Interview with Dr Patrick Barnes

He is a doctor and Stanford professor who specializes in pediatric radiology and neuroradiology, and also is a member of the Lucile Packard Children’s Hospital SCAN [Suspected Child Abuse and Neglect] team. Barnes was a key prosecution witness in the 1997 trial of Louise Woodward, the British nanny who was accused of shaking an 8-month-old baby to death, hitting his head and causing fatal bleeding. The trial was a turning point for Barnes — while it was clear something happened to the child, he now says, “Shaking was irrelevant in that case in retrospect.” This is the edited transcript of an interview conducted on May 26, 2011.

• Diseases that can mimic child abuse
• The Isis Vas case: why the “Sherlock Holmes” approach is ineffective in forensic pathology
• “It’s absolutely critical” to examine a child’s medical history in a possible abuse case
• The “very painful” Louise Woodward case: how it changed his thinking about shaken baby syndrome

Tell me about Isis Vas. You looked at her medical records and her CT scans and X-rays. What did you think when you saw them?

First of all, when I looked at her brain CT and saw the diffuse injury to her brain, primarily swelling, the first thing that I thought of is she may have suffered from a lack of oxygen or blood flow to her brain if she wasn’t breathing properly or if her heart wasn’t getting blood to her brain. She did have a small amount of hemorrhage between the brain and her skull, but it’s not the type of hemorrhage that we would expect to see, for instance, with trauma. So even though it potentially could have been trauma, I was beginning to want to ask questions about other medical conditions that could produce this type of brain injury, including the swelling and the bleeding.

So from the scans, you said this does not look like enough bleeding to be a typical abuse case. Is that what you are saying?

That’s correct, and we started learning mid- to late ’90s, particularly after my experience being a prosecution expert witness in the nanny case, the [Louise Woodward] case in Boston, and then when we started using more advanced imaging techniques such as MRI, we started seeing findings that we had previously attributed to abuse or shaking. Yet we started realizing there were a number of medical conditions that can affect a baby’s brain and look like the findings that we used to attribute to shaken baby syndrome or child abuse.

And what kind of medical conditions are we talking about that seem to mimic child abuse?

Infection is a very important one, and when we started really looking at these cases more carefully, we started finding babies who may have had an ongoing illness. They may have had relatively nonspecific symptoms, because a baby can’t tell you, “I have a headache,” “I have got an earache” or whatever, so they may act with just maybe irritability, not eating well; they may not be sleeping well. And sometimes they can get worse if they don’t get immediate medical attention and diagnosis, and then at some point they may crash, like this child did. So infection is very important, and undiagnosed infection may be even a virus that maybe the majority of babies may get over in a few days.

“We started realizing there were a number of medical conditions that can affect a baby’s brain and look like the findings that we used to attribute to shaken baby syndrome or child abuse.”

There is a small percentage that can progress. They may stop eating, they may not have a normal fluid balance, they get dehydration, and then they collapse and stop breathing, which is a common crash-type symptom, or they may in fact have a epileptic-type seizure. So they may progress slowly, then crash, have brain-injury findings and have a little bleeding, and then the impression might be, “Well, this baby was abused,” was either shaken — and that had to have happened just before the baby collapsed. …

And so here we have a baby that’s handed off from one caretaker — let’s say the mother, as in this case [of Isis Vas] — to another caretaker. And then the last person standing, the last caretaker when the baby crashes, it was pretty much traditional for 30 or more years that that baby had to be abused by the last caretaker. And automatically the caretaker, who could not otherwise explain the baby’s injuries, would be charged — murder, for instance, when we lose a child, such as we did in this case — and be indicted and convicted, for instance, for shaken baby syndrome, just because the baby has what at one time was thought to be the characteristic findings, what we call the “triad,” and that is the hemorrhages in the brain, subdural hemorrhages between the brain and the skull; hemorrhages in the eye; and then the brain injury.

The brain swelling?

Yeah, the brain swelling. And that could carry the case all the way through the child protection process, all the way through the criminal justice system process, and result in convictions with significant prison sentences with little investigation into what was really going on with the baby in terms of days, sometimes maybe a week or so before this happened.

