened is still on
his record, so if anything happens to him, I would feel under
suspicion.”

The Harrises’ children, too, still suffer. “Even now, if I say Connor
has to go to the doctor, my older boys get upset because they think
he’s not going to come back.

“I can’t get rid of the stigma of being accused of hurting my child.
Just two weeks ago, Ryan came home from school in tears because a boy
had said I was a babybeater.” Jo had read about Angela Cannings’s
case, and wrote to her in prison. “I wanted to show my support.
Writing to her reminded me of how lucky I was.

“She would write to me about how awful it was to be in prison when
she hadn’t done anything, that all she wanted was to be at home with
her daughter.

“I know that the doctors at the hospital had my son’s interests at
heart, but I want people to realise that medical experts can, and do,
make mistakes.”

To contact the Five Percenters, the campaign group which supports
parents who have been wrongly accused of SBS, call 020 7639 0942 or
visit www.sbs5.dircon.co.uk


Source:

http://www.vaccinetruth.org/shakenbaby/interrogated.htm

The Reliability Of Confessions

Shaken Baby Syndrome

Do Confessions by Alleged Perpetrators

Validate the Concept?

ABSTRACT


The concept that a certain constellation of findings develops immediately after a baby is shaken, with no impact to the head, is based solely on confessions or admissions by alleged perpetrators. The reliability of confessions in the setting of interrogation by law-enforcement officials is questionable. A review
of the literature reveals very few cases of admissions of “pure shaking.  Methodologic  flaws preclude any definitive conclusions about causation from these cases.

The Origins of the “Shaken Baby Syndrome”

The “shaken baby syndrome” (SBS) is embedded in the collective minds of the public, law enforcement, prosecuting attorneys, child-protection personnel, and physicians. The concept was largely derived from the papers of Caffey, a radiologist specializing in pediatric cases. He had for years suggested that the multiple limb fractures he observed in babies were the result of abuse. It was not until Kempe and his associates at the University of Colorado Medical Center in Denver published their seminal article in 1962 that the theories of Caffey and others began to gain acceptance. A sensational case of a child-care nurse who admitted to shaking and killing three babies in her care attracted Caffey’s  attention, and he apparently thought that her admission explained what he had been seeing for years but had been unable to explain.

Caffey now theorized that multiple fractures of the lower extremities and other bones as well as subdural hemorrhages in apparently abused babies were caused by the flailing legs and a head flopping back and forth with shaking. This mechanism, without any scientific evidence to support it, made intuitive sense to him and others, and thus was born whiplash-shaking  and later the shaken baby” syndrome.
SBS has been embraced by the American Academy of Pediatrics and other organizations. They support the concept that manual shaking of a baby causes a constellation of rapidly evolving processes (subdural hemorrhages, retinal hemorrhages, brain swelling, metaphyseal long-bone fractures, respiratory
failure, and often death) in the apparent absence of signs of external injury, and that these things collectively cannot occur in any other context than abuse.

Conservatively, more than 100 case reports and small series in support of Caffey’s theories have appeared in the literature from the early 1970s to 2001. A number of them provided perpetrator admissions of shaking that seemed to validate the concept of shaking as a cause of the syndrome. However, a literature that challenges the mechanism of injury, the components of SBS, and even the existence of the syndrome itself has also developed. These challenges are in the form of biomechanical analyses, criticism of case-analysis methodology, analysis of admissions of alleged perpetrators, and a consideration of alternate explanations. It is safe to say that there is a deep divide between proponents of the SBS and its critics.

A Review of the Confessional” Literature
Several recent studies have attempted to correlate confessions of perpetrators with injuries typically found in cases deemed to be SBS. These studies have been regarded by many as strong support for the theory of SBS. Of prime concern in these papers, however, is the basic issue of the value of a supposed confession in determining a mechanism for injury. With any confession or admission, there is the issue of veracity. Accused individuals are well known to fabricate historical information, augment certain aspects of what they might have done, say what they think an interrogator wants to hear, or omit important facts, presumably to give a better impression than might otherwise be the case.
Furthermore, though it is difficult to fathom why, accused individuals may confess to things they didn’t do. The issue of duress in its many forms in such cases is a valid one. One scenario in alleged SBS cases is that an interrogator (policeman, child-abuse professional, or child-protection professional) may employ subterfuge to secure an admission of shaking. Deceit is not uncommon, as when the interrogator may communicate to the accused that if you could tell us exactly what happened and if you shook the baby, we could do something for the baby and maybe save its life. There are, of course, no specific treatments in such cases other than those already being given to the baby, and this type of suggestion is disingenuous at best.
There may be other instances in which the results of interrogations and supposed statements by an accused are not what the accused said at all. Thus it is virtually impossible to determine what in an admission or confession is true and complete, false, fabricated, or tainted.To base an injury causation study on such information does not meet the accepted standards of analysis or interpretation because of insoluble issues of bias. This does not say that admissions/confessions are useless, only that validity and helpfulness depend on the context and the use being made of the information.
In a recent report of Biron and Shelton, the authors concluded that shaking alone can produce serious neurological impairment or death. They based their study on 52 cases collected in Queensland, Australia, over a 10-year period (1993-2003). The population analyzed was defined as those children under the age of 2 years who were judged to be homicides or assaults.Ateam of child-protection personnel, pediatricians, welfare, and law-enforcement professionals evaluated the cases. Transcripts and tape-recorded interviews with witnesses and perpetrators were reviewed, as were autopsy reports when they were available. The authors classified those babies as having been injured by shake only by the presence of subdural and/or subarachnoid hemorrhage, retinal hemorrhages, and absence of medical (skull or scalp) injury or witness evidence of impact. The remaining cases were classified as impact only,” as determined by skull or scalp injury, perpetrator or witness evidence of an impact without associated shaking, and the absence of retinal hemorrhages.
Shake impact cases were identified if they had combinations of the above. Cases with insufficient evidence were called indeterminate.”Twenty of 52 babies died. The authors concluded that of the 52 cases, 13 were “shaken only” (five deaths), 3 had head “impact only” (one death), and 25 had evidence of both “shaking and impact” (ten deaths), with 11 cases judged indeterminate  as to cause (four deaths). In five of the 13 shaken only cases recorded, perpetrator confessions were obtained; these five cases and two more were presented in detail.
The authors cited a number of papers that have questioned, from various perspectives including biomechanics, the validity of the concept of SBS but appear not to have been sufficiently impressed to take these criticisms to heart before making their conclusions. The authors did not cite an important paper by Donohoe, which discussed in detail methodological issues in studies like theirs and basically concluded that the existing literature on SBS does not meet sufficiently rigorous standards to conclude that shaking alone causes intracranial injury.
The Biron and Shelton paper has many serious flaws that include selection bias, observer bias, lack of controls, failure to evaluate causal possibilities beyond shaking, and circular reasoning, to name a few. The assertion that retinal hemorrhages are a discriminator for shaking has been challenged in the literature for years, as have other selection criteria. The paper is little different from most of the literature based on case series that try to support the concepts of SBS in that the principles and methods of science were not adhered to and the data presented do not justify the conclusions reached. These same problems apply to most of the literature that makes use of confessions as a justification that shaking alone causes intracranial injuries.
Another recent case analysis, encompassing more than 30 years of published case reports of presumably abused babies, approached the admissions issue from another perspective. Plunkett found 54 instances, in 324 cases with individual case data, of an admission by someone that he had shaken the injured baby in some fashion. In the 270 remaining cases, no record of any admission was reported.

The study found that the reported information in admissions varied widely in the amount of precise information provided and in the context of the shaking: for example, attempts to revive, shaking after a violent event such as strangulation/smothering or throwing the baby to the floor had occurred, and incidental shaking or bouncing during play. It was found that in 11 cases shaking had apparently occurred without evidence of impact. In 12 cases, only shaking was admitted, but head impact was found nonetheless. In 18 cases, admissions of shaking were documented, but there was no information, pro or con, about head impact injury, so these cases could not be analyzed.
An additional 13 cases, those of Hadley et al., in which admissions of shaking may have occurred, were not included in the analysis because of ambiguous statements in the article regarding what constituted an admission of shaking, or even whether it occurred at all.
It is significant that in the 11 shaken and possibly not head impacted babies, all but three survived, thus one cannot be sure that no head impact had occurred in the eight survivors. In the three who died, apparently none had head impacts at autopsy. Thus, these may be the only cases that might qualify as pure and might have sustained their injuries by shaking alone. It should be obvious that with a case population this small, few robust conclusions about causality can be reached.

