Shaken Baby Syndrome Discussion Topics Unit 4 Answers Somthing About the Holocoast

• Introduction
• The Causes of NAHI: The Triad of Injuries
• Skilful Evidence - The Legal Framework
• Charging
• The Part of the Good
• The Criminal Procedure Rules: Part 19
• Parallel Proceedings: Family and Criminal
• Addendum A: Bio Mechanics in Non Accidental Head Injuries (NAHI)
• CRABI (Kid Restraint Air Bag Interaction dummy)

Introduction

This guidance is intended to provide information on the stance taken past the Courts in relation to Non Accidental Head Injury ("NAHI") cases and to assist prosecutors in the arroyo and presentation of such cases.

The use of the term Shaken Baby Syndrome should at present be avoided equally it tin can be considered to accept emotive connotations and, more importantly, does not adequately describe the range of causes of caput injuries.

The grooming and marshalling of good show is of the utmost importance in achieving just resolution of these cases. But advocates who are experienced and expert in the field of what is contended to be the unexplained death of an baby should be instructed to prosecute such a case.

Office of the duty of the advocate will be to help the court and the gauge will invariably discuss the issues of medical testify with the advocates and then that the gauge will exist in a position to construction carefully the summing up to those issues and to identify which prove goes to the resolution of those issues.

The Causes of NAHI: The Triad of Injuries

The encephalon is encased in three membranes. The i immediately surrounding the encephalon is the pia mater. The next one is the arachnoid. Between the pia and the arachnoid is the subarachnoid space. The 3rd membrane, surrounding the brain and continuing downward the body surrounding and protecting the spinal cord is the dura. Between the dura and the arachnoid is the subdural space, as well as veins running between the two membranes called bridging veins.

Generally, cases where NAHI is alleged depend on a trilogy of findings of intracranial injuries (the triad) consisting of:

• Encephalopathy (divers as any disease of the brain affecting the brain'south role)
• Subdural haemorrhages (bleeding in the subdural infinite); and
• Retinal haemorrhages (bleeding inside the retina).

Whilst not entirely understood, the machinery for these injuries is thought to exist the shaking of the infant, with or without impact on a solid surface. This moves the brain within the skull, damaging the brain and shearing the bridging veins betwixt the dura and the arachnoid and sometimes causing retinal haemorrhages. Nevertheless, despite medical doubtfulness surrounding the mechanism, the triad of injuries is a potent medical pointer to the infliction of NAHI.

In that location have been challenges to the triad. Between 2000 and 2004 a team of professionals led by Dr Jennien Geddes conducted research terminal in "Geddes III" which challenged the supposed infallibility of the triad suggesting that there was one unified cause of the three intracranial injuries constituting the triad, non necessarily trauma. This became known as the unified hypothesis.

However, in R five Harris: R v Rock [2006]i Cr App R v, Dr Geddes accustomed that the hypothesis in this paper was not a credible claiming to the triad and was intended only to promote discussion. Attempts to rely on the unified hypothesis every bit a challenge to the triad are now rarely encountered and should ever be field of study to thorough testing. For further word, please run into: R v Henderson; R five Butler: R v Oyediran [2010]2 Cr App R 24 at para. 69.

Those challenging the triad on occasions have likewise invited consideration of bio-mechanical evidence. There is, however, picayune data relating to the distance an infant would have to fall to suffer such injury to the head. About experts besides take the difficulty for whatever biomechanical model to simulate the complex anatomy of an infant'southward brain.

Delight see Annex A for a fuller give-and-take of the problems concerning biomechanics in NAHI.

Expert Evidence - The Legal Framework

Cases which depend on the triad inevitably involve consideration of complex proficient bear witness.

Whilst some of the cases below exercise non involve NAHI, their principles utilize every bit to such cases.

In R 5 Cannings (Angela) [2004] 1 W.L.R. 2607, the Court of Entreatment quashed the appellant'southward convictions for murder where the only prove against her was provided by experts. The issue was whether the two unexplained deaths of her infant sons were natural SIDS (Sudden Infant Decease Syndrome) or had an unnatural but unknown cause. Following her convictions, the Court of Appeal received fresh prove of a substantial body of research suggesting that such deaths could and did occur naturally even when they were unexplained. In quashing the convictions, the Court, at para.178, stated:

In cases like the present, if the issue of the trial depends exclusively or almost exclusively on a serious disagreement between distinguished and reputable experts, it will often be unwise, and therefore unsafe, to proceed.