So we have learned our lesson with that, particularly since we started doing more advanced imaging with magnetic resonance imaging [MRI], which is 100 to 1,000 times more powerful than CT scanning, and then we started seeing other findings that we go, you know, that’s not what we used to think we saw with trauma. We saw no traumatic brain injury, no tearing or bruising of the brain. It just looked like it didn’t get enough oxygen or blood flow.

So why did the baby stop breathing? Why did the baby’s heart stop? Maybe the baby had an infection that became sepsis. The baby bled because of that, and then the baby stopped breathing or had a seizure. So as a result of MRI showing these findings and then correlating in our research the MRI findings with postmortem much more carefully than we did, and particularly correlating the MRI findings with the laboratory testing, which in this particular child also showed the child had a bleeding and clotting problem — previously we would have blamed that on extensive shaking or a shaking-impact injury to the baby’s brain that would secondarily trigger this bleeding or clotting problem. …

When Isis came into the hospital, she had bruising on her body, she had bleeding from her vagina, she had bleeding on her brain, and the doctors at the hospital said, “This looks like abuse.” The forensic pathologist who did the autopsy said, “This child was a victim of blunt-force injuries; this child was violated; this was an attack by adults.” What’s wrong with that analysis?

… We had always assumed using the Sherlock Holmes approach that when we saw these findings that this had to be child abuse. We stopped there. We made that medical diagnosis, and then it carried over into child protection and into the criminal justice system without doing an adequate evaluation of what is going on, and then bring it forward and put it together. So once we put the details of this illness in this baby together and come from the beginning to forward, which is the logical way to analyze these cases and the proper way, it does explain all the injuries of the baby based upon a complicated medical condition.

What are the symptoms of the child [Isis Vas] and the medical history that suggests to you this wasn’t abuse? What stuck out to you that said, “Hey, this might not be child abuse”?

For instance, the pattern of the brain injury made us think something other than abuse. The pattern of the bleeding in the baby’s brain made us think of something other than abuse. We found no evidence on the brain imaging, the CT scan, for instance. And as I recall, on the postmortem imaging, [there was] no impact-type injury to this baby’s brain, tearing, bruising of the brain itself. So those were the types of things that we pay attention to. Of course, a baby that presents with bruises or bleeding, we pay attention to that. And yes, that certainly could be due to impact like trauma, but there ought to be other physical signs of impact trauma or imaging signs of impact trauma.

So that’s, in my mind, what was really lacking in this case, both on the imaging as well as on the postmortem examination, and even though the baby did have an old healing clavicle fracture, that was much older than what could be attributed to this more acute presentation, where most people thought that the beating had to have happened by the second caretaker as opposed to the first caretaker, and trying to split that by a matter of hours or parts of a day between the two. Also, any potential rib deformities that were old or new or acute. So it didn’t all come together as a single acute assault-type of injury pattern. So that’s when we start looking at the other aspects of the case.

This was a child who had a PTT [partial thromboplastin time] score that was off the scale. What does that say to you?

Well, that’s when we start looking into bleeding and clotting problems. That is telling us we have a severe problem, or the baby did, with normal clotting, and she is bleeding because that particular measure of clotting was so far off the scale. And correlating with these multiple areas of breathing or bruising, if we had trauma causing that, there should have been extensive traumatic injury to this child’s brain, tearing of the brain, bruising of the brain, because if you are going to get a secondary bleeding or clotting problem from trauma to the brain, it is that tearing and bruising of the brain that incites that type of bleeding. This baby had none of those findings on the imaging or the postmortem.

If that’s true, you have to start considering other causes of bleeding. Infection, particularly if it spreads, is a cause of bleeding in babies, and we know that particularly if that’s progressing and going on for a while. And if the baby also then stops breathing or the heart stops and there is not getting any oxygen in the brain and you get injury from that, that can contribute to the bleeding. So that particular parameter in itself was quite suspicious for a process going on that was really a medical condition or a natural condition, not a traumatic condition.

Now, the forensic pathologist who did the autopsy shall say: “Dr. Barnes, you got it wrong. Children can get blood-clotting disorders after they have had head trauma. This blood-clotting disorder could have come from the child being abused.” What do you say to that?

What I say to that is if that’s true, then you have to show that there is traumatic injury associated with the abuse, OK? And there was no traumatic injury, direct traumatic injury to this baby’s brain on the imaging or the postmortem. …

Can you get a PTT score of 212 [as was the case with Isis Vas] within an hour of sustaining a head injury, in your experience?

