Clinical History:

In the early afternoon an emergency call is received requesting assistance for an unresponsive 13 month old child, and paramedics are dispatched. The child was in good health and had been behaving and reacting normally when last seen by her parents at approximately 9 am. During the day, she was in the sole custody of a 17-year-old in-home caretaker, who had been living with the child's family for the past 10 months.

The child was apneic and unresponsive when the paramedics first arrived but was resuscitated and taken to a local hospital. At the hospital, a head CT scan reveals a subdural hematoma with cerebral edema. Funduscopic examination reveals bilateral retinal hemorrhages. A body radiograph reveals a fracture of the upper right humerus. The child died two days after admission.

Upon questioning, the caretaker reported that she was changing the child's diaper on a table when the child suddenly arched her back and fell off the table, landing on her head. Investigation of the scene reveals that the surface of the table is 74 centimeters above the floor. The floor is concrete but covered with carpeting and an underlying carpet pad.

Image 9.1:

The external appearance of the child is seen here. Note the absence of signs of major trauma.

Image 9.2:

The scalp is reflected to reveal the surface of the skull at autopsy. There is recent hemorrhage with contusion of the scalp.

Image 9.3:

The skull has been opened to demonstrate the subdural spaces and surface of the brain. Recent hematoma formation has occurred. The brain is swollen.

Image 9.4:

The portion of skull with the fracture is seen here. The suture lines are normal, with a faint linear fracture extending from the point that the sutures meet.

Image 9.5:

Note the soft tissue hemorrhage in the upper arm. This is recent hemorrhage adjacent to the site of fracture.

Image 9.6:

The retinal hemorrhages are demonstrated here. The globe has been sectioned to reveal a series of small hemorrhages on the inner surface of the eye.

Questions:

1. How do you explain these injuries?

This pattern of injuries is consistent with the "shaken baby syndrome" which is results from violent shaking and impact by a perpetrator, often a young single person left in charge of the infant or child.

2. What is the manner (mode) of death?

This is a homicide. The death was certified as "Craniocerebral injuries" due to "Shaken-impact syndrome."

3. What issues need to be addressed in this case?

There is a perpetrator of such a crime who must be charged and brought to trial.