Sunday, June 17, 2007


Honoring my profile, I'm lazy enough so I hardly publish one entry a month in this blog.
The following text is rather long for blogs but the intention is not just to publish it but to make sure stays online. Its is about a rather sorry affair I am not sure will end well. It is written in English because I follow the Miranda advise that anything I say may and will be used against me. So be it. But at least they will have to take the trouble of translating it into Spanish.

Keep on reading:

Child abuse mismanagement in a modern society

Modern societies are supposed to control and rationalize the miseries of everyday life. Child abuse is one of those miseries with a sad tendency to mismanagement. Over the years, the society has produced a vast array of laws, policies, regulations and norms, as well as it has created a number of agencies whose aim is to provide, foster and regulate child protection.

The different agents and administrations involved, however, often collide in their efforts and a child may end up a victim of “institutional abuse”: the wrong results of the combined actions taken by those responsible of caring for the wellbeing of a child.

Social services, child protection agencies, juvenile courts, medical pediatric services, foster homes, concerned parents, NGO’s saving children, foundations, school boards, charities groups, law enforcement agencies, police, district attorneys and many more, seem to include in their charters a special concern for the children and their mishaps. But all too often the firemen trample over each other water hoses and the end result is a one more disgrace overcoming an innocent child.

Such has been experienced recently in our country when a child, placed for adoption because inability of his biological mother to care for him, after three years was returned to this mother by a court order, just to become again a victim of abandonment and abuse by his mentally deranged mother. The legal battle that ensued occupied vast spaces in the news and the “bleeding hearts” television talk --or rather, bark-- shows for weeks. It was called “el niño del Rollo” case, for the name of the little hamlet of El Rollo, in central Spain, where it started.

About a year ago, in Catalonia, a 6 year old girl was diagnosed by the doctors at a large university children’s hospital of being the victim of child abuse. The report to Social services and the judges got sidetracked. The child, who was discharged from the hospital to her parents, was readmitted some weeks later, this time with severe head injuries that left her brain damaged and wheelchair ridden for life. When the situation hit the news it generated a tremendous turmoil in the media, and prompted an interagency revision of child abuse protocols. It was called “el caso Alba”, after the name of the poor child.

This past week another scandalous case loomed over, closer to me. On late April a 5 and a half month old baby was admitted by our Trauma unit with a spiral fracture of her mid femur. She had been sent by her family pediatrician with the suspicion of child abuse. No good explanation for the injury was provided by the family. The doctor sent a regular routine court notice of an injury. The X-Ray survey showed a periostal thickening in the tibia compatible with a previous fracture or injury. With that we reported the case to the judge, in Spain “juzgado de guardia”, judge-in-court on duty. Our report stated clearly that it was a case of child abuse and asked for a forensic evaluation. We also made sure the court had received the family physician initial report. The forensic doctor came over to see the child and we gave him a detailed summary of the medical proceedings that have been carried out (head ultrasound, skeletal X-ray and blood work), with the working diagnosis of child abuse, 995.5 in the International Code of Diseases (WHO-9th ed., the one current in our midst).

It took (!) two days to contact Social Services, in Catalonia the “Direcció General d’Atenció a l’Infant i Adolescent (DGAIA)”, the General Directorate for Care of Childhood and Adolescence. To overcome delays, I sent a personal e-mail to the local DGAIA delegate, with whom I maintain occasional correspondence and a reasonable close contact: we meet once a month for a Child Protection Coordination Conference. She acknowledge the receipt of the report and informed she was starting actions.

The “juzgado de guardia”, the judge on duty shifted the case to another court, the nº 3 “Juzgado de instruccion”. The Spanish court system calls for an “instructor judge” to initiate court actions instead of the equivalent to district attorneys, the “fiscales”, who have no investigation responsibilities. Knowing this, we sent all the information by telefax to both courts and made a telephone call to confirm the reception. We also warned them that the child will be up for discharge from the hospital in a weeks’ time, as soon as the Orthopedic service was able to fix the fracture after few days of extension treatment with weights.

During these days supposedly Social Services contacted the court, the court interviewed the parents and, when we called the day before discharge to the court for instructions regarding the child’s custody, we were told to “do what we have to do”, so the child was sent home with her parents to be followed by the Orthopedic Out-patient clinic and the family physician.

I was going to regret that decision.

On June 10th, the little girl, now almost 7 mo. old, was brought to the ER by paramedics because she had been taken by her father to an emergency clinic in her home town with what appeared to be a grand mal tonic-clonic generalized seizure. She had been administered one dose of diazepam and was in a post convulsive unresponsive state. She also had a bruise on her right malar (cheek bone) area. No explanation for this was given. A CT scan showed a midline subdural fresh hemorrhage, and a subdural effusion of liquid (not blood) content, compatible with a head injury or “shaken-baby” lesions.