I think you could, but it would have to be massive brain injury that we have seen in some children with high-impact brain injuries — diffuse tearing, extensive tearing of the brain, extensive bruising of the brain — and then the release from that injury of those chemical factors that can be associated with this type of bleeding, particularly what we call multiple-trauma victims, not just brain injury but those that particularly have multiple injuries elsewhere — acute bone injuries; acute muscle injury; acute injury, for instance, to the heart or chest. And now you have much more extensive trauma that can trigger to have bleeding parameters that [are] out of normal range. This child had none of those.

So we would be talking about car crash-type injuries?

Yes, and potentially a massive assault by an individual on a child, which would usually be a beating. That would be the classic situation — usually a beating and breaking of bones, impact to the abdomen, injury to the organs, extensive injury that releases these chemicals that then trigger that type of bleeding or a problem. We had none of that in this particular case.

So you just didn’t see the type of injuries that would trigger a clotting disorder of that magnitude?

Correct. And none of those factors supported a secondary bleeding or a clotting problem due to trauma, because we did not have findings of that type of trauma in this case. And that’s true of many other cases that we see of alleged or suspected shaken baby syndrome. So we have gotten smarter in the last decade or so about these.

So our new approaches to this, my part of [it] as being a co-founder of [a] child abuse task force the last 10 years, coming from Boston, and now working with multiple specialists in addition to our child abuse pediatrician and a much more careful approach to these cases, a proper medical workup. While we are also using our very good social workers and our child protection professionals to help us sort out caretaker issues, at-risk potential family members, other caretakers who are protecting the child and the family, and the caretaker is on one side, a simultaneous process [is occurring] while we are also doing the medical workup and getting detailed historical data having to get the records, and maybe even talk directly with prior caretakers to sort out the story and not just automatically turn the case over to police investigators, for instance. So we have really changed our approach to this to a much more thoughtful and compassionate approach.

That was something I wanted to ask you about. As we have been looking at these cases around the country, one thing that seems to come up repeatedly is whether the hospital doctors and whether the forensic pathologists are delving into the child’s past, whether they are looking at lab reports in great detail, whether they are looking at medical history. How important do you think it is to go into a child’s past when you have a possible abuse case?

It’s absolutely critical, because number one, we no longer want to make the mistake of the misdiagnosis, and it really can’t be a medical diagnosis any longer, a misdiagnosis of child abuse when it really doesn’t exist because of what it means to that child, that caretaker or that family. …

Number two, we want to protect that child, particularly a child that may have had a previously undiagnosed condition. Now that we have the advanced laboratory techniques and the advanced imaging to do that, we no longer do what we did in past decades, and that is just because a child presents with a triad, we assume child abuse, and we don’t do the medical workup, and then we find at a postmortem exam when we have lost the child that there was a different diagnosis. Now we have made a huge error.

It is critically important, particularly for children and babies six months and younger, because at that age they could actually have conditions that have yet been diagnosed that stem from birth process, that are delayed effects of trauma at birth or other conditions passed from the mother to the baby and so forth. Plus, for the babies that we lose, or even if they survive, number one, we need to diagnose those conditions, because even if the baby survived, that baby may suffer another episode due to that medical condition. We didn’t diagnose it, we didn’t treat it, or we lost the baby, let’s say, and the mother and father who may have been thinking that the caretaker did this to the baby want to have other children. And if we didn’t diagnose that condition that maybe the next child may have, then we have done a disservice to family planning for that family.

Plus, even in the case that I have seen and others have seen that we cannot 100 percent say that there has not been some neglect or abuse, yet we have diagnosed a predisposing condition, those children need to be protected, but they need to be treated. We have found that many of our physicians were not going back and doing those adequate evaluations of past history, even back to birth and pregnancy. We found that adequate tests were often not being done, and what’s even more unethical, if you want to put it that way, is we had children who we assumed were abused, and then we turned our backs on them. We didn’t follow them up. There were pediatricians and other doctors who did not want to see children that had been abused or parents that may have been accused [of] abuse, so they were being discriminated against.