Time of Onset of Symptoms and Signs
A common theme that emerges from the confessional” literature is the alleged immediacy of the appearance of symptoms after a reported shaking episode as reported by the perpetrator. A common allegation of some child-abuse experts is that all or virtually all shaken babies become ill immediately after having been shaken. Therefore, the individual present when the child decompensates is responsible. The published case literature does not support this contention. In the Leestma study, of the 11 babies who might qualify as pure shaken babies only four had information about a possible interval between shaking and the appearance of symptoms. None of these babies showed immediate symptoms and were reported to have developed symptoms a day or more after shaking.
Considering all 54 admitted shaken babies, only 12 case reports gave information about the time of onset of the symptoms. Only two cases showed immediate symptoms, and all the rest showed delays from hours to days or longer after the supposed shaking episode. One should bear in mind that most of these babies had impact injuries to the head. Even in this circumstance, where an obvious head impact occurred, symptoms did not always appear immediately. Others have also reported these observations.

Differential Diagnosis
It should be apparent that from virtually every perspective many flaws exist in the theory that shaking is causative. No case studies have ever been undertaken to probe even a partial list of possible confounding variables/phenomena, such as the presence of intracranial cysts or fluid collections, hydrocephalus, congenital and inherited diseases, infection, coagulation disorders and venous thrombosis, recent immunizations, medications, birth-related brain injuries, or recent or remote head trauma. Until and unless these and probably many more factors are evaluated, it is inappropriate to select one mechanism only and ignore the rest of the potential causes.

Conclusions

The confessions or admissions of a perpetrator are at best tenuous support for the shaking mechanism for infantile head injury. A critical appraisal of any literature that proposes a causal mechanism of shaking for brain injury must include an evaluation of case selection methodology, population or sample size, possible case control issues, data analysis methods, and whether the conclusions reached are justified by the data presented.
Another vital issue, often overlooked, is a critical evaluation of literature cited. Unless the reader is very well informed on the issues and is intimately familiar with the literature, this component of an informed appraisal of an article almost never gets done, and the reader may accept the conclusions uncritically.

Jan E. Leestma, M.D., M.M

is board certified in anatomic and
neuropathology, and is a consultant in neuropathology at Children’s
Memorial Hospital of Northwestern University Medical Center, Chicago.
Potential Conflict of Interest:

Dr. Leestma has been engaged to provide
expert testimony in various criminal and civil cases, including some
involving alleged SBS. Contact: jleestma@aol.com.
See Original Source For References:

http://www.jpands.org/vol11no1/leestma.pdf

Caregiver Not Guilty Of Shaken Baby Syndrome

DCF Worker Accused Of Killing Foster Child Found Not Guilty

Suzanne Listro

Connecticut Department of Children and Families employee Suzanne Listro stands at her arraignment in Superior Court in Rockville, Conn., Thursday, July 17, 2008. Listro was charged with manslaughter in connection with the death of a 7-month-old foster child in May, 2008. ((AP Photo/WFSB-TV) / July 17, 2008

By DAVID OWENS The Hartford Courant March 30, 2010

TOLLAND – A Mansfield woman accused of killing a 7-month-old foster child in her care was acquitted Monday of charges of first-degree manslaughter and risk of injury to a minor.

Suzanne Listro, 44, a former state Department of Children and Families employee, was caring for Michael Brown Jr. on May 19, 2008, when the baby suffered a massive head trauma. The boy, who was in DCF custody, was rushed to the hospital, but died of his injuries.

Listro said the boy rolled off a bed while she was distracted and fell 26 inches to a linoleum floor.

The state charged Listro with causing the trauma, contending that a fall of such a short distance could not have caused the “massive, bilateral subdural hemorrhage” that the child suffered.

After hearing a host of expert witnesses testify during three weeks of trial, Judge William H. Bright Jr. said that questions remained and he could not say who or what was responsible for Michael’s death.

“I cannot say beyond a reasonable doubt Ms. Listro inflicted these injuries on Michael Brown,” Bright said.

“I’m not saying this was an accident,” the judge added. “I don’t know.”

And then the judge expressed sorrow to the boy’s father, Michael Brown Sr., who attended much of the trial. He told Brown that when a child dies, people want answers, but that he could not provide them.

Outside court, prosecutors, Listro and Brown declined to comment. Hope Seeley, one of Listro’s defense attorneys, said, “The judge said it all, not guilty. We’re just really pleased with the judge’s attentiveness and careful reflection in a very, very difficult case.”

Each side presented medical and other experts to bolster its case. The state charged that Listro caused the trauma, either by shaking or some other impact. The defense attacked the existence of “shaken baby syndrome” and claimed that Michael was medically fragile, suffering from a prior head injury. The short fall, which would not have been a problem for most children, proved catastrophic and killed the boy, the defense argued.

Bright, in his verdict, was not ready to cast aside the existence of shaken baby syndrome, which he noted is accepted by a large portion of the medical community.

It was possible that Listro caused the boy’s injuries, the judge found, but he was troubled by the lack of a sign of external trauma on the boy. It was also possible that Michael had a “time bomb” in his head and that this “may be that rare short fall case that resulted in a death,” the judge said.

After Michael’s death, DCF came under scrutiny and it was revealed that Listro had twice been investigated for allegations of child abuse. The allegations were not substantiated, but DCF Commissioner Susan Hamilton later said the investigation into those allegations “was substandard and unacceptable. Accordingly, it is unclear whether those allegations would have been substantiated [by] a more thorough investigation.” DCF fired Listro after the child’s death.

Source:

http://www.courant.com/news/connecticut/hc-dcf-suzanne-listro-not-guilty-0329,0,5350064.story

Fatal Falls In Childhood

How Far Must Children Fall To Sustain Fatal Head Injury?

Report of Cases And Review Of The Literature

Reiber, Gregory D. M.D.

This article documents 3 cases of deaths from corroborated/witnessed short falls (10-20 feet). The author states that all three children had SDH and fractures. The author documents that 2 of 3 children had lucid intervals and all 3 children died after a delayed period following the fall. 2 of 3 children showed periorbital echymosis. One child suffered a SDH and severe brain swelling from a 6-foot fall onto a carpeted floor. 1 child fell 2-3 feet from a rocking chair. This article suggests that soft surfaces can still cause fatal injuries. Also, this article includes a lengthy literature review on shortfall debate.

Abstract

The question of whether fatal head injuries may occur from short-distance falls is one that continues to cause controversy. The records of the Sacramento County Coroner’s Office from 1983 to 1991 were reviewed for cases of fatal head injury in children aged <=5 years, where a history of a fall was initially given. During this 9-year period, three cases of witnessed falls from heights of > 10 ft (3 m) were found. At autopsy, all children had multiple complex calvarial skull fractures, basal fractures, or both; subdural and subarachnoid hemorrhage was found in all cases, and two showed severe cerebral contusion. None had retinal hemorrhage or axonal injury. These are compared with 19 fatalities initially alleged to have occurred from short falls of <=5-6 ft (1.5-1.8 m). As others have found, most of these “minor fall” fatalities occurred under circumstances where there were no unrelated witnesses to corroborate the initial history. Autopsy findings in these cases tended to be of unexpected severity for the initially proposed mechanism of injury, and a number of cases showed evidence of accelerative injury (retinal hemorrhage and/or diffuse axonal injury) where no such mechanism was accounted for by initial history. After sufficient investigation, most of these cases (74%) have ultimately been proven to represent inflicted trauma. A thorough literature review on the subject identifies two major viewpoints. One is that short falls have a significant potential for fatality. The other, more widely espoused view is that short falls rarely, if ever, cause serious injury or death. These two views, and the data upon which they rest, are compared and contrasted.

Source:

http://journals.lww.com/amjforensicmedicine/Abstract/1993/09000/Fatal_Falls_in_Childhood__How_Far_Must_Children.5.aspx

Dad Not Guilty

Jurors Acquit Virginia Dad in Shaken Baby Syndrome Case


By Tom Jackman
Washington Post Staff Writer
Tuesday, March 16, 2010; B01

After another battle of experts over the concept of “shaken baby syndrome,” a Fairfax County jury found a man not guilty of murder on Monday in the death of his 8-month-old son.

Elmer J. Midence, 39, lived with his girlfriend, Rhonda Brown, and their baby, Albert, in the basement of a brick house on Bath Street in the Springfield area, and by all accounts were a happy family. Photos taken the day before Albert was rushed to the hospital showed the family wearing wigs and mugging for the camera at a Saint Patrick’s Day parade.

But on March 16, 2009, Midence called 911 and said Albert was unresponsive. Midence said he had been in the shower with the baby, stepped out, and slipped and fell. He insisted that he did not drop the baby in conversations with the dispatcher, the paramedics and a police homicide detective.