Because of the hemorrhage we set the child for transportation to a hospital with Pediatric Neurosurgery facilities in Barcelona in case it might need drainage, which eventually did. And again we started the proceedings to notify the courts and the Social Services, sending over by fax the complete summary.

Later in the day, two officers of the Guardia Civil showed up in our floor asking about the child and the father. “La Guardia Civil” of some infamous fame during the Franco dictatorship in the 20th century, now-a-days acts pretty much like the State troopers in the US: highway patrols and inter-county law enforcement. They stated that the mother, who apparently was absent from the home when the child had the seizure, did not know what had happened and had reported the disappearance of her husband and baby the since the night before. Further, in taking the baby to the emergency, the father had abandoned another 4 y/o little girl on her own in the home, that the mother found as she came home from work.

All this seems hard to believe now-a-days when just about everybody carries a cellular phone. During the (short) hospital stay in our service, the nursing personnel had been unsuccessfully trying to contact the mother. The father could not provide information of her whereabouts, nor was possible to contact her workplace, closed at those hours.

As the abandonment of the other sibling and the strange family relationships constituted more than suspicious of another case of child mistreatment, I sent the Guardia Civil officers to the court and called myself to report the incidence.

As I was talking to the court clerk, I mentioned that in this sorry affair we all will not be looking very good. At that moment, the judge in charge (a woman judge) picked up the phone and gave me an overly exaggerated rundown on keeping from criticizing court decisions or I would be charged in contempt (!!). I mumbled an excuse and ended the conversation, surprised of the overreaction which soon enough will regain its meaning.

That evening, with the child being transferred to another hospital, the intervention of the Guardia Civil and the rest, the incidence hit the news agencies. The next morning it was all over the front pages and radio news bulletins, and… the bonfire of vanities came to reality.

It was quite obvious that neither the court nor the Social Services had been diligent enough to make decisions to avoid a second incidence of severe case of child abuse.

It has been some time since I knew the difference between an event and the news related. The event was a perpetuation of child abuse while the victim was supposed to be under official watch. The news was the lack of coordination between agencies and the judicial system. Reminding the “Alba case” it hit the front pages with a vengeance.

I spent more than eight hours, under instructions of the hospital administration along with our PR unit, answering radio stations calls, giving interviews to newspaper journalist and being filmed by 6 or 7 different television stations and networks, telling what had happened.

The social services, the DGAIA refused to answer in the press directly but issued an statement claiming that when, one month before, they have asked the court for a ruling o, at least, information about the case and the family court statements, this had been denied by the judge in the ground that they had not appeared in the initial arraignment. Therefore they carried no further actions. Nothing, nada.

The police, acting under court orders had detained the father in Barcelona, while he was in a waiting room by the ICU at Sant Joan de Deu Hospital, the best children’s hospital in our area, were the child had been sent. The father appeared in court but the judge again released him without charges.

The next morning the media pressure was overwhelming and the different agencies administration officials became hysterical. The hospital Administration was relatively quiet because they though we have done all we could and, particularly, because I was taking all the burden of public appearances in a situation that nobody would look very pretty. But soon enough I was going to suffer the consequences of bureaucratic frantic attitudes.

I had been invited by a major television network to next morning’s talk show, a quite influential show anchored by Josep Cuni, a popular television newsman. I had appeared in that show a few times in the past, usually in matters related to child care, emergency medicine and the overcrowding of ERs in our country, bioethics and, also, child abuse. So it was just natural they invited me this time. They were going to send me a courtesy car to go to the TV station, just to minimize the inconveniences and shorten my time compromised.

That was not going to happen. The shit had really hit the fan and different government agencies were scurrying around and setting up CYA (“cover your ass”) actions and barriers and enlisting all the spin doctors they could get hold of.

The government officials got wind of the possibility of that TV appearance of mine and I was urgently summoned at the, for Spanish schedule standards, ungodly hour of 7.30 a.m. by the Regional representative of our Health Department, with the specific purpose of cajoling me into not appearing at the TV show. They even claimed they were under instructions of the Chief of Staff of the presidency of the Catalan Government, apparently worried sick for another case of governmental agencies malfunction. That really pissed me off. It was not just the obvious lack of confidence on me and on what I would say, but just the sheer censorship in a matter that, by then, was of public record. Along came the idea that our (current) government was not very happy with the TV anchorman, Josep Cuni, and his frequent criticism of the Administration. But to me were just bureaucratic hysterics and a clear form of information control I had thought had gone away with Franco thirty years ago. Bad deal.

