[2026] SADC 67

Prosecution: R Counsel: DR P SALU - Solicitor: DIRECTOR OF PUBLIC PROSECUTIONS (SA) Accused: SR Counsel: MR M ANDERS - Solicitor: EVANS TESTA BARRISTERS & SOLICITORS Hearing Date/s: 07/05/2024 to 14/05/2024, 03/02/2025 to 20/02/2025, 26/02/2025 to 27/02/2025, 17/03/2025 to 18/03/2025, 20/03/2025 to 26/03/2025, 02/04/2025, 07/04/2025, 09/04/2025 to 10/04/2025, 24/06/2025 File No/s: DCCRM-20-1942 B DISTRICT COURT OF SOUTH AUSTRALIA (Criminal) DISCLAIMER - Every effort has been made to comply with suppression orders or statutory provisions prohibiting publication that may apply to this judgment. The onus remains on any person using material in the judgment to ensure that the intended use of that material does not breach any such order or provision. Further enquiries may be directed to the Registry of the Court in which it was generated. R v SR (No 2) Criminal Trial by Judge Alone [2026] SADC 67 Reasons for the Verdict of Her Honour Auxiliary Judge Tracey 12 June 2026 CRIMINAL LAW - PARTICULAR OFFENCES - OFFENCES AGAINST THE PERSON The accused is charged with recklessly causing serious harm to his 6-week-old son. The case against the accused is circumstantial in nature. It was alleged that the child sustained head injuries causing a cardiorespiratory arrest while he was in the sole care of the accused. The defence case was that the child was not injured and that there were underlying medical conditions that explained his symptoms and presentation. The accused gave evidence denying that he inflicted any injury. If the child did sustain head injuries, the defence argued that actions by the family dogs, the child’s 2-year-old sister, the child’s mother, or the resuscitative measures undertaken by the paramedics who attended, could not be excluded as reasonable possibilities responsible for the injuries. Verdict: Guilty Criminal Law Consolidation Act 1935 (SA) s 23(3); Joint Criminal Rules 2022 (SA) r 39.1; Surveillance Devices Act 2016 (SA); Evidence Act 1977 (Qld) s 130, referred to. Murphy (A Pseudonym) v The King [2023] SASCA 107; R v Bonython (1984) 38 SASR 45; Makita (Aust) Pty Ltd v Sprowles ; Lang v The Queen (2023) 278 CLR 323; R v Baxter [2019] QCA 87; R v Baxter [2021] QSC 70; R v Baden-Clay (2016) 258 CLR 308; R v [SR] [2024] SADC 157; HT v The Queen [2019] HCA 40; The Queen v Stuart Lee [2001] ATSC 133; Douglass v The Queen [2012] HCA 34, considered. -- 1 of 345 -- -- 2 of 345 -- R v SR (No 2) [2026] SADC 67 Introduction.......................................................................................................... 9 Overview ............................................................................................................... 9 Prosecution witnesses ........................................................................................ 10 Defence witnesses ............................................................................................... 11 Procedural history ............................................................................................. 12 Defence applications ....................................................................................... 12 21 November 2024 ........................................................................................ 12 3 February 2025 ........................................................................................... 12 20 February 2025 ......................................................................................... 13 25 February 2025 ......................................................................................... 13 24 June 2025 ................................................................................................. 13 Elements of the offence ...................................................................................... 13 General directions .............................................................................................. 14 Agreed facts ........................................................................................................ 15 Listing devices.................................................................................................. 16 Apple iPhone read receipts .............................................................................. 16 Expert evidence .................................................................................................. 16 Application to exclude evidence of Dr Edwards’ on 2 February 2025 ......... 19 BE ..................................................................................................................... 19 AE ..................................................................................................................... 21 The accused ..................................................................................................... 24 DBS Sherratt.................................................................................................... 27 Defence submissions ....................................................................................... 36 Prosecution submissions ................................................................................. 40 Discussion ........................................................................................................ 41 The prosecution case.......................................................................................... 43 TR’s antenatal history and JR’s birth ............................................................ 43 Dr Murphy’s evidence................................................................................... 43 Dr Hargreaves’ evidence .............................................................................. 43 JR’s neonatal progress .................................................................................... 44 Dr Murphy’s evidence................................................................................... 44 Ms Ames’ evidence ........................................................................................ 45 Sofa incident .................................................................................................... 46 -- 3 of 345 -- [2026] SADC 67 2 Dr Gillis’ evidence ........................................................................................ 46 Dr Murphy’s evidence................................................................................... 47 Events on 5 January 2020 ............................................................................... 48 Ms Esplin’s evidence..................................................................................... 48 Accused’s statements to police and 000 call ................................................... 48 000 call made by the accused. ...................................................................... 48 Interview with accused on 5 January 2020................................................... 48 Interview with accused on 23 January 2020................................................. 50 Interview conducted on 24 February 2020 ................................................... 51 Evidence of the paramedics in attendance on 5 January 2020 ..................... 51 Ms Iellamo .................................................................................................... 51 Ms Preece...................................................................................................... 52 Ms Walls........................................................................................................ 53 Mr Kretschmer .............................................................................................. 54 Assoc. Prof. Linke’s evidence ......................................................................... 55 Qualifications and experience ...................................................................... 55 Involvement in JR’s case ............................................................................... 55 Radiological imaging reports of JR undertaken at the WCH ....................... 56 Could the rib fractures have occurred during CPR? .................................... 58 Rickets ........................................................................................................... 61 Osteogenesis imperfecta ............................................................................... 63 Wormian bones ............................................................................................. 63 Cephalohaematoma ...................................................................................... 65 Skull fractures ............................................................................................... 65 Tibial fracture ............................................................................................... 67 Skeletal survey 10 January 2020 at 10.42 am .............................................. 68 Original report ......................................................................................... 68 Addended Report ..................................................................................... 69 Craniotabes ................................................................................................... 70 Mechanism of skull injury ............................................................................. 70 Assoc. Prof. Linke’s response to the opinions of Dr Gootnick. .................... 70 Craniotabes .............................................................................................. 71 Skull Fracture........................................................................................... 72 Looser zone fractures/pseudo fractures ................................................... 74 Growth arrest lines ................................................................................... 75 -- 4 of 345 -- [2026] SADC 67 3 Assoc. Prof. Linke’s response to the opinion of Dr Auer.............................. 78 Pneumonia ............................................................................................... 78 Wormian bones ........................................................................................ 78 Craniotabes/rickets .................................................................................. 79 Rib fractures............................................................................................. 79 Assoc. Prof. Linke’s cross-examination ......................................................... 79 Rib fractures.................................................................................................. 79 Cephalohaematoma ...................................................................................... 81 Growth arrest lines ....................................................................................... 82 Skull fractures ............................................................................................... 82 Tibial fracture ............................................................................................... 82 Biomechanics ................................................................................................ 83 Pneumonia .................................................................................................... 83 Rickets ........................................................................................................... 85 Sofa incident.................................................................................................. 85 Re-bleed ........................................................................................................ 86 Use of images in Exhibit P26 ........................................................................ 86 Assoc. Prof. Linke’s re-examination .............................................................. 86 Summary of Assoc. Prof. Linke’s opinions .................................................... 87 Assoc. Prof. Taranath’s evidence ................................................................... 89 Qualifications and experience ...................................................................... 89 Bridging veins ............................................................................................... 91 Skull fractures ............................................................................................... 92 Hypoxic ischaemic injury or axonal sheer injury ......................................... 92 Assoc. Prof. Taranath’s responses to defence expert opinion ...................... 94 Assoc. Prof. Taranath’s cross-examination ................................................... 97 Summary of Assoc. Prof. Taranath’s opinion ................................................ 98 Dr Edwards’ evidence...................................................................................... 99 Qualifications and experience ...................................................................... 99 Dr Edwards’ role ........................................................................................ 100 Dr Edwards’ involvement in JR’s case ....................................................... 101 Vitamin D/rickets ........................................................................................ 104 Tibial fracture ............................................................................................. 105 Rib fractures................................................................................................ 106 Rib fractures and CPR ................................................................................ 106 -- 5 of 345 -- [2026] SADC 67 4 Possible causes of JR’s rib fractures .......................................................... 106 Skull fractures ............................................................................................. 106 Mechanism of injury for skull fracture ....................................................... 107 Sofa incident................................................................................................ 108 Bridging veins ............................................................................................. 110 Biomechanics of head injury ....................................................................... 111 Possible causes of skull fractures ............................................................... 113 Brain injuries .............................................................................................. 113 Brain injury impacting the cardiac system ................................................. 114 Follow up MRI ............................................................................................ 115 Retinal haemorrhages ................................................................................. 115 What accounts for JR’s head injuries ......................................................... 116 Timing of JR’s head injury .......................................................................... 116 Agonal breathing ........................................................................................ 117 Meeting with the family ............................................................................... 117 Seizures ....................................................................................................... 118 Dr Edwards’ responses to the opinions expressed by Dr Auer. ................. 118 Lung attack ............................................................................................ 119 Head injury preserves breathing ............................................................ 119 Seizures in very young babies, most commonly have a hypoxic or ischaemic origin, not a traumatic origin. ............................................... 122 Pneumonia ............................................................................................. 122 The skull fractures are characteristic of craniotabes/vitamin D/ spontaneous head fractures .................................................................... 122 Vitamin D Levels ................................................................................... 124 Ehlers-Danlos syndrome ........................................................................ 125 Fractures from ‘normal growth’ rather than trauma .............................. 125 Fractured ribs a ‘fictional narrative’ ...................................................... 125 Resolved infection ................................................................................. 126 Oximetry levels indicative of lung disease ............................................ 126 JR was reported to be always ‘unsettled’............................................... 127 JR’s colour change and limpness is circulatory failure, not a clinical picture of head injury ......................................................................................... 127 Vitamin deficiency is associated with pneumonia................................. 127 Change in movement of JR’s right leg-a stroke?................................... 128 -- 6 of 345 -- [2026] SADC 67 5 Subdural haematoma caused by hypoxia ............................................... 128 Epilepsy leading to atraumatic subdural haemorrhage .......................... 129 Retinal haemorrhage caused by hypoxia ............................................... 130 Impact brain apnoea ............................................................................... 131 Coning.................................................................................................... 132 Circulatory system is stimulated not failed by brain injury ................... 132 Brain/lung damage caused by a virus .................................................... 132 Biomechanics ......................................................................................... 134 Dr Edwards’ response to the opinions expressed by Prof. Ackland. .......... 134 Dr Edwards’ cross-examination ................................................................... 144 Did CPR cause a re-bleed – the sofa incident ............................................ 149 Biomechanics of head injury ....................................................................... 151 Brain injuries .............................................................................................. 153 Retinal haemorrhages ................................................................................. 153 Lucid interval .............................................................................................. 154 Timing of JR’s head injury .......................................................................... 154 Pneumonia .................................................................................................. 156 Vitamin D .................................................................................................... 156 Growth arrest lines ..................................................................................... 156 Rib fractures from CPR .............................................................................. 157 Modelling deformity .................................................................................... 158 No sign of injury.......................................................................................... 158 Subdural haemorrhage from CPR .............................................................. 158 Dr Edwards’ re-examination ........................................................................ 159 Summary of Dr Edwards’ evidence .............................................................. 160 The defence case ............................................................................................... 163 The accused’s evidence ................................................................................. 163 TR’s antenatal history and JR’s birth ......................................................... 163 JR’s neonatal progress ............................................................................... 164 Sofa incident................................................................................................ 164 Events on 5 January 2020 ........................................................................... 165 The accused’s cross-examination ................................................................. 166 Dr Gootnick’s evidence ................................................................................. 167 Qualifications and experience .................................................................... 167 Chest X-ray of 5 January 2020 ................................................................... 167 -- 7 of 345 -- [2026] SADC 67 6 Widened Occipital Suture ........................................................................... 169 Growth arrest lines ..................................................................................... 171 Ribs ............................................................................................................. 172 Looser zone fractures .................................................................................. 173 Modelling deformities ................................................................................. 173 Accessory sutures ........................................................................................ 175 Sofa incident................................................................................................ 175 Dr Gootnick’s cross-examination ................................................................. 179 Wormian bones ........................................................................................... 180 Rickets ......................................................................................................... 180 Rachitic rosary ............................................................................................ 180 Craniotabes ................................................................................................. 184 Chest X-rays on 5 January 2020 ................................................................. 184 Pneumonia .................................................................................................. 186 Rib fractures................................................................................................ 186 Rickets ......................................................................................................... 187 Images 6 and 7 - vitamin D deficiency........................................................ 190 Wormian bones ........................................................................................... 191 Skull fractures ............................................................................................. 191 Image 12 skull fractures, X-ray and CT...................................................... 193 Craniotabes ................................................................................................. 194 Looser zone fractures .................................................................................. 201 Growth arrest lines ..................................................................................... 202 Dr Gootnick’s re-examination ...................................................................... 205 Summary of Dr Gootnick’s opinions ............................................................ 206 Prof. Ackland’s evidence ............................................................................... 208 Qualifications and experience .................................................................... 208 Prof. Ackland’s cross-examination............................................................... 214 Prof. Ackland’s re-examination .................................................................... 227 Summary of Prof. Ackland’s opinions ......................................................... 228 Dr Auer’s evidence ........................................................................................ 230 Qualifications and experience .................................................................... 230 Cardiorespiratory arrest due interstitial lung infection- not trauma ......... 231 Head injury selectively preserves breathing - boxing/MMA ...................... 236 Apnoea and circulatory collapse – severe rotational head injury .............. 242 -- 8 of 345 -- [2026] SADC 67 7 Lucid interval .............................................................................................. 243 Seizures causing haemorrhage/retinal haemorrhages ............................... 244 Atraumatic cause of subdural haemorrhages ............................................. 245 Bridging veins ............................................................................................. 246 Retinal haemorrhages ................................................................................. 246 Skull fractures – craniotabes – pseudofractures ........................................ 247 Rib fractures................................................................................................ 248 Tibial fracture – stroke? ............................................................................. 251 Dr Auer’s cross-examination ........................................................................ 251 Qualifications .............................................................................................. 251 Cardiorespiratory arrest due to interstitial lung infection - not trauma .... 255 Rhinovirus ................................................................................................... 259 Lucid interval .............................................................................................. 260 Response to Assoc. Prof. Taranath’s opinions ........................................... 261 Dr Auer’s views on ‘abusive head trauma’ ................................................ 263 Skull fractures- craniotabes/Wormian bones/pseudo-fractures/vitamin D deficient rickets ........................................................................................... 272 Ehlers Danlos syndrome ............................................................................. 274 Pneumonia .................................................................................................. 284 40 cases of lung attack ................................................................................ 287 Brain injury ................................................................................................. 288 Kaplan-Meier plot ....................................................................................... 297 Hypoxia-ischemia related to subdural haematoma .................................... 300 Resuscitation with adrenaline ..................................................................... 302 Bridging veins ............................................................................................. 304 Explanation for cortical bruising................................................................ 305 Dr Auer’s re-examination ............................................................................. 308 Summary of Dr Auer’s opinions ................................................................... 308 Assessment of the medical expert evidence ................................................... 310 Assoc. Prof. Linke.......................................................................................... 310 Assoc. Prof. Taranath.................................................................................... 310 Dr Edwards .................................................................................................... 310 Further application to exclude Dr Edwards’ evidence............................... 310 Dr Gootnick ................................................................................................... 312 Prof. Ackland ................................................................................................. 314 -- 9 of 345 -- [2026] SADC 67 8 Dr Auer .......................................................................................................... 315 Decisions in R v Baxter .................................................................................... 325 Analysis ............................................................................................................. 328 Has the prosecution proven beyond reasonable doubt that JR sustained traumatic head injuries? ............................................................................... 329 Has the prosecution excluded that innocent explanations account for JR’s head injuries? ................................................................................................ 331 Sofa incident................................................................................................ 332 CPR ............................................................................................................. 335 Findings ...................................................................................................... 335 Has the prosecution excluded any reasonable possibility that the injuries were caused by someone or something other than the accused ........................... 335 BR and the dogs .......................................................................................... 336 TR ................................................................................................................ 338 Findings ...................................................................................................... 339 Timing of the head injuries ........................................................................... 339 Findings ......................................................................................................... 340 Was the accused responsible for the injuries JR sustained on 5 January 2020? ........................................................................................................................ 340 Findings ...................................................................................................... 340 Verdict .............................................................................................................. 343 -- 10 of 345 -- [2026] SADC 67 9 Introduction 1 SR (the accused) is charged as follows:1 Statement of Offence Aggravated Recklessly Causing Serious Harm. (Section 23(3) of the Criminal Law Consolidation Act, 1935). Particulars of Offence [SR] on the 5th day of January 2020 at Surrey Downs, caused serious harm to [JR], being reckless as to whether serious harm was caused. It is further alleged that [SR] committed the offence knowing that [JR] was a person with whom he was, or was formerly, in a relationship. It is further alleged that [SR] committed the offence knowing [JR] was under the age of 12 years at the time of the offence. 2 The prosecution alleges that on 5 January 2020, the accused’s son, JR sustained serious and life-threatening injuries. Overview 3 JR was born on 19 November 2019 at the Lyell McEwin Hospital (LMH) at 38 weeks gestation in a ventouse assisted delivery. On delivery JR was said to have been in good condition with appearance, pulse, grimace, activity and respiration (APGAR) scores of eight and nine. 4 JR was approximately six and a half weeks old at the time of the alleged offending. He lived with his mother TR and the accused in Surrey Downs (the home), together with his sister BR. BR was born on 13 August 2017 and was two years of age at the relevant time. 5 On 30 December 2019, JR sustained an injury to his head when his head came into contact with the central console cup holder of a sofa while in the accused’s arms (the sofa incident). He was seen by a general practitioner (GP) who assessed the injury as minor. 6 At around 11.10 am on Sunday 5 January 2020, TR left home to attend a hair appointment in Ridgehaven, approximately five to ten minutes away. The accused was left to care for JR and BR. 7 At about 12.17 pm the accused called 000, telling the operator that his son was not breathing. He said he thought JR’s heart was beating but was taking a breath ‘every now and then’. The accused performed cardiopulmonary 1 Information filed 21 January 2021. -- 11 of 345 -- [2026] SADC 67 10 resuscitation (CPR) on JR until paramedics arrived at 12.20 pm. At about 1.26 pm JR was transported to the Women’s and Children’s Hospital (WCH) by ambulance. 8 On admission to the WCH, JR underwent medical assessments and investigations which are alleged to have shown recent injuries to his head and historical fractures to his ribs and a spiral fracture to his right tibia. The use to be made of the evidence concerning the rib and tibial fractures was outlined in the prosecution’s opening as relevant only to JR experiencing pain which would have made it difficult for him to settle. It is not alleged the accused caused these fractures. They are not uncharged acts. 9 Injuries alleged to have been sustained to JR’s head included: 1. A skull fracture to the right side of the parietal bone with a smaller fracture to the left side of the parietal bone. 2. Subdural haemorrhages, including some occurring directly below the identified skull fractures. 3. Brain injury, including both hypoxic ischemia and contusions with associated loss of brain tissue. 4. Extensive bilateral, multiple retinal haemorrhages. 10 In the opinion of forensic paediatrician Dr Edwards, the constellation of JR’s symptoms was consistent with forceful impact together with a rotational force. This sheered the microscopic bridging veins between the brain and the brain lining, leading to bleeding at the base of the brain which caused JR’s heart to stop, impacting his breathing. 11 The prosecution case is that the accused inflicted JR’s head injuries when JR was in his care on 5 January 2020. 12 The accused denied injuring JR. He argues that JR suffered underlying medical conditions rather than inflicted trauma. In the event the prosecution was to establish that JR did sustain head injuries, the defence argues that BR, the family dogs, TR, the sofa incident or what defence counsel described as the ‘heavy application of force’ by the attending paramedics, cannot be excluded as reasonable possibilities for the cause of JR’s head injuries. 13 The accused elected to be tried by judge alone.2 Prosecution witnesses 14 The prosecution called: 2 Election for trial by judge alone filed 30 November 2023 (FDN 50). -- 12 of 345 -- [2026] SADC 67 11 • Kevin Murphy (Dr Murphy) – TR and JR’s GP. • Lisa Ames (Ms Ames) – registered nurse who assisted with JR’s immunisations on 3 January 2020. • Celeste Iellamo (Ms Iellamo) – paramedic who attended on 5 January 2020. • Brittany Walls (Ms Walls) – paramedic who attended on 5 January 2020. • Madeleine Preece (Ms Preece) – paramedic who attended on 5 January 2020. • Daniel Kretschmer (Mr Kretschemer) – paramedic who attended on 5 January 2020. • Danielle Esplin (Ms Esplin) – TR’s hairdresser. • Samantha Hargreaves (Dr Hargreaves) – expert obstetrician. • Rebecca Linke (Assoc. Prof. Linke) – paediatric radiologist at WCH who reviewed and reported on JR’s radiological investigations. • Ajay Taranath (Assoc. Prof. Taranath) – paediatric neuroradiologist at WCH who reviewed and reported on JR’s MRI investigations. • Michael Sherratt (DBS Sherratt) – investigating officer. • Jane Edwards (Dr Edwards) – forensic paediatrician, Medical Unit Head of the Paediatric Forensic Medical Service with the WCH who reported on her forensic medical assessment. 15 The evidence of Christopher Kirby (Dr Kirby), the surgeon who performed JR’s circumcision and Chris Gillis (Dr Gillis), the GP who examined JR on 30 December 2019 after the sofa incident, was agreed. Defence witnesses 16 The defence called: • SR – accused. • PR – accused’s father. • AE – accused’s father-in-law. • BE – accused’s brother-in-law. • AR – accused’s mother. • Sian Zimmer (Ms Zimmer) – character witness. -- 13 of 345 -- [2026] SADC 67 12 • Craig Kutcher (Mr Kutcher) – character witness. • Timothy Ackland (Prof. Ackland) – biomechanics expert. • Susan Gootnick (Dr Gootnick) – expert radiologist. • Roland Auer (Dr Auer) – expert neuropathologist. Procedural history 17 The trial in this matter was initially listed to commence on 22 May 2023 before a different judge. 18 On 21 May 2023 the defence made an application pursuant to r 39 application3 relating to notice from the prosecution concerning the proposed use of uncharged acts alleged to have been committed by the accused, relating to the historical injuries that JR was alleged to have suffered. As a result of further discussions with the medical experts by both counsel, the trial was adjourned to allow the defence time to consider the expert opinions. 19 The trial commenced before me on 7 May 2024, with the first prosecution witness called to give evidence on 8 May 2024. The trial concluded with final addresses on 24 June 2025, after 34 days of hearing. Defence applications 20 I set out a chronology of the various defence applications made pursuant to r 39(1)(d) of the Joint Criminal Rules 2022 (SA), during the trial before me. 21 November 2024 21 Application for a stay pending payment of legal costs in relation to the adjournment of the trial listed to commence on 22 May 2023 and an adjournment of the part-heard trial4 which commenced on 7 May 2024.5 I dismissed the application with written reasons delivered on 29 November 2024.6 3 February 2025 22 Application for the exclusion of Dr Edwards’ evidence.7 Application dismissed on 13 February 2025.8 3 Interlocutory application r 39 notice – exclusion of evidence. 4 Interlocutory application filed 22 October 2024 (FDN 106). 5 Interlocutory application filed 30 September 2024 (FDN 98). 6 Sent by email to counsel on 29 November 2024 – R v [SR] [2024] SADC 157. 7 Interlocutory application filed 27 February 2025 (FDN 151). 8 T 823. -- 14 of 345 -- [2026] SADC 67 13 20 February 2025 23 Application for me to recuse myself on the basis that because of my ruling on the application for the exclusion of Dr Edwards’ evidence,9 there was an appearance of bias. I dismissed the application on 20 February 2025.10 25 February 2025 24 Application by the defence for a temporary or permanent stay of the proceedings pending payment of legal costs 11 because of deficiencies in the police investigation and disclosure of documents, and because the prosecution case was doomed to fail. I dismissed the applications on 25 February 2025.12 24 June 2025 25 Further applications were made in the Defence final address which related to the exclusion of Dr Edwards’ evidence; the exclusion of evidence relating to the rib and tibial fractures; an application for further particulars; failures by police to properly investigate the matter; and failures by police to disclose relevant material. At the close of defence counsel’s oral submissions, he was reminded of a pre-trial resolution of the application for further particulars and correspondence from the Director’s office in May 2023 informing him that the fractures were not being put forward as uncharged acts or for any form of propensity reasoning and were relevant solely to the issue of the infant settling and its presentation and assessment.13 26 The prosecution made no further submissions in relation to these applications. 27 I will address the further application for the exclusion of Dr Edwards’ evidence later in these reasons. I repeat the reasons I have previously given in relation to the alleged failure by SAPOL to properly investigate in this matter and my reasons regarding failure to disclose relevant material, given on 25 February 2025. Elements of the offence 28 To prove the alleged offence, the prosecution must prove six elements beyond reasonable doubt. These are: 1. The accused performed an act; 2. The act was voluntary and deliberate; 9 Application made orally at T 1130. 10 T 1148-1149. 11 Interlocutory application filed 25 February 2025 (FDN 143). 12 T 1220-1225. 13 Exhibit P194. -- 15 of 345 -- [2026] SADC 67 14 3. JR suffered serious harm; 4. The accused’s voluntary act caused that serious harm; 5. The accused was reckless as to causing serious harm; 6. The accused’s act was unlawful. 7. The accused committed the offence knowing that JR was a person with whom he was, or was formerly, in a relationship. 8. The accused committed the offence knowing that JR was under the age of twelve years at the time of the offence. 