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Death due to natural causes in abused children
Child Abuse a n d Neglect, Voi. 3, pp. 1037 - 1038. © P e r g a m o n Press L t d . , 1979. Printed in Great Britain.
0145-2134/79/0901-1037 $02.00/1).
DFATH DUE TO NATURAL CAUSES IN ABUSED CHILDR]~
John Rarshall Department England.
Brldson
of Paedlatrics,
Barnsley
District
C~neral
Hospital,
South
Yorkshire,
INTROB~K~IO~ I work in a small industrial town. The population my h o s p i t a l practice co~ers is approximately 250,000. The population is mainly from the non-professional classes. On a v e r a g e , 60 new families a year pnesent with child abuse probltus. AmongSt these families there have been thr~ notable childhood deaths in the last three years. The l a t e s t death is still in the hands of the Courts and therefore cannot he discussed. The first two deaths wore attributed to natural causes, that is, sudden, unexpected death in infancy. I propose to discuss these two cases as I thLnk they illustrate a problem. CASE I This child was born at 38/52 gwstation. S h e ~ 8 t h e s e c o n d c h A l d o f a c o u p l e who h a d s e v e r e personality problms t possibly as a result of their disorpnized rear£ng. The child weighed fllb. 9 oz. at b~thand needed to spend seam t~se initially on the Special Care Baby Unit. She was r~oved by her parents from the Special Care Baby Unit early and taken hcs~ aasinet ~dlcal advice. At the age of 11 days she was admitted to hospital, dirty, suffering from a generalized ness which was found to be due to a staphylococcal sopticamia. S h a wa s ill enough to in-patient care for one month. There was no parental visiting during this time.
illneed
She died at home at the age of 9/52. Here are some of the circumstances surrounding her death. During the weeks before her death, both parents admitted physically punishing the child when she cried. She turned out not to be a good child like her elder sister, but was always crying end irritable, so both parents hit her regularly, even though she was stLll u n d e r 9/52 o f a g e . On t h e d a y b e f o r e d e a t h , she was kicked out of her pram by her father on his admission, because she would not shut up. On t h e d a y o f h e r d e a t h , m o t h e r h a d g o n e t o the shops. Father decided to feed her, got her bottle, propped her up age~st e cushion and put her bottle in her mouth and left her. When h e c a m e b a c k s h e w a s l y i n g d o w n , n o t b r e a t h ing with vomit all over har~ He p i c k e d h e r u p , g a v e h e r t h e k i s s o f l i f e a n d s w u n g h e r a round his head, holding on to her legs, as this was how he had been told to resuscitate children by neig~bours. Suhaequently, his wife came hack from the shops and they called an ambulance. The baby was dead on arrival at hospital. Post Mortem revealed a napkin rash, bruises on the anterior chest wall and a narrow line of hemorrhages around the iris. There was a small amount of recent 8undural and a large amount of recent subarrachnoid haemorrhage. The whole of the cerebrum was covered by a recent clot. There was milk feed oozin~ fro~ the nostrils, the naso-pharynx was filled with milk, the larynx contained a small amount of milky feed as did the bronchi. The pathologisUs conclusion was sudden, unexpected death in infancy. The C o r o n e r r e c o r d e d death due to natural causes, r Before the pathologist's report was made available, and the Coroner's verdict reached, the other stb. was taken into the care of the Local Authority, as a result of the parent-admitted abuse on the dead child. Soon after, mother got pregnant. Another daughter was ~orn. She was also taken into the care of the Local Authority.
1037
1038
J.M.
