Case No. ZE22C50109

40.The key expert medical evidence in this case has been provided by experts in two disciplines: a consultant radiologist, Dr Oates, and a consultant paediatrician, Dr Cartlidge. 41.Dr Oates and Dr Cartlidge are both well known to the Family Court. They are both highly sought-after in cases of this nature because each is known to be at the top of their field in their respective disciplines, and has a track record of providing the court with measured and reliable expert evidence. As expected, the evidence of each of them, both written and oral, was thorough, careful and balanced. I am satisfied that in this case the court has had access to expert evidence of the highest possible quality. 42.I have considered also the report of a similarly highly qualified and experienced geneticist, Dr Ian Ellis, which I will summarise briefly later in this judgment. Dr Ellis’s investigations were extremely thorough and he went to significant lengths to explore the potential significance of a genetic variant found during genetic testing of S. In the end no party has sought to suggest that S suffers from any congenital condition which could have caused or contributed to the fractures he has sustained. 43.The evidence of the experts is contained in their written reports, the transcript of an experts’ meeting which took place on 26 January 2023, and the oral evidence of both Dr Oates and Dr Cartlidge. Timing of the injuries44.The radiological evidence is the primary source of medical evidence as to the timing of S’s injuries. On this issue Dr Cartlidge deferred to Dr Oates. 45.Dr Oates emphasised that radiological dating is not an exact science and can provide only a “broad estimation” of the date of an injury. In dating S’s fractures he relied on his understanding of the literature, his own experience of interpreting “hundreds” of fracture radiographs, and his observations, in this case, of how the fracture healing responses evolved over the course of the imaging. 46.Dr Oates reviewed the chest x-rays carried out by the treating hospital on 23 April 2022, the results of the first (“Part 1”) skeletal survey conducted on 26 April, and the results of the “Part 2” skeletal survey which was carried out on 5 May. 47.His unchallenged opinion as to the timing of the injuries was as follows:a.Left rib fracture: this is likely to have been caused between 2 and 4 weeks prior to S’s presentation to hospital, that is between 26 March and 9 April 2022. Dr Oates could not exclude the possibility that this was a birth injury (S was about five weeks old at the time of his admission to hospital) but thought this was highly improbable.b.Right rib fractures: these showed no healing response at the time of the x-rays on 23 April or the Part 1 skeletal survey on 26 April. They were therefore relatively recent. They are likely to have been caused within 7 days of the admission to hospital. c.Humerus fracture: This fracture did not show up on the first x-rays or the Part 1 skeletal survey. It was visible in the Part 2 skeletal survey. Dr Oates’s view was that it was likely this fracture was present at the time of S’s presentation to hospital but not visualised as there was no appreciable healing response, given the very recent nature of the injury. It also is likely to have been caused within 7 days of the admission to hospital. 48.Therefore the medical evidence strongly indicates that S suffered at least two traumatic events. The first, which caused the left rib fracture, probably took place between 26 March and 9 April. Thereafter there were one or more further incidents, between 16 and 23 April, during which the right rib fractures and the humerus fracture were sustained. Mechanism and force49.Both experts emphasised the limitations of their evidence in respect of the likely mechanism and force required to cause S’s injuries. This issue involves an area of complex biomechanics about which relatively little is known. It is, for obvious reasons, not possible to reproduce fractures in live infants in a controlled laboratory setting. There is therefore no source of experimental research on which to rely. Both experts drew primarily on their own experience of reviewing fractures in children and considering the histories provided by their carers. 50.The experts agreed that the rib fractures were caused by either a blunt impact force or, probably more likely, a compression force. The most likely cause, in the opinion of both, was a squeeze around S’s chest by adult hands. 51.The fracture to the humerus is an oblique fracture, which the experts agreed would have been caused by some form of bending or twisting force. There was some discussion in the experts’ meeting about the degree of twisting involved in an oblique, as opposed to spiral, fracture. Dr Oates, to whom Dr Ellis deferred, said that he thought there was likely to have been “some pulling action, but a degree of twisting… I can’t say how much of this was twisting and how much of it was pulling. It is likely to be a combination of both”. In oral evidence he repeated that “trauma does not occur in a lab environment… in reality, if a force is applied, unless it’s applied right down the centre of the bone there is likely to be some associated twisting action”. 