29 The term ‘serious harm’ is defined as:14 (a) harm that endangers a person's life; or (b) harm that consists of, or results in, serious and protracted impairment of a physical or mental function; or (c) harm that consists of, or results in, serious disfigurement. General directions 30 I direct myself as follows: • The accused is presumed innocent unless and until his guilt has been proved beyond reasonable doubt. • The burden of proving the charge lies wholly on the prosecution and the accused is not obliged to prove anything. It is not sufficient for the prosecution to show mere suspicion of guilt or even to demonstrate probable guilt. I must be satisfied that the prosecution has proved beyond reasonable doubt each element of the offence. • The accused elected to give evidence, and I remind myself that he was not bound to do so and could have remained silent. I must assess his evidence and the weight to be attached to it in the same way in which I assess the evidence of the other witnesses whose evidence I have heard in this trial. I give the accused credit for answering police questions in circumstances where he was not obliged to. • I must assess each witness as to their truthfulness and reliability and determine whether I can rely on the evidence of a witness. I can reject or accept all or part of a witness’ evidence. 14 Criminal Law Consolidation Act 1935 (SA) s 21. -- 16 of 345 -- [2026] SADC 67 15 • Certain witnesses gave evidence with special arrangements in place, that is via AVL. I must not draw an adverse inference against the accused because of those arrangements, nor allow them to influence the weight I give that evidence. • As the prosecution case rests upon circumstantial evidence, the accused cannot be found guilty of the charge unless the circumstances exclude any reasonable explanation consistent with innocence. To find the accused guilty of the offence, I must be satisfied not only that his guilt is a rational inference, but that it is the only rational inference that the circumstances I find proven enable me to draw. The approach to the circumstantial evidence in this case requires two steps. First to look at the items of circumstantial evidence the prosecution relies upon and decide which facts are established by that evidence and then consider what inference or inferences I am prepared to draw from those facts. I am required to consider the combined strength of the facts I find have been established by the evidence. • The prosecution and defence provided detailed written submissions, which they then addressed orally. I have considered all their arguments. Agreed facts 31 The following facts were agreed:15 1. Adrian Button was the SAPOL Digital Evidence Section officer tasked with downloading data from the mobile phones seized by SAPOL from [SR] and [TR]. 2. Without access to his work sheet, Adrian Button is unable to say whether all downloads were completed on the same date. He commenced the examinations on Tuesday, 7 January 2020. There is a variance of timeframes for how long a device download can take due to such factors as the total quantity of data stored on a device, more data means more time to extract, and therefore it’s possible that he worked on the phones over a matter of days. 3. No other person was involved in the download process. 4. The data downloaded from the mobile phones was provided to Michael Sherratt. 5. Michael Sherratt played no part in the download process. 6. Adrian Button did not review the contents of the downloaded materials for the purposes of the investigation. 7. Upon completing the phone downloads, Adrian Button performed a visual comparison of random sample data in the downloads with phone contents to confirm the process was done correctly and to confirm that available data had been obtained in the download. 15 T 1195-1196. Exhibit P195. Agreed Facts 1-9 related primarily to Defence arguments regarding failure by SAPOL to properly investigate. T 1334. -- 17 of 345 -- [2026] SADC 67 16 8. Analysis of the data downloaded from [TR] and [SR]'s mobile phones for the purposes of the investigation was solely undertaken by the investigating officer Michael Sherratt. 9. Adrian Button played no further part in the investigation, but for the downloading of data from [TR] and [SR]'s mobile phones. 10. During the journey to the WCH [JR] improved in condition to the point where he started crying in the back of the ambulance. 11. If called, the paramedic, Bradley Webber (Mr Webber), would state as follows – would give the following evidence: that on attendance at [redacted], Surrey Downs, he, one, saw the baby lying on the floor; two, the baby was lying with their head away from the couch and near a coffee table. 12. If called, the paramedic, Brittany Walls, would give the following evidence: when attending [redacted], Surrey Downs, [TR] stated ‘If the baby dies, I’m going to feel very guilty as I’ve not spent much time with him’. Listing devices16 1. Listening devices were positioned at [redacted], Surrey Downs from 24 January 2020 until 24 February 2020. 2. Listening devices were positioned within the [redacted] family motor vehicle, a Peugeot, from 24 January 2020 until 24 February 2020. 3. The listening device evidence has been thoroughly reviewed and there were no statements made that could be interpreted as admissions or evidence supportive of the prosecution case. Apple iPhone read receipts17 1. If read receipts on your iPhone show up days later, it’s likely the recipient either didn’t open the message immediately or they had their phone turned off or in airplane mode, preventing the receipt from being sent back to you until they were back online. 2. Read receipts, which indicate a message has been seen, typically won’t trigger if you only preview the message (e.g., from a notification banner or by swiping down on an iPhone) and don’t fully open the chat window or long pressing message. It will not send a read receipt until you open the conversation. 3. A delayed read receipt on an iMessage is not a true representation that the message was not read immediately. Expert evidence 32 The differences in the opinions of the medical witnesses called to give evidence was a significant feature in this trial. 16 T 1334-1335. 17 Exhibit D104. -- 18 of 345 -- [2026] SADC 67 17 33 In considering the admission of expert evidence in South Australia, the Court of Criminal appeal in Murphy (A Pseudonym) v The King said: 18 The fundamental principle is that the admissibility and purpose of expert opinion evidence is to assist the court to form a sound judgment on matters requiring specialised knowledge or expertise. The expert must have the relevant knowledge and expertise and be capable of expressing an opinion on a matter on which the court requires assistance. 34 And later:19 Expert opinion evidence is only admissible if it satisfies the common law rules relating to its admission, together with any rules of court, practice directions or codes of conduct that apply to the particular forum in which the opinion is to be elicited. (footnotes omitted) 35 In R v Bonython, King CJ addressed the common law requirements in an ordinary criminal trial in the following way:20 The general rule is that a witness may give evidence only as to matters observed by him. His opinions are not admissible. One of the recognized exceptions to this rule is that which relates to the opinions of an expert. This exception is confined to subjects which are not, or are not wholly, within the knowledge and experience of ordinary persons. On such subjects a witness may be allowed to express opinions if the witness is shown to possess sufficient knowledge or experience in relation to the subject upon which the opinion is sought to render his opinion of assistance to the court. Before allowing a witness to express such opinions, the judge must be satisfied that the witness possesses the necessary qualifications, whether those qualifications be acquired by study or experience or both. But when it is established that the witness is an expert in the relevant field of knowledge, he will be permitted to express his opinion, however unconvincing it might appear to be subject always, of course, in a criminal trial to the discretion to exclude evidence whose prejudicial effect is disproportionate to its probative value. The weight to be attached to his opinion is a question for the jury. 36 In Makita (Aust) Pty Ltd v Sprowles Heyon JA, explained the conditions that attach to the admissibility of expert evidence in the following terms: 21 In short, if evidence tendered as expert opinion evidence is to be admissible, it must be agreed or demonstrated that there is a field of specialised knowledge; there must be an identified aspect of that field in which the witness demonstrates that by reason of specified training, study or experience, the witness has become an expert; the opinion proffered must be “wholly or substantially based on the witness’s expert knowledge”; so far as the opinion is based on facts “observed” by the expert, they must be identified and admissibly proved by the expert, and so far as the opinion is based on assumed or “accepted” facts, they must be identified and proved in some other way; it must be established that the facts on which the opinion is based form a proper foundation for it; and the opinion of an expert requires demonstration or examination of the scientific or other intellectual basis of the conclusions reached: that is, the expert’s evidence must explain how the field of “specialised knowledge” in which the witness is expert by reason of “training, study or experience”, and 18 [2023] SASCA 107, [86]. 19 At [87]. 20 (1984) 38 SASR 45, [46]. 21 [2001] NSWCA 305, [85]. -- 19 of 345 -- [2026] SADC 67 18 on which the opinion is “wholly or substantially based”, applies to the facts assumed or observed so as to produce the opinion propounded. If all these matters are not made explicit, it is not possible to be sure whether the opinion is based wholly or substantially on the expert’s specialised knowledge. If the court cannot be sure of that, the evidence is strictly speaking not admissible, and, so far as it is admissible, of diminished weight. And an attempt to make the basis of the opinion explicit may reveal that it is not based on specialised expert knowledge, but, to use Gleeson CJ’s characterisation of the evidence in HG v The Queen, on “a combination of speculation, inference, personal and second-hand views as to the credibility of the complainant, and a process of reasoning which went well beyond the field of expertise.” 37 In Lang v The Queen,22 Jagot J explained that the requirement expressed in Makita that the expert’s evidence must ‘fully’ expose the expert’s reasoning process in explaining what is necessary to show the application of specialised knowledge:23 …does not involve an absolute standard, even in a case where admissibility is governed by the terms of s 79 of the uniform evidence legislation. Much will depend on the field of expertise and the nature of the opinion given. Accordingly in Dasreef Pty Ltd v Hawchar, French CJ, Gummow, Hayne, Crennan, Kiefel and Bell JJ said that for example, “a specialist medical practitioner expressing a diagnostic opinion in [their] relevant field of specialisation is applying ‘specialised knowledge’ based on [their] ‘training, study or experience’ being an opinion ‘wholly or substantially based’ on that ‘specialised knowledge’ will require little explicit articulation or amplification once the witness has described [their] qualifications and experience, and has identified the subject matter about which the opinion is proffered. 38 In that decision Kiefel CJ and Gageler J said:24: Expert evidence need not be opinion evidence. Evidence given by an expert sometimes involves nothing more than imparting expert knowledge and sometimes involves nothing more than giving a technical description of events and processes in which the expert was involved. 39 While generally witnesses may only give evidence about what they have seen or heard, expert opinion evidence is admissible to assist the court to draw on a witness’s expertise to make findings of fact. Experts cannot engage in fact finding. I must assess the evidence that is given by an expert in the same way as any other witness. I must also consider both whether an expert is properly qualified to give their evidence and whether they appeared to me to be impartial or biased. These issues were argued by the defence in relation to the evidence given by Dr Edwards. 40 It remains for me to give such weight to the opinions of the expert witnesses called to give evidence in this case as I see fit. I do not have to accept an expert’s evidence and am entitled to accept or reject the evidence of any expert. I am however required to articulate a proper basis for any rejection of the evidence given by an expert. 22 (2023) 278 CLR 323. 23 At [433]. 24 At [5]. -- 20 of 345 -- [2026] SADC 67 19 Application to exclude evidence of Dr Edwards’ on 2 February 2025 41 On 2 February 2025, before Dr Edwards was called by the prosecution to commence her evidence, defence made an application for the exclusion of her evidence. 42 The application was said to be based primarily on Dr Edwards having attempted to dissuade witnesses. Defence counsel argued that conduct that was evidenced within electronic correspondence between Dr Edwards and SAPOL and the Department of Child Protection (the DCP), showed that Dr Edwards did not occupy a position of objectivity or impartiality and that therefore she should not give evidence. 43 The foundation for the application arose from meetings that took place between Dr Edwards and the accused, [TR], and other family members, and from Dr Edwards’ communications with police during their investigation. 44 In the family meetings, Dr Edwards was provided with information from them that was thought could possibly explain the injuries JR was said to have sustained and which Dr Edwards dismissed. 45 On the voir dire the defence called BE and AE and the accused to give evidence in support of the application. The prosecution called DBS Sherratt to give evidence and tendered the reports of Dr Edwards dated 14 April 202025 and 27 November 2020.26 BE 46 BE, TR’s brother, said that he had attended the home on 5 January 2020 while the paramedics were still in attendance, and at the WCH shortly thereafter. The WCH were not giving any information as to JR’s condition, other than that he had been caused serious harm. 47 He said that he and his father AE and the accused’s parents were requested to attend a meeting at the WCH. When they attended, they were asked to come in separately. He was not sure in which order it occurred but thought that it was the accused’s parents first and he and his father went in separately afterwards. To the best of his recollection this meeting was on 9 January 2020. 48 Dr Edwards led the presentation from the computer. BE said X-rays showed rib and skull fractures and there was a picture of an eye which showed haematomas. Dr Edwards was explaining where they were and what would usually cause those kinds of injuries. 25 Exhibit VDP18. 26 Exhibit VDP19. -- 21 of 345 -- [2026] SADC 67 20 49 BE said that he did not accept what he was being told and felt unsettled and did not know who he was meeting with. 50 He described Dr Edwards’ manner as polite but still stern. He felt that she was a bit off guard because she didn't have the answers. There was, he said, no absorption of their questions or 'How about we go away and look into those and get back to you?'.27 It continued to lead back to the same hypothesis. He said that when Dr Edwards was challenged on the information she provided, the discussion moved to ‘that doesn't happen, it couldn't happen’.28 When she was challenged to dig further it was at that point she closed off, going back to 'You need to start coming to terms with one of these individuals caused these injuries'29… ‘and that there is serious consequences for everybody involved'.30 51 He said Dr Edwards was told about knee dropping by BR and baby car seats being over tightened. When he had asked for the physics behind what kind of weights and pressure need to be applied to break a baby's bone or rib, he was presented with ‘that information doesn't exist’,31 which he then challenged as the conclusions that had been made were not based on actual factual scientific investigation. 52 He said that the whole process felt like somebody looking for one of them to agree that one of JR’s parents had probably caused his injuries. 53 In cross-examination, BE was shown a copy of Dr Edwards’ PowerPoint which he agreed Dr Edwards had shown and explained in the meeting. He was critical of the PowerPoint presentation in that:32 We were being provided proposed pieces of information of the injuries because when you look at the images and putting together this document, that looks like a presentation that my daughter would put together, no offence to the people doing it, but there is no naming on any of the documents, you know, they had screenshots, snippets and some real light wording and that is why at that point in time I was not satisfied with what was being presented and the answers and the reasons to it. 54 When asked what he would have been satisfied with, he said:33 I think a slightly more detailed presentation, you know, and information as to the causes and the reasons as to why these injuries may have occurred and alternatives as to. It was just a bunch of images and a bunch of hearsay at the time of pointing out towards these images as to how they had occurred, not how could they have occurred. ….For such a serious matter that was being presented, that's why I'd walked away unsatisfied and upset 27 T 470. 28 T 471. 29 T 471. 30 T 471. 31 T 472. 32 T 478-479. 33 T 479-480. -- 22 of 345 -- [2026] SADC 67 21 with the outcome based off of what looked like it had been thrown together before we jumped into a meeting. 55 BE said Dr Edwards explained that the rib fractures occurred at an earlier time. He said that it was at that point that they were a bit baffled because JR did not earlier show any signs of discomfort or aggravation or being upset. 56 He agreed that it was possible the meeting with Dr Edwards was on 30 January 2020. He agreed Dr Edwards provided information about JR's symptoms and her opinion that he was hurt by someone two, and possibly three times, and that the head injury would have occurred just prior to JR's collapse. He agreed that his father had said that they wanted answers. 57 BE agreed that he had told Dr Edwards that 'We all have children and are in close contact. It's in our interests to know what's happened'.34 58 He agreed that the purpose of the meeting was so that those issues could be assessed and for Dr Edwards to give explanations as to what, in her medical opinion, had occurred. He did not accept that he and his father had seemed to accept that someone had hurt JR. He agreed that they both expressed concerns about communications with the DCP and that Dr Edwards agreed to feed that concern back to the DCP. 59 BE said that his impression was that Dr Edwards was presenting what she believed to be the facts and that she was presenting her opinion on the evidence that had been pieced together for her to review. As far as he was concerned Dr Edwards did not adequately explain considerations of any pre-existing health conditions that could have related to the timeframes. 60 He wanted to know that other medical conditions had been excluded but also other circumstances or situations and the physics behind what kind of pressure or forces are required to cause an injury. Dr Edwards told him she did not have that information. 61 In re-examination BE said that he became ‘really uncomfortable’ when asked if there was anything that they had seen or heard, or had information to bring forward to contribute to the injuries that were being presented. AE 62 AE described attending at the WCH on 5 January 2020 where a doctor who he thought was named Andrew ‘scared the hell out of us…. staring at us like we were all criminals and it was awful.’35 34 T 482. 35 T 501. -- 23 of 345 -- [2026] SADC 67 22 63 He said his memory has been affected by the trauma of that day to a degree and it had now been over five years ago but thought that his ‘memory is pretty good actually.’36 64 He and his wife were looking after BR. They were required to satisfy the authorities that they knew how to look after children despite being grandparents of three children, which did not sit well with them. They felt they had to comply. 65 They had meetings with Ms Breuer, a social worker for the DCP. He described Ms Breuer as really threatening. He said ‘I've never been treated like it in my life, and we felt, you know, we were guilty of something and all we were trying to do was look after the grandchildren that have been left behind in this mess’.37 66 He said that they had believed that the DCP was there to help them but as it turned out that they were just against them the whole time. 67 They were told to attend a meeting at the WCH and found out that it was with Dr Edwards. At the meeting she had a presentation to put to them. He said that they felt she had a narrative and felt quite pressured into just believing everything she said. 68 She was telling them her version which they did not believe and which she could not one hundred percent explain. He said they felt pressured to see their side of it and because they were looking for answers, they started to believe that it could have been the dogs jumping or could it have been BR in that she used to drop to her knees from standing up. AE said that Dr Edwards’ answer was generally 'no'38 or 'highly unlikely'39 and they felt it did not matter what they said. 69 He felt there was an agenda, and they went along with it for a long time but behind closed doors, they were thinking it did not happen the way Dr Edwards was putting to them. He said:40 We didn't believe a word of it because it was so focussed and put on us that we thought 'What do we do? We've got no idea'. And as it was, it never ever really got - well, it never got investigated, never, by anybody, not even the police. Didn't investigate anything. So we're thinking 'How do you write all this stuff when you haven't even investigated it? You've just gone off images. This is it'. No investigation whatsoever. Nobody even spoke to us. 70 He said they were told on several occasions not only by Dr Edwards, but also the DCP and Ms Breuer that if they did not ‘go along with this’ they would never 36 T 502. 37 T 506. 38 T 512. 39 T 512. 40 T 515-516. -- 24 of 345 -- [2026] SADC 67 23 see their grandchildren. He said that all the threats and the evidence that they put forward they just ‘didn't believe.’41 71 In cross-examination, AE agreed that there was a meeting with Dr Khurram Noori (Dr Noori) where they were still waiting for scans and there was a meeting two or three weeks later with Dr Edwards. He recalled that Dr Edwards showed material on the computer but said it had not included all of what was in the exhibit.42 72 When it was suggested that at the meeting Dr Edwards explained and provided medical feedback using the PowerPoint presentation he said:43 Yeah, vaguely, she sort of explained it. I think we were asking more questions than she was giving. But yeah, she told us what she needed to tell us... 73 He said that Dr Edwards told them a lot of things that they then did not believe and they had gone off and researched after that meeting. He said that for a non-medical person, it was overwhelming, and they wanted answers. The things that she was telling them they absolutely did not believe happened the way she said. 74 At the meeting they were willing to listen to Dr Edwards as all they wanted was answers, but they could not get those answers. He recalled her telling them that the head injury would have occurred just prior to JR's collapse, which shocked him. 75 He agreed that either himself or BE said that they had lots of family contact, and no concerns were seen. He agreed BE said something like they all had children and are in close contact and that it was in their interests to know what happened. 76 He raised JR being passed around a lot especially at Christmas, and that BR would fall to her knees, which she had done several times to him, and it had really hurt. He agreed he was raising these issues with Dr Edwards, and she replied that it was possible but highly unlikely. He agreed that it was because of her using those words that he thought they were not getting a full hearing and what led them to start thinking outside the square a little bit because nobody was giving them any answers whatsoever. 77 AE said that the DCP were at the forefront of all this, and a lot of the information in those meetings was fed down that chain. Dr Edwards’ name got thrown around a lot, and ‘that's what stuck’.44 41 T 518. 42 Exhibit P64 (admitted on Voir Dire as Exhibit VDP13). 43 T 523. 44 T 542. -- 25 of 345 -- [2026] SADC 67 24 78 He agreed Dr Edwards had never suggested to him what to say to the DCP or anyone. 79 In re-examination, AE said that they felt that everything started from Dr Edwards and then it filtered down, because the DCP only found out about severe brain injuries and the issues that might occur from those meetings with Dr Edwards. 80 AE was recalled by defence counsel to give further evidence regarding his communications with SAPOL in around late May or June 2020 regarding providing them with his statement. He said that he was not personally contacted by SAPOL. Police rang his wife’s phone, and he was in the room with her when she answered the call. He heard his wife say that the accused was a good person and that no one was listening, so they were not going to talk anymore. The police officer, who he thought was DBS Sherratt, said ‘It looks like I'm going to get nothing out of you'45 and said goodbye, asking them to contact him if they changed their mind. The accused 81 The accused said that he had little recollection of what he described as a very brief conversation with Dr Noori on 5 January 2020. He said he and TR were very distressed. Police officers arrived at the hospital, and he agreed to be interviewed. He was not asked if he wanted to speak to a lawyer. On 7 January 2020 they had another meeting with Dr Noori who had asked them to come in for a chat. He attended the meeting with TR and AE. Dr Noori was present with two others who he believed to be Child Protection Services (CPS) workers. 82 Dr Noori asked if they had any explanation for JR's injuries. They again went through everything he had told police in his interview. The issue of fractured ribs from car seats came up, the family having done some research, and everything to do regarding TR's pregnancy. 83 Later in the day they met with a lawyer regarding the next day's Youth Court hearing regarding BR and JR. Thereafter they talked to DCP officers without a lawyer because they wanted answers and wanted their kids back as quickly as possible. 84 The accused said that he met with Dr Edwards on 30 January 2020 with TR and AE. Dr Edwards was there with who he believed were two others who he believed were CPS workers. He said that he had wanted to get some answers for JR. 45 T 617. -- 26 of 345 -- [2026] SADC 67 25 85 Dr Edwards went through a PowerPoint presentation, saying that someone had inflicted the injuries on JR. She asked for alternatives and any alternative was just shut down.46 86 The accused said they told Dr Edwards everything that they knew about TR’s pregnancy to assist. Dr Edwards’ response was that those issues did not explain the cause of the specific injuries. At the end of the meeting, he felt like Dr Edwards was interrogating them. 87 Dr Edwards wanted to speak to other family members, so a time was arranged for approximately five days later. He attended the hospital for the second meeting but did not participate. Dr Edwards met with his parents and then with AE and BE. About two weeks later he and TR were arrested.47 88 In cross-examination, the accused agreed that by the end of 5 January 2020, he was aware of police involvement in the matter and agreed to be interviewed. He continued to assist in providing as much information as he could throughout that interview because he thought he was doing the right thing at the time. 89 He agreed he had not wanted to participate in a police re-enactment about the sofa incident as he ‘had enough’ by then. When police had arrived, he went to the bedroom and shut the door. 90 He agreed that there was a PowerPoint of material that Dr Edwards showed them at the meeting. He was in the meeting with TR and AE. He could not remember the questions AE asked but it would have been around alternative causes for JR’s injuries. 91 The accused maintained that AE had attended the meeting with him and TR, not his father PR. 92 The accused agreed that Dr Edwards explained that there were healing injuries to the ribs that had occurred a while before JR's presentation to Accident and Emergency on 5 January 2020. She explained the CT scan of the head and that it showed two fractures and bleeding to the brain that was explained as the subdural haemorrhages. She was giving her opinion that there were old injuries and new injuries as well. She explained the skeletal survey included a spiral fracture of the leg and referred the retinal haemorrhages. She said there was brain injury because of the bruising and the lack of oxygen to the brain. 93 The accused did not recall discussion with Dr Edwards concerning JR's leg not moving a few days before the six-week health check. Nor did he remember TR saying that JR had not looked at her like her daughter did and referring to her not having the same bond with JR that she had with her daughter. 46 T 585. 47 T 588. -- 27 of 345 -- [2026] SADC 67 26 94 He agreed that TR had said that they wanted to know was who did this and that they were baffled, wanted answers and had told 'everything we know'.48 TR had told Dr Edwards that JR had been passed around at Christmas and Christmas Eve, and children also were holding JR and queried if JR's leg might have got caught somehow. 95 TR also said JR had a bruise along his head, front to back, in the same place as the skull fracture with a tennis ball sized lump and the lump was towards the back of his head and that JR's skull shape changed. He agreed that Dr Edwards had told them that the GP said JR's swelling had gone on 3 January and both he and TR told her 'No, it had subsided significantly'.49 96 He agreed that either he or TR said it was a massive blow to the head, JR cried for a bit then fed, took his bottle, was given a Panadol and was taken to the GP. He said that Dr Edwards was told the distance from the push-off to the console was between 10 and 20 cm but that he would ‘lean more towards 20 myself in my opinion.’50 97 TR told Dr Edwards that the family had photos of JR on New Year's Day on the couch showing swelling and that the head shape was not right. He said they gave Dr Edwards a photo. 98 Issues such as the sofa incident, CPR, too tight car seat, the dogs or BR were all raised as possible causes. The accused agreed that Dr Edwards responded to the queries and explained that they were not considered possible explanations. She said that JR had been hurt by someone on more than one occasion. He agreed that towards the end of the meeting, he and TR expressed difficulty at not being able to be with JR. The accused said that he was accepting that it was Dr Edwards’ opinion but was not necessarily agreeing with it. He could not specifically recall Dr Edwards saying that the collapse would have occurred soon after JR sustained his head injury. 99 He agreed that throughout the meeting Dr Edwards was business-like and was there to provide information. She was giving her opinion on material that was before her. The accused said that while he had been given opportunity to ask Dr Edwards anything that came into his head and that they did so, it was always met with 'No, that couldn't happen'51 and pushed to the side. 100 With respect to his evidence that at the end of the meeting he felt like Dr Edwards was interrogating him, the accused said:52 Well, just her persona changed, she sat up on her chair and raised her voice slightly and then, you know, that's when she asked about - she gave that example about the dog, she 48 T 604. 49 T 604. 50 T 605. 51 T 610. 52 T 611. -- 28 of 345 -- [2026] SADC 67 27 went on to talk about sitting in a court of law with this matter if it came to it. She was throughout the whole meeting saying 'These are inflicted injuries' and [TR] and I were obviously saying 'Well that's not true'. DBS Sherratt 101 The prosecution called DBS Sherratt to give evidence on the voir dire. 102 At the relevant time he had been stationed at the Northern Districts Child and Family Investigation Section. He was the chief investigator in this matter which he explained involved collecting any evidence and interviewing respective parties in relation to any alleged abuse. He was aware of the Interagency Code of Practice53 which was applied by SAPOL. On 5 January 2020 he attended a cross- care strategy discussion with members of the DCP and CPS and was then tasked to attend the WCH. 103 He said that as the DCP requested the strategy discussion, in accordance with the Interagency Code of Practice, it would be their responsibility to raise the minutes or memo of that discussion. A Crisis Care Strategy Discussion note54 from 5 January 2020 was on his file. At that time, Dr Edwards was not involved for the WCH in the matter. 104 DBS Sherratt said that Dr Edwards had never asked him to suppress or alter any explanations given by any witness or to persuade a witness away from what they had said. 105 DBS Sherratt said that it is SAPOL's mandate to investigate any criminal charges and, as the chief investigator, he was the one who investigated in this matter. He said that Dr Edwards ‘provides the criminal charge, the evidence of any reports, medical notes and opinion onto the cause of injuries.’55 106 DBS Sherratt said that in normal investigations, SAPOL provides information to CPS at their request to assist them in formulating reports. He was provided with information by Dr Edwards in respect of materials held by the WCH which included results of medical examinations and investigations. 107 DBS Sherratt said that it was absolutely not the case that Dr Edwards 'engaged in communications that were directed towards managing and/or controlling the path of the - the path the police investigation will take'.56 He said that in accordance with the Interagency Code of Practice, any criminal investigation is solely directed by SAPOL and managed from SAPOL's perspective. They take information from outside sources like CPS, in this case 53 Exhibit D68 (admitted on Voir Dire as Exhibit VDP17). 54 Exhibit P69 (admitted on Voir Dire as Exhibit VDP20). 55 T 639. 56 T 640. -- 29 of 345 -- [2026] SADC 67 28 Dr Edwards, but under no circumstance do they direct how SAPOL investigates a criminal offence. 108 During the investigation, they have discussions with the DCP and CPS personnel. He said that from the beginning CPS personnel are involved in the case and are the ones conducting the testing and engaging with the family. Child abuse investigations in South Australia have SAPOL and CPS working together and sharing information to conduct a complete investigation. 109 The SAPOL investigation was run by him with input from CPS and the DCP personnel. There were no occasions where the DCP or CPS directed the investigation. 110 DBS Sherratt said that mobile phones were seized in this matter as they often provided valuable evidence in a criminal investigation. Two phones were seized from the accused, the first on 5 January 2020 and the second on his arrest on 24 February 2020. TR’s phone was seized for the same reason. Neither the DCP nor CPS had asked him to seize the phones. 111 DBS Sherratt was asked if CPS asked whether there was any information that could assist with respect to any relevant timeframe, for example who was at home on 5 January 2020 and the time of the ambulance attendance. He said that SAPOL provided a summary of what both TR and the accused provided to them in an interview. 112 DBS Sherratt gave evidence regarding the email communications he had sent and received in this matter. He said that he emailed Dr Edwards on 4 February 2020 to arrange a confidential meeting with her because SAPOL had a background investigation going on into the accused and TR. To assist in understanding the process of any CPS interviews that were planned and any information that would be gleaned from those CPS interviews, he said he had wanted to contact Dr Edwards to meet with her face-to-face ‘so that they could get that information without the huge amount of spectators that were in that email prior to that’.57 He met with Dr Edwards on 6 February 2020. He said that there was no particular reason why he had not made any notes of the meeting. The meeting related to up-and-coming meetings that Dr Edwards or members of her staff were going to have with the accused and TR, as to when they might occur and the content of what might be discussed. He explained that he did not want a ‘whole lot’ of other spectators in the room when asking questions about upcoming meetings as there was a sensitive investigation going on with the use of devices under the Surveillance Devices Act 2016 (SA). To protect the integrity of that investigation, it was important that there were not too many people asking questions as to why SAPOL were asking for particular details. He said it was very common for police to seize phones in a complex child injury matter. He said that 57 T 644. -- 30 of 345 -- [2026] SADC 67 29 the topic of listening devices did not come up between himself and Dr Edwards at that meeting. 113 DBS Sherratt denied that the meeting was an attempt to 'suppress or conceal'58 his dealings with Dr Edwards. 114 He said that it is very common to get a request for a re-enactment of the events in these sorts of investigations but did not recall Dr Edwards ever asking for a re-enactment of the 5 January 2020 events. 115 DBS Sherratt was asked whether he thought he had used ‘appropriate’59 language in his email to Dr Edwards on 24 November 2020 at 5.28 pm which read: Yeah that’s fine. All police notes are discoverable anyway. Good Luck with your report. I agree I think it is absurd they are making you write another one. I heard they are taking DCP to court over the removal of the children. 116 DBS Sherratt said that it was most probably not appropriate in terms of the emotion that he had put into his email. 117 DBS Sherratt said that in his role he relies on the medical opinion provided to him and if the medical opinion says that there is an innocent explanation as to injuries, his role is to include that evidence in the investigation. 118 If the medical opinion says that there are a limited number of people and that there is a particular time frame for an injury, his role is to assess that in terms of the weight of the evidence in progressing the investigation forward. 119 When he first attended at the WCH on 5 January 2020, not all of the medical investigations that were to be undertaken were then available. 120 The accused was arrested on 24 February 2020 for the charge of criminal neglect, which he said was an all-encompassing charge for all injuries sustained by JR. 121 In cross-examination, DBS Sherratt agreed that he cautioned the accused that he was not required to answer his questions and seized his phone. There were reasonable suspicions that JR had sustained inflicted injuries and that ‘something had happened today.’60 He agreed they were in the ‘realms of a reasonable suspicion but not enough to charge’.61 The accused was again interviewed on 23 January and 24 February 2020. 58 T 645. 59 T 646. 60 T 650. 61 T 650. -- 31 of 345 -- [2026] SADC 67 30 122 DBS Sherratt agreed that on 5 January 2020 he had held off from asserting a deliberate infliction of injuries to the ribs in the hope that he would get the accused talking. There was, he said, no reason why he did not give him his rights to legal advisers at that stage. 123 DBS Sherratt was taken to the Interagency Code of Practice which read:62 Where a SAPOL investigator has reasonable suspicion that an offence has been committed, SAPOL is responsible for leading any interview with the parent or carer suspected to be responsible for the alleged harm. In these circumstances, DCP will not interview a parent or carer as part of a child protection investigation or response until SAPOL have completed their interviews and provided approval. 124 He accepted that it made sense that this statement was in aid of the sanctity of the right to silence. 125 DBS Sherratt agreed that at the accused’s interview on 23 January 2020, the accused had exercised his right to silence and had not been arrested. There was a report back to SAPOL about the discussion Dr Edwards had with the accused, TR and other family members and that they appeared to accept that previous explanations were ‘untenable’.63 126 DBS Sherratt agreed that it would be inappropriate to guide or direct witnesses what to say or to correct them if what they say is untenable which would compromise the evidence. 127 While DBS Sherratt said he was not aware of the Joint Criminal Rules 2022 (SA) regarding experts, he said that he did appreciate the common law, that an expert must be impartial and objective. He agreed that asking for any defences or alibis compromises that. He also agreed an expert is confined to their area of expertise and must identify what they have relied upon in terms of evidence, examinations, tests or investigations and do not conduct the investigation. 