Albert’s brain injury was severe, and Fairfax Commonwealth’s Attorney Kathryn S. Swart told the jury, “that poor child was going to die no matter what the medical people were going to do.” Two days after the baby was hospitalized, he died.

Albert had a subdural hematoma — a blood clot between his brain and his skull — and hemorrhages in the back of his eyes. Both are seen as crucial indicators of shaken baby syndrome, in which an adult shakes a child so hard that his brain bleeds.

But a growing scientific theory holds that it is not possible to shake a baby hard enough to cause brain damage without accompanying trauma to the neck or back or additional severe impact with a hard surface.

In January, a string of experts on both sides of the issue testified in a Fairfax case in which a daycare provider was charged with shaking a 4-month-old baby. The baby boy, after suddenly falling unconscious, suffered lasting brain damage but did not die. The daycare provider, Trudy E. Muñoz-Rueda, testified she did not shake the baby, but the jury convicted her of felony child abuse and child cruelty and sentenced her to 10 1/2 years.

Last week, two of the same experts faced off again. For the prosecution, Craig Futterman, a pediatric intensive care doctor, said he had seen Albert at Inova Fairfax Hospital and that his injuries indicated he had endured severe acceleration and deceleration — the head going back and forth, with the brain colliding off the inside of the skull.

For the defense, Dr. Ronald H. Uscinski, a Georgetown neurosurgeon who has become a renowned critic of shaken baby syndrome, said a sudden fall would provide the force necessary to damage the brain. Forensic pathologist Peter Stephens offered similar testimony.

And they noted that Albert did not have the neck or body trauma that would indicate someone had shaken him with the force necessary to shear veins in the brain. The boy did have a bad bruise on the side of his head.

On the witness stand, Midence said for the first time that he had dropped Albert when he slipped and fell from the shower. Midence said that he had fallen to the side of the makeshift shower in a tiny basement bathroom and that Albert had fallen forward, and when he went to check on Albert, he was unresponsive.

Futterman said Albert’s injuries were inconsistent with a fall. In her closing argument, Swart asked the jury, “Why aren’t children dying by the scores when they fall off their changing tables or off their high chairs?”

Deputy Fairfax Public Defender Dawn M. Butorac pointed to scientific studies that showed it was impossible to generate enough force to shake a baby into brain damage without other trauma and to other studies showing severe or fatal injuries to babies from short falls.

The jury deliberated for more than 12 hours over two days before acquitting Midence of both child abuse and felony murder. Brown, the baby’s mother, declined to comment after the verdict.

Midence’s family members began crying as the “not guilty” verdicts were read.

“We’re very happy, because he’s a good man,” said his cousin, Berta Palm. “He’s a good father and a very generous person.”

Butorac said the case showed “you cannot shake a baby, solely, to get these injuries.” She said there were “dedicated doctors on both sides who disagreed about how you can get an injury,” and without a clear consensus, the jury correctly acquitted.

Source:

http://www.washingtonpost.com/wp-dyn/content/article/2010/03/15/AR2010031503404_pf.html

Categories: Dad Not Guilty

Intracranial Hemorrhage From Normal Birth

Prevalence and Evolution of Intracranial Hemorrhage in Asymptomatic Term Infants

V.J. Rooksa,c, J.P. Eatona,e, L. Ruessa,c,d, G.W. Petermanna,c, J. Keck-Wherleyb and R.C. Pedersenb,d

a Department of Radiology, Tripler Army Medical Center Honolulu, Hawaii
b Department of Pediatrics, Tripler Army Medical Center Honolulu, Hawaii
c Department of Radiology and Radiological Sciences, F. Edward Hebert School of Medicine, Uniform Services University of the Health Sciences, Bethesda, Md
d Department of Pediatrics, F. Edward Hebert School of Medicine, Uniform Services University of the Health Sciences, Bethesda, Md
e Weed Army Community Hospital, Fort Irwin, Calif

BACKGROUND AND PURPOSE: Subdural hemorrhage (SDH) is often associated with infants experiencing nonaccidental injury (NAI). A study of the appearance and natural evolution of these birth-related hemorrhages, particularly SDH, is important in the forensic evaluation of NAI. The purpose of this study was to determine the normal incidence, size, distribution, and natural history of SDH in asymptomatic term neonates as detected by sonography (US) and MR imaging within 72 hours of birth.

MATERIALS AND METHODS: Birth history, delivery method, duration of each stage of labor, pharmaceutic augmentation, and complications during delivery as well as postnatal physical examination were recorded. Brain MR imaging and US were performed on 101 asymptomatic term infants at 3–7 days, 2 weeks, 1 month, and 3 months. Clinical follow-up at 24 months was recorded.

RESULTS: Forty-six neonates had SDH by MR imaging within 72 hours of delivery. SDH was seen in both vaginal and cesarean deliveries. All neonates were asymptomatic, with normal findings on physical examination. All 46 had supratentorial SDH seen in the posterior cranium. Twenty (43%) also had infratentorial SDH. US detected 11 of the 20 (55%) infratentorial SDHs and no supratentorial SDH. Most SDHs present at birth were 3 mm and had resolved by 1 month, and all resolved by 3 months on MR imaging. Most children with SDHs had normal findings on developmental examinations at 24 months.

CONCLUSION: SDH in asymptomatic term neonates after delivery is limited in size and location.

Subdural hemorrhage (SDH) is often associated with infants experiencing nonaccidental injury (NAI).113 Birth-related trauma is used in the court of law as an explanation for SDH in infants with suspected NAI because a variety of hemorrhages have been reported in term neonates. A study of the appearance and natural evolution of these birth-related hemorrhages, particularly SDH, is important in the forensic evaluation of NAI. A few published series report the finding of hemorrhages in infants who were symptomatic in the neonatal period.1418 Some reports suggest that the risk of SDH and other hemorrhages found on imaging of symptomatic infants varies with the method of delivery.19 Sonography (US) is standard practice for detecting germinal matrix hemorrhage in the preterm neonate and has also been proved to demonstrate posterior fossa SDH.14 MR imaging in general has a high sensitivity for intracranial hemorrhage, and, with its lack of ionizing radiation, is a favorable technique for the evaluation of birth trauma over CT, especially for a neonate. Previous studies conducted in an effort to determine the incidence and natural history of asymptomatic SDH in the neonate have been limited by the use of low-field-strength (0.2T) MR imaging, small patient numbers, or variable timing of imaging after birth.2023

The purpose of this study was to determine the normal incidence, size, appearance, and distribution of SDH in asymptomatic term neonates as detected by US and 1.5T MR imaging within 72 hours of birth. In addition, we prospectively studied the natural history of these hemorrhages. This study can then serve as a baseline for comparison with an abnormal pattern of SDH seen in abuse.

Methods

The protocol was approved by the Scientific Review and Human Use Committees of the hospital. Neonates of at least 37 weeks gestation, with normal findings on neonate physical examination by a board-certified physician were eligible for the study. The first 101 patients whose parents gave written consent during the approved study period were included. Birth history, delivery method, duration of each stage of labor, pharmaceutic augmentation with oxytocin, and complications during delivery were recorded. All neonates had normal findings on neurologic examination by a board-certified child neurologist before imaging. Ophthalmologic examination of the retina was not performed on any neonates. The first MR imaging and US for each patient were performed at <72 hours of age.

US was performed on an Acuson Sequoia 512 (Siemens Medical Solutions, Malvern, Pa) by using 8V5 and 15L8 transducers. Standard coronal and sagittal images of the neonatal brain through the anterior fontanelle and images of the posterior fossa via the mastoid fontanelle were obtained. Color Doppler flow imaging was also used when the findings of gray-scale imaging were positive for SDH. US was performed within 1 hour of the MR imaging. SDH was defined as an extracerebral curvilinear echogenicity subjacent to the calvaria without evidence of central traversing vessels on color Doppler imaging.