52.As to the degree of force involved, both experts agreed that the force required for each of the fractures would be something beyond normal handling. Dr Cartlidge pointed out in his report that “normal infant bones are resilient and do not fracture without the application of an excessive force”. Dr Oates said that rib fractures in infants and young children are exceptionally unusual: “a baby is evolutionarily designed to negotiate, without injury, the very narrow space of the birth canal and therefore the ribs are inherently pliable”. 53.Research evidence indicates, and the experts agreed, that rib fractures in young babies can occur in the context of birth-related injuries, and through CPR, but are very rare. Both scenarios would involve force some way above normal handling, although well within the capability of an adult. 54.Both experts were asked to consider whether either potential alternative explanation for S’s injuries offered on behalf of the parents could generate the mechanism and force required. Their joint view was that neither explanation could be excluded, but both would be unlikely. 55.If a parent rolled on a child during sleep that could potentially generate the compressive force required to cause rib fractures, depending on the weight of the adult, the relative positioning and the inherent “give” of the mattress. The humerus fracture could also be caused in this way if the adult rolled in such a way as to apply a bending force to the baby’s arm. 56.An older sibling jumping or falling and landing on a baby, similarly, could generate a blunt impact force which would be sufficient to cause rib fractures. In the experts’ meeting the experts discussed the possibility of both the rib and humerus fractures being caused during an incident of this nature. Dr Oates suggested a scenario in which T jumped and landed on S with one knee landing on his back and one on his humerus, creating a twisting effect. Dr Cartlidge suggested a heel or knee landing on the chest and then sliding down onto the humerus. Both agreed that this would have to be an exceptional and unusual event. 57.Both experts made the point that if it were easy to fracture a baby’s ribs through co-sleeping or the over-boisterous attentions of an older child, clinicians might expect to see a lot of incidental fractures, but in fact such fractures are very rare. 58.Dr Oates in particular gave important evidence as to the frequency of injuries of this nature. As a radiologist at a large paediatric trauma centre he has vast experience of interpreting radiographs of young children. His hospital (Birmingham Children’s Hospital) carries out between 250 and 300 such x-rays each week. They are most often done because there is a concern that the child may have a chest infection or other non-traumatic illness. It is “vanishingly rare” to see an incidental fracture on such an x-ray. Dr Oates emphasised that the issue of fractures in young children was an area of work that he was “passionate about”, read about a lot and discussed with colleagues. He thought that if there were reports of either of the mechanisms suggested on behalf of the parents causing rib fractures in young babies, he would be aware of them. S’s likely response 59.Dr Cartlidge’s evidence was that S would have exhibited an immediate pain response after each fracture. This would have been likely to be a loud scream, distinguishable from the normal cry of a hungry or uncomfortable baby.60.The issue of how long it would take S to settle after such an injury was explored during Dr Cartlidge’s oral evidence. In his written report he gave the opinion that S would have been distressed for about 5 to 10 minutes after each of the fractures was sustained. In his oral evidence he accepted that if he had been breastfed soon after this would have had a soothing effect, and would reduce the duration of his crying; he said he could not say how long the duration would be in those circumstances, but when a timeframe of one to two minutes was put to him he responded that that sounded too brief. In any event, and more important than its duration, the cry would be different in nature to his ordinary cry. 61.In his report Dr Cartlidge described the likely clinical signs of a rib fracture as follows:“Each of the rib fractures would have been initially painful, probably for about 10 minutes. The right-sided fractures could have been caused by a single event. Thereafter the pain would have lessened, but deep breaths, crying and handling around the chest would have exacerbated ongoing discomfort causing S to be more fractious than usual for at least a few days. Yet, young babies cry so frequently without a specific reason being identifiable that the cause of his ongoing distress is unlikely to have been recognised by someone unaware of any trauma. There might have been bruising on the chest if it had been tightly gripped. Occasionally, a crackling sensation can be felt or heard from fractured bone ends grating against each other. […] If the Court finds the revealed accounts of symptomatology to be reliable, then S being noticed to have a popping/cracking sound coming from his torso/chest and also abnormal breathing during the early evening of 22 April 2022 is very suggestive of the right-sided rib fractures being present at this time.”62.As to the effects of the humerus fracture, in his written report Dr Cartlidge suggested that S’s right arm would have appeared limp immediately after being fractured. In his oral evidence he agreed that because young babies move their limbs erratically and without intent, a parent might not notice this immediately; it would be more likely that it would dawn on them over subsequent periods of caring for him. 63.Overall, Dr Cartlidge’s evidence was that any (adult) person witnessing the causal events which led to any of the fractures S sustained would have known that he had been hurt. If the events were unwitnessed, the humerus injury would be likely to be noticed if the right shoulder or elbow was substantially moved, such as during dressing or undressing. If the rib fractures were unwitnessed, any person caring for S would be likely to have noticed that he was crying more than usual, but unlikely to have known that he had been injured. The experts’ views as to causation64.Dr Oates’ view as to the likely causation of S’s injuries is set out in the executive summary to his report as follows:“Rib fractures, particularly are considered to have a high specificity for abusive injury given that they very rarely occur in typical domestic accidents. I note the parents describe co-sleeping and whether this may account for the rib fractures. Based on the likely mechanism involved (i.e. a compressive action to the chest), I cannot exclude such a scenario with certainty but I believe it would have to be considered a highly unusual event to sustain so many rib fractures, and would not obviously explain the right humeral fracture. Similarly, the possibility that S’s older brother T may have inadvertently caused the injuries would seem unlikely. I will expand upon my interpretation in the main body of the report but ultimately, I have concerns that the true explanation for the injuries has not been disclosed.”65.Later in his report he said: “Ultimately, while I cannot exclude the possibility that the actions of T or the co-sleeping arrangements may have caused the injuries, it requires more than 1 very unusual traumatic event which to my mind is increasingly unlikely.” 66.Dr Oates confirmed at the conclusion of his oral evidence that this remained his opinion. 67.During the course of his report Dr Cartlidge reviewed and excluded possible conditions which might have caused or contributed to S’s injuries. There is no suggestion that the injuries could have had any other cause than trauma. 68.Dr Cartlidge’s conclusions were stated as follows:“In my opinion all the fractures were caused non-accidentally as follows:•The left-sided rib fracture was caused by the chest being squeezed excessively firmly about 2-4 weeks before 23 April 2022.•The right-sided rib fractures were caused by the chest being squeezed excessively firmly at or before the early evening of 22 April 2022.•The humerus fracture was most likely caused by a bending force at or before about 08.00 hour on 23 April 2022.I do not discount the right-sided rib fractures and the humerus fracture beingsustained at the same time, but by separate applications of force.ConclusionsIn my opinion, all the fractures were caused non-accidentally during at leasttwo separate periods of time.”69.Dr Cartlidge maintained that view at the conclusion of his oral evidence. Loose ends in the medical evidence70.Finally, there are two ‘loose ends’ in the medical evidence on which no party sought to place weight, but which I record for completeness and because this is a case where it is necessary to carry out the widest possible survey of the evidential canvas. It is conceivable, if for any reason this judgment is revisited in future, that either of these issues may achieve greater prominence. 71.The first is the result of the genetic testing carried out following Dr Ellis’s report. Dr Ellis arranged for S to be tested for a panel of genes associated with a tendency to bone fractures. This testing revealed a rare change in the DNA sequence of the COL1A1 gene. The clinical significance of this variant was unknown and it was classified by the laboratory which carried out the testing as a Variant of Unknown Significance (“VUS”). 72.Dr Ellis was assiduous in following up this result. He arranged for both parents to be tested; this revealed that the mother had the same VUS as S. He contacted a number of laboratories to ask for clinical information about others who had been found to carry the same VUS, obtaining three responses which provided information about 11 patients. Ultimately he concluded that it was unlikely that the VUS found in S had caused any increased bone fragility. This was based on the absence of any relevant clinical features in the mother; the fact that S had sustained no further fractures as he become more mobile; and a lack of evidence of a preponderance of bone fractures in others carrying the same VUS. That conclusion is not challenged. 73.The second medical loose end is that the radiological investigations raised the possibility for Dr Oates that S might have suffered further fractures beyond the rib and humeral fractures identified above. In his written report Dr Oates observed that the Part 1 skeletal survey showed an irregularity and slight angulation of the right distal tibia metaphysis (the lower part of the shin bone). He said that this “raises concern for a specific type of fracture known as a classical metaphyseal lesion fracture…. While I have my suspicions that this is a further injury, I cannot be categorical based on this or the part 2 skeletal survey, and the possibility that the appearance falls within normal limits cannot be excluded”. In his oral evidence Dr Oates explained that he had given this issue considerable thought, and ultimately had decided that he could not state that this was a further fracture. Again, that conclusion is accepted and the local authority does not seek a finding of any further fractures beyond those to S’s ribs and humerus.