128 DBS Sherratt was taken to a chain of emails dated 15 January 2020.64 129 With respect to an email on 15 January 2020 at 3.55 pm from DBS Sherratt to Dr Edwards and DCP (Ms Breuer), DBS Sherratt asked: If DCP or CPS ‘have got any info to help SAPOL on who attends with [TR] and/or [SR] at meetings? Has anyone had any recent meetings with them? How did they go? Are parents offering any new defences or alibis?’ 130 DBS Sherratt agreed that in this email he was asking for defences or alibis, a process he had said he would never embark upon and in total contravention of the 62 T 652. 63 T 657. 64 Exhibit D54 (admitted on Voir Dire as Exhibit VDD3). -- 32 of 345 -- [2026] SADC 67 31 restriction on gathering other evidence within the Interagency Code of Conduct document. He agreed that this was grossly unfair to the accused and that it was not correct to say that he only spoke to CPS to confirm a factual background because he was looking for new defences or alibis. 131 Dr Edwards had replied to his email on 15 January 2020at 4.05 pm as follows: According to hospital notes the only new information in terms of explanations the grandparents are putting forward was the circumcision procedure and also SAAS having caused the rib fractures and /?head injury. They may have said more to [TR]. 132 DBS Sherratt agreed that in Dr Edwards’ reply email she had not chastise him or tell him he was acting inconsistently with the Interagency agreement and agreed the implication in Dr Edwards’ reply was that she was answering his question about new defences or alibis. 133 On 15 January 2020 at 4.31 pm Ms Breuer (DCP) emailed Ms Press (DCP), DBS Sherratt and Dr Edwards. Ms Breuer informed that she met with the parents, TR’s brother, the accused’s mother and TR’s father. She advised that TR collapsed when she told the family JR would not be returning to grandparents’ care at that stage. …neither parent has offered any explanation as to the inflicted injuries, nor have they provided any information to indicate that [JR] has been in the care of anyone else (we haven’t asked them anything to this effect). Today I mentioned that the injuries are inflicted and pointed out that the parents have stated that [JR] has not been in the care of anyone else’s care. The parents didn’t refute this however mentioned that they have been trying to provide additional information that has been dismissed. I attempted to get more information regarding this, and he mentioned that [JR] might have gone out of line of sight with other people at certain times. I didn’t get any other information about this. [BE] also enquired as to whether the family can approach SAPOL to get additional information as to where things are at… 134 When DBS Sherratt was referred to this email, he agreed that Ms Breuer had highlighted that neither parent had offered any explanation as to the inflicted injuries nor said anything about JR having been in the care of anyone else. There was an attempt to get more information relevant to that topic as to whether JR might have gone out of their line of sight. TR’s brother had asked whether the family could approach SAPOL to get additional information as to where things were at, unaware, it was conceded by DBS Sherratt, that they were speaking to SAPOL. Later that day, at 4.48 pm DBS Sherratt emailed Ms Breuer and Ms Press (DCP) and Dr Edwards, informing them that the parents were: 135 Not aware of any planned follow ups and we plan to manage informing them strategically.’ He asked that ‘any further conversations with [TR] and [SR] and extended family do not inform them of possible follow up interviews with SAPOL -- 33 of 345 -- [2026] SADC 67 32 and in fact do not emphasis that there is a significant criminal investigation ongoing at this time. 136 With respect to this reply to Ms Breuer, DBS Sherratt denied that he was using what occurs with the DCP and CPS to get information to manipulate TR and the accused. He said that what police do with their investigation and any interviews is for them to manage and it is not for ‘them to be giving any heads-up with regards to that.’65 137 He said that he had asked if there were any planned supervised visits with TR and the accused with JR because there were other investigations going on in the background in relation to devices that had been installed under. DBS Sherratt said he had no recollection as to whether the use of listening devices was precipitated by information received from Dr Edwards. 138 DBS Sherratt explained that in an investigation, SAPOL work with CPS doctors through the investigation, who provide their reports which SAPOL provide to the DPP. If there are other experts the DPP seek, then SAPOL engage them through contacting the Royal Association of Surgeons and Medical Practitioners. No letters of retainer are used. 139 DBS Sherratt was referred to emails between himself and Dr Edwards on 24 November 202066 140 On 24 November 2020 at 5.35 pm Dr Edwards emailed DBS Sherratt and said: Yep, so I could be giving evidence about this case three 3 times. I'm over it already mainly because it's so blatantly obviously (sic) that he has been assaulted multiple times it doesn't seem like worthwhile time to spend – but then again that is the joys of the job! 141 DBS Sherratt replied to that email at 5.28 pm: ….I think it is absurd they are making you write another one. I heard they are taking DCP to court over the removal of the children. 142 DBS Sherratt said that his response to Dr Edwards that it was absurd she was being made to write another report had been ‘unprofessional and emotive’.67 143 DBS Sherratt was taken through email correspondence that passed between Dr Edwards, SAPOL and DCP, not all of which had been sent or received by him directly. He agreed SAPOL officers acted as a team in the investigation. 144 On 20 January 2020 at 2.07 pm Dr Edwards emailed SAPOL (Mr Stephen Bedford), attaching medical information to ‘help with SAPOL’s planned 65 T 1648. 66 Exhibit D61 (admitted on Voir Dire VDD10). 67 T 1715. -- 34 of 345 -- [2026] SADC 67 33 interviews’ of JR’s parents together with photos of retinal haemorrhages to compare to the normal eye. 145 On 21 January 2020 at 8.40 am Dr Edwards emailed the DCP (Ms Press and Ms Breuer) sending copies of the information given to SAPOL and asked that it not be uploaded as it was only in draft form. 146 In an email from Dr Edwards to DCP (Ms Breuer) (cc SAPOL (Mr Stephen Bedford) and DCP (Ms Press)) on 24 January 2020 at 10.36 am, Dr Edwards asked for a ‘quick discussion’ with Ms Breuer and SAPOL. She said: …we would be keen to have SAPOL feedback from the interviews and know whether the parents have been charged etc. I think you would need to seek the family's views on being present for these medical feedback sessions – if they are consenting we would be happy for you to be present if not we could seek their consent to record the sessions. 147 On 30 January 2020 at 3.42 pm Dr Edwards emailed DCP (Ms Breuer) and SAPOL and DCP (Ms Press) and advised that she had just finished with the family, meeting first with TR, the accused and paternal grandfather. She met with maternal grandfather and TR’s brother separately afterwards. She said: Very cordial discussions occurred and our impression is that the grandparents are on board with the idea that [JR] has been hurt by someone and very keen to have him in the care of extended family. I was clear with them that he has inflicted injuries, has been hurt by someone on at least 2-3 occasions and that the head injury occurred just prior to his cardiac arrest on the morning of January 5th. They seem to have accepted that previous explanations are untenable and that his injuries were caused by high forces. Neither parent provided any further ‘explanations’ and stated that they also really wanted to know what had happened to him and would let me know if they thought of anything else. They have provided a photograph of [JR]’s head on January 1st and have stated that he had bruising on his head which was seen by their GP on the same day as he reported hit his head on the console. I was clear that this incident does not explain his skull fracture nor his intra cranial injuries. Once we have received all the outstanding SAPOL information we will complete our report. 148 DBS Sherratt was asked about interviewing witnesses and agreed that it would be inappropriate to guide or direct a witness as to what to say. 68 He agreed that it would be totally unacceptable to correct a witness if they said something with which he did not agree or tell them what they had said was ‘untenable’. He agreed that would not be what SAPOL did and would compromise the evidence. He agreed that Dr Edwards’ email had been sent to SAPOL while the interview process with the accused was still underway. It was suggested to DBS Sherratt that it seemed SAPOL was getting information that undermined the right to silence because they were getting explanations or exploring an accused person’s narrative. He said that was defence counsels ‘take on it’ but agreed that he would not ask 68 T 657. -- 35 of 345 -- [2026] SADC 67 34 Dr Edwards what the witnesses were saying or whether there were any defences or alibis.69 149 On 7 April 2020 at 12.21, Dr Edwards had emailed DBS Sherratt advising him that she was working on her report as the DCP required it urgently for the Youth Court application. She listed information that she said she did not have and required which included the initial SAPOL interviews with the parents; any walk through of the sofa incident; phone logs to verify the timing of events on 5 January 2020 and 30 December 2019; statements from the paramedics; statement from Dr Kirby and any other statement relevant to the forensic medical opinion. 150 At 4.52 pm DBS Sherratt replied to Dr Edwards advising that police did not do a re-enactment ‘as when arrived [SR] disappeared and did not want to engage with us due to the stress of the situation at that time.’ He advised that police were re-analysing phone extract data and were still to get statements from paramedics or Dr Kilsby (sic).70 DBS Sherratt said in his evidence that he did not interrogate the paramedics or detail the method of CPR as he was not aware of variations in the technique and would get an addendum, which he said, he did not obtain. 151 DBS Sherratt was referred to the Detailed Occurrence Report,71 which he agreed was the central repository of information for all police investigators involved in this matter. There was reference to a report by Dr Edwards that ‘maternal grandmother had raised concerns that rib fractures were caused by car seat straps. She appears to have not acknowledged that injuries are inflicted'. 152 DBS Sherratt agreed that Dr Edwards was the conduit providing the information to the investigation as a whole. He agreed that SAPOL’s investigation responded to Dr Edwards' information and took steps regarding JR’s car capsule which was seized and photographed. 153 As to his entry in the Detailed occurrence report at page 52, which read: ‘There is still a lot of work done in any gathering statements to corroborate the circumstances surrounding the injuries but they are all circumstantial and not direct evidence of any inflicted injury’,72 he agreed he was to corroborate Dr Edwards’ hypothesis that rested on the injuries. 154 He agreed that the maternal grandparents were not interested in providing statements. He denied he said to them that they were not going to be any good to him anyway. Rather, he said he was investigating to gather evidence to provide the court proof beyond reasonable doubt. He agreed an investigation includes embracing other evidence that tends to undermine a central hypothesis relevant to guilt. 69 T 658. 70 (I assume typographical error and means ‘Kirby’). 71 Exhibit D72 (admitted on Voir Dire as Exhibit VDD23). 72 Exhibit D72 (admitted on Voir Dire as Exhibit VDD23). -- 36 of 345 -- [2026] SADC 67 35 155 In an email DBS Sherratt sent to other members of SAPOL on 17 February 2020 at 4.57 pm, he said: Dr Edwards states that the subdural haemorrhages in [JR]'s brain could have occurred up to two hours prior to his respiratory distress and cardiac arrest. Dr Edwards states that if put on the stand that would be her evidence would reflect this. She goes on to say that if the brain injury was even more acute and caused cardiac arrest within 5 minutes of its infliction then the doctors would be more likely have seen blood in the cervical fluid. This was not the case and so the only qualification of the timeline they can give without the blood in the cervical fluid is that the injury was caused up to 2 hours prior to the ambulance being called. The scenario puts [TR] still in the house at a time when the injury could have been inflicted upon [JR] therefore I propose I will arrest both [TR] and [SR] for the Criminal neglect of [JR]. 156 DBS Sherratt agreed he was in consultation with Dr Edwards about charging TR. He was not privy to communications around this issue between Dr Edwards and Assoc. Prof. Linke and had not received an update on the ‘qualification’ that he had attributed to Dr Edwards in his email. 157 DBS Sherratt was asked about an email sent by Dr Edwards to him and Assoc. Prof. Linke on 21 November 2023 at 8.24 pm which read as follows:73 …I’m unsure what other defence strategies there could be short of [SR] pleading guilty or progressing to trial as the latest “expert” report is a biased literature review of “Shaken Baby Syndrome” which was not alleged in this case as [JR] had a high fore head impact injury. 158 DBS Sherratt denied that he took it as a contest between prosecution and defence despite having in other emails referred to the defence case ‘falling apart’, and ‘grasping at straws’ which he accepted was ‘unprofessional’74 and ‘inappropriate’.75 159 DBS Sherratt said that the purpose of his meeting with Dr Edwards on 6 February 2020 was to engage with Dr Edwards to find out what possible meetings that she or CPS were going to have with the [redacted] family, the timings of those and any content that was being discussed for the purpose of the investigation using devices under the Surveillance Devices Act 2016 (SA). He confirmed that he did not take notes of that meeting. 160 DBS Sherratt agreed that Dr Edwards sent an email on 6 April 202076 to the DCP (Ms Breuer) which was copied to him, referring to appointments for JR with paediatric neurology and ophthalmology. He said that statements from experts in those specialities were not sought. 73 Exhibit D75 (admitted on Voir Dire as Exhibit VDD26). 74 T 720. 75 T 720. 76 Exhibit D62 (admitted on Voir Dire as Exhibit VDD11). -- 37 of 345 -- [2026] SADC 67 36 161 In re-examination, DBS Sherratt said that his email dated 17 February 2020,77 setting out what Dr Edwards had said was his understanding at the time, was not word for word. As at that date he had not finished providing Dr Edwards with all the materials that were ultimately provided to her. 162 As to the Interagency Code of Practice78 the document in place as at January 2020 was the version with a publication date of July 2016. DBS Sherratt said that he was familiar with the Code and as best he was able, applying the Code at the relevant time. Defence submissions 163 I received detailed written79 and oral submissions on the application in which it was argued that Dr Edwards: • Failed to maintain the requisite objectivity and/or impartiality necessary for the admissibility of expert opinion evidence. • Failed to act only upon facts, either assumed or provided to her, to provide the foundation for the evidence of opinion she proposes to provide to the Court. • Set about manipulating the witness narratives and thus sought to sway /alter the factual basis upon which her evidence of opinion was to be premised. • In the above context failed to conduct herself with the required level of propriety essential to the role she seeks to perform, and thereafter to the admission of expert evidence. The reliability of the proposed evidence is irreparably compromised as a result. • Engaged in conduct that may be seen as an attempt to pervert the course of justice. He credibility is irreparably damaged as a consequence. • Had not behaved or acted in a manner consistent with the requirements of her purported role in these proceedings. Furthermore, defence counsel particularised the improper conduct in which Dr Edwards had engaged in as follows: • Attempted to persuade others (the accused, TR and family members) to accept her hypothesis that JR had been hurt by someone; that their explanations were untenable; and discounted their alternative innocent explanations. She recorded the witnesses were ‘on board’ with the idea that JR has been hurt by someone. Furthermore, she attempted to persuade them that ‘previous explanations are untenable; the injuries were caused by high 77 Exhibit D63 (admitted on Voir Dire as Exhibit VDD12). 78 Exhibit P74 (admitted on Voir Dire as Exhibit VDP25). 79 Outline of argument on r 39 application exclusion of the evidence of Dr Edwards filed 27 February 2025 (FDN 153). -- 38 of 345 -- [2026] SADC 67 37 forces; and she sought to discount alternative innocent explanations. See email 30 January 2020 at 3.42 pm.80 • Had ‘moved to eradicate evidence’ that tended to exculpate and, sought to gather evidence to support her opinion/hypothesis. In this context she sought to modify/manipulate the facts upon which her opinion was premised - and eradicate narratives that may compromise opposition. See email 30 January 2020 at 3.42 pm.81 • Engaged in communications with both police and the DCP with a view to supressing and/or altering innocent explanations supplied by eyewitnesses - or attempted to have the relevant witnesses move away from narratives that were consistent with the innocence of both the accused and/or his estranged wife with the potential to ‘poison the well’. See email from DBS Sherratt to Dr Edwards et al dated 15 January 2020 at 3.55 pm82; email dated 30 January 2020 at 3.42 pm from Dr Edwards to Kate Breuer et al)83 and Continuation Sheet Inpatient record dated 6 January 2020.84 • Provided firsthand advice to the accused and potential witnesses excluding available explanations for the symptoms. For example, the head injury sustained on 30 December 2020. See email dated 30 January 2020 at 3.42 pm from Dr Edwards to Kate Breuer et al)85; and email dated 20 January 2020 at 2.07 pm from Dr Edwards to SAPOL.86 • Took active steps to undermine the accused’s right to silence and reverse the burden of proof. See email dated 24 January 2020 at 10.36 am from Dr Edwards to Kate Breuer (DCP);87 and email dated 30 January 2020 at 3.42 pm from Dr Edwards to Kate Breuer et al.88 • Acted in concert with police to break down resistance to her speculative hypothesis in attacking expressions of disbelief that the parents deliberately inflicted the injuries. See email dated 30 January 2020 at 3.42 pm from Dr Edwards to Kate Breuer et al.89 • Attempted to manipulate the evidence supplied by the family which was entirely consistent with the innocence of the accused. See email 80 Exhibit D52 (admitted on Voir Dire as Exhibit VDD1). 81 Exhibit D52 (admitted on Voir Dire as Exhibit VDD1). 82 Exhibit D54 (admitted on Voir Dire as Exhibit VDD3). 83 Exhibit D52 (admitted on Voir Dire as Exhibit VDD1). 84 Exhibit MFI D2 – Which I note is a note made in JR’s medical record of a conversation between medical Registrar and Dr Murphy (GP). 85 Exhibit D54 (admitted on Voir Dire as Exhibit VDD3). 86 Exhibit D54 (admitted on Voir Dire as Exhibit VDD3). 87 Exhibit D52 (admitted on Voir Dire as Exhibit VDD1). 88 Exhibit D52 (admitted on Voir Dire as Exhibit VDD1). 89 Exhibit D52 (admitted on Voir Dire as Exhibit VDD1). -- 39 of 345 -- [2026] SADC 67 38 15 January 2020 at 3.55 pm from DBS Sherratt to Dr Edwards and email dated 3 February 2020 at 1.45 pm from Kate Breuer to Dr Edwards.90 • Engaged in communications that are directed towards managing and/or controlling the path of the police investigation and is actively involved in the process of investigation and engaged in confidential meetings with police and results in expert being privy to information that may never be disclosed to defence, falls foul of the restrictions on admissibility/use of evidence spoken to in the High Court authority of HT v the Queen [2019] HCA 40. • See email from DBS Sherratt to Dr Edwards et al dated 15 January 2020 at 3.55 pm.91; email dated 20 January 2020 at 2.07 pm Dr Edwards to SAPOL;92 email from Dr Edwards to Emma Press and Kate Breuer dated 21 January 2020 at 8.40 am.93 and email dated 24 January 2020 at 10.36 am from Dr Edwards to Kate Breuer.94 • Made efforts to engage with police in their investigation including to have the accused engage in a re-enactment, having phones seized and listening devices installed. Steps which appear to have been taken prior to the completion of her report, with the ‘unavoidable’ inference that there existed confidential communications to which the defence will not be privy. See email dated 7 April 2020 at 4.52 pm from DBS Sherratt to Dr Edwards;95 email dated 7 April 2020 at 12.21 pm from Dr Edwards to DBS Sherratt.96 • Attempted to suppress provision of evidence that she prepared as a consequence of protecting police methodology. • Showed a ‘lack of professional decorum and/or fairness (with reference to email from Sherratt ‘it is absurd that they are making you write another one and expressing frustration at the failure of the accused and family to accept her hypothesis. See email dated 24 November 2020 at 5.35 pm from Dr Edwards to DBS Sherratt.97 • There was evidence of undisclosed enquiries and/or involvement of additional experts not disclosed to defence. See email dated 6 April 2020 at 10.05am.98 • That her opinion was that the timing of the respiratory distress and cardiac arrest, if consistent with the infliction of trauma, could have been caused up 90 Exhibit D54 (admitted on Voir Dire as Exhibit VDD3). 91 Exhibit D54 (admitted on Voir Dire as Exhibit VDD3). 92 Exhibit D54 (admitted on Voir Dire as Exhibit VDD3). 93 Exhibit D52 (admitted on Voir Dire as Exhibit VDD1). 94 Exhibit D52 (admitted on Voir Dire as Exhibit VDD1). 95 Exhibit D57 (admitted on Voir Dire as Exhibit VDD6). 96 Exhibit D52 (admitted on Voir Dire as Exhibit VDD1). 97 Exhibit D61 (admitted on Voir Dire as Exhibit VDD10). 98 Exhibit D62 (admitted on Voir Dire as Exhibit VDD11). -- 40 of 345 -- [2026] SADC 67 39 to 2 hours prior to the ambulance being tasked. This aspect of the opinion, which carries a very important concession, has never been expressly and/or clearly stated within any of the reports authored by Dr Edwards. See email dated 17 January 2020 at 4.57pm from DBS Sherratt to parties arising from discussions with Dr Edwards.99 164 The defence contentions in opposition to the admission of Dr Edwards’ evidence can be summarised as follows: 1. An expert’s opinion must be drawn from the expert’s specialised knowledge and be based upon relevant facts; facts which the expert has observed, assumed or been instructed to assume. 2. An expert cannot attempt to manipulate or create a factual basis that will facilitate the provision of a subjective opinion, as has occurred here. 3. It is not the task of the expert to interfere with the basal evidence or interfere with the evidence that the lay witnesses are able to proffer. To do so constitutes an attempt to dissuade a witness. This conduct is not only entirely inconsistent with the role of the expert witness, it constitutes the commission of a serious criminal offence(s). 4. The authorities make clear that the task of an expert witness is to furnish the trier of fact with the necessary scientific/expert criteria to enable the trier of fact to make its own independent judgment on the application of those criteria to the facts it finds. 5. This is the primary duty of the expert, see for example Haydon JA in Makiti (Australia Pty Ltd) v Sprowles [2001] NSWCA 305 at [59]. 6. The process of reasoning cannot go beyond expertise, and delve into assessments of witness credibility, see for example Makita v Sprowles (2001) 52 NSWLR 705 at [85]. The expert cannot “drift into giving the courts reasons why they should accept or reject the evidence of lay witnesses on matters of fact”, per Heydon J in Dasreef v Hawchar (2011) 243 CLR 588 at [58]-[59]; let alone attempt to manipulate/pervert those narratives as has occurred here. 7. An expert must remain impartial and independent and provide their opinion from this objective standpoint. The expert has an overriding duty to remain impartial and to assist the court accordingly. The expert cannot become the advocate. It is not acceptable for an expert to exhibit bias, and/or to act as an advocate or proponent of an argument. 8. When an expert fails to act in an impartial manner, and as was the case here, involves themselves in a process of manipulation of the factual matrix upon 99 Exhibit D63 (admitted on Voir Dire as Exhibit VDD12). -- 41 of 345 -- [2026] SADC 67 40 which their opinion will be applied, they have abrogated their fundamental responsibility to the court – and their evidence is thus liable to be excluded in the exercise of the court’s discretion. The expert here cannot now discharge the role required of them, they have displayed profound bias, and in the context thereof, they have become the facilitator, or a principal protagonist, in the commission of a criminal offence. Prosecution submissions 165 I received detailed written100 and oral submissions opposing the application, which I summarise as follows: • There are three institutions with competing roles to play, that is, SAPOL, which investigate crimes; DCP, which t look to the protection of children and CPS, an arm of the WCH to whom Dr Edwards is attached. Dr Edwards’ role is apparent from the Interagency Code of Practice. It is to provide a medical opinion as to causation and timing. The CPS provided an opinion to the DCP and SAPOL seen from 5 January 2020 in the Crisis Care Strategy Discussion document setting out Dr Noori's opinion at the time that all injuries appear to be inflicted, that there are injuries to the ribs of varying ages and something could have happened that day resulting in JR becoming unresponsive and having seizures. That document has been provided to DCP and to police and fits with the varying institutional roles and, in particular, with the Interagency Code of Practice. • Dr Edwards returned to work on 13 January, which was the start of her involvement, after there has already been a meeting with the family where they understand something really bad has happened and the police are going to be involved. • Dr Edwards’ task was to gather the information and then to report. This was occurring in real time with the competing interests of the welfare of not just JR, but also BR. The involvement of DCP was there front and centre because their obligation is to the children and the CPS is gathering materials to try to work out what has happened. • By the time Dr Edwards became involved, the medical evidence was already plain with reports from Assoc. Prof. Linke and Prof. Taranath. Dr Edwards got the balance of the materials together for the purposes of a report. Dr Edwards was to report on causation, the genesis of the injury. • In answering the various issues raised by the family as ‘possible but not likely’ Dr Edwards was not seeking to dissuade a witness, rather, she was providing her opinion. The purpose of the meetings was to provide medical information. As to that in some way changing their narrative, there was no 100 Prosecution outline of argument on r 39 application; exclusion of the evidence of Dr Edwards filed 27 February 2025 (FDN 154). -- 42 of 345 -- [2026] SADC 67 41 application from defence seeking to exclude evidence of the accused, TR or family members as improperly obtained. • Dr Edwards’ opinion that JR suffered a caused injury, is presented to DCP in a setting where, on the Interagency Code of Practice, their obligation is to the children. It can, the prosecutor argued be inferred that if there are parties who are not prepared to see that there is a problem in this family unit, then it is not safe to let the children return to that setting. That is not something that falls at Dr Edwards' feet. That is the DCP. • All witnesses accepted that Dr Edwards was putting her opinion, and they did not like or agree with it. They were not happy with her rejecting any other alternate hypothesis. • As to the criticisms of DBS Sherratt and the right to silence it would appear, the prosecutor argued, that DBS Sherratt’s involvement in the case was consistent with the earlier Interagency Code of Conduct. Importantly, this was not an application to exclude anything said to DBS Sherratt. Whether or not defence have a complaint in respect of DBS Sherratt's conduct is an entirely separate issue. The application was for the exclusion of Dr Edwards’ evidence. • If all the family were saying 'Nothing to see here', that is a relevant consideration as to whether they are the appropriate caregivers for the infants in the setting of an unexplained injury. • As to the email communications, they provided no basis for the argument that Dr Edwards attempted to persuade others to accept her hypothesis or that she acted in concert with police to break down any resistance to her hypothesis. • Arrangements were made by Dr Edwards for medical feedback after the SAPOL interview. • In her reports Dr Edwards set out the origin of the information and then her opinions drawn from that are set out. • Dr Edwards is the appropriate witness to comment on the forensic pathology in the first-hand manner because that is her role within that institution. • There is, the prosecutor submitted, nothing controversial as to the authorities as regards an expert not being an advocate and being independent but it is in a setting of a statutory scheme. Discussion 166 As I found at the time, there was nothing before me to demonstrate that Dr Edwards had not acted impartially or without propriety in expressing her -- 43 of 345 -- [2026] SADC 67 42 opinions to the accused and the family, or in her communications with SAPOL or the DCP. 167 AE was particularly critical of the approach taken by the DCP. There is no doubt that his and his wife’s interactions with the DCP regarding the care of the child BR, was distressing and frustrating for them, particularly when they were so skeptical of the opinions expressed by Dr Edwards that JR had both pre-existing and recent injuries. That they were in disbelief is not surprising. 168 I have no doubt that those who attended the meetings with Dr Edwards genuinely believe they were not being listened to and clearly, they did not accept what she told them as was their right. In my view, their perception and their disbelief arises from their inability to accept that the accused or TR had anything to do with the findings described by Dr Edwards regarding JR’s presentation on 5 January 2020 or what were assessed as pre-existing injuries. 169 I make no criticism of either AE or BE being able to rationally recognise that what Dr Edwards was no doubt endeavoring to do was to answer their questions which each agreed they were after, or to accept that the processes in place were to ensure the safety of both JR and BR. This was a highly traumatic and confronting set of circumstances which I accept anyone holding the parents in high regard would have difficulty in fully processing, particularly when the family had such a close relationship and given that JR had always appeared ‘well’. Their perception of what occurred is no doubt further influenced by the connection between the DCP and Dr Edwards’ opinion given that was the basis for decisions the DCP made regarding the ongoing care of both BR and JR and charges that were ultimately laid. 170 It would appear the accused is mistaken as to his recollection of who attended the meeting with Dr Edwards on 30 January 2020, but in my view, nothing turns on that mistake. 171 Dr Edwards expressed her opinions based on the findings made in the various investigations and assessments that were made at the hospital earlier by other medical practitioners. The requirement for an expert in expressing their opinion to be impartial is beyond question. There was nothing in the material before me or in the evidence tendered in support of the application that caused me to conclude that she had demonstrated any level of impropriety in carrying out her responsibilities in this matter. 172 While Dr Edwards set out her opinions to the family and was perhaps even dismissive of the evidence they put forward regarding alternative causes for JR’s presentation, that does not equate to attempting to dissuade a witness. It is plain from the evidence of both members of TR’s family that they put forward various suggestions as to possible causes for JR’s presentation which Dr Edwards assessed as possible but highly unlikely. That does not equate to having attempted to -- 44 of 345 -- [2026] SADC 67 43 dissuade a witness. She presented the family with her opinion, which they did not accept as was their right. 173 That DBS Sherratt may have expressed himself in what he described as ‘unprofessional” and ‘emotive’ terms, did not influence my assessment of Dr Edwards’ involvement. On 13 February 2025101 I dismissed the application to exclude Dr Edwards’ evidence. The prosecution case TR’s antenatal history and JR’s birth Dr Murphy’s evidence 174 Dr Murphy said that he first met TR in mid-2019 when she was referred for obstetric shared care to manage her pregnancy. 175 Dr Murphy received his bachelor’s degree in medicine at the University of Nottingham in the United Kingdom in 2008. He has a Diploma of the Royal College of Obstetrics and Gynaecologists and is a Fellow of the Royal Australian College of General Practitioners. Since 2024 he has practiced as a GP at the Golden Way Medical Centre. 176 Dr Murphy understood that JR’s birth had been via an induction of labour at 38 weeks because of intra-uterine growth restriction. TR was having extra monitoring at the hospital, and it was decided that it would be safer to deliver the baby early because of concerns regarding the integrity of the placenta. There was an artificial rupture of membranes to speed up the natural process of labour and an epidural administered. There was evidence of some foetal distress in labour indicated by bradycardia. He understood that JR was delivered by ventouse extraction in good condition. Dr Hargreaves’ evidence 177 Dr Hargreaves practices in Melbourne as an obstetrician and gynaecologist. She has been a fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists for about 24 years. She has delivered between 200 and 250 babies each year since about 1995. 178 Having reviewed the medical records relating to TR’s pregnancy, Dr Hargreaves noted that the pregnancy was complicated by gestational diabetes with insulin required for optimal glycaemic control. As a result, there was a plan to induce labour at 38 weeks, which was commenced on 18 November 2019. Labour came on quite quickly and there was rapid progress to full dilatation. The foetal heart rate monitoring at that time became non-reassuring so the obstetrician on call attended and performed a vacuum extraction after manual rotation of JR, 101 Ruling at T 823. -- 45 of 345 -- [2026] SADC 67 44 who was born in excellent condition on 19 November 2019 with APGAR scores of eight and nine. He did not require resuscitation. 179 Dr Hargreaves noted that there were two pulls to effect delivery. The first was documented at 4:31 am and the second shortly thereafter at 4:33 am. JR’s head was delivered at 4:34 am meaning that delivery was quick and impliedly straightforward in nature. A small tear to TR’s perineum was repaired. Dr Hargreaves described this as very minimal trauma after an instrumental delivery. 180 From her review of the notes, Dr Hargreaves concluded that there was nothing unusual, recorded in relation to JR’s birth. The notes confirmed a series of postnatal examinations. The midwifery staff noted a bruise on JR's scalp consistent with a vacuum extraction. There were two neonatal examinations in the 36 hours that he was in hospital where the fontanelles and the sutures between the bones on JR’s head were noted to be normal. 181 Dr Hargreaves said that had there been substantial or significant head trauma, these examinations would not have been described as normal. There were no observations consistent with head trauma on the next reviews undertaken either at hospital or by the GP, other than that relating to the sofa incident on 30 December 2019. 182 Dr Hargreaves said that she was not an expert on the correlation between maternal vitamin D levels and what they could have been at the birth, so would have trouble expressing an opinion about it. JR had lots of ultrasounds because of the concerns about intrauterine growth and at no point did anyone express a concern about neonatal rickets. 183 She added there was no evidence that JR was affected by neonatal rickets. JR’s neonatal progress Dr Murphy’s evidence 184 Dr Murphy first saw JR on 6 December 2019 for a two-week baby check. 185 He noted that JR’s height, weight and head circumference were all within normal range. 186 TR informed him that JR was breastfed for 24 hours and then bottle fed. She had said that JR was feeding ok but ‘spewing’102 and the Healthline had suggested he be given lactose free formula. Midwives had visited the home and noticed some jaundice, but no treatment was thought necessary. 102 T 31. -- 46 of 345 -- [2026] SADC 67 45 187 Dr Murphy noted that JR’s parents said JR ‘seems to be in a lot of pain’,103 and Dr Murphy questioned whether JR was suffering gastro-oesophageal reflux disease and suggested the medication Losec. 188 A full-body examination of JR was performed which Dr Murphy said would involve palpating the femoral pulses and checking the hips, testes, and anus. The baby’s nappy is removed, and the entire surface of the baby’s skin is checked. He said that these checks revealed nothing out of the ordinary, and he would have recorded anything of significance in his notes. He referred JR to Dr Christopher Kirby for circumcision. 189 Dr Murphy next saw JR on 20 December 2019 and recorded that JR was doing well and was more settled. He was being given a different, thicker formula and was still taking the Losec. He was growing well. Dr Murphy said that JR would have been stripped down to his nappy to be weighed but would not have been formally examined. Again, any observations of note would have been recorded. 190 Dr Murphy saw JR again on 3 January 2020 for his scheduled six-week visit. It was noted that JR was 'still unhappy with bowels’.104 Dr Murphy recommended the dose of Losec be increased and to add the medication Infacol. JR’s height, weight and head circumference were measured. JR was immunised with the assistance of the practice nurse, Ms Amos. 191 In cross-examination, Dr Murphy agreed that on 6 December the parents advised him that JR was in a lot of pain. He was vomiting which seemed to lead to cessation of the pain and he had concluded that this could be consistent with reflux. He said that reflux was a working diagnosis, and JR seemed to be doing well and was improving. Ms Ames’ evidence 192 Ms Ames is a registered nurse employed at the Golden Way Medical Centre. 193 She had assisted Dr Murphy with JR’s immunisations on 3 January 2020 which were administered to the mid-thigh. She said that in administering the injection, she usually kneels on the floor, just next to the child and has a clear view of the legs. 194 She said she did not notice anything unusual concerning the condition of JR’s legs at the time and had she noticed bruising or swelling, she would have raised it with the doctor. 103 T 32. 