Imaging was timed to occur after a morning feeding. Infants were transported to the radiology department in a mobile bassinette, placed on the MR imaging table in an 8-channel head coil, and secured with a sheet, sponges, and tape to minimize motion. Pieces of standard foam ear protection were taped in place, and a pacifier was offered for comfort. No infants were given sedation medications. With a Signa 1.5T MR imaging scanner (software 11.0_M4_0403a) (GE Healthcare, Milwaukee, Wis), we used the following imaging sequences: 1) 3-plane localizer; 2) sagittal T2 single-shot fast spin-echo (SE) 2D pulse sequence imaging option with a TE of 90, TR of 3000, bandwidth of 31.25, FOV of 18, section thickness of 4, 0 skip, matrix of 256 x 192, frequency signal intensity, NEX 1, phase FOV of 0.70; 3) axial multiplanar gradient recall (MPGR) pulse sequence gradient-echo imaging option, flow comp, VBW, with a TE of 20, TR of 355, flip angle of 20°, bandwidth of 15.63, FOV of 18, section thickness of 4, 0 skip, matrix of 256 x 192, frequency AP, NEX 1, phase FOV of 0.75; 4) axial T1 conventional SE 2D pulse sequence imaging option, VBW, TE min, TR of 377, bandwidth of 15.63, SAT I, FOV of 18, section thickness of 4, 0 skip, matrix 256 x 192, NEX 0.75, phase FOV of 0.75, frequency AP; 5) coronal T1 (posterior fossa) 2D pulse sequence SE imaging option, VBW, TE min, TR of 502, bandwidth of 15.63, SAT I, FOV of 18, section thickness of 4, 0 skip, matrix 256 x 192, frequency direction S/I, NEX 0.75, phase FOV of 0.75; 6) axial fluid-attenuated inversion recovery (FLAIR) 2D pulse sequence IR imaging option, tailored radio-frequency fast, zip of 512, TE of 120, TR of 10,000, TI of 2200, bandwidth of 15.63, FOV of 18, section thickness of 4, 0 skip, matrix 256 x 224, frequency direction A/P, NEX 1; 7) axial diffusion-weighted echo-planar imaging (DWI EPI) 2D SE imaging option (DIFF), number of shots 1, TE min, TR of 10,000, DWI screen b-value of 1500, diffusion direction ALL, frequency of 128/128, NEX 1, FOV of 18, section thickness of 44, 0 skip, matrix 128 x 128. Conventional SE T1 was substituted for fast SE after 42 patients were scanned.

MR and US images were independently reviewed on a PACS (Centricity; GE Healthcare) by 2 board-certified radiologists each with a Certificate of Added Qualification in neuroradiology or pediatric radiology. The child neurologist discussed imaging results with parents. Infants with SDH detected on initial imaging were scheduled for follow-up MR imaging and US examinations at 3–7 days, 2 weeks, 1 month, and 3 months or until the MR imaging and US findings were both negative. If the initial US findings were normal, no further US images were obtained. Final interpretations regarding the presence of SDH on MR imaging were determined by consensus of 2 of the radiologists based on SDH seen on both the immediate postdelivery initial MR imaging and the first follow-up at 3–7 days. SDH on MR imaging was defined as an extracerebral curvilinear signal-intensity abnormality corresponding to blood products that did not extend into the sulci. For US and MR imaging, SDH location and size were recorded, with size measured as a maximal width in the axial plane by using electronic calipers. In infants with SDH in multiple locations, the size of the largest SDH was recorded. The presence of cephalohematomas was also recorded. Evaluation for coagulopathy was not routinely performed.

Comparison of the incidence of SDH among the delivery groups was made by using the Fisher exact test. The average labor times and birth weights of those with SDH and those without were compared by using a Student t test or the nonparametric Wilcoxon test if the variance in data was unequal between groups. The Fisher exact test was used to compare prolonged duration of labor and incidence of cephalohematoma in those with SDH versus those without. The comparison of the incidence of SDH in vaginal and cesarean deliveries augmented with oxytocin administration was also performed by using the Fisher exact test in addition to computation of the odds ratio of increased SDH associated with giving oxytocin. Data are expressed as mean ± standard error of the mean and/or as a median within the range of values obtained. For all tests, a value of P < .05 was considered significant. The first stage of labor was defined as the duration from the onset of labor until the fetus was engaged in the birth canal. The second stage of labor was defined as the duration of fetal descent through the birth canal.

Clinical follow-up was performed in all patients who demonstrated SDH on imaging. Patients were evaluated at their 24-month well-child visit and assessed for developmental delay. A developmental delay (motor or speech) was defined as a delay in a particular developmental domain compared with expected norms for age. Developmental delay is used as a temporary diagnosis in young children at risk for developmental disabilities, indicating a failure to achieve age-appropriate neurodevelopmental milestones.24 At our institution, assessing for developmental delays is part of every well-child visit, typically performed at 2, 4, 6, 12, 15, 18, and 24 months. The Denver Developmental Screening Test II is applied to each child at their well-child visit.25

Results

One hundred one patients were enrolled in the study between January 2005 and March 2006. There were 58 male and 43 female infants. Seventy-nine (78%) infants were born via vaginal delivery with (80%) via spontaneous delivery (SVD), 10 (12%) with vacuum assistance, and 6 (8%) with forceps assistance (supplemental on-line Table). Thirty-five vaginal deliveries were induced or augmented with oxytocin. Twenty-two (22%) infants were delivered via cesarean delivery: 13 elective cesarean deliveries and 9 for failure to progress and/or fetal distress after a trial of labor. Four of the cesarean deliveries had a trial of labor augmented with oxytocin. One cesarean delivery was assisted with forceps, and 1 was assisted with vacuum extraction. All neonates had normal findings on neurologic examinations at birth.

All 101 initial MR imaging examinations were successful, without significant motion artifact. Most infants slept through the entire examination. Examination times required <10 minutes to complete. Three MR imaging examinations were thought to be positive for SDH on initial sequences, but the findings were normal at the first follow-up MR imaging by 3–7 days of life. These were presumed to be false-positive findings and were recategorized as negative findings. Forty-six (46%) infants had SDH on initial MR imaging that was confirmed on follow-up studies (supplemental on-line Table). Forty-four of 46 (95.9%) had SDH of ≤3 mm in thickness (range, 1.0–4.3 mm; mean, 2.1 mm). SDH was best visualized on the initial MR imaging MPGR sequence performed before 72 hours of life (Fig 1). All 46 patients with intracranial hemorrhage had supratentorial SDH confirmed on 2 imaging planes on follow-up imaging. All supratentorial SDHs identified within 72 hours postdelivery were seen in the posterior half of the cranium. Twelve (26%) infants had SDH noted in only 1 location, whereas most infants had SDH in 2 or 3 locations. In all, SDH was most commonly seen in the posterior interhemispheric fissure (parafalcine location) (30, 65%), with SDH also noted posteriorly along the occipital lobes in 29 (63%) and over the tentorium in 22 (48%) (supplemental on-line Table). All SDHs were homogeneous in signal intensity on all sequences.

Figure 1
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Fig 1. Posterior fossa SDH in a neonate delivered via SVD. A, Axial MPGR at <72 hours of life demonstrates lobular symmetric low signal intensity with blooming in the posterior fossa (arrows). B, Follow-up T1 images show high-signal-intensity SDH (arrowheads) by 7 days.

Twenty (43%) of the neonates with supratentorial SDH also had posterior fossa SDH (Fig 2). No neonate had only posterior fossa hemorrhage detected by MR imaging. No neonate had MR imaging evidence of subarachnoid, epidural, or intraparenchymal hemorrhage. No parenchymal contusions were seen. Two neonates had grade I germinal matrix hemorrhages (1 unilateral, 1 bilateral) as well as SDHs. Twenty-two neonates had a cephalohematoma noted at MR imaging. Eighteen (82%) of these neonates had SDH. Most (11/18, 61%) had posterior fossa SDH as well as supratentorial SDH. One had a 1.6-cm paraventricular mass incidentally detected on MR imaging, which was not seen on repeat US performed after the initial MR imaging. The mass, thought to be a hamartoma, was observed with expectant management. It remained asymptomatic and unchanged in size on 4-month follow-up at our institution before the patient’s family moved from our area.

Figure 2
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Fig 2. Neonate delivered via SVD with both supratentorial and infratentorial SDH. A and B, Initial examination shows the lobular occipital SDH to be very low signal intensity on MPGR (arrows, A) and isointense to gray matter and difficult to detect on the SE T1-weighted MR image (B). C and D, Five-day follow-up shows high T1 SDH (arrowheads) in 2 locations in 2 planes, axial supratentorial (C) and coronal, both supra- and infratentorial (D). E and F, Two-week follow-up shows complete resolution of hemorrhage on T1 images.

Posterior fossa SDH was seen at US in 11 (11%) neonates, and all SDHs were confirmed on MR imaging (Fig 3). Thus, only 55% of the 20 posterior fossa SDHs seen on MR imaging were identified independently on US examination. US was focused along the lateral aspects through the mastoid fontanelle. Sensitivity of US detection of posterior fossa SDH improved when the 3 infants with posterior fossa SDH isolated to midline were excluded on MR imaging3; thus, 11/17 (65%) lateral posterior fossa SDHs were detected on US. All SDHs seen on US were also seen on MR imaging. No supratentorial hemorrhages were detected at US.

