The medical evidence
12 Alexandra was airlifted to Prince of Wales Hospital where she was assessed by Dr Moran, a paediatrician with the Sydney Children's Hospital, and by Dr Kennedy, a specialist paediatric ophthalmologist. The Crown relied upon the evidence which these two specialists gave. The appellant called no medical evidence.
13 In short, it was the Crown case that the appellant had shaken the baby, causing a rapid acceleration of the brain, and this was possibly associated with a soft surface impact that may have resulted in a deceleration of the brain. The child sustained diffuse brain injury with bilateral preretinal haemorrhages and acute subdural haemorrhages that caused unconsciousness.
14 Whilst at Dubbo Base Hospital, CAT scans were performed which showed soft tissue swelling at the back of the head. They also revealed bilateral subdural haemorrhages, described as old, and an area suggestive of a fresh bleed on the right side. A subsequent scan at the Children's Hospital on 5 February confirmed those findings.
15 Dr Moran examined the plaintiff on 4 February 2002. When he examined her, Alexandra had an impaired level of consciousness and was moving her right limb more readily than her left. This indicated brain damage.
16 Dr Moran agreed that a direct blow to the back of the head could cause bleeding within the brain or subdural haemorrhages and also retinal haemorrhages. However, in the opinion of Dr Moran, had the child fallen and hit her head on concrete, that was not the sort of trauma that would cause the retinal haemorrhages (T 277):
"I think I can fairly confidently say that that sort of injury from a fall [referring to the soft tissue swelling at the back of the head] would not cause the retinal [haemorrhages]. So, in other words, if we look at the soft tissue swelling, if that represents a fall onto something, it would be most unusual that that would have retinal haemorrhages of the type we see in this child associated with it, in fact it has never been described."
17 Then, when asked about the subdural haemorrhage, Dr Moran went on (T 277):
"The subdural haemorrhage - could the subdural haemorrhage be associated with the fall such as this? And the answer is that she could get a subdural haemorrhage. Usually you would expect to see the subdural haemorrhage directly underneath the area of impact and in the case we're talking about, it's not. The other question I guess is, could you get the damage to the brain that we see in this child from a fall such as this? I think that would be most unlikely as well."
18 Dr Moran considered that there was no history of accidental injury and no evidence of medical conditions that could account for Alexandra's clinical findings (T 304). They could not have been caused by the dog knocking her down. Dr Moran was asked these questions and gave these answers (T 304-305):
"CROWN PROSECUTOR: Q. You also say that the eye injuries, the recent subdural haemorrhage, that's the fresh bleed?
A. Yes.
Q. And the brain injury--
A. Yes.
Q. -that's the injury to the white matter and the basal ganglia?
A. Yes.
Q. Those injuries could result from a variety of mechanisms you stated including shaking, contact forces, hypoxic ischaemic injury which is basically a lack of blood supply, and secondary metabolite accumulations causing cell damage in the brain, and you've stated that in your opinion these injuries are the result of abusive head trauma?
A. Yes. When I just look at that again I think perhaps what I should say there is - lest there be any - lest this could be misconstrued, it's from a combination of these mechanisms.
Q. A combination of which mechanisms?
A. Of the shaking, contact forces, hypoxic ischaemic injury and secondary metabolite accumulations causing cell damage in the brain.
HIS HONOUR: Q. What do you mean by abuse head trauma?
A. Well rather than I guess accidental head trauma. Some form of shaking and/or contact injury to the brain, and - yes, that's what I mean by that...
Q. Is there evidence of contact injury here?
A. Well there was evidence - if we take - if we accept that there was the bruising there, that could be evidence.
Q. Bruising there you mean of the occipital area?
A. Yes, that could be evidence of contact injury, but as far as I was concerned at the time, the only evidence that I saw was old bruising on the head, so there wasn't any absolute evidence of contact injury.
Q. So what's the mechanism by which these injuries were received then?
A. The mechanism in my view was that the child had rapid rotational acceleration of her head which could occur with shaking and that could include contact injury. In other words, at the same time hitting something but not necessarily showing that as not necessarily having any bruising or a fracture. So, for instance, the bruising you shook somebody and then their head came in contact with let's say a piece of - a padded fabric, for instance, on a - on a chair, that wouldn't necessarily leave any bruising but there would be a very rapid deceleration of the head and that could lead to these sorts of injuries that we see here."
19 And then (T 308):
"HIS HONOUR: Q. What happened in this case in your opinion to Alexandra?