104 T 39. -- 47 of 345 -- [2026] SADC 67 46 Sofa incident Dr Gillis’ evidence 195 Dr Gillis’ evidence was agreed as follows:105 I'm a registered medical practitioner, having received my Bachelor Degree in Medicine at the University of Adelaide in 1982. I have had further qualifications but do not practice them any further. I have worked for Golden Way Medical Centre, Lot 2, 1040 The Golden Way, Golden Grove, since this centre moved from Greenwith to this location in 2011. I have consulted the notes I made about our medical centre's Best Practice records system. I first saw [JR], date of birth 19/11/2019, at the Golden Way Medical Centre on 30 December 2019. He was brought in by his mother, [TR], in relation to a head injury. One of the staff members said to me that there was a baby to be seen as he had a hit on the head. I had not seen the mother on any other occasion. It was 1.20 p.m. this day when I saw the child and mother. The mother reported the following to me during this appointment. She brought the baby in because the baby had an egg on his head. She said the father was holding the baby at about 10.45 a.m. that morning in front of the television. He has reached down to pick up something on the floor. The baby has been in his arms and then the baby's head has hit a console. I am not sure what that is but presume it to be some sort of harder furniture. The baby apparently cried straight away. The mother said to me that when the father told her what happened, the father was crying. The child had a feed since the incident. I'm not sure if this was a bottle-feed or breastfeed. There was no report of vomiting since the incident. The child was generally reported to have normal behaviour and there were no additional concerns apart from having a swelling to his head. I am aware that the child was given a dose of Panadol prior to my appointment. After getting background information, I conducted an examination of [JR] and made notes of my examination. The baby was not unhappy or crying. The baby looked happy. I checked the swelling on the head which was on the side of the head. It was located on the right occiput. There was no broken skin or bleeding that I observed. The child did not have thick hair and I could see the scalp easily. I shone a torch in the eyes and they were equal and reactive to light. I observed no bleeding or other abnormalities to the eyes or head. I conducted an overall examination of the child's head and did not see any other abnormalities to other parts of his head. The injury was localised to one spot. There was no indication of any loss of consciousness or internal haemorrhaging. I did not conduct any body examination of the child. He was already dressed during my appointment and he was not undressed. I could not say if there were any other injuries to his body, but I did not gain any reason to suspect anything. My determination was that the injury was minor and did not require any further assessment or examination at hospital. This was based on a combination of the history provided and my examination. I reassured the mother that it was highly unlikely to be any intra-cranial issues as a result of the injuries I observed and the mechanism of injury as provided. There was no scheduled review in relation to this injury but I was aware of a scheduled routine appointment on 3 January 2020. I believe the mother mentioned it. The mother communicated in a sensible and intelligent manner, providing me with all the information I needed to know or requested. I held no concerns with how she presented to me. Later that 105 T 1336-1338. -- 48 of 345 -- [2026] SADC 67 47 evening, I spoke with Dr Kevin Murphy and briefly discussed my appointment with [JR] and his mother. Dr Murphy’s evidence 196 Dr Murphy said that he recalled speaking with Dr Gillis about the consultation with JR on 30 December 2019, but had no recollection of that discussion. 197 With respect to checking whether there was still ‘boggy swelling’ which had been noted by Dr Gillis on 30 December 2019, Dr Murphy said ‘I'm sure I had a look, but I can’t say for sure because I didn’t record anything.’106 198 Dr Murphy said the knock to the head, was a topic that came up during the consultation on 3 January 2020. He said that based on what he had told police:107 I didn’t record much in the notes because the child was there for immunisations and a baby check and sometime had already elapsed between the knock to the back of the head and when I saw the child and the danger period for any significant intracranial injury would have passed by then. So I - and I had no cause to be concerned regarding that, non-accidental injury, so I did not put much emphasis on that, but I would have run through, presumably, what happened when the patient came to see Dr Gillis. 199 He said that the parents had not raised any concerns relating to JR demonstrating an altered conscious state, or excessive vomiting. They had not reported that JR did not want to be touched, any jitteriness, seizures or any significant change in behaviour. Such issues would have unequivocally raised concern. He said that the fact that the parents cited none of those issues gave him cause to believe that there was nothing sinister about the head knock a few days before. 200 On checking JR’s head there was still some swelling, which Dr Murphy described as mild. He found that there was no cause to be concerned. Dr Murphy explained that ‘when you sustain a mild trauma to the back of your head, you can get some subcutaneous swelling there. It’s extracranial, meaning it’s between the scalp and the skull. It’s not inside the skull.’108 201 From his discussion and his physical observations, he was not worried about any impact from the knock to JR’s head and in any event, the danger period of 24-48 hours had passed. 202 The plan was for JR to return for the meningococcal B injection the following week. 106 T 40. 107 T 44. 108 T 45. -- 49 of 345 -- [2026] SADC 67 48 203 In cross-examination, Dr Murphy agreed that he had described TR as a ‘helicopter mother’109 when speaking to hospital staff at the WCH on 6 January 2020. He agreed that save for the head injury there were no bruises, markings, lacerations, contusions observed on JR at the 3 January 2020 consultation. Events on 5 January 2020 Ms Esplin’s evidence 204 Ms Esplin had been TR’s hairdresser for nine years and works from her home. 205 TR had contacted her on 2 January 2020 to arrange for her hair to be cut and coloured and an appointment was made for 5 January 2020 at 11.30 am. 206 By reference to a text message that TR had sent her on 5 January 2020, TR arrived at her appointment at 11.19 am. TR took a call on her phone and told Ms Esplin she had to go. Ms Esplin drove TR to the home. Accused’s statements to police and 000 call 000 call made by the accused. 207 The accused called 000 at 12.17 pm on 5 January 2020.110 208 He told the operator that:111 I got my 6-week old son out to feed him and he was not breathing. 209 He said he thought his heart was beating but was taking a breath every now and then. 210 The operator gave instructions as to how to position JR and give mouth to mouth and chest compressions. Interview with accused on 5 January 2020. 211 The accused was interviewed by police at the WCH on 5 January 2020, commencing at 19.31 hours.112 212 The accused was informed that the interview was being recorded and that he did not have to answer questions. The accused described JR’s birth as ‘a straightforward birth and induction’.113 213 He said that JR had only ever been in his and TR’s care. 109 T 52. 110 Exhibit P92. 111 Exhibit P92. 112 Exhibit P38. 113 Exhibit P38. -- 50 of 345 -- [2026] SADC 67 49 214 He said that JR had been ‘fantastic’. He had a ‘bit of reflux’ but was said to be doing fine and saw the doctor every second week. 215 When asked whether there had ever been an opportunity where BR had been alone with JR, the accused said that JR might have been in his bassinette in the lounge room on a stand, with BR watching TV and playing with toys. The accused said that there had never been any time when BR had been a bit rough with JR. 216 The accused said the only incident that might have caused JR an injury was the sofa incident. 217 The accused said:114 He was sitting on my lap; I was getting ready to feed again. Sitting on my lap and our couch has like a centre console with cup holders at the front of it. The centre console is quite soft. Forward of that is where the cup holders are and it’s got on like a sharpish edge, it’s still like got a fabric over it and stuff but it’s quite solid under there. And I had [JR] on my lap with his feet scrunched up kind of thing just sitting there nestling in there and I wanted to get the TV remote and I couldn’t… I’m Right handed so I couldn’t reach over and, reach it so I had to then hold him with my Right hand and reach with my left. As I did that he pushed off my leg and he, like bumped his head upon on the, on the hard part on the corner. 218 The accused explained that JR kicked him in the stomach and pushed off with both his legs and drove himself into the corner of the cup holder. JR had caught his head at the back on the right side. JR had cried then calmed down and he fed normally without throwing up. Then he noticed the bump. 219 When TR returned home, she took JR to the medical centre. TR told him that the doctor said JR looked alright, his pupils were good and his eyes were not rolling back in his head. They were told to monitor JR to make sure he did not throw up or go downhill. If there were any signs they were to take him straight to Emergency. The accused said that within 24 hours the bump started coming down. 220 With respect to the events of 5 January 2020, TR left home at 11.15 am. 221 The accused provided some context for the events of that morning.115 He said:116 And then you know I knew he was coming up for a feed around middayish but I was just sitting on the couch; [BR] was in her bed at this time asleep. And anyway I was just on my iPad just watching YouTube or something. And then he started fussing, I’m like ah that’s normal, he’s coming up for a feed. 114 Exhibit P38. 115 Exhibit P38. 116 Ibid [368-378]. -- 51 of 345 -- [2026] SADC 67 50 And I don’t as soon as he starts fussing I’m not there straight away like cos a baby they just fuss all the time. So I, you know I was, eventually I got up and started talking to him and saying ‘are you hungry mate like I’ll get your feed in a minute. 222 The accused said that he unzipped JR from his swaddle and laid him on a change pad on the carpet. He was not really ‘like screaming’. He took the bottle from the fridge and took it to the microwave. It takes a minute to prepare. The accused said he came back down and started undoing JR’s suit and noticed JR was struggling to breathe. Every now and then he would breathe but it was gasping. 223 He was also very limp and just wasn’t moving. He checked his airway and that was clear. He knew JR was not breathing very well at all. He could not tell if JR had a heartbeat. He could hear something in his chest and was starting to panic. He gave JR two breaths, and nothing really came so at that stage he called the ambulance at around 12.15-12.20 pm. 224 The operator talked him through some compressions. The ambulance arrived within 2 minutes and worked on him for ages. 225 The accused said that the night before JR was being fussy and grunting a little more, but they had put that down to his immunisations. Apart from that he still slept a good four hours. TR fed him around 12-1 am and he fed him at around 4-5 am. The accused described JR’s bottle feeding and medication for reflux. 226 The accused was then informed of ‘historical fractures’ the doctors had found. He said that he had absolutely no idea how they would come about. He also said that he had no idea about any sort of injury to the left side of JR’s head. 227 The accused described TR as an ‘absolutely fantastic mother’ to JR and BR. She had never suffered from post-natal depression. The accused said he loved his children. JR was his little boy and he loved him. Interview with accused on 23 January 2020. 228 This interview took place at the Wakefield Police station at 6.52 pm and was conducted by DBS Mathew Stock.117 229 The accused was informed that he was not being arrested. He had attended in relation to bringing his vehicle in to be examined and photographed. 230 He was told he would be asked questions about JR’s injuries and was informed that he was not obliged to answer. 231 The accused said that he did not wish to answer questions in relation to JR’s injuries at that stage. He said he could not believe that more injuries had been identified and could not see how the injuries to JR’s head had occurred up to a couple of hours prior to him struggling to breathe. He said he would like to know 117 Exhibit P39. -- 52 of 345 -- [2026] SADC 67 51 how the injuries were sustained and that all they knew was what had been told to police about the sofa incident. Interview conducted on 24 February 2020 232 The interview took place at Elizabeth Police Station at 7.50 pm and was conducted by DBS Sherratt.118 233 At the outset, the accused was placed under arrest for the neglect of JR.119 He was given his rights. The accused was informed of the injuries it was alleged JR had suffered and the medical opinion that the injuries occurred up to two hours prior to his cardiac arrest. 234 The accused indicated that he did not wish to make any comment. Evidence of the paramedics in attendance on 5 January 2020 Ms Iellamo 235 Ms Iellamo said she has been a paramedic for approximately five years. In January 2020 she was working as an intern practising under the supervision of paramedic Ms Preece. 236 On 5 January 2020 the SA Ambulance Service (SAAS) was called and dispatched at 12.18 pm. She and Ms Preece arrived at the house at 12.20 pm. 237 On arrival no-one answered the door. They entered and there was someone who she assumed was the father of the baby who said, ‘he's over there’.120 As she walked over, she noticed that there was a baby on the ground and he was gasping for air.’121 She thought the baby was on a change mat. 238 She described the accused as ‘distraught’.122 He was in the kitchen and she remembered asking him what happened, but he just could not talk and would not come out of the kitchen. She said that had to coax him to come over and tell her what happened. He said he was changing the baby and he just stopped breathing. 239 At the time there were no obvious injuries to JR, although she did not look for them specifically. While the baby was on the floor, she and Ms Preece commenced CPR. 240 Ms Iellamo started to do the two-finger method of chest compression but as that was quite fatiguing, she changed to holding the baby with her fingers under the chest and two thumbs on top. When they arrived the baby’s breathing was described as agonal, that is, ineffective breathing, very shallow, not true breathing, 118 Exhibit P40. 119 TR was also arrested. The charge was later dropped. 120 T 64. 121 T 64. 122 T 64. -- 53 of 345 -- [2026] SADC 67 52 just gasping. The baby was blue and floppy. While they performed CPR, the accused was in the kitchen and the baby’s mother arrived. 241 After some time, the baby’s pulse revived, his breathing stabilised and he was fit for transport to the WCH. The baby’s condition improved on the way to the hospital with his conscious state picking up a bit. 242 In cross-examination, Ms Iellamo agreed the baby was held with her hands encompassing or encircling the rib cage, with her fingers resting either side of the spine. She thought she did CPR for 15 minutes with the main pressure to the sternum. She said that it was obvious that the baby was under some form of cardiac arrest. 243 If she had observed any injuries, they would have been documented. She did not see any seizure activity. Ms Preece 244 Ms Preece has a Bachelor of Paramedic Science, completed in 2011 and a Graduate Diploma of Critical Care Paramedicine completed in 2022. On 5 January 2020 she was on duty and supervising Ms Iellamo. 245 She said that had she seen anything wrong with Ms Iellamo’s work she would have stopped, intervened, or corrected her. 246 On entering, the house the baby was laying in the middle of the floor of the lounge room. 247 There was a male who she now knows to be the baby's father who was performing CPR, using two fingers over the centre of the baby's sternum. Ms Iellamo took over the compressions from the father using a two-thumbed technique with her hands around the back of the baby's back. She said that the hands at the back are merely to support the baby and the pressure is generated from the movement of the thumbs on to the sternum. 248 Ms Preece was at the head end of the baby behind his head. She applied defibrillation pads to the baby's front and back. Once the pads were applied, a rhythm analysis found the baby to be in a rhythm called pulseless electrical activity, so the baby did have an electrical heart rhythm but with no pulse. They confirmed a cardiac arrest through to the SAAS communication centre at 12.22 pm. 249 Ms Preece described an agonal respiratory pattern as a gasping motion which occurs in the very terminal phases of life. A breathing tube was inserted into the baby’s mouth, attached to a bag valve mask which was squeezed to provide ventilation via a connection to oxygen. 250 Ms Preece said the baby’s father was hysterical. -- 54 of 345 -- [2026] SADC 67 53 251 The baby was undressed and they asked the father for a towel or a blanket so that they could support the baby's shoulders to provide ventilation. 252 To check if there is a pulse they perform a ‘charge and check’123 where the monitor is charged, the rhythm is assessed, followed by a pulse check to confirm if there is a return of spontaneous circulation. Ms Preece said that in her practice she was accustomed to the defibrillator charging to 200 joules for an adult, so from an audible perspective she had anticipated quite a long charging tone of about ten seconds. Because the monitor was only charging a very short amount of time to 15 joules, it was a very short dial-up tone. Ms Preece said that confused her and in the ‘chaotic’ nature of the scene, she inadvertently pressed the defibrillation button instead of the cancel button. She said that the discharge of the unit had no impact on the baby’s heart and he did not visibly move.124 253 During the initial resuscitation she tried to gain a history from the father about what had led to the baby being in cardiac arrest. He told her that he had been with the baby, had placed him either on the floor or in a rocker and then had left the room to get something. Ms Preece said she told him the baby’s mother needed to be there and for him to call her. 254 The second ambulance crew of Ms Walls and Mr Webber arrived, together with two intensive care paramedics, Mr Kretschmer and David Funnell. Intraosseous adrenalin was administered into the left leg by Ms Walls. Return of spontaneous circulation occurred at 12.44 pm before the baby’s mother arrived. Ms Preece described the baby’s mother as hysterical. 255 After the return of spontaneous circulation, the baby was moved to the ambulance and conveyed to the WCH. Seizures were not observed in the ambulance, and the baby started to move his arms and open his eyes. At the WCH the baby was handed over to the team of doctors and nurses. 256 In cross-examination Ms Preece said that while there was quite a bit of chaos, at the house, that chaos ultimately was successful in reviving the child.125 She agreed that there had been a lot going on. She thought the father was appearing to show an appropriate response to the situation. 257 Ms Preece agreed that there was no evidence of any trauma to the baby, and that it was a cardiac arrest and a respiratory issue. Ms Walls 258 Ms Walls said she had been a paramedic for seven-and-a-half years. 123 T 1239. 124 T 1239. 125 T 1245. -- 55 of 345 -- [2026] SADC 67 54 259 On 5 January 2020, she was tasked to the home as part of the second crew who arrived. She was working with Mr Webber. 260 When she arrived, the baby was on the lounge room floor, just near the couch. Ms Iellamo was providing compressions, and Ms Preece was organising the airway at the baby’s head, getting equipment out to provide the respirations. 261 She said Ms Iellamo was at the foot end of the baby with her hands around his chest using the thumbs on the anterior portion of the chest to perform compressions from the front. She recalled seeing the baby’s father at some point but had no interaction with him. 262 Ms Walls said she assisted with the airway and then put an intraosseous cannula into the baby’s tibia and assisted to help draw up adrenalin. 263 Intraosseous access involved inserting a cannula into the bone. The notes recorded that the cannula in the left tibia was initially patent and 50 mcg of adrenalin and saline administered at 12.38 pm. As the cannula stopped working, or became dislodged, a new cannula was inserted into the right tibia by another paramedic.126 264 The baby’s heartbeat and breathing were revived at just short of 20 minutes and the baby could be moved. 265 In cross-examination, Ms Wall said that intraosseous access is deployed in a cardiac arrest after attempts to get intravenous access has been unsuccessful. Anterior cubital fossa access in the front of the elbow was reported in the notes, as unsuccessful. She said that tibial fracture as a complication of the intraosseous infusion during paediatric resuscitation was not within her area of expertise.127 266 In re-examination, Ms Wall explained that intraosseous access was to the right and left tibia, that is, the long bone in the leg, below the knee at the knee end. 267 From just below the knee, the cannula goes from the outside towards the inside below the knee joint. The needle used is 15 mm in length. The aim is not to get it down the bone itself, but rather just inside, into the bone’s blood supply. Mr Kretschmer 268 Mr Kretschmer said he had been an intensive care paramedic for just over 20 years. 269 He explained that an intensive care paramedic is a paramedic who has been internally merit selected to undergo further training to receive another level of qualification.128 126 T 88. 127 T 93. 128 T 97. -- 56 of 345 -- [2026] SADC 67 55 270 He said that if any seizures were noted during his attendance, that would have been noted. Referring to the case card, he could say there were no seizures. 271 In cross-examination Mr Kretschmer described his role as a supervisory clinical role, providing advice and assistance to those physically administering care. He was unable to recall if he individually performed any procedures. 272 In re-examination, Mr Kretschmer said that had something been unusual in terms of the care being provided to the baby by those performing CPR, if he was present, he would you have intervened and made notes accordingly. Assoc. Prof. Linke’s evidence Qualifications and experience 273 Assoc. Prof. Linke holds a Bachelor of Medicine and a Bachelor of Surgery from the Flinders University. She studied to become a radiologist with the Royal Australasian College of Radiologists in Australia and is an Associate Professor of the University of Adelaide, teaching in the field of medical and diagnostic imaging.129 Assoc. Prof. Linke holds the qualification of specialist paediatric radiologist and supervises trainees in paediatric radiology. 274 She has published several peer-reviewed articles in scientific journals. 275 Her primary area of practice is in relation to medical imaging and paediatrics and she is a member of the North American Society of Paediatric Radiology, the Executive of the Australian and New Zealand Society for Paediatric Radiology and the European Society of Paediatric Radiology. 276 She estimated that she reviews on average, approximately 9,000 images per year. 277 She has held the position of the Chief Radiologist and Campus Clinical Head for Medical Imaging at the WCH for approximately 15 years, where, in the course of her duties she had cause to both interpret and review imaging relating to JR. Involvement in JR’s case 278 Assoc. Prof. Linke detailed the various images that were taken of JR at the WCH and discussed her findings with reference to a PowerPoint presentation she had prepared.130 She also addressed the findings and opinions she understood were made by the defence experts regarding those findings. 129 Exhibit P8. Curriculum Vitae of Assoc. Prof. Linke. 130 Exhibits P9/P10. -- 57 of 345 -- [2026] SADC 67 56 Radiological imaging reports of JR undertaken at the WCH Chest X-ray taken on 5 January 2020 at 2.03 pm131 279 The findings were reported as follows: 132 FINDINGS: There are multiple bilateral rib fractures. On the right side involving the postero-lateral sixth and seventh ribs, there are fractures with evidence of bony callus formation and healing. The posterior right eighth rib also has a fracture with some bony callus formation with the fracture line slightly visible. Furthermore, there is a minimally displaced fracture involving the posterior ninth rib demonstrating some bony callus formation, however the fracture line is still visible. On the left side, there are fractures involving the posterolateral sixth and seventh rib, both of which demonstrate bony callus formation. The fracture line involving the seventh rib is still visible. Bony irregularity involving the posterolateral left fifth rib reflects a minimally displaced fracture without discernible evidence of bony callus formation. Given the location and appearances of the fractures, non-accidental injury is suspected. The results of this study were discussed with the PICU consultant and registrar at the time of reporting in person. Skeletal survey is recommended. 280 Assoc. Prof. Linke said the X-ray showed a bulbous expansion on certain of JR’s ribs. She said the most common reason for new bone formation like that seen on the X-ray is a healing fracture. 281 As a result of her findings, Assoc. Prof. Linke agreed with the registrar's report that the X-ray showed multiple healing rib fractures and their location. 131 Exhibits P9/P10, image 1. 132 Exhibit P11. -- 58 of 345 -- [2026] SADC 67 57 282 That there was already a bulbous enlargement, called a 'bony callus',133 meant that the fractures had occurred at least two weeks beforehand. Assoc. Prof. Linke said she could not be specific as to the timing of the fractures and that all she could say was that they did not happen in the previous five to seven days. 283 Assoc. Prof. Linke explained that looking at the X-ray, it was highly concerning that there were fractures of different ages, which meant there had been two separate episodes of trauma, plus the third episode where JR had presented acutely, where there was no explanation. 284 Assoc. Prof. Linke said that the results of this study were discussed with the paediatric intensive care unit consultant and registrar. Due to the unexplained fractures appearing to be of differing ages, a skeletal survey was recommended to find any evidence of trauma elsewhere, or to find genetic or metabolic abnormalities that may predispose JR to fracture. 285 Assoc. Prof. Linke said that had there been any signs of infection or obstruction in JR’s lungs, the X-ray would have appeared lighter. She explained that different forms of infection can have different appearances, but they are all diagnosable by increased opacity. A viral pneumonia will have more of an interstitial pattern,134 in that the lines will be thicker and broader and it will be more of a linear pattern, while a bacterial pneumonia is more likely to give a solid pattern of opacity. 286 Assoc. Prof. Linke said that as someone whose job is to diagnose pneumonia on a chest X-ray, she was confident that radiologically JR, did not have pneumonia. Cardiothymic contours were reported to be within normal limits and lung, and pleural recesses were reported as clear. Chest X-ray taken on 5 January 2020 at 8.32 pm135 133 T 170. 134 T 171. 135 Exhibits P9/P10, image 3. -- 59 of 345 -- [2026] SADC 67 58 287 A further chest X-ray was taken on 5 January 2020 at 8.32 pm and the findings were reported as follows:136 FINDINGS: Cervical spine: The infant is intubated and the distal tip of the ET tube lies in the origin of the right main bronchus. Posterior alignment is maintained in the cervical region. The vertebral bodies and disc heights appear normal. No acute fracture identified. Chest: As result of positioning of the ET tube, there is volume loss in the left lung with collapse of the left lower lobe. The clavicles appear intact. There is mild atelectasis bronchial wall thickening in the right upper lobe. There are multiple rib fractures. There is thickening of the posterior aspects of the right fourth and fifth ribs may be exaggerated by composite shadows. Similar appearances are seen in the posterior aspects of the left third fourth and fifth ribs. There is a lucency through the posterior aspect of the left sixth rib at the costovertebral junction could represent an acute fracture. There are healing fractures of the posterior aspects of the left fifth sixth and seventh ribs in the mid clavicular line. There is also expansion of the anterior ends of the left sixth and seventh ribs raising the possibility of trauma at the costochondral junctions. There are healing fractures of the posterior aspects of the right eighth and ninth ribs. This is in the mid clavicular line. Further healing fractures of the anterolateral aspects of the right sixth and seventh ribs. The appearances are consistent with inflicted injury and a CT chest is recommended to clarify the chest x-ray features. 288 Assoc. Prof. Linke said that this chest X-ray showed some streaky opacity in JR’s lungs, more prominent than on the prior X-ray. She explained that because JR had a nasogastric tube inserted and had been intubated, he likely coughed and aspirated some content from his oesophagus. It was, Assoc. Prof. Linke described, ‘not gross’ and ‘a fairly nonspecific finding’.137 The lung was previously seen as clear a few hours earlier and it would she said, be very unusual to suddenly develop pneumonia that quickly. Could the rib fractures have occurred during CPR? 289 Assoc. Prof. Linke described having a ‘large amount’138 of experience in identifying fractures caused by CPR, having seen the effects of CPR on many children at the WCH, and also in her work with the Coroner at the Forensic Science Centre. She saw the outcome of both juvenile and adult death, often in the setting of attempted resuscitation. All patients that present to the coroner have a CT scan of their whole body and she is called to help interpret the findings. 290 Assoc. Prof. Linke said that there was no evidence of injury consistent with CPR to JR’s chest, primarily because the majority of the fractures demonstrated healing. If JR had CPR performed very close to his admission to hospital and these X-rays were performed within a few hours of him being in hospital, there was no 136 Exhibit P12. 137 T 177. 138 T 179. -- 60 of 345 -- [2026] SADC 67 59 time, even if the child did have CPR fractures, for those to mount a healing response. She said that these fractures had to have occurred on another day. Chest CT scan taken on 10 January 2020 at 11.36 am139 291 A CT scan of JR’s chest was performed on 10 January 2020 at 11.36 am. The findings were as follows:140 FINDINGS: There are multiple bilateral rib fractures as described below. The right-sided rib fractures are as follows: • Sixth postero-lateral = bony callous formation with the fracture line still visible. • Seventh postero-lateral = bony callous formation with the fracture line still visible. • Eighth posterior = minimal degree of bony callous formation with the fracture line grossly visible. • Ninth posterior = minimal degree of bony callous formation with the fracture line grossly visible. The left-sided rib fractures are as follows: • Fifth postero-lateral = bony callous formation with no discernible fracture line. • Sixth lateral = bony callous formation with no discernible fracture line. • Seventh postero-lateral = bony callous formation with the fracture line still visible. Incidental note of an azygos fissure, which is a normal anatomical variant. 139 Exhibits P9/P10, image 4. 140 Exhibit P13. -- 61 of 345 -- [2026] SADC 67 60 No pulmonary masses or nodules. No pericardial or pleural effusions. No pathologically enlarged intrathoracic or axillary lymph node. No abnormalities of the partially visualised upper abdomen. CONCLUSION: Multiple bilateral rib fractures of varying appearances. The appearances and location of these are consistent with non-accidental injury. 292 Assoc. Prof. Linke said that the chest CT scan was performed specifically to look at the rib fractures identified on the plain X-ray and to investigate whether there were rib fractures that had been unable to be seen. This is, she said, common practice across paediatric institutions. 293 Assoc. Prof. Linke explained that plain chest X-rays are particularly unreliable for fractures that are right at the back of the ribs, given overlapping bone adjacent to the spine. 294 Assoc. Prof. Linke reconstructed the high-resolution images to make a three-dimensional model of the chest for easier interpretation.141 295 In addition to the fractures that had already been diagnosed on the plain X-ray, the CT scan showed evidence of a further fracture at the back where the rib has a joint with the spinous transverse process. The CT scan also confirmed bony callus formation, with the fracture line still visible on the 6th, 7th and 8th posterior ribs, with a minimal degree of bony callus formation on the 9th posterior rib. 296 The CT scan showed the chest was completely clear, consistent with removal of the endotracheal tube. 297 Assoc. Prof. Linke explained that the conclusion in the report that 'Multiple rib fractures of varying appearances. The appearances and location of these are consistent with non-accidental injury',142 was arrived at because of the pattern of injury. She explained that a six-week-old child is fairly dependant on a carer to move them around. Normal breathing is not going to cause these findings and JR did not have the type of fractures associated with CPR. 141 Exhibits P9/P10, image 4. 142 T 181. -- 62 of 345 -- [2026] SADC 67 61 CT scan taken on 10 January 2023 – bone windows143 298 Assoc. Prof. Linke said that the left image on image 5, using a particular setting that highlights the bone over the soft tissues, showed there was a healing fracture with no visible fracture line. She said that fracture had undergone central healing down the middle of the bone cavity. It still had some callus on the outside, but it would take numerous weeks for that to remodel. 299 On the right, there was an acute fracture through an old fracture. She explained that while it is possible that the acute fracture could have been caused by CPR, there is also evidence of healing, so there were two episodes of trauma in that rib. Rickets 300 Assoc. Prof. Linke said that from a radiological point of view, rickets is a description of a bony abnormality. She said that endocrinologically rickets is a symptom complex of numerous things. There needs to be very low vitamin D, and an abnormality of parathyroid hormone, alkaline phosphatase, and calcium. You can have low vitamin D but not rickets, that is, there can be a vitamin D deficiency without it impacting on the bones or bony structures. It is only characterised as rickets when it is actually capable of being seen or noted on imaging. 301 Assoc. Prof. Linke said that she considers any form of genetic abnormality or bone disease, including metabolic bone diseases such as rickets, as a potential cause for fracture. Another reason for ordering a skeletal survey is to look for other findings that could hint that there is an underlying problem that could predispose JR to fractures. 302 Rickets has an appearance on X-ray, which can be called a Rachitic rosary where the ends that join with the cartilage become quite round and bulbous. Assoc. Prof. Linke said that when you have a metabolic bone disease such as rickets, it does not just pick off one bone. Rickets will affect all the bones in a similar way. All ribs would be affected. She explained that the body is not good 143 Exhibits P9/P10, image 5. -- 63 of 345 -- [2026] SADC 67 62 enough to say 'I just want to pick out that bone’144 but rather will affect the metabolism and the laying down of calcium in all the bones. 303 Assoc. Prof. Linke said that Image 6 seen below showed a child with rickets who was perhaps a little older than JR, where the ends of the long bones were very abnormal. Image 6 Image 7 304 Assoc. Prof. Linke explained that the role of vitamin D is to help to lay down calcium in the growing ends of long bones, and the part of the bone that does most of the growing is the end of a long bone, where there is cartilage. With a deficiency of calcium, the bones become very soft, so they very easily become remodelled. 305 In image 7 showing JR’s wrist, the difference could be appreciated. The image showed a very straight line with no frame, or cupping, or what in medical terms is called widening of the zone of provisional calcification, meaning the area 144 T 186. -- 64 of 345 -- [2026] SADC 67 63 where new bone would be laid down to extend the length of that bone for it to grow. She said that JR’s wrist was completely normal in appearance. Osteogenesis imperfecta Image 8 306 Assoc. Prof. Linke said that there is a spectrum of disease in osteogenesis imperfecta, which is an abnormality in the mineralization of bone. The bones are very weak, and they fracture with the lightest pressure. In the very severe forms, it can be diagnosed in utero as early as 18 weeks gestation. Assoc. Prof. Linke said image 8 showed osteogenesis imperfecta in the more lethal form145. 307 If a child has the milder form of osteogenesis imperfecta, usually when they are born, the bone looks thin, or osteopenic, meaning it looks like it has less calcium and there may be fractures. The types of fractures are different in distribution and appearance to the fractures seen in trauma from inflicted injuries, and usually those children are diagnosed via genetic testing. Wormian bones 308 Assoc. Prof. Linke explained that there are other clinical manifestations of osteogenesis imperfecta such as the sclera in the eyes can look blue or multiple Wormian bones may be seen in the skull as seen in Image 9. 145 Exhibits P9/P10, image 8. -- 65 of 345 -- [2026] SADC 67 64 Osteogenesis imperfecta – Wormian bones – Image 9146 309 Assoc. Prof. Linke referred to the above left image showing a bony reconstructed model from a CT scan of a child with multiple Wormian bones. She explained that the skull is made up of multiple plates of bone and between those plates are spaces, called sutures, to enable brain growth. Extra bones in the line of the suture, like little islands of bone, are called Wormian bones. 310 She said that it is accepted that it is normal to have to have about ten to twelve such bones. With osteogenesis imperfecta there is usually over 20. JR had none and therefore on radiological criteria, he did not have any specific features of osteogenesis imperfecta. 311 If there were idiopathic conditions that would predispose an infant to injuries of the type seen in JR by normal handling, she would expect to see the mineralisation or whiteness of the bone to be reduced. 312 When children present with multiple fractures, because some metabolic or genetic conditions can be mild, those children get a full work-up to determine whether they could be suffering from osteogenesis imperfecta that cannot be diagnosed radiologically. It is a holistic approach with the clinicians performing appropriate blood tests to either corroborate her findings or say the child is suffering something else. 313 JR’s bone formation appeared normal to her and his bone growth was age appropriate. The laying down of the bones appeared appropriate. 314 There was nothing on the X-rays, CT or imaging that raised a flag for her in terms of any other potential known condition or causes that should be investigated. 146 Exhibits P9/P10, image 9. -- 66 of 345 -- [2026] SADC 67 65 Cephalohaematoma 315 Assoc. Prof. Linke said that the CT scan showed thickening of the bone of the skull, with the location quite typical for a baby born via ventouse extraction. 316 All bones have a membrane which when broken, results in some bleeding. That bruise heals with calcification. Assoc. Prof. Linke said she would not consider the cephalohaematoma a suspicious finding in an infant of JR’s age. The bruising is on the outside of the skull, with the actual bruise gone away and replaced with calcium. There was no fracture in relation to that at all. It eventually remodels and goes away, but it can take up to six months. Skull fractures 317 Assoc. Prof. Linke explained that while gaps in the bone of a skull are normal, abnormal lines are fractures. While the imaging showed JR had normal sagittal and lambdoid sutures, he had lines at the back of the head, one on each side as seen in the right sided Image 9 of Exhibits P9/P10, marked by the blue arrows in the image. Assoc. Prof. Linke said these lines would be considered skull fractures as he had other changes in his brain that went along with those findings. 318 Assoc. Prof. Linke said that it is very difficult to tell whether the fractures occurred at the same time because the skull does not have the same healing response as a rib or a long bone. It is very difficult just looking at the scan on its own to determine whether one fracture was older and healing, compared to the other fracture. To help determine the age of a skull fracture they look to see whether there is associated swelling. 