What To Expect

Getting The
Medical Records

Where Do You Start?

A friend or family member takes their baby to the hospital and the next thing you know they have been arrested. If the baby died then the police file homicide charges. If the baby lives then assault charges are filed and the baby is taken away from his parents. It seems like there is nothing that can be done to derail this medical-legal freight train. The criminal attorney has no idea about how to defend the bleeding in the baby’s head or the fractures that have been found on the x-rays and he is talking plea bargain. The child protective services take the position that unless or until the other parent “acknowledges” the circumstances, they won’t get their child back. What can you do?

If you are trying to help a friend or family member in that situation you must understand that there are certain presumptions at work in the medical and legal community. Most of the medical community and all of the law enforcement and child protective community has bought into the shaken baby syndrome hypothesis that in the absence of any external signs of trauma, the very presence of a subdural hematoma (or hemorrhage) gives rise to a presumption that the cause of the subdural bleeding is abuse. Then (according to the hypothesis) the burden shifts to the parents to provide an “explanation” for the injury. If the parents (or caregivers) can provide no “explanation” then in their minds (and oftentimes in the mind of the court) the case for abuse has been proven. Any fractures discovered in the ribs or extremities only confirm the diagnosis of abuse. This entire scenario repeats itself multiple times each day in the United States.

The bottom line is that as long as the medical community, led by the child abuse “expert”, are the ones interpreting the medical records, it is a virtual certainty that the medical diagnosis and legal conclusion will be that the child was abused by his parent or caretaker. It is the medical records and the interpretation of those records that will convict the parent or caretaker. In order to defend your loved one you must get the medical records, and get all of the medical records, and then get a second opinion. Keep in mind that there is a lot of political pressure in the medical community to tow the shaken baby syndrome line and doctors are oftentimes reluctant to disagree with the child abuse “expert,” at least publically. Don’t be surprised if you find that most doctors simply rubber stamp the opinion of the child abuse “expert” without really considering all of the potential alternative explanations for subdural hematoma’s or fractures. So, where do you even start?

Start with the records and be persistent. Get the prenatal records – all of them. Find out how many prenatal visits were attended by mom and whether she took prenatal vitamins and had prenatal blood work performed. Get the birth records – all of them. Get the nurses notes and the actual charts with the handwritten notations. Find out when contractions started, when the water broke, were there any complications, medications administered or notes about the baby’s condition after birth. Was there any blood work done? Get the pediatrician’s records – all of them. Get the chart that shows the notes of any sick visits, the newborn visit, the one-month visit, two-month visit, etc. Was any blood work done? When and which vaccinations were administered. Were there any sick visits, emergency room visits or hospital admissions? Get the records! (If you are noticing a pattern, you should.) Get the records of any hospital admission – get all of them. Get the handwritten chart notes, any reports from the emergency room admission, reports of any treating or consulting physicians, get the social worker reports, get a list of every order written by a doctor, get all of the lab results, get the radiology reports and, this is absolutely critical, get the actual radiological studies (this means the actual film for x-rays or, as is more common now, the CDs containing the digital data of the x-rays, CTs and MRIs).

Be persistent and don’t accept anything less. Somewhere in all of these records is the answer to the question of what happened to this child. You will have no defense unless and until you find out what happened to this child (Forget the notion that a person is innocent until proven guilty, when it comes to allegations of child abuse it is guilty until proven innocent.) Then you need a thoughtful attorney who is experienced in these types of cases and can assemble a medical team that can review these records and get to the bottom of what happened to this child or all of your efforts will be in vain.