For a fourth dimension, this judgment was taken to hateful that where there was a conflict between skilful witnesses, the prosecution case was effectively neutralised in the absence of testify independent of such testimony. This contention was rejected by the Court of Entreatment in the more than recent case ofR 5 Kai-Whitewind [2005] EWCA Crim 1092, describing information technology every bit the "overblown 'Cannings' statement". Such an approach should only be practical, in the calorie-free of contemporary medical cognition, to cases which depended solely on the inferences based on coincidence or the unlikelihood of two or more than infant deaths in the aforementioned family.

In other cases, where there is a disagreement between experts near the estimation of findings, such a dispute does not extinguish the findings themselves. In such cases, information technology remains for a jury to evaluate the skillful evidence.

Charging

Cases which involve the triad must be approached with caution. In R v Henderson: R v Butler: R v Odeyiran [2010] ii Cr App R 24 information technology was stated:

Where the prosecution is able, by advancing an array of experts, to identify a non-adventitious injury and the defence can identify no alternative cause, it is tempting to conclude that the prosecution has proved its example. Such a temptation must be resisted. In this, every bit in so many fields of medicine, the evidence may exist insufficient to exclude, beyond reasonable uncertainty, an unknown cause. (para. one)

We emphasise that we are dealing with natural causes of decease within the purview of up-to-date medical noesis because in this appeal we were properly reminded that at no phase can noesis in a field such as this be regarded as consummate and comprehensive. There are limits to the extent of knowledge and no conclusion should exist reached without acknowledging the possibility of an unknown cause emerging into the light of medical perception and that the mere exclusion of every possible known cause does not evidence the deliberate infliction of violence. (para. 21)

The Court emphasised:

Where relevant, the jury should be reminded that medical scientific discipline develops and that which was previously thought unknown may afterward exist recognised and acknowledged. In such a case the jury should be reminded that special circumspection is needed where expert opinion evidence is fundamental to the prosecution

In a example where a kid dies (or suffers serious injury), equally the above makes clear, it is rare that a charge of homicide (or attempted murder or attack) could be sustained where the merely evidence available is the triad of pathological features. Such prove is rarely conclusive of NAHI and prosecutors should await for other, supporting evidence.

Sometimes, the evidence is in the grade of additional medical evidence. In Henderson, in addition to the triad, the prosecution relied upon the show of retinal folds and axonal damage (damages to the nervus fibres). In Oyediran the prosecution relied upon prove of a small bruise on the inner surface of the scalp and a previous arm fracture.

The 2016 study entitled Sudden Unexpected Expiry in Infancy and Childhood: the Report of a Working Group convened by The Royal Higher of Pathologists and The Royal College of Paediatrics and Child wellness identified a listing of non-exhaustive factors that could suggest a death was suspicious and could provide supporting evidence of NAHI:

• Previous on-going child safeguarding concerns;
• Previous sibling deaths;
• Delay in seeking help;
• Inconsistent explanations;
• Unexplained injury, either present or previously;
• Evidence of past or present drug and/or alcohol abuse;
• Neglect;
• Previous convictions of parents or partners, in particular violence towards children.

All of the surrounding evidence must exist fully considered by a prosecutor before a decision can exist fabricated on the evidential sufficiency of any case in accordance with the Full Code test in the Code for Crown Prosecutors.

The level of charging will accept to be considered carefully in the calorie-free of the comments in R v Allen (Tony) [2005] EWCA Crim 1344 and Harris and Others as to whether the necessary intent can be inferred from the degree of force believed to have been used. Regard must be had to the proficient evidence equally to the level of strength and duration of assault.

In advisable cases where expiry has occurred, prosecutors may wish to consider a charge contrary to Department 5 of the Domestic Violence, Crime and Victims Act 2004 too equally murder or manslaughter. Guidance on the implications of this grade can be found in the CPS Legal Guidance on Homicide.