319 Here there was some blood associated with the larger fracture on the right side of the image of JR’s skull, while no swelling was associated with the fracture on the left. Image 12147 147 Exhibits P9/P10, image 12. -- 67 of 345 -- [2026] SADC 67 66 320 Assoc. Prof. Linke described sutures having ‘little fingers of interdigitation’.148 In a suture the bone margin is irregular so when a suture comes together, the bone will eventually form, whereas a fracture is going to have extremely straight margins and are asymmetrical as seen on JR’s scans and shown in image 12. CT brain taken on 5 January 2020 at 2.37 pm 321 The findings report of the CT brain scan taken on 5 January 2020 at 2.37 pm reported: 149 FINDINGS: There is a linear fracture extending from the coronal suture to the lambdoid suture of the right parietal bone. The fracture is separated by approximately 4 mm. There is overlying soft tissue swelling and underlying subdural haematoma associated with this fracture. In addition, there is an undisplaced fracture extending from the posterior sagittal suture and terminates within the mid-portion of the left parietal bone. Minor degree of overlying soft tissue swelling is noted as well as an underlying subdural haematoma with this fracture. Furthermore, there is a subdural haematoma with maximal depth measuring 2.4 mm located along the right parafalcine at the vertex. There is an equivocal hyperdensity along the left parafalcine at the vertex and it is uncertain whether this also represents a small subdural haematoma. In conjunction with the chest x-ray finding performed earlier today, the constellation of findings is highly concerning for non-accidental injury. No intracranial space occupying lesion within the limits of a non-contrast study. No mass effect or cerebral herniation. Preservation of the grey-white matter differentiation. Ventricular and sulcal calibre are age appropriate. The results were discussed with the PICU registrar at the time of reporting via telephone. CONCLUSION: Bilateral parietal bone fractures, right worse than the left. Multiple subdural haematomas as described within the body of the report. The constellation of findings in conjunction with the chest x-ray performed earlier today is highly concerning for non-accidental injury. 322 Assoc. Prof. Linke had added an addendum to the report on 6 January 2020 at 8.23 am as follows:150 148 T 192. 149 Exhibit P14. 150 Exhibit P14. -- 68 of 345 -- [2026] SADC 67 67 There is a well circumscribed area of calvarial thickening in the posterior superior right parietal bone consistent with a healing/calcifying cephalohaematoma. The right parietal skull fracture passes through the inferior aspect of this calcified cephalohaematoma. 323 With respect to the finding that, 'In conjunction with a chest X-ray finding performed earlier today, a constellation of findings is highly concerning for non- accidental injury’,151 Assoc. Prof. Linke said that the reason for that finding was that there appeared to be fractures in different parts of the body, not only in the chest, all of different ages. 324 As to the finding that 'The right parietal skull fracture passes through the inferior aspect of this calcified cephalohaematoma',152 Assoc. Prof. Linke said that was just to demonstrate that the location was not through the cephalohaematoma, it was just offset, but through the lower margin. 325 There was a description of the fracture involving the right parietal bone and there was also evidence of some blood products between the skull and the brain in relation to that fracture, that is, a subdural haematoma.153 326 This CT scan showed two different fractures which were both linear skull fractures, but of different widths. The report noted 'Subdural haematoma with a maximal depth measuring 2.4 mm located along the right parafalcine at the vertex'.154 327 Assoc. Prof. Linke said that if the haematoma was large, then it may prompt neurosurgical input, but this was a very shallow measurement of blood. That blood could be seen meant it was fairly recent. Had the trauma occurred at the time of delivery six weeks earlier, Assoc. Prof. Linke said it should not still be there. 328 The report indicated that JR’s brain ‘looked good’155 so there was no reason to perform a contrast study. On the CT scan, there did not appear to be brain swelling. Tibial fracture 329 Assoc. Prof. Linke said that a skeletal survey was requested as it was necessary to look at the whole of JR’s body to see if there were other fractures, and to see if JR was suffering some other symptom complex that could predispose him to fractures, or fractures that could have been caused by some other means. 330 In JR 's case, the skull, the full spine, chest, long bones and dedicated imaging of the joints (knees, ankles, wrists, pelvis, hands and the feet) were included. 151 T 197. 152 T 194. 153 T 195. 154 T 196. 155 T 197. -- 69 of 345 -- [2026] SADC 67 68 Assoc. Prof. Linke explained that a skeletal survey is a standard imaging protocol across every paediatric department in Australia. Skeletal survey 10 January 2020 at 10.42 am156 Original report FINDINGS: Calvarium: The horizontal fracture is present in the right parietal bone, extending from the coronal suture to the lambdoid suture. Another nondisplaced fracture is demonstrated within the left parietal bone extending from the sagittal suture posteriorly. Spine: Normal spinal alignment is demonstrated. No evidence of acute bony injury. Normal appearance and alignment of the pedicles are seen. Chest: Chest x-ray is correlated with the CT — Right: Previous fractures with callus formation are demonstrated at the posterior right sixth, seventh, eighth and ninth ribs. The CT also demonstrates a healing fracture of the posterior aspect of the right fifth rib at the costovertebral junction. There is modelling deformity and irregularity of the anterior aspect of the right seventh, ninth, tenth and eleventh ribs at the costochondral junctions. Left: Healing fractures are demonstrated at the left lateral sixth and seventh ribs. The CT has also identified – A healing fracture at the posterior aspect of the left fifth rib and the anterior aspect of the left sixth and seventh ribs at the costochondral junction and also in the anterior aspects of the ninth and tenth ribs at the costochondral junction. Lungs and pleural spaces are clear. No pneumothorax is demonstrated. Cardiothymic contours are normal limits. Bilateral upper limbs No spiral or metaphysical fracture is demonstrated. Normal alignment. Pelvis: Both hips are well enlocated. No evidence of acute bony injury. No periosteal reaction is demonstrated. Right leg: There is spiral fracture involving the distal tibia. There is associated periosteal new bone formation – this is seen on a background of physiological new bone formation seen bilaterally in the midshafts of the femora and tibia bilaterally. No evidence of 156 Exhibit P16. -- 70 of 345 -- [2026] SADC 67 69 malalignment. There is also a wedge shaped lucency in the medial aspect of the proximal tibia metaphysis. Appearances are consistent with intraosseous resuscitation attempts. Left leg: Physiological periosteal reaction is demonstrated at the left femur and tibia. Tunnelling appearance demonstrated at the proximal tibia, may relate to intraosseous resuscitation. CONCLUSION: There are multiple fractures of different ages. Overall appearance is highly suggestive of nonaccidental/inflicted injury. Addended Report157 This addendum is to clarify my interpretation of the lower limbs. There are bilateral wedge- shaped lucencies in the proximal tibia metaphyses on the right and left side. There are consistent with intraosseous resuscitation attempts. There is a separate isolated lucency in the distal third of the right tibia, well away from the sight of intraosseous resuscitation. There is associated periosteal new bone formation consistent with a healing fracture This addendum was created by REBECCA LINKE Consultant, 26/05/2023 10:55 AM 331 Assoc. Prof. Linke noted that the survey showed nothing new in the skull or spine. There was however a new finding of a spiral fracture to JR’s right leg. Assoc. Prof. Linke described a spiral fracture as an obliquely orientated fracture, that is not straight down, but oblique. 332 She noted needle tracks associated with intra osseous cannulisation to JR’s tibia. JR had needle tracks in both tibia, and the scan showed a little web-shaped area of blackness where a resuscitation needle would have gone into the bone, consistent with intraosseous cannulisation of a 15 mm needle bilaterally. 333 Assoc. Prof. Linke said that in all the cases she has seen in her career, she had never seen a fracture caused by such a technique. The fracture on which she had reported showed a healing response of the bone which occurs at around day five to seven. This was she said, a pretty immature periosteal reaction, which was not very thick which had not yet completely consolidated with the native bone. Assoc. Prof. Linke said that from her experience she aged this fracture to be anything from 5 to 12 or 14 days. She said that as the finding was made at five days post JR’s hospital admission it could have occurred before he came into hospital, or a few days before. 334 Assoc. Prof. Linke said that the spiral fracture JR had in in his lower limb, was the most common lower limb fracture she would see in a toddler of two years 157 Exhibit P17. -- 71 of 345 -- [2026] SADC 67 70 of age because they are walking about and going down slippery slides. It is a very common fracture, and not a fracture you should see in a six-week-old baby. Craniotabes Image 13158 335 Assoc. Prof. Linke described craniotabes as a thinning of the skull. Image 13 of Exhibit 9 showed the skull of a child with craniotabes and an image of JR’s skull. She said that because craniotabes is an abnormality of calcium deposition in bone, there are islands where the skull is extremely thin and almost wafer like. JR had very good mineralisation of his skull with no radiological features of craniotabes. Mechanism of skull injury 336 With a vaginal birth, quite often the plates of bone in the skull overlap and ‘moulding’159 is observed. Assoc. Prof. Linke said that JR did not have any overlap of the plates of his bone but had two fractures, the mechanism for which she said would have to be a fall from height. She was unable to say what mechanical force would be required to exactly do that because experiments are not carried out on children, but a common occurrence that she sees includes a fall from a lap onto a tiled floor, which would be enough to cause such fracture in a normal infant. 337 She could not say with certainty whether the fractures involved one or two incidents. Assoc. Prof. Linke’s response to the opinions of Dr Gootnick. 338 Assoc. Prof. Linke had been provided with a report prepared by radiologist Dr Gootnick and was asked what, if any, were the differences between a radiologist and a paediatric radiologist. 158 Exhibits P9/P10, image 13. 159 T 204. -- 72 of 345 -- [2026] SADC 67 71 339 Assoc. Prof. Linke said that as part of training, and particularly in the United States, where she believed Dr Gootnick is from, they offer, as in Australia, specialist paediatric radiology training, such as a fellowship. 340 Specialist paediatric radiologists tend to work in a paediatric imaging centre. While all private practices will do a little bit of paediatric imaging, most of the high end clinical paediatric practice occurs within a paediatric hospital institution. 341 Assoc. Prof. Linke was asked to comment on statements said to have been made by Dr Gootnick in her report. 342 As to Dr Gootnick’s statement that brain swelling was not confirmed by X-ray, Assoc. Prof. Linke noted that X-rays are a two-dimensional image and for example, with a swelling on the forehead, unless an X-ray was performed tangential to the swelling, it would not be something that would be appreciated. A CT scan however can have three-dimensional cross-sectional imaging, where the swelling may be seen. The CT scan of JR’s skull indicated swelling and subdural haematoma. Craniotabes160 343 In response to the lateral image of JR’s skull, that is, the top figure in Exhibit P18, which Dr Gootnick said showed craniotabes, Assoc. Prof. Linke referred to an image demonstrating skin folds of a patient’s scalp.161 Assoc. Prof. Linke said that little babies are born with quite redundant skin on their scalp, partly because the skull undergoes a fairly rapid rate of growth during the first six months of life, and the redundant skin like seen on a puppy, allows them to grow into their skin. When a child is laying down for a skull X-ray, the folds tend to concertina at the back of the skull. Assoc. Prof. Linke said that it is a finding that would be familiar 160 Exhibit P18. 161 Exhibit P18. -- 73 of 345 -- [2026] SADC 67 72 to a paediatric radiologist and something she would not comment on because it is so common. She added that craniotabes is a very rare diagnosis, even in the setting of rickets. Skull Fracture 344 The yellow arrow on the top image shown in Exhibit P18 showed the occipital suture. Assoc. Prof. Linke disagreed with Dr Gootnick’s opinion that JR’s occipital suture was significantly widened, adding that it was not significantly widened on the CT scan. She explained that an image of a skull fracture will appear narrow but the dark line on radiological investigation will appear broader if the angle is diagonal to the break itself. In this case the occipital suture is an oblique line in any event, so it makes it even harder to get it exactly straight. There were no definitive signs of raised intracranial pressure on the CT scan. Nor was there evidence on the radiological imaging of the presence or absence of low vitamin D. 345 With respect to Dr Gootnick’s reference to an ‘AP view of the skull from a CT scan of 10 January 2020’ (image below),162 Assoc. Prof. Linke noted that it was not a CT scan, but rather a plain skull X-ray. 346 Assoc. Prof. Linke disagreed with Dr Gootnick that the lines vertically in the parietal bones were actually accessory sutures or extensions of accessory sutures.'163 Assoc. Prof. said they are asymmetrical in their size and shape and lack the normal features of accessory sutures. The edges of fractures are quite sharp on X-ray. 347 Assoc. Prof. Linke said she found it surprising that Dr Gootnick had called these ‘accessory sutures’ on the image, as she had labelled the same line on the right side as a fracture in another part of her report and had therefore contradicted herself. 162 Exhibit P19. 163 T 259. -- 74 of 345 -- [2026] SADC 67 73 Figure 2 referred to in Dr Gootnick’s report164 348 With reference to this image, (described as Figure 2 in Dr Gootnick’s report), Dr Gootnick had identified that figure as evidence of the parietal skull fractures. Assoc. Prof. Linke agreed it was one of the parietal skull fractures and said that the plain skull X-rays and CT scan show that the gaps in parietal bone are fractures and not accessory sutures. The CT scan supported the plain X-ray interpretation. 349 Where Dr Gootnick marked fractures on her observation, Assoc. Prof. Linke agreed there were fractures and marked the fractures on Exhibit P19. 350 Assoc. Prof. Linke’s evidence was that the CT scan of JR’s skull confirmed skull fractures and noted that Dr Gootnick had given no opinion in relation to the CT scan of the skull. Assoc. Prof. Linke said that the CT scan of the skull makes the finding definitive. Dr Gootnick had made a comment that there was no soft tissue swelling however, Assoc Prof. Linke said that sometimes that is not as clear on a skull X- ray unless you get the fracture tangentially. On a CT scan, because of the way the image is taken, you can have a three-dimensional reconstruction, and you can also see the soft tissues separate from the bone to determine that there was soft tissue swelling at the site of the fracture, which there was. The brain and blood could also be seen. 164 Exhibit P20. -- 75 of 345 -- [2026] SADC 67 74 Looser zone fractures/pseudo fractures AP chest X-ray dated 10 January 2020165 351 With respect to Exhibit P21, an AP chest X-ray taken of JR on 10 January 2020, Assoc. Prof. Linke confirmed the red arrows showed the location of healing rib fractures while Dr Gootnick had suggested these were ‘looser zone fractures typical of poorly ossified ribs’. 352 Assoc. Prof. Linke denied these were 'looser zone fractures',166 but rather, were healing fractures demonstrating normal bone healing. Looser zones are an area of bone insufficiency, so decreased mineralisation, that is, a lack of calcium deposition. 353 She said that as a ribcage needs to move with breathing this makes rib fractures inherently unstable, and they take longer to heal. 354 She agreed with Dr Gootnick that ‘looser zone fractures’167 may be described as cortical infractions, milkman lines or pseudo fractures. To have looser zone fractures there would be areas of widened zone of mineralisation, usually at the long end of bone, not in the middle of the bone where JR’s factures were. It is usually at the anterior end of the rib, and it would occur where the bone meets the cartilage, which is the growing part of the bone. She said that looser zone fractures tend to be symmetrical because in metabolic bone disease and any metabolic deficiency in a child, whether it be vitamin D or vitamin C, does not just affect one bone, it affects the whole skeleton. A metabolic bone disease will not pick out one bone over another. For instance, a child with extremely low vitamin D, if they have rickets, will have changes in their chest and wrist and in other long bones in their body. 165 Exhibit P2. 166 T 265. 167 T 265. -- 76 of 345 -- [2026] SADC 67 75 355 Dr Gootnick had suggested that one reason for the rib fractures being of different ages could be that at some point there was enough calcium to calcify the cartilage surrounding the fracture to a relatively normal degree, which then became unavailable, making the rib fractures look of different ages. Assoc. Prof. Linke said Dr Gootnick’s statement demonstrated a complete lack of knowledge of bony anatomy because the fractures, in particular fractures in the back, are where there is no cartilage. Growth arrest lines Image of JR’s wrist dated 1 October 2024168 356 Dr Gootnick had inserted red arrows on the image to indicate ‘growth arrest lines, which occur in children with metabolic disease. In neonates these most frequently occur in children who have neonatal rickets.’ 357 Assoc. Prof. Linke said that growth arrest lines can occur in any child and in adults and agreed they are often an indication that there has been stress at some point and that stress can be caused by metabolic causes. She agreed that the bottom red arrow on the image could well be pointing to a growth arrest line. 358 She added that the blue arrow was pointing to an area of osteopenia which is an area of demineralised bone which she said was very common in infants because any child who may be laying dormant for whatever reason will very quickly get a zone of demineralisation or non-use osteopenia. 359 Assoc. Prof. Linke explained that little babies still have a big chunk of cartilage which sits at the end of the bone that cannot be seen on X-ray because it does not contain calcium. 360 Assoc. Prof. Linke said that there was nothing unusual about JR’s image and that it was a normal X-ray. 168 Exhibit P23. -- 77 of 345 -- [2026] SADC 67 76 Image of JR’s pelvis dated 10 January 2020169 361 Dr Gootnick had said that the red arrows in this image of JR’s pelvis marked the ‘last time’ there were adequate nutrients to normally calcify the growing cartilage and the blue lines indicated poorly or non-calcified cartilage, which appears white/grey. 362 Assoc. Prof. Linke said that she disagreed with Dr Gootnick ‘anatomically’.170 She said that understanding that JR had been in hospital not moving for five days by the time the image was obtained, the white/grey line just represents non-use osteopenia. Assoc. Prof. Linke said that again, the image showed nothing that she would not expect for a baby of JR’s age who has been in hospital for five days, not moving. She said that where the bottom red arrow appears is an area where there is no cartilage at all and hoped that a radiologist would know that. 363 Assoc. Prof. Linke said that she did not understand what Dr Gootnick had meant by ‘last time’.171 As there is no cartilage there, Dr Gootnick’s statement that blue lines show poorly or non-calcified cartilage is false. Figure 11 ‘lateral lumbar spine of OS’ and figure 12 ‘lateral view of the lumbar spine in a neonate’172 169 Exhibit P24. 170 T 273. 171 T 274. 172 Exhibit P25. -- 78 of 345 -- [2026] SADC 67 77 364 Assoc. Prof. Linke agreed that figure 11 was an image of JR’s lateral lumbar spine. She agreed with Dr Gootnick that the red lines mark the calcification of the outermost portion of the vertebral bodies. It was however incorrect to say that the blue line demonstrates poorly calcified cartilage in the interior of the vertebral bodies. Assoc. Prof. Linke said that the dark line represents a vascular bundle that runs through the middle of the vertebral body. It was, she added, nothing to do with a system process caused most likely by lack of vitamin D and calcium. There was nothing on figure 11 that would give a paediatric radiologist cause for concern. 365 With respect to figure 12, Dr Gootnick stated this was a ‘lateral view of the lumbar spine in a neonate and that [Assoc. Prof. Linke], gave the opinion that the red arrows mark a poorly calcified horizontal line that traverses the vertebral body, this is a normal nutrient foramen.’173 Assoc. Prof. Linke noted that again Dr Gootnick had contradicted herself in pointing out the same line and called it two different things. She said that both images 11 and 12 have been taken in the same place and are effectively demonstrating the same thing. Figure 11 shows the very artefact seen in figure 12, being the normal nutrient foramen. Assoc. Prof. Linke said that Dr Gootnick had described it correctly for figure 12, that is, it was the same normal anatomical feature and was the type of review that she would do daily. 366 Assoc. Prof. Linke agreed with Dr Gootnick’s view that gestational diabetes is caused by hormones produced during pregnancy that can make insulin less effective and can cause macrosomia, that is, a large baby. That however had no relevance in respect of neonatal rickets and JR. 367 Assoc. Prof. Linke disagreed with Dr Gootnick’s opinion that JR had multiple radiographic findings consistent with metabolic bone disease. There are, she said, no features of metabolic bone disease on JR's presentation and in his radiological investigation. 173 T 275. -- 79 of 345 -- [2026] SADC 67 78 368 Assoc. Prof. Linke had produced a picture of an infant (left image) to show what rickets would look like in a baby of his age and compared that with the picture of JR’s left lower limb (right image) to see the difference.174 369 On the left image, of a child with rickets, the blue arrow points to flaring, going out like an umbrella, of the growing end of the long bone. It appears irregular at the end. On the right-hand image JR's lower limb has a very smooth margin, with no flaring and was normal for his age. Assoc. Prof. Linke’s response to the opinion of Dr Auer 370 Assoc. Prof. Linke was asked about opinions that had been expressed by Dr Auer. Pneumonia 371 As to Dr Auer’s reference to pulmonary disease, Assoc. Prof. Linke said that on presentation on 5 January 2020, there was no evidence of pulmonary inflammation; the lungs were clear and there was no collapse or consolidation in the lungs. Wormian bones 372 Dr Auer had referred to Wormian bones and accessory sutures. Assoc. Prof. Linke said that it is normal to have up to twelve Wormian bones, but JR had none. There would she said, need to be approximately 15 to 20 Wormian bones before a finding of Wormian bones, which, she said, can be an indicator of an inherited disorder such as osteogenesis imperfecta. There were no indications here and the presentation was of a simple non-depressed skull fracture with sharp lucencies and non-sclerotic edges. This was to be contrasted with accessory sutures which present like interlocking fingers. 174 Exhibit P26. -- 80 of 345 -- [2026] SADC 67 79 Craniotabes/rickets 373 Assoc. Prof. Linke said there is no radiological evidence of craniotabes or any radiological evidence of rickets or vitamin D deficiency. JR’s blood levels showed 'a quite mild deficiency range,'175 not low enough to demonstrate radiological evidence of rickets. There were no other indicators of rickets. When looking for evidence of rickets, the parathyroid hormone, calcium, phosphate and alkaline phosphate levels are looked at, and which were all normal for JR. Therefore, JR did not have rickets either biochemically or radiologically. Rib fractures 374 As to Dr Auer’s opinion that JR was suffering common asymptomatic rib fractures, Assoc. Prof. Linke described rib fracture as one of the most painful things possible. She said that because infants cannot speak, their presentation can usually just be one of irritability. She said that whether the baby was symptomatic or asymptomatic is moot and does not assist one way or the other. 375 As to Dr Auer’s link between rib fractures and infection, Assoc. Prof. Linke said that if Dr Auer was referring to pneumonia, there was no pneumonia, and if he was referring to infection of bone, there were no stigmata of osteomyelitis which is the term used to describe bone infection. There were, she said, no radiologic signs of, or consistent with pneumonia. 376 Using lay terms, pneumonia would appear as a ‘white-out’ in the lung. JR had a tube placed in his trachea to assist with breathing and there was a misplaced endotracheal tube. Because the left lung was not being inflated it was white due to collapse. Once that collapsed lung was up and running again a further X-ray showed there was no evidence of pulmonary disease. 377 As to Dr Auer’s assertion of transient thrombus rather than a healing fracture, Assoc. Prof. Linke said that thrombus has nothing to do with a fracture and that thrombus in a vessel cannot be seen on an X-ray. She described Dr Auer’s opinion as ‘ludicrous’.176 Assoc. Prof. Linke’s cross-examination Rib fractures 378 Assoc. Prof. Linke explained that JR’s rib fractures had a very defined location which were of different ages, and which demonstrated healing that could not have occurred during the resuscitation efforts. She agreed that while CPR that involved grabbing the child and squeezing, was not ideal, you do what you have to get the infant ‘back’.177 She accepted that it does enhance the risk of fracture. 175 T 286. 176 T 287. 177 T 403. -- 81 of 345 -- [2026] SADC 67 80 379 Assoc. Prof. Linke added that causing a fracture by picking a child up around the chest would only occur if they were squeezed. Babies come out of the vaginal canal, and they get squeezed and do not suffer fracture. If the baby is big, the most common fracture is usually a clavicular fracture, but not rib fractures. 380 With respect to Dr Auer’s opinion that rib fractures sustained during the birth may well go undetected, Assoc. Prof. Linke agreed they may go undetected because there is no medical examination, but said that this was ‘very, very rare’. 381 Assoc. Prof. Linke said that post-birth, medical examinations made no difference to what she sees on a report as a radiologist. She said that the fact no bruising was observed does not necessarily mean no fracture. She reports what she sees. If a baby does not have bruising and there is a fracture, it is still a fracture. 382 Assoc. Prof. Linke disagreed that a painless fracture is more likely to be consistent with rickets. She said that pain is not a phenomenon that is universally applied to medical disease as being a scoring principle for how bad that disease is. 383 She said that while not aware of the mother's history, JR’s vitamin D level at birth was in the higher range of low. It was not bad enough to have bony changes of rickets, and the rest of his biochemistry was completely normal. Biochemically, JR did not have rickets. He had slightly low vitamin D that is seen in up to 30% of all infants, and he did not have bony changes of rickets. JR was given vitamin D supplementation while receiving formula, along with breast milk because the vitamin D level was noted to be slightly low. This was to supplement the child, not because there had been a skeletal survey confirming rickets. 384 Assoc. Prof. Linke said that she did not think that anyone disagrees that JR had low vitamin D. He just did not biochemically have rickets, and to have a diagnosis of rickets you not only need low vitamin D, but you need to demonstrate disordered calcium and bone turnover metabolism, which JR did not have. It was all in the normal range. She said that just because you have low vitamin D, even at the levels shown for JR, does not mean you have rickets. 385 Assoc. Prof. Linke said that she had seen many cases of rickets in her career, and many cases of normal bones. She reports what she sees. If there are changes which lead her to believe that a child might have low vitamin D, or rickets, she contacts the clinician and gets them to check the biochemistry. 386 Assoc. Prof. Linke said that JR having been born 13 days before his due date did not worry her with respect to vitamin D deficiency and bone development. She maintained that it had no relevance and disagreed with the opinion she understood had been expressed by Dr Gootnick that JR’s skeletal development, and the issues associated with vitamin D, and the imaging capacity where bones are under mineralised, is impacted upon by premature birth, even of two weeks.178 178 T 399. -- 82 of 345 -- [2026] SADC 67 81 387 Assoc. Prof. Linke said that still low vitamin D at 43 nmol/L as of 7 July 2021, had no impact on JR’s bones, because his biochemistry was otherwise normal.179 388 Assoc. Prof. Linke said that if she were to see a fracture in a child with an inability to heal because of disordered calcium metabolism, that would add to the level of difficulty in aging a fracture. She disagreed with the proposition that a vitamin D deficiency and a potential compromise to bone development, impact upon the quality of radiological images. She said today’s machines auto calibrate, and radiographers have their own ability to adjust a radiation dose to get a clear image.180 389 The abnormal appearance of the ribs was a manifestation of healing fracture and not rickets. Use of the word ‘bulbous’ was a descriptor giving the reader an image in their head of the roundness that the rib takes at the anterior rib end when it undergoes healing.181 390 She agreed that you can get flared and bulbous ends of ribs in rickets, but that is due to the nature of the metabolic bone disease, not due to fracture healing in rickets. It does not matter that there is no rib displacement. A rib can move and then go back to being not displaced. Cephalohaematoma 391 Assoc. Prof. Linke said that a healing cephalohaematoma looks completely different to a healing skull fracture. The nature of the cephalohaematoma, its healing and how calcified it was, fit perfectly with the time of JR’s birth to when he presented on 5 January 2020. The cephalohaematoma had no relationship to the fractures. It was in a different location and was showing healing. Its appearance and the clinical history were consistent with vacuum extraction and resolving cephalohaematoma. On the right-hand side the fracture runs to the area, but it does not extend from it.182 392 Assoc. Prof. Linke said that a fall while JR was intra utero had no role to play here, nor did the concerns about growth retardation. She said that ‘obviously’ force had been applied to JR, but she was not going to comment in regard to how much force. 393 Assoc. Prof. Linke said that it was not unusual that all the paramedics spoke to the absence of any evidence of any application of external trauma. In her daily practice, a child presents for a completely different reason, and she notices a fracture that no-one knew about. It is not uncommon, not unheard of, and happens in practice. 179 T 399. 180 T 401-402. 181 T 409. 182 T 414. -- 83 of 345 -- [2026] SADC 67 82 Growth arrest lines 394 Assoc. Prof. Linke said that growth arrest lines are very non-specific. They are a period of static growth, and can occur if a baby has gastroenteritis, a respiratory tract infection, or any form of stress. They can even occur because of emotional stress or lack of nutrition. It is demonstrating that there is a period of no growth. She said that the causes are very non-specific because there are so many causes that can make a growth arrest line appear, including issues with metabolic bone disease.183 Skull fractures 395 She said that JR had bilateral undisplaced skull fractures extending from the posterior sagittal suture, terminating from the mid portion of the left parietal bone with overlying soft tissue swelling. The right parietal skull fracture, which was the larger, had soft tissue swelling. There was another fracture with a minor degree of overlaying soft tissue swelling. In addition, there was blood beneath the fracture between the fracture and the brain. That blood did not cause any swelling or injury to the brain- the brain did not have any internal bruising. 396 Assoc. Prof. Linke disagreed that in referring to Exhibit P18, she was comparing apples and oranges in that the image that she produced with the scalp folds did not correspond and enable any proper comparison with the image of JR. She disagreed that the blue lines marked an issue emblematic of or symptomatic of radiological rickets.184 397 As to Exhibit P19, it was suggested to Assoc. Prof. Linke that the imagery was not of sufficient quality to conclude that the edges are quite sharp and illustrate that they are in fact fractures. She disagreed based on her experience and the fact that they were demonstrated to be fractures on a subsequent CT scan in any event. Tibial fracture 398 Assoc. Prof. Linke was asked about the conduct of the paramedics and whether their actions could account for a spiral fracture. Assoc. Prof. Linke said that it would take extreme force and would not be something she would expect in the general course of resuscitation. She said that in her work she sees a lot of infants who have been traumatised in road traffic accidents as part of inflicted injury, and she knows the patterns of injury. She said that she sees many children who have had intraosseous needles in their bones for resuscitation, particularly babies. She said that in her report she commented on the fact that there were lucencies in the tibia from the intraosseous resuscitation attempt, but she did not call them fractures.185 399 Assoc. Prof. Linke said that as a radiologist, the fact that the nurse did not think that there was anything wrong with JR when injections were administered, 183 T 400. 184 T432. 185 T 385. -- 84 of 345 -- [2026] SADC 67 83 meant nothing. She reported what was seen on the imaging and she saw there was a fracture. 400 Assoc. Prof. Linke agreed that spiral fracture can be sustained by a twisting or jerking movement. Here, JR was not weight bearing and laying down most of the time. A fracture would not occur unless an infant is picked up and then dropped against a hard surface or picked up by their leg or had the leg rotated. 401 One mechanism for the spiral fracture, is a twisting of the leg. Assoc. Prof. Linke agreed with Dr Gootnick’s opinion that changing a child's nappy, when you lift legs and they squirm or twist, could account for a fracture of that type. 402 She said the degree of force used in resuscitation would not have caused fracture and was ‘just not something that happens in resuscitation’.186 Assoc. Prof. Linke described it as ‘ludicrous’.187 She said that while anything can happen in any situation, it was ‘very unlikely’. Assoc. Prof. Linke said that in her experience resuscitation causing the spiral fracture would be very rare, otherwise she would expect to be seeing more spiral fractures in the tibia of children who have undergone resuscitation. 403 Assoc. Prof. Linke agreed that if a child sustains a spiral fracture, they are not ambulating or weight-bearing and the fracture goes unnoticed. She said that she was sure that there are fractures that occur that are not presented to her as a radiologist, depending on how the infant is at the time, but the absence of bruising, the absence of perceived pain, makes no difference.188 Biomechanics 404 Assoc. Prof. Linke added that there are patterns of injury, mechanisms of trauma or mechanisms of force that are more likely to produce certain fractures. Children cannot be treated like crash test dummies, so the problem with mechanical, biomechanical force in the literature and how it relates to the amount of force that can cause fractures, is very difficult because experiments are not done on children. Currently there is no literature that quantifies how much force is required to cause a fracture in a child.189 Pneumonia 405 Assoc. Prof. Linke said that in general, children with a viral pneumonia or bacterial pneumonia may present with shortness of breath. She disagreed that bacterial pneumonia is more likely to present in imaging than viral pneumonia.190 186 T 387. 187 T 387. 188 T 389. 189 T 389. 190 T 419. -- 85 of 345 -- [2026] SADC 67 84 406 She agreed that viral pneumonia can be a little more difficult to see in radiology because it may present as just a viral bronchitis or it may have interstitial opacity. She agreed that viral pneumonia, or indeed bacterial pneumonia in its early stages, may not necessarily be readily visible in the lungs. 407 Here there was an added complication because of the positioning of the endotracheal tube, there was volume loss in the left lung, collapse of the lower lobe, with a mild bronchial wall thickening in the right upper lobe.191 408 Assoc. Prof. Linke said JR had an X-ray earlier on presentation where the lungs were very clear. The following X-ray where those changes were as described was after there had been a lot more intervention with a tube being inserted. She said that the changes on the X-ray were caused by the instrumentation. Another later X-ray showed those changes cleared. Whilst JR could possibly have been suffering a mild viral lower respiratory tract infection, that certainly was not severe enough to cause significant parenchymal abnormality. 409 Assoc. Prof. Linke disagreed with Dr Auer’s opinion that a potential origin of JR’s cardiac arrest could be a viral pneumonia, given the other trauma that she was aware JR suffered. 410 It would she said, require a fairly severe pneumonia for a child to go into respiratory arrest. She agreed that rhinovirus can have a rather profound effect on an infant's respiratory process but said that a child who ends up being hospitalised for a viral pneumonitis or a significant bacterial pneumonia will usually have changes on their X-ray. 411 When asked about JR’s gram-positive cocci result, which can be staphylococcus, she observed that the notes read that JR was asymptomatic. He was treated with antibiotics, and he had not been suffering a fever. A repeat blood culture was suggested if signs of infection developed.192 412 With respect to an article said to speak of ‘pneumonia not being detected effectively in 11% of cases where it is subsequently established to be evident in radiographical images,'193 Assoc. Prof. Linke said that the article is about determining what sorts of infections these children have when they present to hospital. The criteria was that they had to have blood evidence, respiratory-like aspirates from their airway, and chest radiograph confirmation by a paediatric radiologist that they had pneumonia. Accordingly, there was a certain percentage of children who were excluded from the study because they did not have radiological evidence of pneumonia even if they had respiratory evidence.194 191 T 420. 192 T 425. 193 T 430. 194 T 430. -- 86 of 345 -- [2026] SADC 67 85 413 She agreed children can have a mild viral or respiratory tract infection without it necessarily seen easily on X-ray. 414 Assoc. Prof. Linke disagreed with the suggestion that if someone suffers from a viral or bacterial pneumonia or are dehydrated for any reason, that compromises the quality of images. Rickets 415 Dr Auer had referred to 'calcium seen on the shaft of long bones with excess cartilage coating the bone shaft'195 and referred to 'uncalcified cartilage covering the entire shaft of the bone a reliable sign of resolving rickets'.196 Assoc. Prof. Linke described Dr Auer’s comments as incorrect anatomically because cartilage does not cover the whole shaft of a long bone. The cartilage is at the growing ends of the long bone, not along the shaft. Cartilage is not visible on an X-ray. She said that Dr Auer’s whole statement was wrong and ‘anatomically incorrect’.197 416 Assoc. Prof. Linke said that once the baby is born the shafts of the long bones are all bone, but you are left with cartilage at the growing ends of the long bones so the child can grow. She said that Dr Auer was simply wrong and wrong to suggest that there are craniotabes. 417 Assoc. Prof. Linke said that she had not ‘been witness’ to Dr Auer’s opinion that 'rib fractures occur in low vitamin D during times of rapid growth of the thorax'198 and said that it was not a well-known or recognised feature in the literature and that when diagnosing rickets, she is not diagnosing rib fractures. 