Bridson
CASE I I This little boy first came to the notice of the hospital Authorities at the age of 3/12 when he was admitted to hospital with a history of vomitinE and d/~rrhoea and found to be suffering from severe dehydration with hypernatralmia and an acidosis. From the point of admission to hospital there was no vof-itin4r Or dial~rhoea. His condition rapidly heproved with rehydration and he was discherged how. His height and weight at that ti~ were reasonable for his age. At the a~ of 10/12 his Health Visitor was worried about his motor development. At the age of 13/12 the Clinical Medical Officer referred h i m t o me b e c a u s e o f d e l a y i n m o t o r d e v e l o p Rent, notinE that ha was very dirty with fluff and old skin hetw~n his liners and toes, the buttocks showinE a severe napkin rash and co~ntinE that overall the picture was one of neElect and miseana~nt. The child died before his Outpatient appointment. He h a d b e e n w e l l t h e d a y b e f o r e h i s d e a t h a n d w a s p u t t o b e d a t 7 pro. Be e a s h e a r d t o c r y t h e f o l l o w i n E n o r n i n g a t a p p r o x i m a t e l y 8 am, but no-one went to ~t him up until 4 l~ that day, i.e., 21 hours after bQinE put to bed. Be was found to be dead. The est/~ated time of death was 9 an. The P o s t M o r t e m r e p o r t concluded sudden, unexpected death in infancy. No p r o s e c u t i o n was carried out for ne~ect on the basis of the followinE reasoning, which is a little hard to follow:as the child died at 9 even though he was not looksd at until 4 pc, one cannot ne~ect a .dead child. DISCU~ION Both these fmallies have o t h e r c h i l d r e n and are continuing t o have f u r t h e r children. Great c o n c e r n may b e f e l t f o r t h e o t h e r c h i l d r e n . How b e s t c a n we m e e t t h e n e e d s o f t h e f a m i l y ? Neither family wishes to accept help. If co-ope~ation cannot he obtained on a voluntary basis, should observation Just he left to occasional Health Visitor and G.P. surveillance? How e a s y i s i t t o o b t a i n a C a r e O r d e r o r S u p e r v i s i o n Order when the Coroner*s verdict is death due to natural cmuses? In the first f a m i l y , we o b t a i n e d a Care Order on the elder sister prior to the Coronnr's verdict which was lucky. I think, h a d we a p p l l e d for it subsequently, we s a y n o t h a v e g o t i t . In the senond family, lackin~ the parents' co-operation, we have no superwision. The reason for presontlng those two cases is to stlaulato dlscusslon with families in which abuse occurs, yet the abused child's death is D~ t U l ~ 1 C a u s e s .
Two f m m t l i o s a r e d i s c u s s e d . was said to be duo to natural and care for these families.
on the ways of dealing certified as duo to
In each family a child is abused and subsequently cauSmSo Difficulty usually arises in providing
dies. Death adequate help
0145-2134/79/0901-1037 $02.00/1).
DFATH DUE TO NATURAL CAUSES IN ABUSED CHILDR]~
John Rarshall Department England.
Brldson
of Paedlatrics,
Barnsley
District
C~neral
Hospital,
South
Yorkshire,
INTROB~K~IO~ I work in a small industrial town. The population my h o s p i t a l practice co~ers is approximately 250,000. The population is mainly from the non-professional classes. On a v e r a g e , 60 new families a year pnesent with child abuse probltus. AmongSt these families there have been thr~ notable childhood deaths in the last three years. The l a t e s t death is still in the hands of the Courts and therefore cannot he discussed. The first two deaths wore attributed to natural causes, that is, sudden, unexpected death in infancy. I propose to discuss these two cases as I thLnk they illustrate a problem. CASE I This child was born at 38/52 gwstation. S h e ~ 8 t h e s e c o n d c h A l d o f a c o u p l e who h a d s e v e r e personality problms t possibly as a result of their disorpnized rear£ng. The child weighed fllb. 9 oz. at b~thand needed to spend seam t~se initially on the Special Care Baby Unit. She was r~oved by her parents from the Special Care Baby Unit early and taken hcs~ aasinet ~dlcal advice. At the age of 11 days she was admitted to hospital, dirty, suffering from a generalized ness which was found to be due to a staphylococcal sopticamia. S h a wa s ill enough to in-patient care for one month. There was no parental visiting during this time.