Figure 3
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Fig 3. Neonate delivered via SVD with posterior fossa SDH seen on US and confirmed on MR imaging. A, Axial sonogram of the posterior fossa through the mastoid fontanel demonstrates initial curvilinear echogenic focus adjacent to the transverse sinus (arrow). B, Axial T1-weighted MR image confirms high-signal-intensity posterior fossa SDH (arrowhead) on day 7 of life.

The incidence of SDH versus mode of delivery is shown in Table 1. All 4 neonates with SDH delivered by cesarean birth had supratentorial SDH only. One of the neonates with SDH and delivered by cesarean birth was born via elective cesarean delivery for macrosomia, whereas 3 of 4 (75%) neonates with SDH and delivered by cesarean birth had failed a trial of oxytocin-augmented labor before cesarean delivery. One of these cesarean deliveries required vacuum assistance. In comparison with the neonates delivered via cesarean delivery, rates of SDH were significantly higher in all the vaginal delivery groups (Table 1). There was no statistically significant difference in the presence of SDH in each of the vaginal delivery groups.

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Table 1: SDH versus mode of delivery

The duration of the first and second stages of labor was recorded for all neonates delivered vaginally. For neonates with SDH, the mean duration of the first stage of labor was not significantly different from that in those without SDH (Table 2). The second stage of labor was significantly longer in neonates with SDH than in those without SDH. A prolonged second stage of labor (>2 hours) was also significantly longer in the group with SDH, compared with the group without SDH. The incidence of cephalohematoma was greater in neonates with SDH than in those without SDH. There was no difference in average second-stage labor duration in those with a cephalohematoma compared with those without. The mean birth weight of neonates with SDH on MR imaging was higher than that of those with normal findings on MR imaging (Table 2).

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Table 2: Vaginally delivered neonates with and without SDH: mean length of each stage of labor, birth weight, and incidence of cephalohematoma

The overall incidence of SDH in the 39 patients who received oxytocin was not different from the incidence of SDH in the 62 patients who did not receive oxytocin (Table 3). This was also true for the subgroup of vaginal deliveries. However, closer examination of cesarean delivery revealed that the incidence of SDH when oxytocin was given before cesarean delivery was much higher (Table 3).

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Table 3: SDH and use of oxytocin in vaginal and cesarean deliveries

Follow-up imaging was completed in 18/46 (39.1%) patients with SDH. All 18 patients demonstrated resolution by 3 months. Two patients were only imaged at birth and at 3 months due to scheduling conflicts. Both of these patients had normal MR imaging findings at 3 months. Fifteen of 16 patients (93.8%) whose follow-up imaging included a 1-month MR imaging had interval resolution of their SDHs. One patient had a new frontal SDH on the 2-week MR imaging follow-up examination (Fig 4). This patient had bilateral occipital and posterior fossa SDH on initial imaging at birth, confirmed on the 7-day follow-up MR imaging. He was also noted to have extra-axial collections of infancy. At 26-days postnatal age, the MR imaging demonstrated left frontal subdural collections that did not conform to CSF signal intensity. Of the 46 infants with SDH, 43 children had records of 2 years of well-baby examinations at our institution. One child was only followed to 2 months, 1 child’s family had moved out of the area, and 1 child was not eligible for continued care in our system. None of the 43 infants had gross motor delay. Six (14%) children were noted to have speech delay, and 1 (2%) is currently being evaluated for an autistic spectrum disorder.

Figure 4
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Fig 4. Images obtained at 7 and 26 days postnatal age for follow-up of bilateral occipital SDH in a neonate with extra-axial collections. Axial T2, T1, gradient-refocused echo (GRE), and FLAIR images (left to right, top row) show CSF-intensity frontal subarachnoid collections that were present since birth. Also note a thin linear T1 hyperintense GRE hypointense bilateral posterior occipital SDH. At 26 days postnatal age (bottom row), left frontal subdural collections that do not conform to CSF signal intensity are present, consistent with spontaneous SDH. The patient had no history of trauma and had a negative evaluation for NAI.

Discussion

We confirmed reports that SDH occurs in the asymptomatic neonate after delivery.2022 The incidence of SDH (46%) is significantly higher in our study than in previous reports. Our higher incidence may be related to improved detection and increased sensitivity with a higher magnetic-field-strength 1.5T MR imaging scanner. Whitby et al,20 by using a low-field-strength 0.2T magnet, reported an SDH incidence of 8% overall and 10.5% in vaginal deliveries when they imaged within the first 48 hours of life. Our reported incidence is most like that of Holden et al,21 who, in a pilot study also using 1.5T MR imaging in 1999, saw SDH in 4 of 8 (50%) asymptomatic neonates in the first 4 days of life. These results suggest that SDH after uncomplicated vaginal delivery is a common finding on MR imaging.

Patient age at the time of MR imaging is an important factor in determining the incidence of SDH in neonates. We imaged neonates within the first 72 hours of life and found SDH most readily detectable on a gradient-echo sequence, confirmed on follow-up T1 sequences at 3–7 days of life. Most of the SDHs resolved by 4 weeks. Whitby et al20 also found that their 9 patients with SDH first seen within 48 hours of life had resolution of hemorrhage on MR imaging at 4-week follow-up. Recently, Looney et al,22 by using 3T MR imaging, reported SDH in 26% of neonates delivered vaginally. Infants in this study were scanned between 1 and 5 weeks of age. We agree that the true incidence in the population of Looney et al may have been higher than the prevalence reported because they may have missed SDHs that were present earlier in life and had resolved by the time of first imaging. Patient age at the time of MR imaging may also be important in determining an etiology for neonate SDH. In our patients, not only were most SDHs resolved by 1 month but SDHs had resolved by 3 months in all patients. This information may be useful to the radiologist asked to comment on the etiology of SDH in an infant. Our study suggests that SDH in an infant older than 3 months of age is unlikely to be birth-related regardless of the mode of delivery.

Proposed mechanisms for SDH have included tears of the falx and tentorium or bridging cortical veins secondary to stretching,11 difficult delivery,26,27 or abnormal labor.19 One suggested mechanism of hemorrhage after vaginal delivery is that increased circumferential pressure and squeezing of the head in the birthing canal result in overlap at the sutures, mechanical compression, and shearing of the bridging veins during delivery, resulting in SDH.28 The true etiology remains unknown because there is a paucity of evidence-based literature on this subject. Most reports of SDH in the neonate appear in the larger body of literature on infants who present with symptomatic SDHs.

The forensic literature suggests that SDH can result from rupture of bridging cerebral veins; however, it is difficult to demonstrate rupture of bridging cerebral vessels at autopsy.29,30 Towner et al19 suggested that abnormal labor was a common risk factor for hemorrhage in infants, after a retrospective review of deliveries in nulliparous women demonstrated a low incidence of intracranial hemorrhage. Pollina et al27 suggested that the method of assisted delivery rather than the urgency of the delivery or dysfunctional labor is a more important variable in cranial birth injuries. Although all types of intracranial hemorrhage were more common in vacuum extraction, not all term neonate SDHs can be explained by circumferential head squeeze and overlapping sutures. This finding is particularly true because we found SDH after cesarean delivery as well. Perhaps additional forces during parturition are at work contributing to the rupturing of veins and or capillaries.

In our study, the first and second stages of labor were longer in the infants with SDH than in those without SDH. Perhaps compressive force from the uterus during the first stage, which propels the infant into the birth canal, is a causative factor. A prolonged first stage in combination with a prolonged second stage of labor may be causative in that there may not only be increased prolonged propulsive forces but also increased molding and overlapping of sutures, which may lead to failure of tensile strength of the stretched vessels. Increased pressure during the labor process may augment the intracranial venous pressures, which also may be an additional factor leading to SDH. The incidence of SDH in our study was greater in neonates with cephalohematoma and was also associated with a longer second stage of labor. The overall birth weight of neonates with SDH was also significantly higher, which may have resulted in increased circumferential pressure forces from the birth canal. Although all of these factors or a combination of these factors is plausible for the mechanism, SDH as a product of parturition has now been documented in asymptomatic neonates in multiple studies.1423,2628

Although most of the asymptomatic SDHs seen at MR imaging and US were in neonates delivered vaginally, 18% (4 of 22) of our neonates delivered by cesarean birth also had SDH. Most infants with SDH delivered by cesarean birth (75%) had a trial of labor with oxytocin administration before the cesarean delivery. This supports the proposal that SDH may be related to labor. Presumably, the neonate experienced labor during oxytocin administration before the decision for cesarean delivery.

