Striking the balance on abuse

In December 2011 Rohan Wray and Chana Al-Alas were acquitted of charges related to the death of their four-month old son Jayden, who had undiagnosed congenital rickets and died of a head injury caused by a fracture to his skull in July 2009. Last month, both were acquitted in the care proceedings issued by their local authority of Islington relating to their second child, Jayda, born in October 2010 and taken into care at birth due to the charges her parents were facing.

The case highlights a number of important issues, including the role of experts in such proceedings and the need for research to identify the consequences of Vitamin D deficiency. It also raises a larger question about the role of medical and health sector practitioners in cases of suspected child abuse.

On 22 July 2009, Wray and Al-Alas visited their GP, concerned about Jayden’s health. They were referred to University College London Hospital (UCLH) walk-in centre. As the day progressed, Jayden’s condition deteriorated with increasing fits and seizures. The A&E staff detected a skull fracture and medical staff suspected that his injuries had been inflicted by his parents, who were 16 and 19 years old at the time. According to the medical records, a radiologist at UCLH raised rickets as a possibility, based on a chest X-ray. However, the consultant paediatrician ruled this out based on the baby’s normal calcium levels.

Skeletal survey
Jayden was transferred to Great Ormond Street Hospital (GOSH) later that evening. The consultant paediatrician also strongly suspected non-accidental injuries. A skeletal survey revealed a number of other fractures that the consultant paediatric radiologist reported were not caused by metabolic bone disease, but were likely to have been caused by non-accidental injuries. Interestingly, the pathologist who performed the post-mortem observed the radiological signs of rickets on the X-rays taken at GOSH. Wray and Al-Alas were arrested on 23 July 2009. Their son died two days later.

Section 11 of the Children Act 2004 places an obligation on most health professionals to safeguard and promote the welfare of children they come across in the course of their work. A great deal of emphasis is placed on the role of frontline practitioners in identifying signs of abuse in children. This is particularly important for those working in the health sector who are uniquely well-placed to identify such abuse. However, the duty to safeguard and promote the welfare of the child does not supersede the moral and ethical duty of care that medical practitioners have towards their patients.

The National Institute for Clinical Excellence (Nice) guidance for medical practitioners, entitled When to Suspect Child Maltreatment states: “Suspect child maltreatment if a child has one or more fractures in the absence of a medical condition that predisposes to fragile bones.”

The British Medical Association guidance states that “any child admitted to a hospital about whom there are concerns about deliberate harm must receive a thorough, carefully documented examination within 24 hours of their admission,” except where this is not in the child’s best interest.  It should be common practice to carry out sufficient tests to rule out any underlying organic reason for the fractures first before asserting that the injuries might be caused non-accidentally.

Protecting children from harm and ensuring their safety and wellbeing is fundamental, but the case of Wray and Al-Alas has some important lessons. While it is unsurprising that Jayden’s injuries caused staff at UCLH and GOSH to suspect abuse, rickets can be diagnosed through a blood test and this should have been done when the radiologist at UCLH mentioned it as a possibility. It is a fine balance – on the one hand ensuring that a child who presents suspicious injuries is protected from significant harm, and on the other hand ensuring that any accusations against parents are based on all the information that is or should be available. The stakes in such cases, particularly when there are other children involved, are too high for every effort not to be taken to ensure the right balance is struck.