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SPECIAL ARTICLE |
a Chadwick Center for Children and Families, Children’s Hospital-San Diego, San Diego, California
b Department of Pathology, University of California School of Medicine, San Diego, California
c Department of Social Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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ABSTRACT |
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 TOP ABSTRACT THE CONTRIBUTIONS OF MEADOW...METHODSFINDINGSPRESENT EFFECTSCOMMENTSREFERENCES |
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Key Words: abuse • sudden unexpected death • SIDS • testimony • licensure
Abbreviations: GMC—General Medical Council • SIDS—sudden infant death syndrome
Within a little more than 1 year (2004–2005) the governmental licensing agency for medical practitioners in the United Kingdom, the General Medical Council (GMC), found 4 doctors guilty of serious professional misconduct because of their actual or offered testimony about child abuse cases; 3 involved the same case. The case, in its criminal form, is known as Regina v Clark, and it also led to a civil protection case involving a child born after the 2 previous siblings had died suddenly and unexpectedly, each at 
3 months of age. The 2 doctors who were disciplined, Professors Sir Roy Meadow and David Southall, are pediatricians recognized internationally for pioneer work in defining and describing child abuse by suffocation. A third doctor is a pathologist who performed autopsies in both of the fatality cases. Another practitioner had been involved in other cases. This article reviews the cases of the 2 pediatricians who have studied suffocation.
In February 2006, a court of appeals1 overturned the GMC verdict in Meadow's case. However, Southall is still excluded from work in child protection, and the spreading and international effect of the GMC actions persists. The first and most important concept cited by the appeals court judge was a theory of witness immunity, a technical legal theory. The judge also opined that the GMC had not made its case, but it did not pursue the underlying issues of sudden infant death syndrome (SIDS) and child abuse that were at the heart of the original case.
In this licensure process, the 2 doctors and their research work came under attack, and the issue of the definition of SIDS was subjected to intense and flawed analysis. However, the most important effect of the actions of the GMC may be a general chilling of activity and a pall of silence cast over doctors in the United Kingdom and elsewhere who use their skills to identify and protect abused children. Child abuse medical research may also be inhibited by the public information campaign that accompanied the GMC actions.
In an effort to "protect the public," the GMC attempted to assess the quality of the doctors' expert testimony. Their efforts seem to have failed because of difficulties in understanding the technical issues involved and the absence of clear standards and guidelines for this peculiar class of medical practice. In this article we address the medical issues raised by the GMC, the fairness of the GMC processes, and the issue of the regulation of expert testimony by licensing agencies.
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THE CONTRIBUTIONS OF MEADOW AND SOUTHALL |
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TOPABSTRACTTHE CONTRIBUTIONS OF MEADOW...METHODSFINDINGSPRESENT EFFECTSCOMMENTSREFERENCES |
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Southall first showed that apneic episodes in premature infants did not predict later SIDS,11 demonstrated then by video-monitoring acts of suffocation by parents inflicted on their hospitalized infants.12–17 These infants were all still alive when they encountered health care, a fact that made them somewhat easier to recognize than those in whom the first suffocation was fatal. However, the very dangerous acts committed and recorded in the hospital established their reality in the face of incredulity.
Taken together, the work of these 2 British pediatricians (confirmed in the United States and elsewhere7,8,18–23) has established the fact that parents sometimes suffocate their young infants and may cause their deaths by this form of abuse. The exact incidence of the phenomenon has never been known; however, it seems probable that the cases in which suffocated infants present as sudden infant death without findings of trauma at postmortem examination would be much harder to identify (without confessions by their caretakers). Therefore, an unknown proportion of infanticides are still unrecognized, uncounted, and lumped in with SIDS.
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METHODS |
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FINDINGS |
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TOPABSTRACTTHE CONTRIBUTIONS OF MEADOW...METHODSFINDINGSPRESENT EFFECTSCOMMENTSREFERENCES |
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The Medical Issues
The medical issue in the Meadow case concerned a statistical estimate of the risk of recurrent SIDS presented to the criminal court as part of his testimony. The issues in the Southall case were both the significance of the nosebleed incident and the manner in which Southall inserted himself into the case.
We have considered both issues in great detail. It is our opinion that, although both physicians may have been led to overstate their positions, the testimony that Meadow gave and that Southall offered was within the range of responsible medical testimony based on the available medical literature. In Meadow's case, the prosecutor who called him to testify asked certain questions but not others. Southall seems to have been led by another (possibly conflicted) expert witness who had been asked to evaluate his evidence before it went to the judge in the case and who met with Southall to evaluate his opinion.
The statistic used by Meadow was that the risk of SIDS death in a family such as the Clark family would be 1 in 8543 births, and that the risk of 2 SIDS deaths in the same family would be the square of this number, or 1 in 73 million. This latter estimate came directly from a government report that was in the process of publication at the time of his testimony and was published soon after with the exact same figure that he quoted.28 The government report included a caution that this squared estimate might not account for risk factors that might be the same for the 2 children in the same family. This issue of the lack of statistical independence not being addressed in his testimony was the crux of the GMC charges against Meadow. A number of estimates made by other authors exist, and some were cited during the GMC testimony.29–33
An important caveat that was ignored in the GMC hearings is that SIDS, as currently understood, includes an unknown proportion of infanticides by "soft suffocation."34 This fact confounds the definition of "innocent SIDS" and any comparisons between SIDS and infanticide incidence. Only Meadow testified about that fact, and his testimony seems to have been ignored despite the fact that 2 prosecution experts were SIDS experts and one of them had written about this fact. Finally, it is essential to recognize that the definition and incidence of SIDS has changed over time35–37 and will certainly continue to do so.