All previous reports of SDH associated with cesarean deliveries have been in symptomatic infants. Welch and Strand31 reported a series of neonates with a variety of intraparturitional intracranial hemorrhages, including 3 who had SDH and complicated cesarean deliveries either for failure to descend, forceps failure, or fetal distress. Studies reporting the incidence or prevalence of SDH in asymptomatic neonates have not reported hemorrhages in association with cesarean deliveries. The series by Whitby et al,20 using low field strength, did not report SDH after cesarean delivery even when vacuum-assisted delivery was attempted. Most recently, Looney et al22 reported no SDH in 23 cesarean deliveries. The delayed initial imaging at 1–5 weeks could account for the low incidence of SDH detection in that study because most SDHs in our patients resolved by 4 weeks.

The only hemorrhages detected were SDH. The location and size of the SDHs were limited. Most SDHs in our neonates were ≤3 mm. There were 2 neonates with an initial SDH >3 mm. One of these neonates had a presumed hamartoma with an occipital SDH measuring 3.3 mm. The other infant had increased extra-axial spaces and an initial occipital SDH of 4.3 mm. We believe that these infants had factors that may have predisposed them to a larger initial SDH. Like other investigators,20,22 we found most SDHs were in the posterior half of the calvaria.

In our patients, supratentorial hemorrhage was more common, with 39% also having infratentorial posterior fossa hemorrhage. Both Looney et al22 and Whitby et al20 reported infratentorial hemorrhage alone being significantly more common. We believe that confirmatory coronal imaging was helpful in assessing supratentorial-versus-infratentorial hemorrhage. Only if we saw the blood products below the tentorium on the coronal view, would we assess the hemorrhage as infratentorial, which is depicted in Fig 2D. This finding was difficult to assess on the initial imaging series obtained within the first 72 hours of life but was confirmed on subsequent coronal T1 imaging. Also very small 1- to 2-mm supratentorial hemorrhages, which were raised as possible SDHs on initial gradient-echo sequences, were not confirmed to be SDH unless found as hyperintense on the T1 follow-up imaging. This finding on 2 subsequent imaging studies may have increased the number of overall supratentorial SDHs that were detected in comparison with that of other investigators.

In our patients, both the infratentorial and supratentorial hemorrhages were posterior in the cranium except for 1 SDH not present on the initial MR imaging (<72 hours postdelivery) but found at a follow-up study. Initially, this patient had bilateral posterior occipital SDHs, which were being followed for resolution. At 26 days of life, the patient returned for the follow-up MR imaging and was noted to have a 1-cm extra-axial left frontal collection that did not conform to CSF attenuation, consistent with a spontaneous SDH. The patient was admitted for full evaluation for nonaccidental injury to include skeletal survey, ophthalmologic examination, coagulation panel, metabolic studies, as well as social work enquiries. These investigations did not reveal any additional injuries or findings to support NAI as an etiology of the spontaneous frontal SDH (Fig 4). At a 5-month follow-up MR imaging, the left frontal SDH resolved; however, the subarachnoid space remained prominent in this patient. This finding suggests that though not typical in a neonate, prominent extra-axial space is a predisposing factor for SDHs as has been reported by other authors.3235

Although SDH along the interhemispheric fissure, parafalcine in location, is widely associated with NAI, we would suggest that the pattern and location of SDH alone should not be used to make a distinction between SDH due to NAI or birth injury. In the pilot study of Holden et al, 21 there is a description and illustration of an interhemispheric SDH in an asymptomatic neonate. The posterior location of the SDH is generally common to reports of asymptomatic SDH, including our study. Interhemispheric SDHs have been previously reported in accidental trauma as well as in birth trauma and are no longer considered specific for the type or mechanisms of injury.3638 We noted that the SDH was in a more dependent position on follow-up imaging regardless of the location of the initial hemorrhage and propose that this is likely due to the recommended practice of the American Academy of Pediatrics of placing infants on their backs for sleep.39 When lying supine, gravity may account for the posterior locations of the SDH, indicating communication of the subdural space.

Although US could detect approximately half of the SDHs, the area imaged was limited to the lateral posterior fossa via the mastoid fontanelle. Midline imaging of the posterior fossa was not routinely performed and thus the utility of US for detection of SDH may have been underestimated. Still, no supratentorial SDHs were detected on US. Clearly, MR imaging is more sensitive than US for the detection of SDH.

The 2-year follow-up of the infants with SDH was reassuring because all (100%) of the 43 children with documented follow-up had no gross motor delay. In our study population, 6 (14%) of the children were noted to have speech delay, which is similar to the known incidence in the general population.40 The 1 boy being evaluated for a possible autistic spectrum disorder is not unexpected because autism is currently reported to have a prevalence of 1:150, with the prevalence in boys reported as high as 1:80.4143 Normal findings on clinical follow-up are reassuring but are limited because there is no baseline for comparison in the study design. We compared normal development with that in children who met the criteria for the Denver Developmental Screening Test, which lists expected milestones at each chronological age through 5 years. This expected development is our norm when assessing children in our clinic. Children not meeting expectations are marked as having a delay and are referred for further evaluation to a subspecialty clinic.

One limitation of our study was the evaluation for rebleeding of SDH, which has been reported in the literature. Rebleeding may present either with or without clinical symptoms.44 Although none of our infants re-presented clinically with an SDH rebleed, the subclinical incidence of rebleeding in our population was not studied because none of the infants were reimaged after 3 months of age. Normal development on clinical examination is reassuring, indicating that major rebleeding did not take place.

Another limitation in our study included the need to change MR imaging sequences and timing. We found early on that SDH was isointense to gray matter and intermittently difficult to see on initial imaging within the first 72 hours of life. The SDH was seen as lobular low signal intensity with blooming on the gradient-echo imaging. The MR imaging findings were considered positive for SDH if the positive gradient-echo sequence was confirmed on subsequent T1 imaging with hyperintense signal intensity by 3–7 days. To improve MR imaging for maximal sensitivity, we changed the original T1-weighted fast spin-echo imaging sequence, spoiled gradient-recalled (SPGR), to a spin-echo T1 sequence. The initial study performed with fast spin-echo SPGR was recategorized from positive for extra-axial blood products to negative for extra-axial blood products if findings of the follow-up study performed at 3–7 days were negative. The recategorization from positive to negative for SDH may have underestimated the actual number of SDHs in our neonate population. The SDH on initial MR imaging may have been very small and resolved by the second MR imaging between 3–7 days of life. Therefore, the true incidence of SDH may be slightly higher than that reported in this study. The initial follow-up time interval was also changed from 3 days to 5–7 days to account for the signal-intensity conversion changes. The initial follow-up at 3 days did not consistently demonstrate T1 hyperintense signal intensity. We, therefore, lengthened the interval to 5–7 days to allow blood products to change to T1 hyperintense, consistent with methemoglobin. This variability of the time-interval imaging may have masked the actual timeframe in which fetal hemoglobin changes signal-intensity characteristics.

Another limitation to the study is the lack of follow-up imaging in some patients. Follow-up imaging was only completed in 18 of 46 infants with SDH. We were surprised to find that, despite the parent knowing that their infant had SDH, follow-up appointments were often missed after the first 2-week follow-up MR imaging and US. Selection bias of the patient population is also a potential limitation. We relied on a random selection process limited by our ability to obtain written consent from the parents for our sample population.

Conclusion

SDH is a common result of parturition and may be seen after vaginal and cesarean delivery. MR imaging is more sensitive than US for the detection of SDH. The hemorrhages seen in asymptomatic term neonates are limited in size and location. SDH after 1 month of age is unlikely to be birth-related.

Acknowledgments

We thank Dr. Adam Huillet for recruitment assistance, Tess Schmidt for early morning sonography support, Paul Inuuk and Cindy Lopes for early morning MR imaging expertise, Dr. Kristen Liddell for obstetric knowledge, Drs. Catherine Urethra and John Claybaugh for statistical support, and Dr. Michael V. Krasnokutsky for manuscript review and comments.

Footnotes

Previously presented at: Annual Meeting of the American Society for Neuroradiology, April 29–May 5, 2006; San Diego, Calif.

The views expressed herein are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or the US Government.

indicates article with supplemental on-line table.

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Received November 13, 2007; accepted after revision December 24, 2007.

Source:

American Journal Of Neuroradiology

http://www.ajnr.org/cgi/content/abstract/29/6/1082

http://www.ajnr.org/cgi/content/full/29/6/1082

Fall Down Stairs Caused Bleeding And Swelling In Brain

Head wins appeal over falling death of three-year-old playing Batman game on the steps of his school

By LUKE SALKELD

19 May 2008

James Porter
Headteacher James Porter has won his appeal against the conviction over the death of a three-year-old boy in a playground fall

A headmaster who was held responsible for the death of a three-year-old boy in a playground fall has won an appeal against his conviction.