The Role of the Good

If an babe has died, a post-mortem will have been conducted by a paediatric pathologist. Where a criminal investigation is on-going or where meaning concerns have been raised about the possibility of abuse or fail contributing to the infant's expiry, a forensic pathologist should accompany the paediatric pathologist and the joint post-mortem examination protocol should exist followed.

Consideration will demand to be given to instructing a range of experts who should non be the attending clinicians who treated the infant at the time of the admission to hospital.

Such experts will include consultants with expertise in the fields of:

• Paediatric neurosurgery;
• Paediatric neuroradiology;
• Paediatric radiology;
• Paediatric histopathology;
• Paediatric ophthalmology; and
• Paediatric neuropathology.

Information technology is sometimes of assist to instruct an immunologist if issues about infection are raised.

Ultimately, a consultant paediatric intensivist can provide an overall framework in which the big amount of different specialisms tin can exist understood.

Guidance on the prosecution disclosure obligations in respect of expert witnesses is provided in Chapter 36 of the Disclosure Manual and should ever be referred to when any expert is instructed.

The Court of Appeal in Henderson placed significant emphasis on the issue of whether or not an expert was in clinical practice at the time of the report in determining the admissibility of any expert'southward report further to the Criminal Procedure Rules.

Guidance as to the correct arroyo to the direction of such cases was given past the Court in Henderson, where it was stated that a conviction based merely on the evidence of experts could only be regarded as safe if the instance proceeded on a logically justifiable basis for rejecting or accepting the evidence.

The Criminal Procedure Rules: Role 19

Proper and robust pre-trial management is essential and the rules provided in Role 19 of the Criminal Procedure Rules ("CrimPR") should be adhered to strictly.

Rule nineteen.ii(1) provides that an expert must assistance the court to achieve the overriding objective by giving opinion which is:

1. Objective and unbiased, and
2. Within the skillful'due south area of expertise.

By Rule 19.6(iv), a party may non introduce expert evidence without the court'due south permission if the expert has not complied with a management under this rule.

In particular, this part of the Rules provides that information technology is the obligation of the expert to ascertain their area or areas of expertise (xix.2(3)(a) CrimPR) and, when giving evidence in person, to draw the court's attending to any question to which the answer would be outside the expert's area or areas of expertise.

Rule 19.6(ii) is also of importance. As part of the courtroom's example management powers, a approximate may direct the experts to:

1. Talk over the practiced issues in the proceedings; and
2. Set up a statement for the courtroom of the matters on which they agree and disagree, giving their reasons.

In Henderson, the Court of Appeal stated that it would by and large expect a meeting to be held and then that a statement could exist prepared well in advance of the trial. Such a meeting should be attended by all significant experts, including the defence experts. A careful, detailed set of minutes would demand to be taken and signed past all the participants. Information technology would be preferable that the legal representatives did not attend.

It is difficult to envisage a case involving an accusation of NAHI where such a meeting would non take place.

InR 5 Reed and Reed: R v Garmson [2010] ane Cr App R 23, the courtroom dealt with the complex science of admissible Dna evidence. There is useful guidance in that instance which is applicable to complex NAHI medical show, in particular a 'primer' or guide to the basic science applicable to be agreed and provided to the jury.

A judge could as well exercise their powers of case management under the CrimPR to ensure that, in advance of a trial, a defence expert made disclosure of any relevant previous reports and any adverse judicial criticism. A case management hearing could present an opportunity for concerns every bit to previous criticism of an expert and an expert'due south previous tendency to travel across their expanse of expertise. Such a history would not necessarily exist a ground for refusing the access of the evidence but information technology could raise issues about the advisability of relying on such a witness.

Parallel Proceedings: Family unit and Criminal

Where in that location are associated family proceedings, besides every bit a criminal investigation, regard should exist had to the Legal Guidance on Children as Victims and Witnesses , in particular the section on Family Proceedings. Prosecutors should consider making enquiries through the police of the local authority solicitors near the family proceedings.

In addition to seeking disclosure from the Family Court proceedings, the legal guidance provides guidance on disclosure of criminal material to the Family unit Courts.

Regard should also be had to the Legal Guidance - Disclosure of Material to Third Parties.