A. Well in my opinion one of two things happened, or both of these things happened, and that is that there was some shaking causing whip lashing and the head impacted something or else there was just purely shaking alone. My view would be that in a child of this age it would be much more likely that you would have some impact causing the injury as well.
CROWN PROSECUTOR: Q. The fact that she was well and the fact that you have seen the video taken that morning, she was well just before her going unconscious, do you have a view as to when the injuries were sustained, the injuries that made her unconscious?
A. Yes, I think it is highly unlikely that injury to this degree, that produces pretty much instant unconsciousness it would appear from the history, so that the child was well at one stage and then was unconscious a few seconds later, that that - so the injury must have occurred in close proximity to the time she became unconscious. Very close proximity, or indeed immediately."
20 Dr Moran rejected the possibility that a fall from a highchair onto the lino-covered concrete floor would have caused the injuries the victim suffered (T 320).
21 In cross examination, Dr Moran agreed that the pulpy mass at the back of the child's head could have been caused by a fall when the child was being carried. Dr Moran was then asked whether, if there was a fall, this could account for the retinal haemorrhages (T 363):
"Q. Secondly, could a fall in those circumstances account for the retinal haemorrhages as observed by you?
A. I'm not in a position - I think that they would be unusual under those circumstances but I'm not in a position to say to you that they could not occur but I would consider them extremely unusual under those circumstances.
Q. It would depend essentially on the extent to which the head did move on its axis during the course of the fall and the way in which it struck the floor at the point of impact with the floor, is that right?
A. Well I think it depends, as I said there has been a suggestion that occipital impacts may cause more in the way of retinal haemorrhage than other impacts. I think that there is a significant degree of rotational acceleration in the scenario that you describe, whether or not - certainly traditionally I think I would have to say that a lot of people would say, no that the retinal haemorrhages could not occur under those circumstances that they're too wide spread, too diffuse and that they only occur with shaking. I'm not so sure that I could agree entirely with that proposition now, so while I would say that they're unusual I don't think I'd be able to say that they couldn't have occurred under those circumstances.
Q. A fall in those circumstances could also account I suggest to you for the fresh bleed or the area of the fresh subdural haemorrhage that you've given evidence about?
A. Yes.
Q. And a fall in those circumstances could account also for the instantaneous loss of consciousness, couldn't it?
A. I would say yes, yeah."
22 Dr Kennedy, who was the head of the Department of Paediatric Ophthalmology at Sydney Children's Hospital, examined Alexandra on 12 February 2002 after an MRI scan. He reported that the child had many retinal haemorrhages in both eyes and that these were both retinal and preretinal. He believed that the presence and extent of the haemorrhages in the various retinal layers indicated a violent and repeated shaking, and this was a pattern seen in non-accidental injury. The pattern of retinal haemorrhages with accidental injury was usually a little different. His evidence (T 394) was as follows:
"CROWN PROSECUTOR: Q. You also say at point 4 of your statement, the presence of haemorrhages in various retinal layers extending out to the retinal periphery, would indicate to you that this was due to violent and repeated shaking, a pattern seen in non accidental injury?
A. I believe so yes.
Q. Is that your expert view on the cause of--
A. That's my view.
Q. Can you think of any other cause of retinal haemorrhage apart from violent and repeated shaking?
A. Yes, retinal haemorrhages are not specific obviously, retinal haemorrhages can occur occasionally in accidental injury, although the pattern is a little different usually. They can occur in bleeding disorders such as the leukemias, meningitis, some rare metabolic disorders, it can occur after childbirth even, is quite common after childbirth. You see retinal haemorrhages in some other diseases of the eye, such as retinopathy of the prematurity iseikal (?) cell disease, and there's a list of a number of causes of retinal haemorrhages. However the pattern is by and large a little different, but it's usually not as extensive as this.
Q. Are you able to comment on the pattern in Alexandra's retinal haemorrhaging and relate that to your view of - the cause of it?
A. Yes the pattern that I observed was - what I commonly see in what I term non accidental injury or inflicted injury if you like.
Q. And does the pattern include the position on the retina of where these haemorrhages were?
A. The position and the extent."
23 Then (T 395):
"Q. You've said that in your view the retinal haemorrhages are most likely due to the violent and repeated shaking, a pattern seen in non accidental injury, are you able to say what causes the retinal haemorrhaging from the shaking?
A. The current general view of the causation of the retinal haemorrhage is that it's - it's a shearing force, the shaking causes a repeated shearing force between the jelly that fills the eye and the retina, to which it is attached as a young child. So the light blue of the diagram which is the cavity if you like of the interior of the eye is filled with a jelly, and that is actually attached to the retina, and those shearing forces puts stress on the blood vessels on the surface of and within the retina which causes the bleeding. That is the current general view that the ophthalmological community if you like take.