James Porter, 66, was blamed for Kian Williams’s death because he was said to have wrongly allowed small children access to a flight of steps from which the child jumped while pretending to be Batman.

Kian banged his head, causing bleeding on the brain, and died five weeks later.

Mr Porter, a teacher for more than 30 years, was ordered to pay £20,000 in fines and legal costs after being found guilty of health and safety breaches.

He was said to be “delighted” after the verdict was overturned yesterday, in a ruling described as having “critical importance” to controversial health and safety legislation.

The original ruling had fuelled rows over the “cotton wool culture” which teachers say is hindering their jobs.

Mr Porter’s solicitor said yesterday’s successful appeal would have a far reaching and positive impact on schools across the country.

Steffan Groch said in a statement on behalf of the headmaster and his wife: “James and Sylvia Porter have run Hillgrove school for over 30 years, during which time they have achieved the highest standards of care and an exemplary safety record.

“While their sympathies are very much with Kian’s family they feel the court’s judgment today has vindicated their own position and also struck a blow for the teaching profession who would have faced an almost impossible burden had the conviction remained.

“The Porters would like to thank the many well-wishers who have supported them during this ordeal and are now looking forward to getting back to their day-to-day work in running the school.”

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Kian WilliamsKian Williams was allowed access to a flight of steps from which he jumped while pretending to be Batman

Mr Groch said he believed the ruling would be of critical importance in defining the health and safety standards that teachers and employers in general will have to satisfy.

He added: “You can’t wrap children in cotton wool. You have to allow them to experience risk.”

Last night Mr Porter chose not to comment on his ordeal, but Mr Groch said the headmaster was “delighted with the verdict” after three judges at the Court of Appeal said the conviction was “unsafe”.

He said: “Mr Porter and his wife have found the whole process very difficult. They are very relieved, but they always maintained that their school was safe.

“They have had a lot of support throughout, and this verdict will have a real impact on the wider issue of health and safety rulings.”

Kian, described by teachers as “lively and energetic”, jumped down four steps at Hillgrove private school in Bangor, Gwynedd, but lost his footing.

Although he broke no bones during the accident, he suffered swelling to the brain and died in hospital a few weeks later from an MRSA strain of pneumonia.

An inquest into Kian’s death in February 2005 recorded a verdict of accidental death.

The accident happened in July 2004 at £3,000-a-year Hillgrove School in Bangor, North Wales, which has been run by Porter and his wife, Sylvia, 61, since 1975.

During the six-day prosecution brought by the Health and Safety Executive, Mold Crown Court heard there was only one teacher supervising 59 pupils in the playground. Gates have since been erected at the steps where Kian fell.

Porter, the proprietor and head of the school, was found guilty by an 11-1 majority verdict of failing to do enough to make the school steps safe.

He was fined £12,500 and also ordered to pay prosecution costs of £7,500.

Yesterday he was in court to hear Lord Justice Moses, Mr Justice Openshaw and Sir Richard Curtis overturn the conviction, which his lawyer described later as a “common sense judgment”.

Lord Justice Moses, who described the accident as a “terrible tragedy” said: “In our view the evidence in this case was all one way.

“There was no evidence on which a jury, properly directed, could reasonably conclude that this child was exposed to risk by the conduct of the school.”

Porter was described during the trial as having an exemplary safety record.

It was argued by the Health and Safety Executive, which brought the prosecution, that more staff should have been on duty, and there was no reason why the gate erected following the accident could not have been put up before.

But Lord Justice Moses said there was no evidence of risk other than the risk that everyday a child might go unsupervised down a flight of stairs.

The judge expressed the court’s sympathy for Kian’s parents, who have previously denied being vindictive in pursuing a case against the Porters.

Following the guilty verdict last year, Kian’s mother, Jackie Williams, said: “Every parent knows you should put stairgates up to stop children climbing up or falling down steps, but there was no barrier to stop Kian falling.

“Schools and nurseries should be safe environments so a parent feels totally safe leaving their children.”

But at yesterday’s hearing, Lord Justice Moses said: “In the 29 years before this accident, during which this appellant and his wife ran the school, there had never been any complaints about standards of health or safety.”

Inertial Neck Injuries

Infant Injury Evaluation

More biomechanical data

More evidence that shaking alone does not result in head injuries and that neck injuries are more likely to occur than head injuries in shaking without impact. Just to put the injury tolerance levels and the loads during shaking into perspective: I recently published a paper (see attached) where we ran frontal crash simulations using a pneumatic sled and measured the head and neck response of a 3-year-old dummy restrained at the torso by the 5-point belt of a forward-facing child car seat. So, this is a situation analogous to shaking where the torso is held and the head rotates about the neck without contact. Because we simulated a frontal crash and the child seat was faced forward, the deceleration created flexion of the head (chin-to-chest). During a 20mph crash, the resulting head accelerations were 40-45g, well below the injury tolerance (~175g). However the upper neck tension was 250-350lbs. These values are in the range of the neck injury tolerance value of 254 lbs used in federal crash test standards. The 30mph crashes resulted in 70- 75g head acceleration and 450-500lbs upper neck tension. The chest acceleration was 50-55g. The 40mph crashes produced 80-85g head acceleration and 500-700 lbs of tension in the upper neck. I have investigated several real-world crashes that reflect the above results. Young children restrained in very severe frontal crashes. No evidence of head impact and no serious head injuries with severe tensile neck injuries (AO dislocations, spinal cord damage, etc).



  • 1. A severe crash (30mph) results in inertial loading of the head below head injury levels (assuming the occupant does not contact the vehicle interior). If a person is to shake (without impact) a 3-year-old child and cause serious head injuries then he/she has to produce loads more severe than a car hitting a wall at 30mph (30mph velocity stopping in less than 0.1 sec). This is absolutely impossible.
  • 2. Even if someone could … During a situation where the torso is held and the head rotates as a result of inertial loading (non-impact), the neck forces exceed the injury tolerance before the head acceleration reached injurious levels. The 30mph crash resulted head accelerations below levels for serious head injury while still producing neck loads approximately double the accepted neck injury tolerance.

Notes: We did not measure angular acceleration of the head in these tests. Currently, similar 1-year-old
crash test data is not available due to the fact that this age is usually tested in the appropriate restraint
configuration using a rear-facing child seat.
-Michael Prange

Inertial Neck Injuries In Children Involved In Frontal Collisions

http://www.sae.org/technical/papers/2007-01-1170

Author(s):
Michael Prange – Exponent, Inc.
William Newberry – Exponent, Inc.
Tara Moore – Exponent, Inc.
Daniel Peterson – Exponent, Inc.
Brian Smyth – Exponent, Inc.
Catherine Corrigan – Exponent, Inc.

Abstract:
There is a paucity of data regarding the potential for pediatric cervical spine injury as a result of acceleration of the head with no direct impact during automotive crashes. Sled tests were conducted using a 3-year-old anthropomorphic test device (ATD) to investigate the effect of restraint type and crash severity on the risk of pediatric inertial neck injury. At higher crash severities, the ATD restrained by only the vehicle three-point restraints sustained higher peak neck tension, peak neck extension and flexion moments, neck injury criterion (Nij) values, peak head accelerations, and HIC values compared to using a forward-facing child restraint system (CRS). The injury assessment reference values (IARVs) for peak tension and Nij were exceeded in all 48 and 64 kph delta-V tests using any restraint type. The test at a delta-V of 64 kph using only the vehicle belts as restraints resulted in peak upper neck tension, peak upper neck extension moment, and Nij values two times greater than the corresponding IARV. Only small differences were found in the injury metrics between a CRS installed with and without webbing tension except that head excursion was greater in the installation without webbing tension. These data show that the potential for neck injury exists for children involved in severe frontal crashes and restrained in either a forward-facing CRS or by vehicle belts-only, even in the absence of head contact.

CONCLUSIONS
A series of frontal sled tests was performed using a 3-year-old ATD seated in three different restraint configurations: a properly installed CRS, an improperly installed CRS, and using the vehicle belts only (no CRS). ATD injury measurements increased with increased crash severity. The belts only configuration produced the highest neck tensions, neck moments, Nij values, head accelerations, and HIC values. With the exception of head excursions, the amount of vehicle belt webbing tension used to install a CRS did not substantially affect head accelerations and neck loads.

Medical Experts Manufacture Evidence

FALSE   WITNESS

Most Americans know that politicians lie, even though they live as though certain fictions were true: the value of the dollar, the sacredness of entitlements, and the integrity of public health officials and regulatory authorities.

Most Americans assume that criminal defendants and defense attorneys will lie. Some are willing to accept such perjury, even in the Oval Office, at least on some subjects by politicians who give them what they want.