418 There is no point in time at which there is a rapid growth of the thorax such as to cause ribs to be very weak. If there were such a time, she said she would expect to be able to present to the court multiple images of children with rib fractures. 419 Assoc. Prof. Linke said that there are universal guidelines in paediatric forums in Australia which are very consistent with the UK and USA setting of what would universally be called non-accidental injury. Sofa incident 420 Assoc. Prof. Linke agreed that the head knock from the sofa incident could have given rise to a fracture that, if not scanned would not be known. However, given that JR had two fractures: the one on the right was definitely acute; the one on the left was quite thin and narrow and it is quite possible that occurred on a 195 T 288. 196 T 288. 197 T 288. 198 T 291. -- 87 of 345 -- [2026] SADC 67 86 different occasion. She said that radiologically, regardless of any history there was evidence of an acute skull fracture.199 Re-bleed 421 Assoc. Prof. Linke agreed that subdural haematomas can rebleed with minimal force. It was however not her experience that if there was a subdural haematoma at birth that would still be present or bleed three months down the track.200 Use of images in Exhibit P26 422 As to the appropriateness of utilising the image in Exhibit P26 as a comparator, Assoc. Prof. Linke said she was describing or showing an image of pathology that defence was insisting JR had, and demonstrating what that pathology looks like and illustrating why, in comparison, JR's leg looks normal. Assoc. Prof. Linke denied that the image showed a child ‘possibly to be quite a bit older’201 than JR and said that it was of a comparable age because the ossification centres, that is, the round blobs of bone, were of similar size. It would, she said, be ‘give or take’202 one or two months but it does not matter because the image is of a child. Assoc. Prof. Linke denied that the fact that JR was premature renders obsolete or inappropriate the utility of this image, adding that bony changes of rickets are going to be universal regardless of the age of the child. 423 Assoc. Prof. Linke’s evidence remained that the radiology evidenced rib fractures that predated 5 January 2020. Assoc. Prof. Linke’s re-examination 424 In re-examination, Assoc. Prof. Linke said JR’s medical history was potentially consistent with the type of stress that could cause growth arrest lines, adding that it was not relevant and that radiologically, JR showed no evidence of any metabolic bone disease. 425 Assoc. Prof. Linke said that on the radiology there no evidence that JR had rib fractures from birth or any evidence of rickets such as to delay healing of rib fractures. 426 She said that in all the babies that are in extremis enough to require intraosseous cannulation for resuscitation, she had not seen a fracture as an adjunct. 427 As to her agreement that lifting a baby to change their nappy by one leg could be capable of resulting in a spiral fracture, Assoc. Prof. Linke said that it was ‘very, very rare’203 to see spiral fractures at that level on babies six weeks old. 199 T 415. 200 T 419. 201 T 433. 202 T 433. 203 T 438. -- 88 of 345 -- [2026] SADC 67 87 Summary of Assoc. Prof. Linke’s opinions 428 In summary Assoc. Prof. Linke’s opinion was that: • X-ray showed that JR had multiple healing rib fractures which may have been of different ages. • The fractures had not happened in the previous five to seven days. • Due to the unexplained fractures of different ages, a skeletal survey was recommended to find any evidence of trauma elsewhere or to find a genetic or metabolic abnormality that may predispose JR to fracture. • JR did not have rickets which is a condition that affects all bones equally and would be shown in the ends of long bones. There was no evidence of abnormality in the end of JR’s wrist which was completely normal in appearance. Neonatal rickets would affect all ribs and would be symmetrical. • Biochemical analysis showed JR did not have rickets. His level of vitamin D is seen in up to 30% of all newborn infants. Assoc. Prof. Linke said that low vitamin D does not equate to a diagnosis of rickets. His birth at 38 weeks, two weeks shy of term, had she said, no relevance. • X-ray showed healing fractures, consistent with normal bone healing. Rickets would be seen as a widened zone of mineralisation, usually at the long end of bone, rather than in the middle of bone where JR’s rib fractures were seen. • The radiology showed no evidence of osteogenesis imperfecta or Wormian bones. • The cephalohaematoma was attributable to JR’s ventouse assisted delivery, where there is bruising between the scalp and the skull. JR had very good mineralisation of his skull with no radiological features of craniotabes. • The rib fractures were not those typical with CPR and in any event, were healing. • The healing seen in the tibial fracture would place the fracture as occurring between 5-14 days prior. Given the date on which the scan was performed, that is, 10 January 2020, the fracture could have occurred around the time of admission. • That JR’s legs were exposed during the visit to the GP on 3 January 2020 and there was no observation of bruising, swelling or discolouration, did not change her opinion as regards to the radiology. Assoc. Prof. Linke said she would not expect such a fracture to have occurred during resuscitation. -- 89 of 345 -- [2026] SADC 67 88 • JR’s lungs were clear and there were no signs of infection. He was asymptomatic. Changes in the X-ray were caused by the positioning of the endotracheal tube. • The radiology showed JR had two skull fractures with swelling and subdural haematoma. • The right sided fracture to JR’s skull was definitely acute. • For JR to have sustained skull fractures would require a fall from height. • There is no literature quantifying how much force is required to cause a fracture to a child. • The radiology did not show widened occipital sutures. The CT scan supported what had been reported on the plain skull X-ray. • The CT scan did not show any internal bruising to the brain. • A growth arrest line could be seen on an X-ray of JR’s wrist. The area of demineralised bone is very common in infants because for bone to have good bone turnover, muscles need to be used. Any child that may be laying dormant for whatever reason would very quickly get a zone of demineralisation or non-use osteopenia. • The image of JR’s pelvis taken on 10 January 2020, in the context of not moving for five days, showed non-use osteopenia. • She would expect a radiologist to know that there is no cartilage in the area, that Dr Gootnick described as the ‘growing cartilage’.204 • As to Dr Gootnick’s opinion that the image demonstrated poorly calcified cartilage in the interior of the vertebral body, Assoc. Prof. Linke said that the line to which Dr Gootnick had referred was due to a vascular bundle which is the way nutrients get into the spine and nothing to do with a lack of vitamin D and calcium. • An inability for fractures to heal because of disordered calcium metabolism would impact on the ageing of the rib fractures but here, there was no such disorder. • Dr Auer’s reference to uncalcified cartilage covering the entire shaft of the bone as a reliable sign of resolving rickets was anatomically incorrect. 204 T 273. -- 90 of 345 -- [2026] SADC 67 89 • Rib fracture occurring in low vitamin D during times of rapid growth of the thorax is not a recognised feature in the literature. Assoc. Prof. Taranath’s evidence Qualifications and experience 429 Assoc. Prof. Taranath is the head of Paediatric Neuroradiology at the WCH, a position he held since 2011.205 He undertook specialised training in paediatric neuroradiology and developed the neuro imaging protocols for magnetic resonance imaging (MRI) studies of the neck and head. 430 He explained that he works with MRI which looks to soft tissue rather than the bones, that is, in contrast to plain X-ray which looks to the bony structures. While computed tomography (CT) does look at the soft tissues, an MRI provides a higher degree of resolution. 431 Assoc. Prof. Taranath said he has published extensively and reviews articles for the purpose of determining whether they are fit to publish for journals in his field. He has presented internationally including at the Hospital for Sick Children in Great Ormond Street in London, which he said is one of the leading international institutions in paediatrics. 432 He contributed to the neuroimaging protocols for children who are the victims of abusive head trauma for the Royal Australian and New Zealand Colleague of Radiologists. 433 In the course of his duties as a neuroradiologist consultant for South Australia Medical Imaging at the WCH, he reported on the MRI study of JR’s head and spine performed on 8 January 2020. His findings were originally reported as follows:206 FINDINGS: Foci of diffusion restriction are identified in the peri Rolandic region, depth of left frontal sulcus/G-W junction, the depths of the insular sulci/G-W junction left to a greater extent than the right, left occipital lobe, cortical ribbon and subcortical white matter of the left inferior frontal gyrus and the splenium of the corpus callosum. No other focus of restricted diffusion is appreciated. No other focus of diffusion restriction. Foci of susceptibility are noted in the posterior fossa ventral to the sinuses, posterior interhemispheric fissure, around the occipital poles and extending into the parieto-occipital regions reflecting subdural haemorrhages. Multiple linear/curvilinear foci of susceptibility are noted in the high parietal sections biparietally. Whilst some of them could represent subdural haemorrhagic foci, a few of them could be representative of a combination of subdural haemorrhage associated with bridging vein trauma (compression/laceration). Also noted are foci of susceptibility in relation to the subcortical white matter of the left inferior frontal gyrus. A focus of susceptibility is noted in relation to the temporal aspect of the 205 Exhibit P44. 206 Exhibit P45. -- 91 of 345 -- [2026] SADC 67 90 optic nerve head on the left side. This can be better correlated with the eye examination findings. No other focus of susceptibility. No other intra or extra-axial space occupying lesion. No other focus of intra or extra-axial signal intensity abnormality. The myelination is unremarkable. No abnormality involving the ventricles of the sulcal spaces are. Prominence of pericerebral subarachnoid spaces noted bifrontally is in keeping with the age. No Chiari I deformity. No tonsillar ectopia. No midline shift. No flow voids have a normal course and calibre. No abnormality appreciated on the MR angiogram. Bridging vein entering the anterior aspect of the superior sagittal sinus is appreciated on the MR venogram. However the posterior aspect of the superior sagittal sinus does not demonstrate bridging veins draining into it and therefore this finding in association with susceptibility foci noted in these regions suggests bridging vein trauma (compression from subdural haemorrhage / laceration). The fracture involving the skull vault is very seated on the preceding CT scan. Alignment and intensity of the vertebral bodies and their appendages is within normal limits. No syrinx. No obvious intra or extramedullary space-occupying lesion. No subdural haemorrhage in relation to the spinal canal. The conus is seen to terminate at mid L2. From the sagittal sequences there is no indication of a lipoma of the filum terminale. No pre or paraspinal oedema. CONCLUSION: Foci of diffusion restriction in the peri Rolandic regions and in the depths of the sulci/G- W junction with pre wallerian degenerative changes (manifested as diffusion restriction) in the splenium of the corpus callosum suggest the possibility of a hypoxic ischaemic brain injury. Axonal shear injury could co exist. The focus of diffusion restriction associated with susceptibility in the left inferior frontal gyrus and left occipital region represent contusional trauma. Subdural haemorrhage identified in the posterior fossa, posterior interhemispheric fissure and parieto-occipital regions. Refer report regarding the probability of bridging vein of trauma. Focus of susceptibility noted in the temporal aspect of the left optic nerve represents a retinal haemorrhage. This will need to be correlated with the eye examination. No concerning MRI findings pertaining to the spine. 434 With respect to his finding that 'foci of diffusion restriction are identified',207 Assoc. Prof. Taranath explained that normally the protons that the MRI targets in the body can move in a certain direction in response to the gravitational field. When they move, they need space. If the cell is swollen, the space in between the cells becomes less. It is referred to as ‘diffusion restriction’208 and means that the cell is swollen. 435 Assoc. Prof. Taranath went on to detail the locations of the diffusion restriction found on JR’s scan, that is, in the perirolandic region in the brain (the area of the brain that contains neurons that will aid in motor activity and sensory 207 T 850. 208 T 851. -- 92 of 345 -- [2026] SADC 67 91 activity), and several others which are concerned with neurons that will aid in different activities in the human body. He described a focus of diffusion restriction in relation to the splenium of the corpus callosum, a structure that runs from right to left in the brain, very close to a fibrous structure called the falx, which is the fibrous structure that separates the right cerebral hemisphere from the left hemisphere.209 436 Assoc. Prof. Taranath said that the changes that were indicators of swelling are on the surface of the brain, in the depth and in the structure that separates the right and left hemisphere of the brain. There were ‘foci of susceptibility’210 noted in the posterior fossa. Susceptibility, he explained means the area where there is either blood or calcium in the brain. There are sequences that will help in differentiating if what is seen is blood or calcium and, in JR’s case, it was blood around the cerebellum hemispheres, in between the hemisphere and the dural covering that surrounds the cerebellum hemispheres. There was blood between the brain tissue and the lining of the brain that sits below the skull. Bridging veins 437 Assoc. Prof. Taranath explained that normally the brain is surrounded by three layers. The pia mater is very close position to the brain. Outside the pia mater is the dura mater, and then between the pia and the dura, the arachnoid mater. Normally the dura is not separated from the arachnoid, and they are very close to each other. In a subdural haemorrhage, the blood has dissected into the space and created a space that is full of blood. In JR’s case he reported the presence of subdural blood in a space where it is normally not present, that is, in an area of the bridging veins.211 438 Assoc. Prof. Taranath explained that the bridging veins are, as the name suggests, veins that bridge the gap between the surface of the brain and the veins that will carry the blood into the veins of the neck and down into the heart. These bridging veins run from the surface of the brain through the subarachnoid space, penetrate the dura, and then enter the sinuses. If there is a rupture of these bridging veins, a subdural haemorrhage will accumulate and create a space which is normally not there. He said that here there is an inference that something has happened to the bridging veins because of the presence of blood in that location. 439 If the bridging veins were the subject of an insult or damage, the bleeding could be localised but could also be diffused because the blood is going to cleave and move, meaning that if a bridging vein is ruptured, it would bleed in the subdural space.212 209 T 851. 210 T 856. 211 T 853. 212 T 854. -- 93 of 345 -- [2026] SADC 67 92 440 Assoc. Prof. Taranath noted a focus of susceptibility in relation to the outer aspect of JR’s left eyeball, which could be correlated with an eye examination picking up a haemorrhage in the region of the retina. Skull fractures 441 By reference to his PowerPoint presentation,213 Assoc. Prof. Taranath said the focus of haemorrhage was in the subarachnoid space, the space that immediately surrounds the brain. When asked whether this was an indicator of illness, disease or trauma, Assoc. Prof. Taranath said the clinical details provided to him were 'seven-week-old male, rib fractures, biparietal skull fractures, likely nonaccidental injury'.214 In that context, he would call the haemorrhage the result of trauma. 442 While MRI does not allow a clear visualisation of the skull fractures, on comparison with the CT scan, he found that the haemorrhage on the right side was away from the fracture and the one on the left side was close to it. 443 He noted swelling in the perirolandic area, an area that deals with motor and sensory activities, which starts from the periphery and moves towards the midline, moving deeper, suggesting that there could be a hypoxic ischaemic injury to the brain or an axonal shear injury. 444 Assoc. Prof. Taranath explained that an axonal shear injury is usually the result of an acceleration, deceleration-type of injury. There is an acceleration that pushes the brain inside the skull cavity forwards and there is a deceleration that pushes it backwards. In acceleration deceleration-type injuries the axons that sit in the surface of the brain start to shear and they suffer injury, with the swelling causing a brain injury.215 Hypoxic ischaemic injury or axonal sheer injury 445 Assoc. Prof. Taranath said that the images showed injury in JR’s frontal lobe, specifically the sulcus in the left frontal lobe, consistent with either hypoxic ischaemic injury or an axonal shear injury. He explained that it is sometimes hard to differentiate between the two which is why in his report he said that axonal shear injury could coexist with hypoxic ischaemic injury. Sometimes axonal shear injuries tend to have haemorrhages along with them in which case it could be said to be a haemorrhagic axonal shear injury. 446 While in this case, he did not see any definite axonal sheer injury, the scan diffusion restriction seen in the left half of the brain at the lower aspect of the left cerebral hemisphere, was a finding that led him to think in terms of axonal shear injury because it was slightly away from the location that he would expect if it was a pure hypoxic ischaemic brain injury.216 213 Exhibit P46. 214 T 856. 215 T 857. 216 T 860. -- 94 of 345 -- [2026] SADC 67 93 447 Assoc. Prof. Taranath said that the presence of a diffusion restriction in the splenium of the corpus callosum is an indicator of axonal injury or axonal shear injury. As to whether one would see this type of bright signal diffusion restriction simply from a hypoxic injury, Assoc. Prof. Taranath said:217 This is a possibility that we can sometimes see as hypoxic ischaemic, as a result of hypoxic ischaemic brain injury, but it can also be the result of axonal shear because of the splenium coming into contact with the fibrous falx that sits right above it. 448 Taking the injury or the damage seen in the images marked ‘B05’ in Exhibit P46 together with the damage in image marked ‘B04’, could, he said, provide a further degree of comfort towards axonal shearing. 449 The images marked ‘C11’, read in conjunction with images marked ‘F’ (from the MR venogram), suggested bridging vein trauma. He said that whether that was total laceration or compression is hard to resolve on the MRI, but the MR venogram, alongside the blood sensitive MR image, showed that the signal from the bridging vein was not picked up on the MR venogram which could mean that the vein is either lacerated or compressed and hence not picking up signal within the vein. 450 When asked about his understanding of what can cause the trauma observed on ‘C11’ to bridging veins, Assoc. Prof. Taranath said:218 So the bridging veins have an anatomy that is as follows, so you have the bridging veins that come from the surface of the brain and they enter the main vein in the midline, so they have to run from periphery to centre and they have a sort of a transference course at right angles to this main vein that is sitting in the midline. So they can get injured only when there is a front to back movement because it’s going to be perpendicular to their axis. And hence acceleration, deceleration-type of injury is what we consider would have happened in the context of bridging vein trauma. 451 Assoc. Prof. Taranath compared the MRI soft tissue findings, that is the brain and the coverings around the brain, with the CT scan. He said that in terms of the visualisation available on an MRI, the MRI does not have the sufficient resolution to show the tear of bridging veins. The presence of trauma is however inferred from the fact of the vein at the epicentre of the haemorrhage. The fact that the MR venogram, the image marked ‘F’ in the PowerPoint, is a sequence meant to pick up signals from the veins, cannot show the veins, would suggest that there is a trauma to the vein.219 452 Assoc. Prof. Taranath said that his findings support the clinical suspicion of non-accidental injury. He said that he had access to the CT scan and chest X-rays prior to the scans performed on 5 January 2020 and prior to his MRI reporting. On the MRI he found the presence of subdural haemorrhages. He found the presence of MRI haemorrhagic and non-haemorrhagic contusions in the brain substance. 217 T 862. 218 T 867-868. 219 T 869. -- 95 of 345 -- [2026] SADC 67 94 There was the possibility of retinal haemorrhage and going back to the CT scan, there was a fracture, and the subdural haemorrhage was seen on the CT scan as well. Going further back, he saw that there were rib fractures that were predominantly situated at the back end of the ribs, to the sixth to ninth ribs on the right and fifth, sixth and seventh on the left. He said that based on the CT scan and MRI alone he would have considered a non-accidental injury to be a possibility. The possibility of the rib fractures added to that suspicion. 453 With respect to the document titled 'Consensus statement on abusive head trauma in infants and young children'220 (the Consensus Statement), Assoc. Prof. Taranath said that the statement was prepared by authors spread across Europe and North America, who asked if other societies across the world including the Australian and New Zealand Society of Paediatric Radiology, would endorse it. He said that their endorsement has been reflected in an addendum or a letter that accompanies the main article. He said that the Consensus Statement allows those reporting abusive head trauma clarity about how certain signs present, and how all the alternate theories could impact judgment on an MRI scan, and how to see through that and produce a report. It talks about the various causes of an abusive head trauma and about the presentation of the child in a situation of abusive head trauma. It deals only with abusive head trauma, not with the rest of the body, but it makes some references to other parts of the body that might help in making a diagnosis of abusive head trauma. 454 Assoc. Prof. Taranath described the Consensus Statement as a good reference article for people reporting abusive head trauma in the paediatric population. In his opinion, the Consensus Statement represents a guide to practitioners working in his specialty in Australia and one he would go to if having to explain a constellation of injuries to another practitioner. 455 Assoc. Prof. Taranath said that while preparing the matter he had access to other CT scans and X-rays which had been performed on JR, none of which gave him cause to alter his opinion or gave cause to query the clinical detail of likely non-accidental injury. Assoc. Prof. Taranath’s responses to defence expert opinion 456 Assoc. Prof. Taranath had been provided with reports from Dr Auer and Prof. Ackland. 457 As to Dr Auer’s proposition that:221 Bleeding can originate from arteries or veins. Usually, the only consideration given in medico-legal cases is venous tears from trauma. However, a brief consideration of the three vessels supplying the dura matter indicate that arteries can also bleed into the dura which has a rich arterial supply, as every neurosurgeon knows. 220 Exhibit P47. 221 T 885. -- 96 of 345 -- [2026] SADC 67 95 458 Assoc. Prof. Taranath said that throughout his training, subdural haemorrhages are the result of venous trauma, particularly in the paediatric age group. In adults and the elderly, they could sometimes be arterial in origin, but he had never in his experience come across an arterial subdural haemorrhage in a paediatric patient.222 459 As to Dr Auer’s suggestion that:223 It’s natural to invoke trauma if infantile stroke is forgotten. However, the 10 January 2020 MRI of brain and spine shows multiple areas of the brain which appear to have sustained injury from a lack of blood and oxygen. Likely secondary to the cardio respiratory arrest and the need for CPR. Foci of diffusion restriction identified in the perirolandic region. Depth of the left frontal sulcus/GW junction depth of the insular sulci/GW junction, left to a greater extent than the right. Left occipital lobe, cortical ribbon and subcortical white matter of the left inferior frontal gyrus and the splenium of the corpus collosum. Axonal shear injury could coexist in these locations'. 'The unknowable from imaging is stated as if it’s definitely-known areas of constitutional trauma, diffusion restriction associated with susceptibility'. 'Diffusion restriction refers to the freedom of water molecules moving within the cerebral tissue and is not an index of trauma, let alone intentional trauma'. 'Diffusion restriction refers to the freedom of water molecules moving within the cerebral tissue and is not an index of trauma let alone intentional trauma. This is a diagnostic overreach here. 460 Assoc. Prof. Taranath said that:224 ….diffusion restriction does not refer to freedom of water molecules. In fact, it is a restriction on the freedom of water molecular movement. Diffusion would be freedom of water molecular movement. Diffusion restriction is when there is a restriction on that movement. That happens when you have an ischemic episode which is a part of a stroke situation or a hypoxic ischemic brain injury. It can also happen when you have a traumas, as we discussed earlier, which could be associated - which could be deep within the brain when it's a part of the axonial injury. It could happen on the surface of the brain which when it comes into contact with the skull vault or the fibrous structure, so you could have diffusion restriction in a variety of situations. 461 He said that there could be diffusion restriction in a variety of situations. The fact that there is a restriction of diffusion of water molecules means that there is not enough space between the cells for the water molecules themselves to move. In other words, the cells have swollen. 462 Assoc. Prof. Taranath explained that he reports on the inability of the diffusion to happen, which is an indicator of a swelling of the cells. Diffusion is normal. Diffusion restriction is as the name suggests, restriction upon normal 222 T 885. 223 T 886. 224 T 886-887. -- 97 of 345 -- [2026] SADC 67 96 diffusion. Normally the water molecules would move, but here they do not and that is because of the swelling which is picked up on the MRI. 463 As to a finding that the posterior aspect of the superior sagittal sinus did not demonstrate bridging veins draining into it, which Dr Auer described as a ‘diagnostic overreach and it is unknowable to a neuroradiologist if there has been trauma or ischemia',225 Assoc. Prof. Taranath said that the location is what matters. If it is trauma-related diffusion restriction, it is going to be superficial. If it is ischemia it is going to follow a certain pattern which involves the perirolandic area. He said that certainly a radiologist can differentiate between trauma-related diffusion restriction and an ischemia-related diffusion restriction. 464 Trauma-induced diffusion restriction would have a different distribution to diffusion restriction associated with ischemia, explained here by trauma occurring as a consequence of impact with the skull. Additionally, trauma that has occurred by impact of the brain with the fibrous material that separates the hemispheres would present as different to ischemia. 465 In this matter there was, Assoc. Prof. Taranath said, evidence of trauma based on some of the locations where diffusion restriction and haemorrhage were found. 466 Assoc. Prof. Taranath was asked about Prof. Ackland’s opinion that:226 From my research in the area, in this area, I've formed the opinion that the current state of the science does not permit any scientific, clinician to conclude with confidence that shaking alone an infant can or cannot cause the injuries associated with shaken baby syndrome including subdural haematoma, retinal haemorrhage and/or encephalopathy, i.e., the triad of injuries. 467 Assoc. Prof. Taranath said that he disagreed with the fact that there is lack of evidence that shaking alone can produce the triad of changes. He said the Consensus Statement provides a basis to his opinion in that regard. Biomechanical research cannot truthfully replicate the internal milieu of a child's cranial cavity, neck or spine. When asked whether it is necessary to proceed with caution in terms of biomechanical research in terms of infants and injury, Assoc. Prof. Taranath said that he did not think it had a great bearing on what a radiologist would report in this situation because the biomechanics cannot replicate the environment of a child's head, neck, spine. It is all based on models and in some cases monkeys. It is not possible to have a child as a model for this.227 468 As to Prof. Ackland’s statement that vigorous shaking of JR, with or without head impact might have occurred and could have contributed to such damage, Assoc. Prof. Taranath said that in his experience, injuries consistent with the forward/backward injuries to the brain are not always accompanied by neck and 225 T888. 226 T 891. 227 T 893. -- 98 of 345 -- [2026] SADC 67 97 cervical spine injury. He said that it is not a given that if there is acceleration/deceleration, something will be found in the neck and spine. Assoc. Prof. Taranath’s cross-examination 469 In cross-examination, Assoc. Prof. Taranath said he had not examined the evidence of the first responders, the 000 call, the events of 5 January 2020 or the evidence of Assoc. Prof. Linke. He had seen the CT scan and Assoc. Prof. Linke’s report. 470 At the time he reported on the MRI, Assoc. Prof. Taranath only had the information on the request form for the MRI. He accepted that the conclusion that was drawn in relation to a non-accidental injury relied on the condition of the child's skull, the ribs, and the leg which predated the presentation to the WCH. 471 He was not aware that ultimately Assoc. Prof. Linke resolved the leg fracture potentially was sustained on 5 January 2020. 472 Assoc. Prof. Taranath agreed that Exhibit D34 showed the resuscitation that he would have expected in a six-week-old child. He said he was not aware that CPR can cause a hypoxic brain injury but guessed it was possible for failed tracheal intubation to cause a hypoxic brain injury. 473 He was aware there were rib fractures, four ribs on the right and three on the left and described the anatomical variant of JR’s ribs as a variation of normal. 474 He said that he could not support the biomechanical theory because it is not possible to reproduce the internal environment of a child of six weeks by using adult primates as models or creating models and throwing them off certain heights. He agreed that it is a vexed area, with many variables and is deeply complex. 475 Assoc. Prof, Taranath said that the cephalohaematoma cannot be a source of rebleeding. 476 He only became aware of the sofa incident during a meeting the previous week with Defence counsel. 477 As to retinal haemorrhages, Assoc. Prof. Taranath said that he went through the various situations where Dr Auer said that retinal haemorrhages can occur and disagreed that a six-week-old child could find itself in those situations which would lead to retinal haemorrhage. He said that he was not aware of CPR, seizures or viral infections causing retinal haemorrhages, but added that these issues were outside his expertise. 478 He agreed as a broad proposition that subdural bleeding can arise from other causes that are non-traumatic but said that a traumatic origin is able to be readily inferred here. Subdural haematomas are not aged on MRI, rather, a CT scan is used to age the subdural haematoma. The appearance or hyper density allows subdural -- 99 of 345 -- [2026] SADC 67 98 haematomas to be aged. It does not matter how much of blood is there, it is the appearance of the blood that allows the ability to age it on a CT scan.228 Summary of Assoc. Prof. Taranath’s opinion 479 In summary Assoc. Prof. Taranath’s opinion was that: • Areas of diffusion restriction (swollen cells) were found on the MRI of JR’s brain. • Blood was present in the area of the bridging veins. • If there is a rupture of the bridging veins a subdural haemorrhage will accumulate and create a space that is not usually there. • The CT scan showed two skull fractures with haemorrhage on the right, away from the fracture and haemorrhage on the left close to the fracture. • Swelling was noted in the perirolandic area suggesting hypoxic ischemic injury to the brain or an axonal shear injury. • No definite axonal sheer injury was seen, however the scan diffusion restriction led him to think in terms of axonal shear injury because it was slightly away from the location that he would expect if it was a pure hypoxic ischaemic brain injury. • An axonal shear injury is usually the result of an acceleration, deceleration-type of injury. • The presence of a diffusion restriction in the splenium of the corpus callosum is an indicator of axonal injury or axonal shear injury. • It is possible to see bright signal diffusion restriction simply from a hypoxic injury, but it can also be the result of axonal shear because of the splenium coming into contact with the fibrous falx that sits right above it. • Taking the injury or the damage that is seen in the images together provides a further degree of comfort towards axonal shearing. • The images read in conjunction with images from the MR venogram, show the trauma to the bridging veins. • The MR venogram, alongside the blood sensitive MR image, shows that the signal from the bridging vein is not picked up on the MR venogram which could mean that the vein is either lacerated or compressed and hence not picking up signal within the vein. 228 T 913. -- 100 of 345 -- [2026] SADC 67 99 • Acceleration, deceleration-type of injury would have happened in the context of bridging vein trauma. • Trauma induced diffusion restriction would have a different distribution to diffusion restriction associated with ischemia. A radiologist can differentiate between trauma related diffusion and ischemia related diffusion restriction. • The MRI does not have the sufficient resolution to show the tear of bridging veins however trauma is inferred from the MR venogram which looks at vein flow. Here there was no flow suggesting trauma. • The MRI showed subdural haemorrhages and haemorrhagic and non- haemorrhagic contusions in the brain substance. There was the possibility of retinal haemorrhage and the CT scan showed fracture and subdural haemorrhage. • Rib fractures that were predominantly situated at the back end of the ribs, to the sixth to ninth ribs on the right and fifth, sixth and seventh on the left. • Based on the CT scan and MRI alone he would have considered a non- accidental injury to be a possibility. The possibility of the rib fractures added to that suspicion. • The Consensus Statement allows people reporting abusive head trauma clarity about how certain signs present, and how all the alternate theories could impact judgment on an MRI scan, and how to see through that and produce a report. • The Consensus Statement represents a guide to practitioners working in his specialty in Australia. Dr Edwards’ evidence Qualifications and experience 480 Dr Edwards gave evidence of her qualifications and experience.229 She holds a Bachelor of Medicine and Bachelor of Surgery and completed her fellowship with the Australian College of Physicians in Paediatrics in 2002. She completed a master’s degree in forensic medicine at Monash University and became a founding fellow of the faculty of Clinical Forensic Medicine through the Royal College of Pathologists of Australasia (the RCPA). 481 A position statement from the RCPA230 describes the role of the specialist in clinical forensic medicine which includes both adult and paediatric forensic work. 229 Exhibit P77. 230 Exhibit P66. -- 101 of 345 -- [2026] SADC 67 100 482 Dr Edwards is required to complete professional development for both pathology and the paediatric colleges. Those requirements include attendance at seminars and the presentation of papers. There are different categories on which evidence of professional development is required which include teaching, training, and auditing her own practice. 483 From 2010, Dr Edwards has been the Medical Unit Head of Child Protection Services with the WCH. In May 2024 the name of the unit changed to Paediatric Forensic Medical Service (the Service). Dr Edwards’ role 484 As the Medical Unit Head, her role is to supervise other doctors within the Service. There are associated administrative and clinical roles involved in assessing children who are referred with suspicious injuries, sexual assaults, neglect and other forms of maltreatment. 485 Dr Edwards described the Interagency Code of Practice, relevant to January 2020, published in 2016, 231 as an integral part of the work the Service undertakes. She said the document sets out a framework for those government agencies responsible for the investigation of suspected child abuse and neglect and dictates how the agencies work together in those investigations. 486 Dr Edwards said that there are three agencies that deal in a day-to-day sense with the issue of child abuse, namely the two statutory agencies, SAPOL and the DCP, and the non-statutory agency, CPS. The role of CPS is to provide information to the statutory agencies to help inform their decision-making. Dr Edwards works within the Service which works together with CPS on every matter that is referred to the Service. 487 Dr Edwards said that referrals to the Service are received from multiple sources. Often initial contact comes from doctors or other health staff, either within WCH or other hospitals, or GPs who are asking for advice where they have an injured child and want some further information or clarification. Often their suspicion can be resolved without report to the DCP. However, if there are remaining concerns that cannot be addressed by the doctor or the team involved with the child, a notification is recommended. Sometimes a notification has already been made and the DCP then determine whether it would benefit from one of the CPS services. 488 If a child has been referred the next step, in accordance with the Interagency Code of Practice, is to convene a strategy discussion which includes police, the DCP, and medical and psychosocial members of CPS and the Service. The purpose of that strategy discussion is to share information that is relevant to the concerns, and each agency will share information. A joint plan is made as to which agency will take the lead, and which agency will be the first in contact with the child and 231 Exhibit P74. -- 102 of 345 -- [2026] SADC 67 101 family. In a situation where a baby has come into hospital with a suspicious injury, usually the approach will be for police and the DCP to speak to the family about the fact that a notification has been made and that they are requesting a forensic medical assessment be done by someone like her. Consent will be sought to gather further information.232 489 Dr Edwards said that her role is to conduct the forensic medical assessment which involves gathering a medical history, relevant history about any explanations for injury, a physical examination of the child, and reviewing the investigations. Sometimes at that point the suspicion is resolved, and feedback provided to police and the DCP. It is then discussed and if agreed, then that is the end of the matter. If there is no reasonable explanation or if further information is needed such as through conducting a site visit, there is further discussion and the process evolves over time with gathering further information through forensic investigations, medical investigations and interagency inquiries. When those inquiries lead to concern that there is no adequate explanation and therefore a high suspicion of inflicted injuries, decisions are then made by police and the DCP in relation to the child's safety, whether criminal charges will be laid and when, and either agency will request a report. Usually, the final report is only prepared once all the information needed to inform an opinion has been provided. 