Q. These forces set up from the shaking, would you agree that they are described as rotational forces?
A. Yes rotational forces."
24 Dr Kennedy was then asked these questions and gave these answers (T 396):
"Q. Are you able to comment on the duration of time that the shaking would have to last to cause the retinal haemorrhaging that you saw in Alexandra' case?
A. No I couldn't there's been no - obviously you can't do a control trial to see what forces you need to create haemorrhages, it's something you can't - experimentally you can't do, so we don't know the extent of the force needed. We do - there has been some sort of estimation of people falling out of buildings, being in fast accelerating vehicles or this sort of thing, bungy jumpers can get retinal haemorrhages occasionally, but it's thought to be considerable if it's a translational force. In other words if you just - if you're thrown from a motor vehicle or fall out of a building, it's not just a short bump that causes the - short fall that generally causes a haemorrhage, you've usually got to - it's got to be considerable if it's due to say a head injury.
Q. Would you consider a short fall to be a fall from a high chair?
A. Yes.
CROWN PROSECUTOR: Can Dr Kennedy be shown C16 please your Honour, just that it's a high chair, it's relevant to this case.
Q. Just as a hypothetical situation, say Alexandra fell from the seating part of that and she fell onto a concrete floor, would that cause the pattern?
A. No I don't believe so."
25 In cross examination, Dr Kennedy agreed that it would be possible for retinal haemorrhages of the type here seen to occur in a fall. He was asked these questions and gave these answers (T 400):
"Q. And for example it would be possible for retinal haemorrhages of the kind that you saw to be created if a person fell in a particular way and hit their head a piece of protruding concrete, that's one example I think where you would allow for retinal haemorrhages to possibly occur of the type you've described?
A. Yes in less than three per cent of cases, that's the papers that have - that sort of fall with severe head injury the series that have been done and there have been several shows that it's uncommon but they do occur.
Q. Now even though you suggested that you can't put a figure or precise description on the degree of force required, you definitely in your opinion to violent and repeated shaking don't you?
A. Well I think it has to be considerable the force to cause retinal haemorrhages.
Q. Do you disagree or agree that it can be caused by certain manner of turning with a child, for example?
A. Can you explain that a little bit more, elaborate a bit?
Q. Yes I think the description was turning with a child a particular way while the child's being held?
A. I wouldn't have thought so."
26 Dr Kennedy was asked these further questions and gave these further answers (T 402-403):
"Q. Doctor do you agree that if a head of a child was unsupported whilst the child was being held such that during the course of a fall in the arms of the carer, that is the carer falling, the head was allowed to move on its axis on the neck because it was unsupported, that would add a rotational component to the fall if the child's head then came to hit a hard surface on the ground?
A. I can't see how you can quantitate that clinically from my point of view, I can't really give a comment on that I'm afraid. I wouldn't have thought that in the normal course of events that sort of thing would give sufficient - we see retinal haemorrhages uncommonly and we examine lots of children and very rarely do we see retinal haemorrhages in children and I would have thought if something like that was the cause we'd be seeing a lot more than we do.
Q. If a child though was being held by someone so the child wasn't falling from its own weight, from its own legs but rather was being held by someone and so if the child was held around its body but its neck was then in movement or in motion in a backwards and forwards manner perhaps while the person went to the ground that could add a rotational element to the fall though, couldn't it?
A. It may add a rotational element to the fall but I can't see it be a great amount of rotational element. I mean flexing of the neck I don't think would be enough to shake the vitreous jelly which is what causes the haemorrhages, it's the shaking of the vitreous jelly. It would take quite a lot of force to shake the vitreous jelly.
Q. If the fall commenced though by virtue of the person who was carrying the child tripping, that is, not just falling over or falling to the ground but actually tripping on something, that would add some velocity or some force to the fall wouldn't it?
A. Yes.
Q. And perhaps to the suddenness with which the child's head might move on the neck during the course of the fall?
A. Yes.
Q. And in those circumstances I suggest to you if a child were to make contact with a hard floor --
A. Yes.
Q. -after going to the ground in those circumstances, that is they're moving forwards and downwards from the carer --
A. Yes, yes I understand what you mean.
Q. -but at the same time their head is moving because it's unsupported, that could result in retinal haemorrhages I suggest of the kind that you've observed here?
A. Well I mean you can get retinal haemorrhages from falls and undoubtedly but the incidents as I've pointed out is in accidental falls and injuries, motor vehicle accidents is low, it's generally reported to around three per cent."