Meadow testified that in low-risk families (as defined), successive births leading to SIDS might occur about once a century in the United Kingdom. We calculate this event as likely to occur about once a decade or so among educated and employed mature parents if the relative risk for a sibling SIDS death is between 5 and 10, the upper range of relative risk among estimates for siblings published in the medical literature. In charging Meadow, the GMC estimated that a second SIDS death is likely to occur at a rate of 1 in 200 families, an estimate that requires a relative risk estimate of at least 40 or >4 times higher than the highest published risk estimates for siblings.29–33 Neither Meadow nor the GMC got the statistics quite right, although Meadow quoted an official report; the source of the GMC estimate was not provided. Testifying about statistics can be complicated, but it seems that Meadow's testimony was held to the standard of a professional statistician by the GMC. The incidence of SIDS is unstable and probably falling.
It is worth noting that in Regina v Clark, no expert testified that either infant had died as a result of SIDS.
The significance of the nosebleed incident was backed by published work by Southall and others.5,6,20,21,38–45 Although evidence and argument can be advanced that the physicians' positions may not have been as definite as they may have put them in the context of their formal statements, that evidence and those arguments were easily available to all parties at "all material times." The evaluation of conflicting expert testimony of this sort is the daily bread of juries and judges.
The Conduct of the Hearings
The conduct of the hearings at the GMC seems to have been unfair. Both physicians were represented by counsel employed by a malpractice insurance carrier that had no financial interest in the case. One of their solicitors had recently served as a defense counsel in a case involving alleged suffocation. The GMC's prosecuting barristers (litigators) represented both the GMC and the complainants! The prosecutors called a large number of expert witnesses to guide the thinking of the GMC panels. Cross-examination of these experts by the defense counsels failed to bring out important facts. The defense counsels called no witnesses except the defendants, who pled their own cases and then were subjected to prolonged and unrestrained cross-examination by the prosecutors.
Expert Testimony and Medical Licensing
In conducting these cases, the GMC set itself up to regulate the expert testimony of doctors. This is a novel excursion. In the Meadow case, the GMC held Meadow to standards testified to and established by professional statisticians, not by doctors, as the standard for his expert testimony.
Two of us have attempted to define "irresponsible expert testimony" in child abuse cases.46 That article contains a recommendation for peer review of expert testimony but stops short of recommending review by state medical boards in the United States. Although expert testimony may be considered a part of the practice of medicine, competent review and regulation is a task that requires great expertise and a great deal of time. The state licensing boards in the United States may lack these capacities.
Whether the GMC has the competence to accomplish this task is also open to question. In both countries there is a paucity of both statutory and case-law signposts, and considerable disagreement exists about the idea of expert witnesses who can or should explain both sides of a case.46
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PRESENT EFFECTS |
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COMMENTS |
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Child protection by physicians in the United Kingdom is reported to have been crippled by the actions of the GMC. Time will tell if the apparent chilling effect of the actions of the GMC will adversely affect child health in the United Kingdom.
The GMC failed to conduct balanced hearings in the cases involving Meadow and Southall. It also went beyond its competence in attempting to regulate medical expert testimony in child abuse cases, and its own documents reflected difficulty comprehending the self-same statistical issues that it claimed one of the charged physicians had misrepresented.
The counsel that represented the physicians in these 2 cases seems to have failed them by not pursuing testimony by outside experts or clarifying its own role in an earlier trial in which it defended a family against charges of multiple deaths by inventing a defense theory of serial sudden infant death. One of the pediatricians whom the firm was defending had been a prosecution witness in the earlier case.
The rest of the English-speaking countries can learn from these mistakes. Although peer review of expert testimony is needed, regulation by licensing bodies is premature until they can demonstrate both competence and fairness.
The epidemiology of child abuse is clear.41 We believe that continued application of medical expertise is required, and we hope that physicians will not be discouraged from developing expertise in this area by the incautious incursion of an unprepared licensing authority. Ongoing medical research about child abuse is also essential and should not be discouraged by attacks on researchers. We must encourage the younger generation of child abuse doctors to do their work in both practice and research.
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FOOTNOTES |
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Address correspondence to David Chadwick, MD, Chadwick Center for Children and Families, Children’s Hospital-San Diego, 4816 Rushville Lane, San Diego, CA 91941. E-mail: dlchadwick1{at}earthlink.net
The authors have indicated they have no financial relationships relevant to this article to disclose.
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REFERENCES |
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TOPABSTRACTTHE CONTRIBUTIONS OF MEADOW...METHODSFINDINGSPRESENT EFFECTSCOMMENTSREFERENCES |
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This article has been cited by other articles:
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  H. Payne The jigsaw of child protection J R Soc Med, February 1, 2008; 101(2): 93 - 94. [Full Text] [PDF]
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 C. Jenny The Intimidation of British Pediatricians Pediatrics, April 1, 2007; 119(4): 797 - 799. [Abstract] [Full Text] [PDF]
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C. Williams United Kingdom General Medical Council Fails Child Protection Pediatrics, April 1, 2007; 119(4): 800 - 802. [Abstract] [Full Text] [PDF]
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