490 Within CPS, Dr Edwards’ role is limited to gathering medical information and reviewing and incorporating information gathered by police and the DCP relevant to the formulation of her opinion. She is called on to provide an opinion for either SAPOL or the DCP or both as to the causation of injuries, neglect or sexual abuse, very much based on the factual basis established and based on her experience and expertise. Further information is requested to assist with an opinion if necessary. 491 The DCP must work within their own legislative scheme. Any decision for removal of a child must accord with the relevant legislation. Generally, Crown advice is sought before making that decision. The DCP's paramount interest is the safety of the child.233 Dr Edwards’ involvement in JR’s case 492 While in her role at CPS, JR’s case came before her. She was on leave when he was first admitted to hospital. On her return on 13 January 2020, she received some handover information and JR’s file. She became aware that JR was a six- week-old infant who had multiple injuries for which there was, at the time, no adequate explanation. She was aware that there were further investigations planned, so her approach was to review all the imaging and documents and meet with Assoc. Prof. Linke. 232 T 921-922. 233 T 924. -- 103 of 345 -- [2026] SADC 67 102 493 Dr Edwards said that where multiple injuries are reported on imaging it is her practice to meet with the paediatric radiologist, in this case Assoc. Prof. Linke, to go through the images to clarify any aspects that were unclear in the report, and to decide whether any further investigations are indicated.234 494 JR’s x-rays showed evidence of healing fractures to the ribs. Dr Edwards said that it takes on average 7 to14 days before healing from a fracture can be seen radiologically. JR’s bone scan confirmed the presence of the injuries that had been seen on the other modalities. 495 The spiral fracture of the tibia had been identified as had the injuries relating to the intraosseous needles used in JR’s resuscitation. 496 Dr Edwards said that in a six-week-old baby whose X-rays showed normal bones, normal handling of the baby does not result in fractures. Any fracture found in a baby of that age is concerning and requires further investigation. 497 As at the 13 January 2020, Dr Edwards had the information that was brought in with JR by ambulance to the WCH, which at that stage did not include statements or the 000 call. Dr Edwards said that any information that describes the state in which the child was found prior to any intervention by the paramedics is important in terms of formulating an opinion about causation and timing, particularly in relation to JR’s head injury.235 498 From 5 January 2020, the suspicion that JR suffered an inflicted injury had been raised multiple times prior to her involvement. Dr Edwards concurred with that opinion, and decisions were made by the DCP in terms of JR's safety. 499 The material available to Dr Edwards at the time she provided her final report dated 27 November 2020 included TR’s neonatal records and JR’s birth records from the LMH. 500 The notes that Dr Noori took at the time that he was contacted by the paediatric emergency department consultant at 3.15 pm on 5 January 2020, showed that he was provided with information that JR had been brought into hospital by the ambulance after an unresponsive episode at home. The information was that his mother had gone out for an appointment and his father was at home looking after JR. He had fed JR and then put him on the floor in the lounge room. JR became pale and limp and stopped breathing and turned blue. The father called 000 and started CPR. He had done two cycles of compressions and two breaths when the ambulance arrived. When JR arrived at the WCH, he was breathing spontaneously, however there were concerns about seizure activity, so he was given an anticonvulsant, and he settled. He was noticed on examination to have a boggy swelling over the right side of his scalp. No bruising on his scalp was seen. 234 T 930. 235 T 932. -- 104 of 345 -- [2026] SADC 67 103 501 There were no other external signs of injury on examination of JR’s body. A CT head scan had been performed, which showed bilateral parietal skull fractures and subdural haemorrhages. A chest X-ray showed multiple healing bilateral rib fractures. The parents had reported that a week or two prior, JR was not using his right leg, but there was no history of trauma reported in relation to that. 502 Blood testing showed that JR’s vitamin D level was slightly low at 33 nmol/L and the rest of the blood tests were all normal. There was no indication that JR had osteogenesis imperfecta. Urine collected for a medical drug screen and metabolic urine screen showed no abnormality. JR’s respiratory pathogens were tested which indicated the presence of rhinovirus (the common cold). Dr Edwards said that while the result does not necessarily indicate that JR currently had rhinovirus, he may have in the recent past.236 503 Initially there was a contaminant from staph epidermidis, a skin bacterium which is a common contaminant of blood cultures, and a repeat blood culture was performed which was negative. 504 A whole-body scan was undertaken on 14 January 2020 showing an increase tracer uptake in the bilateral ribs and the right tibia which corresponded to the known fractures in the ribs and tibia. 505 A repeat MRI undertaken of JR’s head on 24 March 2020 was reported as showing a subtle increased T2 signal within the thalamus globus pallidi and internal capsules especially in the posterior limbs. Dr Edwards said this was likely reflective of sequelae from the prior insults, but there was no associated volume loss and the corpus callosum was described as a little thin. 506 In the left inferior frontal lobe in the region of the previous parenchymal contusion, there was now subtle volume loss indicating loss of brain tissue as a result of the trauma. There were no new haemorrhages or no large haemorrhages around or in the brain. 507 Dr Edwards noted that from the SAAS records the 000 call was received at 12.18 pm on 5 January 2020 and the ambulance service arrived at the scene at 12.20 pm. The first observation recorded at 12.25 pm noted that there was no respiratory or pulse rate and the GCS was 3, which is the lowest possible score out of 15. JR’s pupils were unreactive. 508 The first dose of adrenaline was given at 12.38 pm, when there was no respiratory or pulse rate, but at 12.44 pm there was a respiratory rate of 60 and a pulse rate of 160, that is, a return of spontaneous circulation. There was no specific time for the intraosseous intravenous cannula insertion but it was obviously prior to the adrenaline being given, so prior to 12.38 pm. 236 T 949. -- 105 of 345 -- [2026] SADC 67 104 509 Dr Edwards explained that the importance of the loss of the capacity to breathe in terms of a head injury is that it indicates that there has been damage to the brain stem, specifically the medulla, which is a part of the brain stem and which is the area of the brain that controls breathing and respiration. The loss of cardiac output indicates injury in the same location. 510 Dr Edwards said that she interprets the radiologist’s findings in the context of all the other information in a case. Her interest in their findings is to look to questions of causation. The question of causation and the interpretation of the results presented from a CT scan or MRI, are matters she is routinely required to undertake. She explained that to report on causation is a separate task to reporting on what is seen on the scans themselves. The radiologists report what they can see, which she then interprets in the context of all the other material. She draws together a variety of sources of material that may assist in terms of her opinion. It would be of note for example, if diffuse swelling as opposed to no diffuse swelling was reported. With respect to JR, multiple areas of focal swelling, different to broad or diffuse swelling was reported.237 511 In the CT scan, the brain initially was reported as normal, so did not look swollen. The MRI scan done two days later showed areas of focal changes which reflected a lack of oxygen or blood supply to certain areas with some local cell swelling. Vitamin D/rickets 512 Dr Edwards said that it is standard protocol at the WCH to undertake bone biochemistry on all infants who are admitted to hospital with fractures. 513 Dr Edwards described rickets as a condition where the vitamin D levels are so low that the bone has had to be resorbed to keep the calcium levels in the blood at a normal level. Rickets is diagnosed biochemically, radiographically and clinically. 514 Dr Edwards explained that JR would not meet criteria for being an infant at risk of vitamin D deficiency or rickets because his radiology was normal. She said that most infants who have rickets in Australia are from a migrant family with nearly all having dark skin and exclusively breastfed. While JR was not a migrant child, was on formula from birth, which contains a standard amount of vitamin D and his bones appeared normal on the imaging, bone biochemistry is always performed, particularly those with multiple fractures.238 515 Dr Edwards said that a low vitamin D in the absence of rickets does not predispose to fractures. JR’s injuries could not be accounted for by normal handling, disease, illness, vitamin D deficiency, congenital disorder such as osteogenesis, or any other metabolic disorder. 237 T 959. 238 T 934. -- 106 of 345 -- [2026] SADC 67 105 Tibial fracture 516 The fracture to JR’s leg was in the distal tibia which is the bottom of the shin bone just above the ankle. There was periosteal new bone formation which is the early stage of bone healing. Dr Edwards said that the mechanism of injury is rotational or twisting forces applied to the right lower leg. She said this is an inflicted injury in an infant of this age because they cannot cause that fracture to themselves. They have very limited mobility at six weeks of age. The twisting must be applied by a person usually with the knee bent and a twist of the ankle in either direction, or less likely, if the child is suspended and the body rotates around the lower leg. She said that if the baby was picked up by one leg and the baby then twisted, that might cause such an injury. 517 Dr Edwards said you cannot be specific in dating that injury based on the X-ray, apart from to say that it most likely had occurred seven to ten days or greater, prior to the X-ray on 10 January 2020.239 518 With respect to there being any relationship with the fracture and the birthing process, Dr Edwards said that a newborn baby check by a paediatrician or a paediatric registrar prior to discharge which occurred in this case, reported no issue with hip dysplasia or anything of that type. 519 Dr Edwards said she had looked at photos of JR in terms of the movement of his leg.240 She said that while limited information could be gained from still photographs, when she met with the family on 30 January 2020, she was told that JR was not moving his leg approximately two days before his six-week check-up. 520 She noted that there was a series of photographs taken about 7.45 pm on 31 December 2020, where JR’s right leg was in different positions in different photographs.241 It was bent and it was extended, it was in the air, and it was on the carpet. The information she had was that when it had been noticed JR had not been moving his leg spontaneously, but from the series of images she had seen, it looked like he was. 521 Dr Edwards said that typically when a child is seen with a recent tibial fracture, there might not be any outward signs of trauma, so there might be no bruising or swelling but when looking at baby's reflexes, they do not move that leg the same as they do the leg on the other side. If the child's leg is picked up to put them in and out of a jumpsuit, for example, they are much more likely to become irritable when there are compression forces around the site of the fracture. That tends to last for a couple of days and once the healing has started and the inflammation is settling down, then they do not exhibit any of those symptoms. 239 T 977. 240 T 978. 241 T 978. -- 107 of 345 -- [2026] SADC 67 106 Rib fractures 522 Dr Edwards said that the location of the rib fractures are relevant to the mechanism by which they are caused. There was one fracture at the costovertebral junction but there were also fractures posterolateral, mid-posterior and at the costochondral junction. 523 All the fractures were healing and would have pre-dated the head impact on the sofa console, six days before the hospital admission. Rib fractures and CPR 524 Dr Edwards said that rib fractures arising from CPR would be a rare finding but does happen in certain circumstances. However the CPR does not explain the healing rib fractures. She said that if an infant was carrying rib fractures, you would expect them to be more unsettled. Dr Edwards said that babies admitted with recent rib fractures often have irritability. If left still, then often they are not in pain, and it is just with movement that you notice that they become more irritable. Often that only lasts for a few days before it resolves, and any signs of underlining rib fractures are not exhibited. Possible causes of JR’s rib fractures 525 As to the degree of likelihood that a two-year-old such as BR, could cause rib fractures to a six-week-old baby, Dr Edwards that a two-year-old child would not be able to use the chest encirclement method to squeeze a baby's chest to cause fractures.242 526 Dr Edwards explained that she had seen cases where older children, have fallen onto children lying on the ground, causing rib fractures. She said she thought it possible that, if a two-year-old fell from a height, they could cause a rib fracture onto the child, but there was no report of that happening in this case. There was no report of JR having fallen from a height or having been dropped or similar. A car seat would not explain JR's healing bilateral posterior rib fractures. All infants are firmly restrained with a harness in a capsule and that has never been reported as a cause of rib fractures. 527 The circumcision procedure does not involve any restraint around the chest. 528 Dr Edwards said she had considered and discounted all the information provided to her by the family about what might have happened. Skull fractures 529 JR had two skull fractures identified on the CT scan taken on 5 January 2020 which were also seen in the skeletal survey of 10 January 2020. 242 T 986. -- 108 of 345 -- [2026] SADC 67 107 530 The right-sided fracture was a long, horizontal fracture which was present through the right parietal bone extending the full length of the parietal bone from the coronal suture to the lambdoid suture. This fracture ran parallel above the ear, the full length of the parietal bone, on the right side of the head. The gap between the fracture edges was 4 mm, with soft tissue swelling above the fracture.243 531 On the left side the fracture was smaller and present in the left parietal bone, extending posteriorly from the coronal suture towards the lambdoid suture with associated minor soft tissue swelling. There was no separation or displacement of that fracture. 532 An area of thickening of the skull was noted which was explained as a healing cephalohaematoma, and it was known that JR's delivery was assisted by a ventouse extraction. The skull thickening was consistent with that recovery process. The right sided fracture went the full length of the bone and at the back it was through the inferior aspect of the calcified cephalohaematoma. Mechanism of injury for skull fracture 533 As to the mechanism of injury which would account for the skull fractures, Dr Edwards said that skull fracture is the result of forceful impact and in this situation the right-sided fracture was the result of a forceful impact to the right side of the head. Because of the sutures between the infant's skull bones, forces can be transmitted, so a single impact can give bilateral skull fractures. 534 Dr Edwards said she had spent ten years working as a paediatrician and undertook Emergency Department training in Australia and in Canada. In her work she had experience with babies with skull fractures prior to working in forensic paediatrics. Additionally, the WCH Emergency Department consult with her unit frequently about infant skull fractures. She said her unit has a good knowledge of the types of impacts and heights of falls that result in skull fractures.244 535 In an infant of JR’s age, quite short-distance falls can result in skull fractures, and in older children, it is usually around a metre or so before you get a fracture. It depends on whether there is initial acceleration and the surface that they fall on. It is not just the height of the fall, but rather the whole mechanism of injury and all the information that can be gathered before a conclusion can be drawn. 536 The degree of force cannot be specifically quantified in terms of a skull fracture. The mechanism of the fall or impact would be a relevant consideration. 537 One impact can cause bilateral fractures because the bones are joined together by sutures which allows the propagation of force across the suture to the 243 T 987. 244 T 990. -- 109 of 345 -- [2026] SADC 67 108 opposite bone, but this does not discount the possibility of two traumas to the head.245 Sofa incident 538 Dr Edwards said she had received an account of the sofa incident in the accused's record of interview. The estimated distance of the travel of JR’s head was reported to be 10-20 centimetres with the impacting force generated entirely by JR himself. 539 Dr Edwards was provided with photographs of the lounge.246 She said that from what she understood from the incident, she would describe it as trivial low impact. She said that occasionally with trivial impacts, if the impact is over a scalp vein that is quite superficial, you can get a bruise or some swelling. It would, however, not be sufficient to cause a fracture or any other significant head injury. 540 With respect to photographs of JR taken on 31 December 2020, there were views of the back side of JR's head which to her observation, showed no obvious bruising or swelling. 541 The information given to her when she met with the family on 30 January 2020, was that following that incident there was a large area of bruising on JR's scalp. She noted that the GP did not observe that when he saw JR immediately following that incident, nor would she expect a very large area of bruising from that trivial impact. 542 She said that it is very common for infants to have their head bumped on door frames, particularly getting a child in and out of a car, and those incidents do not result in skull fractures. 543 Furthermore, skull fractures do not develop visible bone healing on X-rays. It is only possible to age skull fractures in relation to whether there is recent swelling above, or recent bleeding below them. Here there was obvious swelling over the right-side fracture, and it was reported to be minimal swelling on the CT scan on the left side. Clinically on examination, no-one had documented feeling any swelling on the left side of the head. Dr Edwards said that the right-sided fracture was recent because there was swelling over that side and there was recent subdural blood associated with that fracture.247 544 Boggy swelling was not observable or noted 24 hours after admission on 6 January 2020, which, Dr Edwards explained, just says that sometimes these swellings can dissipate across the scalp so that you cannot necessarily appreciate 245 T 992. 246 Exhibit P81. 247 T 994. -- 110 of 345 -- [2026] SADC 67 109 the swelling. JR having been in a supine position, might be one explanation or it might have just resolved.248 545 It is not possible to get a definitive aging from the radiology in that skull fracture does not heal by periosteal new bone formation. There was swelling described in association with a fracture on JR’s CT scan and adjacent subdural blood which was bright. That is, there was swelling above the fracture and bleeding beneath it in that location. It is understood that the longest bright blood lasts on a CT scan is nine days. It is not possible based on the radiology to be specific about the timing of the skull fracture. 546 The mechanism of the incident involving the centre console of the sofa was in her opinion, a low-impact trauma and would not have fractured the skull because there was no significant impact force. JR was not dropped onto it, it was under his own force generation, there would have been no involvement of significant gravity forces and, from her experience with babies bumping their heads and presenting with swellings, a lot of them do not have underlying fractures if the forces are minimal.249 547 Dr Edwards said that she is aware of the literature of witnessed incidents which involves falls and has experience working in the Emergency Department and being consulted by doctors in that Department. She said if a child has a simple skull fracture and a fall from a metre or more, most times she would not be contacted because it is understood that is an acceptable mechanism. However, if there is any loss of consciousness or intracranial injury, bleeding or diffuse injury, then that is well known to not be the result of a simple fall and is the sort of case in which the Service is consulted. 548 Dr Edwards gave an example of where she had recently been called about a baby who rolled off the bed who had a swelling. A CT scan showed there was no fracture under the swelling, but there was a fracture on the other side of the head. She asked for more history without telling the family what the finding was, and there was an incident two weeks previously where the child had got over the railing of a cot and landed on a charger. When she looked at the fracture, she could see it was a small, depressed fracture that would fit with the given history and on examination, found a small graze on the child's head that corresponded to that. They were no longer concerned that the injury was unexplained. 549 Dr Edwards said that although skull fractures cannot be aged definitively, and it is possible that the right-sided skull fracture occurred at the time of the reported scalp swelling six days earlier, that fracture would require a higher-force impact than that which was described.250 248 T 995. 249 T 994. 250 T 1002. -- 111 of 345 -- [2026] SADC 67 110 550 As to how the underlying subdural haemorrhage fits in with the hypothesis of a more significant injury predating 5 January 2020, and related to the sofa incident, Dr Edwards said that subdural haemorrhages can occur focally, so when the skull fractures, it can damage the blood vessels directly underneath it, so you get what is called a focal subdural, just in that one location underneath the fracture. In JR’s case, the subdural haematomas were bilateral and over the surface of the brain, which would not be explained by a linear acceleration force. There would have needed to be some rotational acceleration involved.251 551 Hypoxic ischaemic changes and retinal haemorrhages would not have been present for six days because of the sofa incident as was described. 552 She said that by all reports, based on the GP's examinations on the two occasions, there was no description or observation of JR having an abnormal consciousness level over that six-day period. 553 Based on the description of what occurred with respect to the sofa incident, it was not a high-force impact and could not have caused the hypoxic ischaemic changes, retinal haemorrhaging or the focal swellings within the brain as reported on by Assoc. Prof. Taranath. 554 In Dr Edwards’ opinion, it is most likely that the entirety of the injuries, including the skull fracture, underlying subdural haemorrhages and the brain injuries all occurred at the same time on the day of presentation on 5 January 2020. 555 Just by looking at the skull fracture, does not allow for specific timing. The timing in this case really, Dr Edwards’ said, not related to the change in JR’s consciousness level which is the most significant factor. Bridging veins 556 The CT scan of JR’s head that was performed on 5 January 2020 showed bleeding, and it is referred to as subdural, meaning that there is bleeding between the arachnoid membrane and the dural membrane. Normally there is no space between those membranes, they are continuous structures. With trauma, that causes bleeding to the bridging veins which travel from the surface of the brain to the sagittal sinus, which is a large vein between the two halves of the brain. The veins drain blood from the brain and eventually back to the heart. 557 Dr Edwards said that the bridging veins are particularly vulnerable to damage from acceleration forces. The brain moving at a different rate to the skull provides shearing forces that lead to the blood vessels being stretched and then torn and they then bleed into that space created by the blood between the arachnoid and the dura. That is what is referred to as a subdural haemorrhage. Those blood vessels can also be damaged just by direct impact, where they get crushed. When there is 251 T 1003. -- 112 of 345 -- [2026] SADC 67 111 widespread bleeding, they have been stretched and torn and usually multiple blood vessels are involved, not just one under a fracture. 558 The CT scan on 5 January 2020 showed multiple areas of recent bleeding. The word 'recent'252 is used when the blood looks white or hyper-dense on the CT scan. Dr Edwards said that research shows that ‘recent’253 is generally less than seven days but occasionally reported up to nine days. She added that a recent review had not found recent blood looking white on CT scan, greater than for nine days. 559 The CT scan also included the fracture of the right side of the skull and either side of the interhemispheric fissure. That location is well described in terms of having subdural bleeding as a result of rotational acceleration forces. 560 The MRI performed on 8 January 2020 confirmed the CT scan findings of multiple or extensive subdural haemorrhage. The bleeding was noted in the posterior fossa, the posterior interhemispheric fissure, and the parietal occipital region. The MRI, visualised the haemorrhages more accurately than the CT scan, particularly bleeding around the back and the lower part of the brain which is harder to see on CT scanning. 561 Dr Edwards said that sometimes she sees children who just have subdural haemorrhages but without any brain injuries at all. In JR’s case, the MRI scan showed that there was bruising on the surface of the brain and deeper within the structures of the brain. She said that the totality of the findings are indicative of a significant head trauma explained by predominantly angular acceleration force to cause the movement of the brain within the skull, meaning that the head rotates around the neck. The fractures indicate that there has also been impact to the head.254 Biomechanics of head injury 562 Dr Edwards used a diagram255 to demonstrate the different types of forces that are considered when determining what has happened to cause an injury. Based on the MRI, you look at the extent of injuries and then consider what forces would have been required to cause those injuries and then match that with whether the explanation that has been provided contains those forces that are considered necessary. 563 She said that basically head injury happens because there is a loading force applied to the head. If somebody is laying down and they get impacted to the head or there is a crush to the head, that is called a static impact, meaning that the head is not moving, and injuries that result from that are related to the impact site. Dr Edwards explained that if you got hit on the head with an object and your head 252 T 1008. 253 T 1008. 254 T 1010. 255 Exhibit P83. -- 113 of 345 -- [2026] SADC 67 112 does not move, you are going to get injuries to the scalp, the skull and the brain directly under that impact site, but your brain is not moving within your head, so you only get focal injuries. In those situations, it is very uncommon if ever, to lose consciousness, because it is a focal injury.256 564 The other type of head loading is called dynamic or impulsive, meaning that because of either an impact to the head or movement of the body, that sets the head into motion. The head is moving because of the loading forces. 565 Linear acceleration refers to the fact that whilst the head moves, it does not rotate around its centre of gravity, meaning that the head, body and the neck remain somewhat aligned. Most times if a child is dropped, they fall and their head and their body are in alignment, so most of the forces therefore are linear, not rotational, and those injuries also predominantly result in focal injuries because there is no rotation. 566 As illustrated on the diagram, the head rotating around its centre of gravity can happen in three different directions. That is, front and back (sagittal), ear to ear, (coronal) or axial, (when the chin goes across to the opposite shoulder). Dr Edwards said that the weight of a baby's head is 20% of their body weight, whereas in adults it is about 2-4%, so babies have a very heavy head on a very weak neck. This means that their head, with an acceleration of force applied, is much more likely to move in multiple different directions around their neck and that is the type of situation where the brain and the skull move at different speeds, and the brain blood vessels can be stretched and bleed. The brain can also impact the inside of the skull, causing bruises on the surface of the brain and the axons that are the branches of the neurons that transmit signals, can get stretched and torn, and the blood vessels in the back of the eye can get stretched and torn. That constellation of injuries allows a conclusion that there has been an episode of angular or rotational acceleration. Dr Edwards said she uses the term 'acceleration'257 to encompass both speeding up rapidly and slowing down rapidly. 567 She said the totality of the head injuries JR sustained are explained by angular rotational acceleration injury but there also had to have been impact to cause the fractures to the skull. However, all the intracranial injuries, the retinal haemorrhages, the subdural haemorrhages, the brain contusions and the deeper brain injuries are all explained by angular acceleration forces and those injuries are not consistent with the description provided of the sofa incident. 568 Dr Edwards said that extensive bilateral subdural haemorrhages do not result from a short distance linear fall if it is a simple linear fall. There can be short distance falls but with an acceleration component to them which is why a very detailed history is taken. If a ‘fall explanation’ is provided, Dr Edwards said that 256 T 1011. 257 T 1013. -- 114 of 345 -- [2026] SADC 67 113 it is really important to take a very detailed history and often to get a re-enactment done to see exactly how the baby's head was reported to move during that event. 569 For there to be shearing forces there needs to be a rotational acceleration force. 570 JR did not have an identified predisposition to bleeding or predisposition to brittle bones. The intracranial injuries, together with the fracture to the skull, are an indicator of a higher force being involved. 571 Dr Edwards said that the majority of injuries that children sustain to their head are minor head injuries, so they will have either scalp swelling or with higher force skull fractures, light bleeding underneath the skull fracture. When the head injury involves rotational acceleration, depending on the type of direction of the force and the amount of force, there will be an increase in the constellation of injuries. Some children may present just with a concussion, where you would do an MRI scan and it is completely normal. Some of those children will have subdural haemorrhaging and then brain injuries and in the severest presentation they present in cardiorespiratory arrest.258 Possible causes of skull fractures 572 A normal vaginal delivery does cause compression to the head and particularly because the skull bones at that point are very thin, you can get compressive forces that result in some subdural bleeding around the back, particularly around the back of the brain. You can also get retinal haemorrhages from birth. Dr Edwards said however that they do not persist and most of the research has shown that retinal haemorrhages and bleeding around the back of the brain would resolve within two to three weeks. 573 Dr Edwards said that the subdural blood that JR had was not from birth because it was still bright on the CT scan and that only lasts as bright blood for up to nine days. On that basis, sequelae of the birthing process from the presentation on 5 January 2020 can be excluded because the loss of consciousness cannot be a delayed phenomenon from birth out to six weeks.259 Brain injuries 574 The MRI scan documented multiple areas of the brain which appeared to have sustained injury from a lack of blood and oxygen. 575 When talking about brain injuries, focus is on what is a primary injury, that is, what is the direct result of the external forces applied and what is a secondary injury. Dr Edwards said that the body mounts an inflammatory response to injury which includes changes to the cell wall and there are changes in the ions that flux in and out which can cause secondary damage, so the cells can swell up and then 258 T 1014. 259 T 1016. -- 115 of 345 -- [2026] SADC 67 114 they can get less blood supply and less oxygen delivery. A primary injury would be an axonal or neuronal cell injury, and a secondary injury would be a hypoxic ischaemic injury, that is, a consequence of the primary injury. 576 Dr Edwards explained that hypoxic ischaemic damage is seen as diffuse throughout the whole brain with large brain swelling that can evolve over hours after a head injury. That is readily observable on a CT scan, and the child will have signs of raised intracranial pressure, or there can be more focal areas of damage to the brain that surrounds the areas that had the primary injury.260 577 In JR's case, there was not diffuse hypoxic ischaemic injury throughout his brain, rather it was limited to certain areas that were described on the MRI report. 578 Dr Edwards said that the injuries identified on the MRI - the retinal injuries, the subdural and the contusion injuries, were all a consequence of an acceleration injury. They would be considered the primary brain injuries. Brain injury impacting the cardiac system 579 As to whether that primary brain injury impacted on the cardiac system, Dr Edwards said that would be so only if there was also axonal injury within the brain itself. When asked whether there was evidence of that, Dr Edwards said:261 So the difficulty is, and the way the MRI was reported and the distribution of the changes, indicated that it was likely that there was coexisting axonal shear injury, but that is a microscopic finding, so you cannot see it on a scan. It is inferred from the distribution and the appearance. 580 She said that it is not possible to differentiate on brain imaging between the primary and secondary effects of brain injury. When babies with head injuries attend at hospital with these extensive injuries, there are lots of different presentations and they do not all present the same way. It is, she said, very much dependent on the type and degree of the initial primary force, and whether medical attention is sought straightaway or not. Some babies present with already quite widespread hypoxic ischaemic damage. That is often in the setting of a delayed presentation, so the child has been unconscious at home, so there is time for those secondary changes to develop, and they may also not have been ventilating normally, so might not have been getting good oxygen delivery to the brain, and it is a cascading phenomenon.262 581 The more the brain swells, the less the blood can get to the brain, so it worsens the situation. If there is no intervention at a very early point, it is a cascade that can lead to death, so you can see children that die in the Intensive Care Unit one or two days later after presentation, so there is a spectrum of presentations. 260 T 1016. 261 T 1018. 262 T 1019. -- 116 of 345 -- [2026] SADC 67 115 Follow up MRI 582 The reason a follow-up MRI is performed is to look at whether those areas that were identified on the first MRI led to any permanent brain tissue loss because if a significant area of the brain is damaged and does not recover, it degenerates. Dr Edwards said that if you compare the two MRI scans, there is an area where there is less brain tissue than there was before. She said that some of the babies who she sees, can have quite significant changes on their follow-up MRI scan, relevant to the high risk of cerebral palsy and other complications. 583 In JR’s case, the MRI that was followed up showed some residual changes and there was contusional injury to the brain in the inferior left frontal lobe which, on the follow-up MRI scan, was described as being associated with some loss of brain tissue. There was not widespread loss of brain tissue, which would be expected if there had been global hypoxic ischaemic change, so it was a relatively good follow-up MRI with a good prognosis.263 584 The contusion or the bruise to the brain was not located directly under the skull fracture, which was the site of impact on the right side. It was on the opposite side- the inferior left frontal lobe, which Dr Edwards said is quite a common site for contusion. The brain moves and then impacts the skull at a distance from the impact site, which indicates acceleration has been a component of the injury. 585 Dr Edwards said that this was a high-velocity infant head injury. It involved rotational acceleration, and it was sufficient to cause subdural haemorrhaging, concussion, brain injury and obviously a cardiorespiratory arrest. Retinal haemorrhages 586 On 6 January 2020, JR was examined by the ophthalmology team at the WCH, and it was documented that he had multilayered numerous, too many to count, retinal haemorrhages in both eyes extending to the ora serrata at the back of the eye and a haemorrhage at the level of the vitreous. 587 A follow-up ophthalmological review was undertaken on 9 January 2020, again showing retinal haemorrhages, too many to count, which extended to the ora serrata, the full way around the retina. They were said to have faded and were lessening in number compared with the previous review. 588 Dr Edwards said that complex retinal haemorrhages are those that are multi- layered, extensive and extend all the way around the retina to the ora serrata. Dr Edwards said those complex retinal haemorrhages are highly associated with rotational acceleration head injuries and can happen in significant crush head injuries as well. Lesser degrees of retinal haemorrhages are seen in a variety of different situations, accidental head injuries, and ruptures of aneurysms within the brain which rapidly change the pressure. There are several different causes and you therefore need to look at the retinal haemorrhages in the context of the whole 263 T 1020. -- 117 of 345 -- [2026] SADC 67 116 clinical picture. In JR’s case there were other findings on the imaging to suggest rotational acceleration forces and there is a very common association between widespread subdural haemorrhages, concussion and retinal haemorrhages in infant head injury from rotational forces.264 What accounts for JR’s head injuries 589 Dr Edwards said that the mechanism that would account for all injuries is a forceful impact to the right side of the head associated with rotational acceleration/deceleration forces. When asked whether that would explain the skull fractures, the bilateral subdural haematomas, the brain contusions, the retinal haemorrhages, the suspected axonal injury and the development of the hypoxic ischaemic changes in the brain (which is the secondary injury component), Dr Edwards said:265 There was no explanation provided of an incident of head trauma having occurred prior to the onset of [JR]’s symptoms, so we can’t assess any further because there was no explanation provided, but there would have to have been a situation where either an impact to the head set the head in motion, so an unrestrained head was impacted, or there was another mechanism where the body is grasped which causes the head to rotate around the axis of the neck. So there needed to be an action applied to the baby that caused those forces to result. 