Lies may be acceptable if necessary for the greater good: the defeat of the Nazis, the detection of a terrorist plot, or the apprehension of serial killers.

Some feel that lies may be tolerable if the intentions are good enough: protecting the public against bad doctors, winning compensation for victims of malpractice, stopping drug dealers, or perhaps even maintaining public confidence in vaccines. That is apparently why the AMA and its Federation support absolute immunity even for bad-faith peer review, and why the public isn’t outraged if a plaintiff’s expert witness invents a convenient “standard of care.”

Most Americans, however, still believe in the integrity of the criminal justice system. They also think that prosecutors are hamstrung by the exclusionary rule and other legal technicalities. With respect to certain unambiguous crimes that involve a body or damaged property, this may be true.

The idea being reinforced by numerous “law and order” television dramas, people believe that 95% of federal defendants end up pleading guilty or being convicted because, as The New York Times stated, “only the cases with the most compelling evidence ever make it to the indictment phase.” Even in the scientific literature, the fact of a jury conviction or a confession is taken to confirm, for example, the pretrial diagnosis of “shaken baby syndrome” in the absence of any direct evidence that the only person on the scene actually abused the child.

If a defendant decides to plead, as Dr. Jeri Hassman did (see AAPS News, June 2003), she must assert her guilt in public after the judge instructs her in all the rights she is giving up, as well as the standard of proof (“beyond a reasonable doubt”). Such “acceptance of responsibility” can shave years or decades off prison time under the 1988 federal sentencing guidelines that drastically limit judges’ discretion. If the defendant takes the stand to state her innocence, as Marla DeVore did, and the jury convicts, she can expect a sentencing enhancement because she is then presumed guilty of perjury.

Marla DeVore and her husband, Robert Mitrione, M.D., (AAPS News, May 2003 and March 2004) are now both incarcerated in federal prisons, serving terms of 15 and 23 months, respectively, for fraud proved at trial amounting to $75.25. Ms. DeVore must live in a 12 ft x 14 ft cell, into which 10 women are crammed owing to prison overcrowding. Meanwhile, Malcolm “Tadd” McVay, the former chief financial officer of HealthSouth, accused of $2.7 billion in accounting fraud, was sentenced to six months of home detention, a $10,000 fine, and forfeiture of $50,000. U.S. District Judge U.W. Clemon took into account McVay’s admission of guilt and cooperation with the investigation (Wall St J 6/3/04).

Defendants are held to a very high standard. Dr. Sergius Rinaldi was accused of misrepresentation for saying he “was a Medicaid provider,” meaning he “had been,” whereas he now treats Medicaid recipients without charge (Telegraph 1/24/04).

Prosecutors, however, frequently use witnesses with a history of fabricating testimony. Three key witnesses in an allegation of conspiracy to commit murder against Charles Thomas Sell, D.D.S., (AAPS News, June 2004) have such a record (St. Louis Post-Dispatch 3/21/04). They haven’t been cross-examined yet, as Dr. Sell has been imprisoned without trial for nearly 7 years.

Lying by wired undercover investigators is a favorite tactic for entrapping physicians. Some recommend that physicians purchase a radio-frequency (RF) detector and wear it while seeing even long-standing patients, especially if they prescribe controlled substances. (An RF detector responds to cellular telephones, but that signal is intermittent rather than constant.)

Prosecutors conceal or distort the truth with impunity, as extensively documented by investigative reporter Bill Moushey (“Win at All Costs,” available at www.post-gazette.com ). And under a new Court standard, defendants who prove perjury also have to prove that a jury would have acquitted in the absence of perjured testimony (Mitrione v. U.S.A.), contravening 75 years of precedents in the Seventh Circuit, the law in at least four other Circuits, and Supreme Court teachings. Evidence for criminal intent by the Mitriones depended on the false testimony of a member of the prosecutorial team.

As Andrew Schlafly writes in a petition for Writ of Certiorari, “the implications of the new standard…would be catastrophic for the integrity of the criminal justice system, sacrificing rights of due process and fair trial.” He notes that had the Mitriones been convicted in the Fourth Circuit, they would have obtained a new trial. If the Seventh Circuit’s decision stands, “the fate of defendants victimized at trial by lying witnesses thereby becomes subject to the happenstance of where the trial occurred.” The scourge of conviction by lies, already rampant, will be worsened by the inconsistent standard.

With a jury tainted by false testimony on counts later dismissed, the Mitriones were convicted of “substitute billing,” which is legal under a formally promulgated federal regulation but not allowed under an informal state handbook, and of “mail fraud” on a disputed $25 claim a “derivative crime.”

“Show me the man, and I will find his crime,” said the KGB. Shall American jurisprudence say: Show me the man, and I will create his crime, and manufacture the evidence?

Robert Moffit is Director, the Center for Health Policy Studies at the Heritage Foundation, Washington, D.C.


Volume 60, No. 7 July 2004

Source:

http://www.aapsonline.org/newsletters/july04.htm

Are You A Disruptive Physician

Abuse of the “Disruptive Physician” Clause


Editorial:
Lawrence R. Huntoon, M.D., Ph.D.
Buried deep in the “Corrective Action” section of most medical staff bylaws is a provision known as the “Disruptive Physician” clause. It is arguably the most dangerous and, in recent years, the most abused provision in medical staff bylaws.

The term “disruptive physician” is purposely general, vague, subjective, and undefined so that hospital administrators can interpret it to mean whatever they wish.

How this treacherous trap got into medical staff bylaws is no mystery in most instances. It was added at the urging of hospital administrators, often with help from a medical staff president who was duped into believing that the clause would only be used in those extreme cases where a physician was found running drunk or naked through the halls of the hospital.

Lack of vigilance by physicians, and failure of medical staffs to obtain independent legal advice on changes to the bylaws, allowed most hospital administrations to insert this clause without difficulty or any meaningful opposition.

Why this clause was strategically placed in medical staff bylaws is also no mystery. It is part of the strategic plan developed in 1990 by the hospital industry. The stated goal was to gain more control over physicians in hospitals. Abuse of the disruptive-physician clause and increasing use of sham peer review has allowed hospital administrations to make great strides in achieving that goal.
Attorneys who specialize in representing hospitals have definite recommendations on how “disruptive physician” can be defined by a hospital, in order to remove a targeted physician from staff. In fact, some law firms offer seminars for hospital officials and their legal representatives that teach optimal methods for eliminating certain physicians that the hospital dislikes. Here are a few of the criteria for identifying a “disruptive physician”:


1) Political: Expressing political views that are disagreeable to the hospital administration.
2) Economic: Refusing to join a physician-hospital venture, or to participate in an HMO offered to hospital employees, or offering a service that competes with the hospital.
3) Concern For Quality Care: Speaking out about deficiencies in quality of care or patient safety in the hospital, or simply bringing such concerns to the attention of the hospital administration.
4) Personality: Engaging in independent thought or resisting a hospital administration’s “authority.”
5) Competence: Striving for a high level of competence, or considering oneself to be right most of the time in clinical
judgment.
6) Timing: Making rounds at times different than those of the “herd.”

Although the disruptive-physician clause and sham peer review are current weapons of choice used by hospital administrations across the country, more weapons of physician destruction loom on the horizon.
Physicians should be aware of the “Code of Conduct” and Exclusion from the Hospital Premises” clauses currently being promoted by the hospital bar.
AAPS has posted a letter dated January 31, 2003, to the General Counsel of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which was drafted by the leaders of the credentialing and peer review practice group of the American Health Lawyers Association, in the Hall of Shame on our website (see www.aapsonline.org). The letter is rated “R” for stark Reality. Physicians need to wake up quickly and take notice because this is what hospitals really have in mind for medical staffs across the nation. Interested readers can also learn more about the
hospital industry’s strategic plan, developed in 1990: see Hospital Industry Reveals Its Strategic Plan: Control Over
Physicians” in theAAPSHall of Shame.
Physician vigilance, and advice from knowledgeable, independent counsel, are key to preventing further abuse of medical staff bylaws by hospital administrations.

Lawrence R. Huntoon, M.D., Ph.D., is a practicing neurologist and editor-in-chief of the Journal of American Physicians and Surgeons.
Memo to the Disruptive Physician
Oh how we strive
For quality high,
For health
And most of all safety.
But a word to the wise:
Reproof we despise
And outspoken physicians:
We hate thee.
Feel free to opine,
But note we define
All critics
As never constructive.
And, thus shall ensue
A sham peer review
And henceforth
You’re labeled “disruptive.”
68 Journal of American Physicians and Surgeons Volume 9 Number 3 Fall 2004

Source:

http://www.jpands.org/vol9no3/huntoon.pdf

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