illneed
She died at home at the age of 9/52. Here are some of the circumstances surrounding her death. During the weeks before her death, both parents admitted physically punishing the child when she cried. She turned out not to be a good child like her elder sister, but was always crying end irritable, so both parents hit her regularly, even though she was stLll u n d e r 9/52 o f a g e . On t h e d a y b e f o r e d e a t h , she was kicked out of her pram by her father on his admission, because she would not shut up. On t h e d a y o f h e r d e a t h , m o t h e r h a d g o n e t o the shops. Father decided to feed her, got her bottle, propped her up age~st e cushion and put her bottle in her mouth and left her. When h e c a m e b a c k s h e w a s l y i n g d o w n , n o t b r e a t h ing with vomit all over har~ He p i c k e d h e r u p , g a v e h e r t h e k i s s o f l i f e a n d s w u n g h e r a round his head, holding on to her legs, as this was how he had been told to resuscitate children by neig~bours. Suhaequently, his wife came hack from the shops and they called an ambulance. The baby was dead on arrival at hospital. Post Mortem revealed a napkin rash, bruises on the anterior chest wall and a narrow line of hemorrhages around the iris. There was a small amount of recent 8undural and a large amount of recent subarrachnoid haemorrhage. The whole of the cerebrum was covered by a recent clot. There was milk feed oozin~ fro~ the nostrils, the naso-pharynx was filled with milk, the larynx contained a small amount of milky feed as did the bronchi. The pathologisUs conclusion was sudden, unexpected death in infancy. The C o r o n e r r e c o r d e d death due to natural causes, r Before the pathologist's report was made available, and the Coroner's verdict reached, the other stb. was taken into the care of the Local Authority, as a result of the parent-admitted abuse on the dead child. Soon after, mother got pregnant. Another daughter was ~orn. She was also taken into the care of the Local Authority.
1037
1038
J.M.
Bridson
CASE I I This little boy first came to the notice of the hospital Authorities at the age of 3/12 when he was admitted to hospital with a history of vomitinE and d/~rrhoea and found to be suffering from severe dehydration with hypernatralmia and an acidosis. From the point of admission to hospital there was no vof-itin4r Or dial~rhoea. His condition rapidly heproved with rehydration and he was discherged how. His height and weight at that ti~ were reasonable for his age. At the a~ of 10/12 his Health Visitor was worried about his motor development. At the age of 13/12 the Clinical Medical Officer referred h i m t o me b e c a u s e o f d e l a y i n m o t o r d e v e l o p Rent, notinE that ha was very dirty with fluff and old skin hetw~n his liners and toes, the buttocks showinE a severe napkin rash and co~ntinE that overall the picture was one of neElect and miseana~nt. The child died before his Outpatient appointment. He h a d b e e n w e l l t h e d a y b e f o r e h i s d e a t h a n d w a s p u t t o b e d a t 7 pro. Be e a s h e a r d t o c r y t h e f o l l o w i n E n o r n i n g a t a p p r o x i m a t e l y 8 am, but no-one went to ~t him up until 4 l~ that day, i.e., 21 hours after bQinE put to bed. Be was found to be dead. The est/~ated time of death was 9 an. The P o s t M o r t e m r e p o r t concluded sudden, unexpected death in infancy. No p r o s e c u t i o n was carried out for ne~ect on the basis of the followinE reasoning, which is a little hard to follow:as the child died at 9 even though he was not looksd at until 4 pc, one cannot ne~ect a .dead child. DISCU~ION Both these fmallies have o t h e r c h i l d r e n and are continuing t o have f u r t h e r children. Great c o n c e r n may b e f e l t f o r t h e o t h e r c h i l d r e n . How b e s t c a n we m e e t t h e n e e d s o f t h e f a m i l y ? Neither family wishes to accept help. If co-ope~ation cannot he obtained on a voluntary basis, should observation Just he left to occasional Health Visitor and G.P. surveillance? How e a s y i s i t t o o b t a i n a C a r e O r d e r o r S u p e r v i s i o n Order when the Coroner*s verdict is death due to natural cmuses? In the first f a m i l y , we o b t a i n e d a Care Order on the elder sister prior to the Coronnr's verdict which was lucky. I think, h a d we a p p l l e d for it subsequently, we s a y n o t h a v e g o t i t . In the senond family, lackin~ the parents' co-operation, we have no superwision. The reason for presontlng those two cases is to stlaulato dlscusslon with families in which abuse occurs, yet the abused child's death is D~ t U l ~ 1 C a u s e s .
Two f m m t l i o s a r e d i s c u s s e d . was said to be duo to natural and care for these families.
on the ways of dealing certified as duo to
In each family a child is abused and subsequently cauSmSo Difficulty usually arises in providing
dies. Death adequate help