Fatal Child Abuse:

A Case Study & Perspectives

Dr Steve R Naidoo

Forensic Pathologist

Independent Practice, DurbanSAPSAC 14TH ANNUAL NATIONAL CHILD ABUSE CONFERENCE 20 JUNE 2013

Case Study

The doctors at Durban’s Gale Street mortuary arrive on the Monday morning and review the case files of the autopsies to be done for the day

20-odd cases received over weekend; one is the body of a young child 3 years old (Day 3 after death)

The SAPS 180 document simply says “Found dead

at home” and no additional history provided

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Case Study

• A part-time doctor about to start autopsies, including this one ...

• Case halted by senior pathologist who had decided that the history was insufficient and on a instinct decided to stop by the autopsy room

• A preview external examination without dissection is done – this is what it showed:...

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IN SUMMARY

1. Evidence of medical attention

2. Oval recent abrasion with granulating edges over

central forehead; facial contusions

3. Swollen, deformed L arm & elbow, with

discoloured blue-green bruise on outside of arm;

4. Broad and discoloured healing abrasion with

exfoliation of skin across buttocks;

5. Inverted U-shaped discoloured blue-purple bruise

& linear blue/black tramline abraded bruise

across L upper quadrant of abdomen

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The investigating officer is called & arrives on the Wed mid-morning (Day 5 after death)

Report: does not know much, since his call-out to hospital where the child was declared dead.

No, he did not look at body, but took statement from woman who knew child from settlement

No, he did not interview anyone else, & was waiting for autopsy advise on what had caused death before investigating further...

No, he did not suspect any non-accidental injury...thought it might have been natural causes...

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Child was reported to be very ill one Saturday morning after he failed to appear for several days. He was taken to hospital.

His mother had died a year before and he had been living with his grandmother in an informal (shack) settlement in Durban but was left to be with an uncle for about a month whilst she was away at her rural village in northern KwaZulu-Natal.

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Case Study

Autopsy examination, having confirmed initial preview external findings, also reveals intra-abdominal haemorrhage from a delayed splenic rupture and mesenteric contusion, and long bone fractures.

The immediate medical cause of death was concluded to be:

“Intra-abdominal haemorrhage from a ruptured spleen secondary to blunt

abdominal injury”7

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The spectrum of our autopsy findings in fatal abuse

Autopsy detection and Diagnosis

High index of suspicion (history)

Typical physical features & patterns of injury

Meticulous autopsy

Results of medical special investigations

Exclusion of natural diseases

Consultation and referral

Case conference discussion***

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Post-mortem examination

• Meticulous external examination

• X-rays (skeletal survey) & special views as

necessary

• Documentation & Photography

• Autopsy technique

• Identify sexual abuse

• Laboratory investigations

• Crime scene examination (if necessary)

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International Autopsy Protocols

• American Academy of Paediatrics (2007):

Report – Evaluation of Suspected Child

Physical Abuse

Every US state has a protocol for

medical investigation of suspected child

abuse

• Canada: post-Goudge Inquiry (2008): –

investigated the errors made by pathologists

in over 200 cases of child deaths

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• UK: Sudden unexpected death

• in infancy: A multi-agency protocol for care

and investigation (“Kennedy Protocol”)

(2004) – arose out of the acquittal of Sally

Clark, Angela Cannings and Trupi Patel

• Since 2010 the Working Together to

Safeguard Children program, every county

has had to comply by creating a Child

Death Overview Panel to review the death

of every child under 18 years...

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South Africa?

What guiding documents are there for the

forensic pathology services?

1. National Health Act

2. Regulations – re Rendering of Forensic

Pathology Services

3. National Code of Guidelines for Forensic

Pathology Practice

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March 2013: Johannesburg: Setting Minimum

Standards for Forensic Medicine in Africa