Miserably altogether a fool’s errand: I called the TV station to decline my appearance. The station had enough footage from my interview the day before, so they just edited it in between interventions of the rest of the program guests. That way I ended up having a larger show time than what I could have been allotted had I been present. Not that I could care less. By then I was pretty fed up with the whole affair and very unhappy with the censorship.

The next morning the Sant Joan de Deu Hospital issued a statement on the child status and mentioned that, along with the injuries previously described, a more careful review of the images showed evidence of a parietal skull fracture. On those grounds the judge. Who obviously had been chastised by the press and, undoubtedly, her peers, ordered the immediate arrest of the father again.

I was then called to testify in court. The judge, after informing me of my rights in a rather, and probably hardly legal, perfunctory way, announced that she only wanted to take my statements in regard the second admission of the child. Then she went on asking about the skull fracture and “how in earth had we had missed that(!)”, which to her was of paramount importance as she had had to put a man in jail because of it. Knowing the judge demure from this and the previous contact, I contained myself as much as I could. I tried to illustrate Her Honor of the clinical significance of two serious intracranial lesions such as the subdural hematoma and the subdural effusions, versus a hardly clinically significant linear skull fracture which, in its own merits had not been accompanied by intracranial lesions, would have not required other treatment than watching. The same that the more than 60 cases of accidental asymptomatic linear fractures in small infants we may see in a year in our ER. But she was all excited by the skull fracture, I gathered because that had been diagnosed in a major hospital and all that. I cut myself short of asking if the tremendous femoral fracture of the first admission had any meaning to her.

All the agencies involved in the case: the Social services (DGAIA), the Overhead Committee of the Supreme Court that watches over judges, and the Department of Health (in behalf of the hospital) issued statements saying that, with the information available, all services had followed the protocols and that they did not contemplate any mishandling of the situation (sic!).

Probably out of surprise and concern, the Catalonia Ombudsman, Mr. Rafael Ribó, a former leader of the Catalan Communist Party, now retired from politics and a sensible man --not all communist had horns and devil’s tails—called for an interdepartmental conference on the case held this past Friday, but from what I heard in the news, the Ombudsman office will take a distant stance until specific responsibilities are cleared at the departmental levels.

It has been some time since I read Tom Wolfe’s “The Bonfire of Vanities” but the scenario came to me very vividly. I do remember, however, quite distinctly the scene in the movie of the same title where Morgan Freeman, acting as the presiding judge in one the final sequences, made a strong call for DECENCY to all present. That again is what I found missing in this sorry affair.

The child remains in the SJDD hospital pediatric ICU. They inserted a drainage in his head and are waiting for recovering.

The little sister, who was also a victim of abandonment, to my knowledge is in care of her mother who does not seem a very reliable person, something meriting revision.

Meantime the press is watchful of further developments and promising more exposés in the near future.

As for myself, I will stick to my guns and probably review the chapter on child abuse of the new edition of my book on Psychosocial Pediatrics. Probably I will recommend the readers that, in case of child abuse, if they want things done, report to not only social services and the courts, but to the press as well and all at once. It is possible that under the public eye the bureaucrats may be more diligent.


delantal said...

Creo que he entendido la sustancia, escalofríante.
Es una lástima que tengamos que depender de la prensa para que se vele por los derechos de los niños, es mezquino que sólo por "salvar la cara" se interesen por ellos.

Camille said...

Pues será que soy curiosa, pero aquí estoy haciendo caso de tu llamada.

Un caso terrible, lo más triste de todo es que en una semana hubo tres.El que te tocó de cerca a ti el más light de todos. Terrible.
Te vi en las noticias. Supuse que eras hermano de Manuel por el apellido, pero si no sacas el tema jamás lo hubiera confesado...

Siento no saber responder en inglés, hubiera tardado dos semanas ;)


Francel said...

La sustancia es simple y es vieja como el mundo. Los que mandan se tapan unos a otros para defender su chiringuito y por miedo. Se aislan así más y más del mundo, crean su mundo, lo enclaustran, construyen un discurso que les legitime y tanto les da que la gente muera, enferme o la apaleen al nacer. Tanto y tantyo sobre mujeres maltratadas, pero como los bebes van a poder movilizarse para defenderse de sus mayores. Dónde está ahora el movimiento feminista, los movimientos de derechos humanos o el orgullo gay. No he oído ni leído que nadie se haya pronunciado.