Multiple events of child abuse with fatal outcome

Abstract

Introduction: Diagnosing child abuse, its interpretation, and the reconstruction of the cause of the injuries are a major challenge for forensic physicians and often require interdisciplinary cooperation. Material and Methods: We report the case of the death of a 10-week-old baby who died from an abdominal haemorrhage caused by tears in the mesentery of the transverse colon. Results: The accused father had stated that he had accidentally sat down on the baby who had been lying on the couch, that he got up immediately and noticed that the child was no longer breathing. The emergency doctor who had been called diagnosed no external injuries on the baby, but a reduced oxygen saturation of 90%. The lungs were aerated, there was no pneumothorax, and the heart rhythm was regular. It was stated that subsequently, the oxygen saturation fell further, bradycardia occurred, and the child had to be artificially respirated and finally resuscitated. On admission at the hospital, the Hb value was 3.3g/dl and the pH-value were not measurable. An intra-abdominal haemorrhage of unknown origin was diagnosed on sonography. Despite volume replacement and the administration of lyophilized plasma, the lactate value remained consistently high (21mmol/l), pH value remained unmeasurable, and the child died. The post-mortem X ray examination revealed multiple rib fractures that had occurred at three different times. The autopsy established the cause of death as an abdominal haemorrhage of 400ml from two tears in the mesentery of the transverse colon exactly above the spine. Discussion: The fatal injury could not be explained by the father’s statement that he had sat on the infant, because the size and localization were consistent with a very punctual force, e.g. the impact of an object or a fist, and not with blunt force impacting a larger area, as one would have expected if someone had sat on the infant. The rib fractures of different ages ultimately confirmed that the infant had been abused several times previously. Conclusion: The police investigation revealed that the older rib fractures had already been diagnosed by a paediatrician, who had sent the mother to a paediatric surgery department for further treatment. The father had prevented the mother from going to the hospital because he feared that the violent act against the child would be discovered. The father was sentenced to life imprisonment for multiple counts of child abuse resulting in death, while the mother received a suspended sentence. The images from the paediatric radiology department showing that the child had been abused several times were crucial for solving this case as they proved the lacking plausibility of the father’s statement.