We have a 100-year history of discrimination regarding mothers, their babies and young children that we’re just now getting around to realizing. There are conditions there that can predispose children to brain and bone findings that look just like abuse, particularly under six months, and actually stem from conditions in the mother passed on to the baby. So the important thing here is a much more compassionate, thoughtful, comprehensive approach in these cases, particularly if we have an injured child that maybe is not too severely injured but did have injuries, and that’s to do our best to help bring the families back together if we can with that child ultimately — reunification — look after that child and family with regard to their follow-up care and diagnosis for any of these predisposing or complicating conditions.

And because in this particular era of American [medicine], with all of our cultural challenges, the lack of adequate education, people being sent home from the hospital with sick preemies, not adequately being educated on how to take care of them — and, for instance, sick preemies become babies who are thought to be abused when in fact that they were premature was part of why they had these type of injuries.

So our approach has changed from working at the back end, calling [it] child abuse — breaking up the family, sending the other children elsewhere, maybe they go to foster care, and then they are adopted out of state, never seen again, send one or both parents to prison — breaking up that family to now really working hard with our professionals to try to hold these families together better. …

What was it exactly about the Louise Woodward case that made you rethink your approach to child abuse?

It was a very painful case. … The baby had a skull fracture, and even though we were talking about shaking in that instance, we couldn’t really time the skull fracture [so] that it had happened within a few hours of when the baby came to Children’s [Hospital Boston], and that would implicate the nanny as opposed to anyone else. That could have been an older skull fracture.

The collection between the brain and the skull on that baby’s head and the bleeding in it, that may have all happened during that period of time, but the imaging didn’t exclude that there was an older collection with a new bleed in it. Plus, the baby had a much older fracture of the wrist that was up to four weeks old, and there were rumors that maybe there had been some prior, maybe accidental traumatic event in that baby.

So I was really affected by all of that and began to question my role as a pediatric radiologist and a neuroradiologist as part of the child abuse team in these particular cases and [decided] that I needed to be more proactive in these cases and insist that we do more thorough investigations in these particular cases. …

Do you think Louise Woodward was wrongly convicted?

I think it’s possible. I think looking back on the case — and subsequently I was contacted by writers about that case. Looking back on it, and [taking] a second look and [thinking] about some other individuals that had come forward, witnesses about other things that may have been going on in that home or elsewhere, I was forwarding this information on. And I knew from that point on that I just have to be more careful with these cases. I do believe it was a trauma case; it wasn’t a medical condition. It could have been potentially abuse. I am not sure Louise Woodward was the one who abused the child. …

[Editor's Note: In October 1997, British au pair Louise Woodward was convicted of second-degree murder in the death of 8-month-old Matthew Eappen, who was in her care. Less than a month later, the judge in the case reduced her sentence to involuntary manslaughter and sentenced her to time served.]

… Do you think the child in that case was shaken to death?

No, the child had an impact injury. You can’t get a skull fracture from shaking. You can’t get a wrist fracture from shaking. The child had a traumatic impact injury. Shaking was irrelevant in that case in retrospect.

But the prosecution’s theory was this child was shaken.

That’s correct. And at that time, that was my theory going into that case, based on my previous 20 years of experience in child abuse and accepting shaken baby syndrome without ever questioning it. And that case changed my entire approach. …

If you were called to testify in the Woodward case today, what would you say?

I would say that this is most likely a traumatic impact injury, that I would not be considering shaking, that this could be accidental just as it could be non-accidental or abusive. And I would say that from the imaging findings, my area of expertise, you cannot select out, accuse, indict or convict any particular caretaker based on the medical evidence that we have.

Do you believe it is possible to shake a small child to death?

I believe in a situation, that the current state of research and science shows, and particularly for babies under six months of age, [what] I am concerned [about] particularly with a violent shake, and maybe not so much violent shaking but a baby that [is] maybe shaken. But there is an impact associated with it, is [there] the possibility that for these particularly young infants that don’t have good head control and they have very weak necks. It would be the neck that would, with severe shaking, potentially, that could be injured, and a neck injury particularly involving the spinal cord and the upper neck where it attaches to the brain stem at the skull base where the breathing center is, for instance, could potentially be lethal.

So that’s the one scenario that I would worry about with a potentially violent shaking, or what may not be a shake at all, but an assault that would involve impact.

We spoke to a shaken baby theory proponent the other day, and this person said to us: “We have never said that these children were only shaken. We have always said that there had to be some impact along the way, that they were shaken and their small heads hit something as well.” Is that true?