It is important that all information sharing takes into account the guidance in the Child Abuse Protocol: 2013 Protocol and Expert Practice Model – Disclosure of Data in Cases of Declared Child Abuse and Linked Criminal and Instance Directions Hearings at https://www.judiciary.uk/wp-content/uploads/JCO/Documents/Guidance/protocol-good-exercise-model-2013.pdf

Addendum A: Biomechanics in Non Adventitious Head Injuries (NAHI)

The written report of biomechanics is the practise of applying the principles of mechanics to biological systems.

Some specialists, medical and non-medical, in Child Corruption and NAHI cases believe that show of biomechanical studies should not be part of the circuitous investigation and prosecution of such cases.

One straightforward problem is that the dummies do not replicate the detail human structures that are central to the 'triad of injuries'; they have no brain, optics or venous architecture (network of veins). It is also worth noting that the neck mechanism in such dummies only replicates movement in one direction (backwards and forwards) and does not reflect the range of move possible in a baby or kid.

These dummies are designed to replicate a frontwards and astern motility, with no capacity for side to side or athwart movements. The skull of a child is flexible due to immaturity and, dependent upon age and birth circumstances, the sutures (areas of the skull) are not withal fused. By contrast, the fibreglass skull of the dummy is solid; it is made of several layers of fibreglass matting, coated with resin and allowed to react with a catalyst which causes the fibreglass to set vary hard.

A human encephalon is of course set within fluid, with a circuitous bridging vein structure; the Child Restraint Air Bag Interaction dummy ("CRABI") skull (see beneath) contains a metal box set inside the fibreglass skull with data cables and sensors attached.

Depending on the age of a child, no response values are considered if, for example, a child is erstwhile enough to break their fall by placing hands or arms out before bear upon. The dummy arms and legs are bolted on and set to a certain Yard-force of response in an attempt to replicate immature knee joint responses.

Outlined below is a basic clarification of a widely used model in bio mechanical studies, the CRABI.

CRABI (Kid Restraint Air Bag Interaction dummy)

The CRABI is used to evaluate air bag exposure to infants restrained in child safety seats that are placed in the front seat. CRABI dummies come up in three sizes: six-month-old, 12-month-sometime and xviii-calendar month-old.

Figure one CRABI Dummy

The CRABI was merely intended to exist used in this context. It was never intended to be used in experiments to replicate paediatric internal caput injury as seen at infirmary and at post mortem.

The CRABI 12-Month Old was developed in 1993 past a Guild of Automotive Engineers (SAE) Task Force for the purpose of testing forward and rearward facing child restraints.

Head

The skull is manufactured from fibreglass with a steel weldment insert, and the head skin is moulded urethane. An upper neck load jail cell simulator is assembled with the head to allow for installation of three uniaxial accelerometers in a triaxial configuration at the centre of gravity (CG). A separate uniaxial accelerometer can be installed at the rear of the accelerometer mount to measure athwart acceleration in the sagittal aeroplane.

Figure ii CRABI Dummy Head

Cervix

A flexible moulded safe neck is used to give the caput assembly human-like flexion and extension characteristics. A 6-axis load cell can be mounted at both the upper and lower ends of the neck assembly.

Figure three CRABI Dummy Neck

Torso

Chest foam and a chest foam support associates mounted on a thoracic spine box brand up the upper body. The shoulders are fabricated of flexible rubber joints. A two-axis load jail cell tin can be mounted in each shoulder. The thoracic spine is a welded aluminium structure that provides a mounting location for the triaxial configuration accelerometers at the T1 vertebrae.

The pelvis/lumbar assembly includes a welded aluminium pelvic structure and a flexible moulded prophylactic lumbar spine. A six-axis load prison cell may be mounted between the base of the lumbar spine and the top of the pelvis. The pelvic aluminium structure also provides space for triaxal configuration accelerometers which are mounted at the bottom of the lumbar. The pelvis as well can accommodate an optional two-axis pubic load jail cell. The intestinal insert is made of an open cell urethane cream. The body flesh is moulded urethane with nylon netting reinforcement.

Figure 4 CRABI Dummy Torso (image 1)

Figure 5 CRABI Dummy Torso (Image ii)

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Source: https://www.cps.gov.uk/legal-guidance/non-accidental-head-injury-cases-nahi-formerly-referred-shaken-baby-syndrome-sbs

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