No, that’s not true. For 20 years prior to the nanny case in the mid- to late-’90s, we were implicating shaking for just about every injury that we are seeing, particularly in the young infants. …

And looking back on it, does it seem strange to you that you would see these children presenting with bleeding on the brain but no bruising on their heads, no sign that their head had hit anything?

Yes, that was very important. Probably the next case that opened my eyes was the baby [Mariah] Scoon case in New York that I was, after the nanny case, asked by the defense to review. And that was a very sick young baby girl, former preemie, who had meningitis and strokes in the brain and the imaging supported that, and the postmortem, yet the father was convicted of shaken baby syndrome.

Do you believe people have been wrongly convicted of shaking their children to death?

I do, yes.

Is it a big number? Is it a small number? I mean, what’s your guess?

I don’t know for sure. What I am worried about and concerned about in terms of my role in the past and even what continues to this day [is] that there is more than we think that have been convicted because of shaken baby syndrome. …

So there is a whole range of cases in which people may have been wrongly convicted of killing children. Is that correct?

Yes. And that’s why it’s so important for the pediatricians who are training in child abuse pediatrics, now that it’s board-certified, is to make sure they have the adequate training outside of child abuse and keep up on the conditions and the environmental conditions and the safety factors out there that can hurt children that have nothing to do with abuse.

That’s just in the environment and the safety issues at home, that accidental injuries can happen at home that can hurt and kill children that are not abused. … There is a lot of factors going on that really have to be looked at more carefully and in fact are being looked at more carefully: the lack of good nutrition in this country — I’ve talked about vitamin D deficiency, but deficiencies in other nutrients that can be passed on from mother to baby; toxic factors in the environment; child safety factors with regard to child seats and child swings and child toys. And this means we need to be better with educating our new parents about those potential safety issues, things that can happen in the home that are accidental but get called child abuse. …

I want to run a scenario by you. A child dies in the hospital after having three probes inserted into his head. When the child is autopsied, the forensic pathologist says, “These three bruises on the child’s head were caused by abuse.” What does that say about the forensic pathologist?

Yes, we have seen other cases like that, where some of the pathologists — there is a total disconnect with the process of a postmortem examination in isolation, [where it's] separate from the medical record, completely dissociated, out of context, and that’s, believe it or not, still happening in some cases that we see. We just can’t allow that to continue to happen, particularly once it gets into the justice system. Then here come the experts who go back through and look at everything that they should look at everything in a proper CSI way, right, crime scene investigation way, you know? So that’s a big problem. …

But you have seen that in other cases, where it seems like there is a disconnect between the doctor and the morgue and the doctor and the hospital.

Yes. For instance, a situation where I looked at a postmortem exam and a pathologist reported a laceration in the right frontal lobe, and I looked at the imaging, and there was a probe put there, a catheter by the surgeon to try to help reduce the pressure in the baby’s brain, and I go, “You know, that’s not really a penetrating traumatic abusive brain injury; that was a medical intervention.” …

The stance you have taken is not popular with a lot of people. A lot of people who have similar views in the medical field to you did not want to go on camera with us. Tell me about that.

Well, I didn’t either. And I have really tried to stay away from this. I didn’t want to do The New York Times Magazine article recently. But after participating in a number [of cases] for [the] Innocence Project in this country, and the Innocence’s cases convicted individuals getting new trials and everything and looking at the entire environment on all of this, I just felt that it was important to be more involved and hopefully, possibly become maybe not so much a leader, but [a] modeler in this particular area, and for us to develop these types of model programs, because I see abused children as part of our child abuse team.

We see neglected children; we see abused children, physically abused, and we see sexually abused children. But we make sure that those cases that are alleged cases get — we are doing our best to get a thorough workup, and we get the right specialists involved and come to determination that maybe this is not abuse.

So instead of splitting up the family, sending someone to jail, let’s do our best, and it takes a lot more work to do that, to protect this child and the other children in the family, and see if there is a process working with our very good social workers and child protection workers, that we can bring these individuals back together, because what we have found in the past, talking with public defender[s], colleagues of mine, that children who have been separated from parents, for instance, say, on alleged child abuse and maybe they have gone in a foster home, or maybe have been adopted, something like over 50 percent of those children when they get older want to go back and find their original parents and try to reunify [sic]. I was struck by that, and those are cases that in retrospect you look at and go, “This may not have been abuse at all.” …

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