590 She said that the injuries are consistent with a rotational force – that is, movement in a rotational manner, but then there would have to be a separate impact or rotational force leading to an impact. Dr Edwards said it is unknown whether there was one or two impacts. There was, she said, certainly rotational force either together with an impact or as a separate event. 591 Dr Edwards said that if the skull fracture occurred when scalp swelling was noted six days earlier, the rotational injury could not have occurred at that time because the rotational injuries that JR had would have been associated with a change in consciousness, which has not been reported or observed. There was no parental report of a change in conscious level at the time or subsequently and in that period JR was examined twice by a doctor. Timing of JR’s head injury 592 Dr Edwards said that there are different ways that babies present to hospital with head injury and research has tried to categorise them into groups. A hyper-acute encephalopathy is when a child comes in, either in cardiac arrest or with significant breathing problems. It is a very sudden onset of symptoms and attributed to axonal shearing occurring in the brain stem, which controls breathing and the heart rate and rhythm. From the ambulance records JR had issues with his heartbeat and breathing putting him into this more serious or acute category.266 264 T 1021-1022. 265 T 1022. 266 T 1024. -- 118 of 345 -- [2026] SADC 67 117 593 Dr Edwards said that one of the crucial factors in terms of working out when a head injury happened is working out when there was an obvious change in the child's conscious level or behaviour. When a baby is so young as six weeks old, they have quite a limited repertoire of behaviours but establishing what their normal routines are and when things have changed are considered. According to the information that was provided, JR was put to sleep and was normal beforehand, he woke at a normal time as expected for a feed, he was undressed and picked up and there were no abnormalities in his tone. He was described as awake, was put on the ground for a few minutes and then, on return, he was said to have gasping respirations and was floppy and pale. From that information there was a very sudden change and in Dr Edwards’ opinion that is the most likely time frame within which the head injury that led to all the subsequently observed findings occurred. 594 It is, Dr Edwards said, known from witnessed incidents, that where somebody has a pure head injury that cessation of breathing will happen within minutes of the injury happening. There is around a ten-minute critical time in which to intervene after a head injury if it is of the type that has led to breathing problems.267 Agonal breathing 595 When the paramedics arrived, they described JR having agonal or gasping respirations which then ceased, suggesting to Dr Edwards that the head injury had occurred very recently prior to their arrival, around the time of the description of him becoming unwell. 596 Agonal breathing describes irregular or ineffective breathing that typically occurs at an end stage prior to death. It does not just happen with head injury; it can happen in any other process as well. She said that it is just a description that people use so that you can understand what they mean in terms of what they observed about a breathing pattern. It is a disordered, ineffective breathing pattern, with oxygen not getting to the lungs. The oxygen levels would not instantly deteriorate when you stop breathing because oxygenated blood is still circulating for a period, and that is why there is a window of opportunity to intervene.268 Meeting with the family 597 Dr Edwards made notes in the hospital record of the two meetings she had with JR’s family members at 1.30 pm and 2.30 pm on 30 January 2020.269 Present at the meeting were the CPS registrar, Malithi Gamage, and Joe Carbone, a psychologist with their team. JR's parents and the paternal grandfather, PR were present at the first meeting.270 267 T 1027. 268 T 1027-1028. 269 Exhibit P65 (admitted on Voir Dire as Exhibit VDP14). 270 T 906. -- 119 of 345 -- [2026] SADC 67 118 598 Dr Edwards said that the family had requested a meeting to better understand the nature of JR's injuries and her opinion. The family had requested via DCP to meet with either Dr Noori or herself. 599 At 2.30 pm she met with AE, JR’s maternal grandfather, and BE, a maternal uncle. Seizures 600 As to any relevance of seizure activity observed on presentation to the WCH, Dr Edwards said that seizures following infant head injury are extremely common when there is injury to the brain as part of the constellation of injuries. In some situations, prophylactic antiepileptics are administered to prevent seizures. Seizures are caused because of the damage to the brain through the shearing forces.271 Dr Edwards’ responses to the opinions expressed by Dr Auer. 601 Dr Edwards said that in the reports that she had been provided with from Dr Auer, he had completely excluded trauma as a possible explanation for any of JR's clinical findings. Instead, he had proposed multiple alternative causes for which, Dr Edwards said, there was no evidential basis. 602 Dr Edwards summarised those alternative hypotheses as follows:272 • JR’s cardiorespiratory arrest was due to interstitial lung infection which was of such severity that it caused him to suddenly stop breathing, which Dr Edwards noted was said to have occurred without there being any changes on his X-ray or any sign of lung infection over the course of his admission. • JR’s seizures were explained by pneumonia or an unidentified cause of seizures. • JR’s skull fractures were either craniotabes, Wormian bones, intraparietal pseudofracture or a fracture from vitamin D deficient rickets. • JR’s eight healing rib fractures were not a significant finding as rib fractures in infants are common and maybe the result of the normal growth of the infant's thorax or normal handling. • JR’s bilateral subdural haemorrhages were not the result of trauma but rather from a lack of oxygen or reperfusion during resuscitation. • JR's bilateral multilayered retinal haemorrhages were from raised intracranial pressure or from one of the other multiple causes of retinal haemorrhage. 271 T 1028. 272 T 1070. -- 120 of 345 -- [2026] SADC 67 119 • The history of JR not moving his right leg days prior to admission could be due to a transient thrombus or stroke. Lung attack 603 Dr Edwards said that Dr Auer’s description of JR suffering pulmonary insufficiency and ‘a lung attack’ is not recognised terminology or conventional clinical terminology, and pulmonary insufficiency is not something that specifically leads to one diagnosis. 604 The presentation of not breathing and hence the child turning blue, can she said, be caused by several different things. It does not mean that the cause of the problem was something wrong with the lungs. If the breathing control centres in the brain are damaged, then you can present without breathing with perfectly normal lungs. Dr Edwards said that it would be incorrect to infer a ‘lung attack’273 as inferring that turning blue only occurs when the primary problem is with the lungs. Breathing is controlled by the brain, particularly the respiratory centres in the medulla of the brain stem and an injury to the brain can result in an impact to breathing even when the lungs are healthy. Head injury preserves breathing 605 As to Dr Auer’s suggestion that 'Having stopped breathing is not a feature of head injury, having a head injury ‘preserves' breathing, this obtains even if the person struck on the head later dies. It also obtains if the person loses consciousness or not',274 Dr Edwards described this statement as fundamentally incorrect. She said that it is very common knowledge that some people die as a direct result of a severe isolated head injury and many die immediately or within the first twelve hours because the damage to the brain leads to a cessation in breathing. The control centres responsible for breathing and circulation are located within the brain so it makes no sense to say that a brain injury in that region could not stop breathing and it certainly does. It can happen from a primary head injury, or also a secondary impact. 606 Dr Edwards said that particularly in infancy, apnoea or the cessation of breathing is a very well described common feature of head injury because it is likely there is some vulnerability in the infant brain development that means that they are more likely to have apnoea and respiratory compromise from head injury than adults. She explained that people are more prone to brain injury from acceleration rather than direct impact or linear forces, and this is particularly so in infants. They have a big head, but they also have bigger spaces around the brain, their axons or their nerves are not covered in myelin so are not as well protected, and they have immature responses to changes in the neurochemistry, which include affecting blood flow. 273 T 1030. 274 T 1031. -- 121 of 345 -- [2026] SADC 67 120 607 Dr Edwards said that there is a very large evidence base regarding why it is that infants' brains are more vulnerable to rotational forces than adults. She said that coming in with an altered breathing pattern or stopping breathing from a head injury is extremely common. 608 Dr Edwards said that Dr Auer's hypothesis does not accord with accepted medical knowledge in paediatrics. 609 Dr Auer’s opinion was said to be that: 'This cessation of breathing is not the clinical picture of a head injury which preserves breathing selectively. Traumatic head injury as in fatal playground falls and household falls in children'.275 He referred to an article that he said, 'teaches us that breathing is selectively preserved'.276 610 Dr Edwards said that if you had a linear force fall, you are not going to get brain injury, so you are not going to have impaired breathing. It is not that the brain preserves breathing, it is just that you do not have brain injury, so you do not get problems with your breathing. 611 Dr Edwards said that an article by Dr John Plunkett, 277 to which had Dr Auer referred, did not support Dr Auer’s hypothesis. She said that the article described 18 fall-related head injuries, with none of the children under one year of age. One of the cases in the study showed that there was an apnoea because of head injury. That child then started breathing again, as happens, but there was clear evidence that the head injury did affect the control of breathing in that case. She added that Dr Auer did not make any comment as to that infant in the article having any other reason to stop breathing. 612 Dr Edwards said that paper does acknowledge that apnoea and catecholamine release (adrenaline and noradrenaline) have been suggested as significant factors in the outcome following head injury, therefore, she argued, that paper acknowledges that apnoea does occur because of head injury. One of the references to that paper described 28 infants with severe head injury in whom 57% had apnoea prior to hospitalisation. The other article in that paper says that 'Apnoea', 'is a known response to concussive head injury, hypoxic or ischaemic brain injury has been documented in a high percentage of severe head injury deaths. Apnoeic patients found at the scene of severe head injury are common'.278 613 Dr Edwards said that while it was hard to understand what Dr Auer was saying, it was basically that the brain can respond to a head injury by preserving breathing, whereas there is a wide knowledge base and her own experience to say that is not correct. 275 T 1630. 276 T 1630. 277 Exhibit D116. Plunkett, 2001. Fatal Pediatric Head Injuries Caused by Short Distance Falls. Ther American Journal of Forensic Medicine and Pathology 22(1): 1-12. 278 T 1034. -- 122 of 345 -- [2026] SADC 67 121 614 As to Dr Auer’s opinion that 'Careful reflection will reveal that this principle obtains as well in adult head injury from boxing and MMA, none of which selectively affect breathing, instead selectively preserve breathing',279 Dr Edwards said that trying to compare professional athletes to a six-week-old infant has limited relevance. 615 She said that it is known that people do die from one-punch attacks and certainly people get knocked out and lose consciousness because of impacts to the jaw, particularly in boxing, that causes the head to rapidly rotate and that causes a concussion and a person to lose consciousness. 616 Dr Auer’s opinion was said to be that:280 Impact head injury, even when it occurs however does not selectively knock out breathing. This is apparent not only from adult injury seen in boxing and mixed martial arts but also in paediatric head injury including infants with none of these hundreds of infants had an actual traumatic head injury showing apnoea. It is fictitious and inconsonant with the way a head injury works to assert that [JR]’s breathing difficulties were due to a head injury. Head injury does not selectively knock out breathing. 617 Dr Edwards said that obviously not all people with head injuries have breathing problems. There is a spectrum of injury severity, and the impact on a person's breathing from head injury depends on their age and variations individually, the mechanism of injury, and specifically the amount and type of forces involved. Dr Edwards said that one of the most common features is apnoea and cessation of breathing, or alterations of breathing at the scene of a head injury event. It is a significant factor associated with rotational head injury and inflicted head injury throughout the recognised literature. 618 Dr Edwards said that apart from her knowledge gained from working in her current role and in emergency departments, she is also a chair of the Mortality Committee and reviews all child deaths at the WHC. Ambulances are called following head injuries because children have stopped breathing. She said it happens regularly and nothing about Dr Auer’s statement is correct. 619 Dr Edwards was asked about Dr Auer’s statement that 'A six-week-old male infant hit his head on a dashboard, cried and became pale but had no subsequent symptoms. Radiographs revealed bilateral temporoparietal fractures. It’s noteworthy that after striking his head on the dashboard, there was no apnoea despite the bilateral skull fractures'.281 She said that Dr Auer gave limited detail of how the injury occurred and she did not really understand how that example related to JR’s case. Dr Edwards said that where there are linear forces, the head is still in line with the body. If the baby was dropped on to the dashboard, then he may not have experienced angular acceleration forces. The skull fractures themselves do not lead to apnoea. It is the brain injury that leads to apnoea and if this child hit 279 T 1636. 280 T 1640. 281 T 1036. -- 123 of 345 -- [2026] SADC 67 122 their head, had a fracture and then had no symptoms, then they did not have a brain injury. It is therefore unsurprising that they would not have had any breathing difficulties. If a child with that history of an impact to their head had those symptoms, then it would be very likely that would be accepted as an adequate explanation because it would be predominantly linear forces compared to acceleration forces involved. Seizures in very young babies, most commonly have a hypoxic or ischaemic origin, not a traumatic origin. 620 As to Dr Auer’s opinion that 'When [JR] was admitted to the paediatric intensive care unit, he was noted to have eye deviation from hypoxic seizures and was given Midazolam. Seizures in very young babies, most commonly have a hypoxic or ischaemic origin, not a traumatic origin',282 Dr Edwards said that post-traumatic seizure is an extremely well recognised phenomenon and in infancy, seizures following head injury is a very common presentation. She said that seizures can be caused by a variety of things, trauma, infection, metabolic, genetic causes and that consideration needs to be given to the context of the case at hand and the clinical context. 621 Dr Edwards said that in JR's case, at the point he went to paediatric intensive care, and even in the Emergency Department, he had evidence of seizure activity, and we know he had a head injury. She said that it is known that head injuries can damage the way the nerves talk to each other and therefore lead to seizures. Either it may be the secondary hypoxia, or it might be the primary damage that leads to the seizures. Either way, head injuries can result in seizure activity. Pneumonia 622 Dr Edwards said that there was no evidence of pneumonia in JR’s case. 623 The initial chest X-ray showed no evidence of pneumonia, he did not have any haematological changes that would go along with infection, he did not have a raised white cell count or a raised c-reactive protein (CRP), which is a measure of infection, and there were no reported symptoms of a chest infection. 624 Dr Edwards said that it would be extremely unlikely that an infant who had pneumonia would suddenly collapse within minutes with no preceding symptoms and no findings on the X-ray or the blood tests. Neither chest X-rays or CT scans showed any findings consistent with pneumonia or pulmonary insufficiency. The skull fractures are characteristic of craniotabes/vitamin D/ spontaneous head fractures 625 Dr Auer’s opinion was said to be that: 283 282 T 1037. 283 T 1038. -- 124 of 345 -- [2026] SADC 67 123 Bilateral skull fractures are characteristic of craniotabes. The reason is that the parchment- like bone of vitamin D deficiency breaks first, like parchment itself, in the area where the brain is growing fastest in a six-week-old, that brain region being the parietal lobes. 626 And further: 284 The parietal skull fractures may be insignificant trauma since the skull is very weak at this age, which commonly shows craniotabes. There was, in fact, minimal impact while the father was carrying [JR] previously and that impact was unilateral. If vitamin D is deficient, the skull of the baby will be like parchment and a fracture is easily produced. Fractures in vitamin D deficiency are commonly spontaneous based on the muscles inserted into the skull pulling on very weak bone. 627 With respect to the presence or not of craniotabes, Dr Edwards said that she deferred to the opinion of Assoc. Prof. Linke, adding that there is no evidence of clinically significant vitamin D deficiency. JR had a low level of vitamin D but no biochemical or radiological evidence of rickets and, in the absence of those changes, a child is not more prone to fracture. She said that just a low vitamin D but nothing else, does not make a child prone to fracture from lower degrees of force. Dr Edwards said that she completely disagreed with Dr Auer’s statement. 628 As to Dr Auer’s comment:285 'The biparietal skull fractures are typical for craniotabes, the skull manifestation of rickets, they occur in the parietal region because that is where the brain growth is fastest, giving rise to the parietal boss bilaterally. Skull growth is determined by brain growth. Where brain growth is most rapid, the fractures appear because the calcification cannot keep pace with brain growth period, thus, when growth abates, rickets subside. It is generally not seen in the skull at two years or beyond. It is a temporary kinetic disorder that children grow out of'. 629 Dr Edwards said that one part of what Dr Auer said was true, that is, the fact that skull growth is determined by brain growth, is well accepted. However, the remaining statement is unsubstantiated by any scientific evidence, and she noted that no reference was provided. 630 To suggest that every baby's brain and skull grows means that babies are all developing skull fractures is, Dr Edwards said, basically ridiculous. Dr Edwards said she did not know how else to say it. There is, she said, no such thing as a temporary kinetic disorder that leads to spontaneous fractures of the skull in infants. She said that Dr Auer’s opinion did not accord with accepted medical understanding of how babies' heads grow. Any literature about infant growth and development, the experience of any clinicians that care for children, is that they do not have skull fractures in the absence of trauma. 284 T 1038. 285 T 1044. -- 125 of 345 -- [2026] SADC 67 124 631 That there is a skull fracture and scalp swelling is clear evidence that there has been head impact. There is no evidence base to support the assertion that a skull fracture can occur spontaneously even in a child with rickets. Vitamin D Levels 632 As to Dr Auer’s statement that 'We do not know the vitamin D status of JR, but the mother had reduced vitamin D levels during pregnancy at 33',286 Dr Edwards suggested that Dr Auer had become confused because 33 nmol/L was the vitamin D level for JR. She had not been provided with a result for the mother. As to whether TR’s vitamin D deficiency during pregnancy necessarily impacts bone formation and healing of bones, Dr Edwards said that in this case, JR did not have rickets, so whether the mother had a low vitamin D in pregnancy or not is irrelevant. 633 She said that JR’s low level of vitamin D is not a diagnosis of disease, but rather, the vitamin D level is a laboratory value. The SA Health guidelines for defining vitamin D deficiency state that it is sufficient over 50 nmol/L, insufficient is categorised as 30 to 50 nmol/L and deficiency is less than 30 nmol/L. JR's result was 33 nmol/L which would be regarded as insufficiency, but it is not categorised as a deficiency.287 Dr Edwards said that more recent research would suggest that levels up to 30 nmol/L are probably sufficient for bone health in infants, and there is ongoing research because a lot of babies without other risk factors are being treated when there is no evidence that is causing any problems with their bones. In the SA Health guidelines, written by an endocrinologist based on world-wide literature, it is clearly stated that a low vitamin D, in absence of any other findings, does not predispose to fractures. 634 Dr Edwards said that a low maternal antenatal vitamin D level would in no way explain JR’s multiple rib, tibia and skull fractures. Bone development in utero is not dependent on vitamin D, and it is dependent on the maternal levels of calcium and phosphate, so it is the actual minerals that determine whether the bones of the baby develop normally or not. Rickets are only seen in infants shortly after birth in developing countries where mothers have severe osteomalacia, which is the adult version of rickets, and that has led to them having low calcium and phosphate levels, which means that the developing foetus does not have enough of these to form bones normally. That is why we do not see congenital rickets in Australia. 635 As to Dr Auer’s statement that 'Broken bones are broken weak bones rendered weak due to likely vitamin D deficiency ubiquitous in babies',288 Dr Edwards said that having a low vitamin D level around the level that JR had, is actually very common, while fractures in babies are extremely uncommon. To suggest that there are a lot of babies with weak bones having developed fractures 286 T 1039. 287 Exhibit P129. 288 T 1043. -- 126 of 345 -- [2026] SADC 67 125 is not in line with the experience of any paediatrician working, in any part of the world. Ehlers-Danlos syndrome 636 As to Dr Auer’s opinion that ‘The consequences of forgetting common conditions such as Ehlers-Danlos syndrome and vitamin D deficiency due to indoor living is that false allegations of child abuse to explain broken bones in 72 documented families broken up as a result',289 referring to an article by Dr Michael Holick (Dr Holick),290 Dr Edwards said that this was a non-scientific article that has been widely criticised for significant methodological flaws. There was no control group. The information was incomplete and written by people retained by the defence in court matters. 637 Dr Edwards said that case-controlled research has found no correlation whatsoever between Ehlers-Danlos syndrome and an increased propensity to fractures in non-mobile infants. Dr Edwards explained that Ehlers-Danlos is a condition of connective tissue, and it leads to increasing flexibility, particularly around the joints. It is a genetic condition, not always with an identifiable genetic mutation but it is based on clinical findings of hyper-mobility of joints. It is something that you have it for life and if it were to cause you to have fractures at six weeks of age, you expect that would continue to be a problem for JR throughout his life. 638 There is no evidence whatsoever of the involvement of Ehlers-Danlos syndrome in respect of JR at all. Fractures from ‘normal growth’ rather than trauma 639 As to Dr Auer’s statement that 'The thorax is another region of rapid growth in a baby of this age. The chest cage is expanding rapidly to adult size at this time. When growth abates, the tendency to rib fractures disappears over time',291 Dr Edwards said that infants do not get fractures just from normal growth and that it was of note that in this and throughout Dr Auer's report, he never considered the possibility of trauma for the skull or the rib fractures. Fractured ribs a ‘fictional narrative’ 640 As to Dr Auer’s opinion: 'Producing these fractures would require highly selective, focused breakage of ribs without leaving a trace in the overlying skin. This is hard to conceive and may be a fictional narrative',292 Dr Edwards said that rib fractures can be caused by a compressive force and so if hands are encircling and compressing the chest, generalised forces are applied, and they can cause fracturing without causing damage to the skin or the subcutaneous tissues. 289 T 1041. 290 Article not referenced. 291 T 1045. 292 T 1045. -- 127 of 345 -- [2026] SADC 67 126 641 Dr Edwards said that it is not a fictional narrative, it is an experience of all paediatricians and why skeletal surveys are undertaken because it is known that fractures can be found when there is no overlying injury to the skin. That is, Dr Edwards said, why all the radiological colleges throughout the world recommend skeletal surveys in situations of suspicious injuries to a child. Resolved infection 642 As to Dr Auer’s opinion that 'Breathing difficulties were more likely due to an infection that resolved',293 Dr Edwards said that it would make no sense if an infection had resolved. When an infection resolves the symptoms go away, so to suggest that an infection had been present and then resolved and then the child would suddenly deteriorate makes no sense based on the knowledge of how illnesses progress. Again, there was no evidence of infection leading to significant abnormalities of the lungs. JR had a normal white cell and CRP level and apart from having a cold virus, he did not have any other infection that would explain his sudden respiratory arrest. Oximetry levels indicative of lung disease 643 As to Dr Auer’s opinion '[JR]'s blood gases show that he was hyperventilating with a pCO2 of 52 (normal 40) and despite 8 litres of oxygen per minute had oxion had oximetry of 97%, this indicates lung disease',294 Dr Edwards said that when the ambulance arrived at the home two minutes after receiving the 000 call, JR's father was doing CPR and JR was in cardiac arrest, he was not breathing, and his heart was not pumping blood around his body. He was completely unconscious; he had a GCS of three, which is the lowest possible number. 644 Ambulance officers put an airway into the level of his vocal cords to help give oxygen and he was given adrenaline and fluids. It is recorded that JR did not start breathing again for 13 minutes. While timing is a bit unclear, it was certainly more than ten minutes and when his circulation and breathing returned and his conscious level started to improve, they removed the airway and at that point his oxygen saturation was 100%. Dr Edwards said that oxygen saturation can be measured on the ear, finger or the toe and it is basically a gauge of how much oxygen level is in the blood. Anything over 96, 97% is normal, so straightaway after he had been resuscitated, his lungs were working well enough to make sure that JR had a normal oxygen level in his blood. They were clearly not affected by significant disease. 645 Dr Edwards said that if a child had cardiac and respiratory arrest from severe pneumonia, even resuscitation is not going to be effective if the lungs are full of pus and debris, which is what pneumonia is. When JR got to hospital, he had a blood test at 1.45 pm that same day. The results were consistent and were what 293 T 1046. 294 T 1046. -- 128 of 345 -- [2026] SADC 67 127 would be expected after a baby had a cardiorespiratory arrest and not in any way indicative of lung disease. 646 Dr Edwards said that the most clinically significant testing in respect of a problem with the lungs is the very first test done in the resuscitation room, that is, a chest X-ray. A clear chest X-ray shows that there is no significant consolidation in the lungs which would impair oxygen transfer between the air and the bloodstream and the initial blood gas also did not show any features that would indicate a severe lung infection sufficient to cause JR to stop breathing. 647 Dr Edwards said that Dr Auer incorrectly interpreted the blood gas as indicating lung disease when there is no evidence to support that. JR was reported to be always ‘unsettled’ 648 Dr Auer said that TR said JR was always unsettled, ‘this possibly indicates that the child was sick'.295 Dr Edwards said that Dr Auer knows that JR had healing rib fractures and a tibial fracture and that obviously fractures cause pain. Dr Edwards noted that Dr Auer does not consider trauma as the potential cause for the onset of behaviour that JR was described as having. JR’s colour change and limpness is circulatory failure, not a clinical picture of head injury 649 As to Dr Auer’s opinion: '[JR] was in the cot and ready for a feed but when [the accused] returned from the kitchen after getting his bottle of formula, he found [JR] was limp and had changed colour. The colour change is deoxygenation due to pneumonia, and the limp condition is circulatory failure, this is not a clinical picture of head injury',296 Dr Edwards said that apnoea and circulatory collapse are known manifestations of severe rotational head injury in infancy. When you stop breathing the oxygenation of the blood is compromised and the blood becomes deoxygenated and the infant will appear blue, which is the description of JR by the paramedics. He did not have pneumonia, and this was a clinical picture of head injury. Vitamin deficiency is associated with pneumonia 650 As to Dr Auer’s opinion 'Vitamin D deficiency is associated with pneumonia due to immune deficiency associated with lack of this vitamin',297 Dr Edwards agreed that vitamin D does have some impact on immunity, but it was not relevant to this case because JR did not have deficiency of vitamin D and he did not have pneumonia. 295 T 1048. 296 T 1049. 297 T 1049. -- 129 of 345 -- [2026] SADC 67 128 Change in movement of JR’s right leg-a stroke? 651 In relation to JR's right leg, Dr Auer said: 'Mother also informed that a few weeks ago [JR] was not moving his right leg properly, this seemed to resolve spontaneously. This is likely left-sided brain ischaemia or transient ischaemia attack a stroke, not a left-sided head injury weeks previously'.298 652 Dr Edwards said that we know that JR had a fracture of that leg, which would explain the mother’s observations of him not moving his right leg properly, and it is normal for a baby with a fracture to not use their limb spontaneously for a few days and then for that to resolve. She added that any person who has experience with assessing infants or children would know that. 653 Strokes in infants are extremely uncommon and only occur if there is a vascular abnormality or an inherited condition. There has never been any evidence on the scans to suggest that JR had a stroke weeks earlier. Subdural haematoma caused by hypoxia 654 As to Dr Auer's comment that '[JR] had multiple and extensive subdural haematomas. Subdural haematoma can be arterially driven not only traumatic',299 and reference to a particular article, Dr Edwards said that the article describes the meningeal vascular anatomy and how it relates to the surgical treatment of chronic subdural haematomas, with no discussion relating to the cause of acute or recent subdural haemorrhages. 655 She said that when a child has a recent bleed, most of those go away, but some persist and when they do, the body tries to resorb them by forming a membrane around them and that membrane can be made up of very tiny blood vessels which can bleed with minor trauma. With a chronic subdural haematoma and you have small areas of recent bleeding, that is a possibility that you consider, but JR did not have a chronic subdural haematoma. Rather, he had a recent subdural haematoma, as evidenced by the imaging. The article that Dr Auer referenced has, Dr Edwards said, no bearing on this case and she attributed no relevance to it. 656 Dr Auer said that: 300 Subdural haematoma can be due to hypoxia ischaemia, the mechanism being the high cerebral blood flow diverted through permeable damaged vessels. Why is the dura so prone to bleed? The anatomy of the dura shows that it is richly vascular, it is also a tissue that is naturally anteriovenous shunt and a high cerebral blood flow must necessarily return a copious amount of venous blood via dural venous channels to the superior sagittal sinus. 657 He then went on: 301 298 T 1049. 299 T 1050. 300 T 1051. 301 T 1051. -- 130 of 345 -- [2026] SADC 67 129 Anything that increases cerebral blood flow increases the burden on the dura and its venous channels to drain that increased flow of blood. With high blood flow, the chance of leakage and oozing is increased. With hypoxia opening the junctions between the linings of the dural blood vessels, the chance of leakage and oozing is further increased. 658 Dr Edwards said that there were no references for that hypothesis and there is no credible research to support the fact that subdural haematomas are caused by hypoxic ischaemia or changes in cerebral blood blow. There has been research looking at drownings, for example, where children have hypoxic ischaemic damage to the brain, but they do not have subdural haemorrhages. Subdural haemorrhages are not common as Dr Auer implies, and they do not result from hypoxic ischaemic damage. 659 Dr Edwards said that the issue of whether hypoxia can cause subdural haematoma has been a theory put forward for years, which has been entirely refuted by the literature. She said that one of the people who put this issue forward was Dr J Geddes who acknowledged in the Court of Appeals in London in 2005 that the idea that hypoxia can cause subdural haemorrhages was only a theory and meant to stimulate debate. Dr Geddes accepted that her hypothesis was inconsistent with the lack of subdural haemorrhages and retinal haemorrhages in the majority of clinical circumstances in which sudden rises in central venous pressure and intracranial pressure occur in the context of acute severe hypoxia, or raised or unstable arterial pressures such as strangling and drowning. 660 Dr Edwards said that her own opinion in terms of the link between subdural haemorrhaging being caused by hypoxia or ischaemia, accords with the current thinking by Australian paediatricians working in the field. Epilepsy leading to atraumatic subdural haemorrhage 661 Dr Auer had given this opinion: 'Epilepsy alone by dramatically increasing CBF and hypoxia by increasing both leakage and flow of blood lead pathogenically to atraumatic subdural haematoma'.302 662 Dr Edwards said that she was not aware of any peer-reviewed accepted literature which would support the hypothesis that increased blood flow to the brain during an epileptic seizure would lead to subdural haemorrhaging over the surface of the brain. It is she said, an unsupported, novel hypothesis which does not rely on any scientific evidence and is without literature support. She said that epilepsy is extremely common. There is no association between epilepsy and subdural haemorrhages in the literature. She had not seen any link in the patients that she had treated over the years and that while on the review panel for deaths, the only time you could have a link between epilepsy and subdural haematoma is if a seizure led you to have a head injury. 302 T 1054. -- 131 of 345 -- [2026] SADC 67 130 663 Dr Edwards said that she had reviewed several articles that were referred to by Dr Auer in relation to the statement Dr Auer made that epilepsy could cause subdural haemorrhages, she said:303 • The first paper he referenced was an article that he had written, which did not mention subdural haemorrhages. • An article relating to rats' brains which made no mention of subdural haemorrhages. • A case report of an 82-year-old woman who was hit by a car whose initial scans identified that she had sustained a subdural haemorrhage and an underlying brain injury which resulted in her developing a seizure disorder, [Dr Edwards said] supports a traumatic cause for the subdural haemorrhaging, which is contradictory to Dr Auer's theory that the epilepsy caused the subdural haemorrhages. • A study of four adults with epilepsy, none of whom had subdural haemorrhages. • The next was a study of, again, four adults with no mention of subdural haemorrhages. • Another paper that was 13 patients with partial epilepsy who did not have subdural haemorrhages. 664 Dr Edwards concluded that the material referenced did not support the opinion that Dr Auer had given, and there is no literature that would indicate that seizures lead to subdural haemorrhages. 665 Dr Auer referenced a further Japanese article that was a case report which was written in Japanese and for which Dr Edwards had not been able to access a translation in English.304 The information that Dr Auer referenced was all included in the English synopsis of the article, which was of a child in Japan who had subdural haemorrhages and seizures and from the abstract it was not possible to determine whether the subdural haemorrhages were not present prior to the seizures. Retinal haemorrhage caused by hypoxia 666 Dr Auer said:305 Hypoxia itself, meaning decreased arterial oxygen content, also leads to doubling and tripling of blood flow under controlled experimental conditions'…. 'humans undergo similar increases in cerebral blood flow with hypoxia'… 'since the retina undergoes similar increases in blood flow being central nervous system tissue, retinal haemorrhages also arise from hypoxia as in high-altitude mountain climbing' and he provides some further references. Then the last paragraph is referred to and I quote: 'The idea that child abuse can be divined by looking at the retina has no basis. Also, retinal haemorrhages are due to panoply of causes listed generally anaesthesia, pseudo motor cerebri, weight lifting, tug of war, handstand, cartwheel, cheerleading, yoga, sprinting, marathon running, finger pressure on hard palate, oratory, blowing balloons, joking, thorax compressions, conch 303 T 1050. 304 Article not referenced. 305 T 1056. -- 132 of 345 -- [2026] SADC 67 131 blowing, working in a hyperbaric or hypobaric chamber, coitus, endoscopy, pregnancy and labour, COVID-19 and seizures' and then there is a reference to an article, 'Seizure related Valsalva-like retinopathy' and a reference is given, '10-year-old with intraocular hypertension performing CPR birth. The causes of retinal haemorrhages are too numerous to count. As can be seen above in the brief literature review above, they are not indicia of child abuse and cannot be. 667 Dr Edwards said that she readily acknowledged that retinal haemorrhages do have several different causes and no one doing her work would divine child abuse from retinal haemorrhages alone. A comprehensive assessment is done looking at the pattern of the retinal haemorrhages. Dr Edwards said that most of the causes listed by Dr Auer can be immediately excluded with relation to JR. 668 Dr Edwards said that nothing Dr Auer suggested gave her any cause to alter her opinion in any way. Impact brain apnoea 669 In response to Dr Edwards’ report, Dr Auer in his report said:306 Impact brain apnoea. An entirely new entity. I've never heard of this and no reference provided. There is no impact, so she must be thinking of shaking, but there is no head injury here. I will not respond to this since it seems to be an ad hoc fictional narrative created within this opinion piece and there is no pathophysiological basis for this new diagnosis. It is discordant with all of what we know about head injury from neurosurgery, neuropathology and clinical neurophysiology of breathing. 670 Dr Edwards said that in her report she had provided a reference in relation to impact brain apnoea. She said that it was not a new entity and there was a pathophysiological basis. She added that the article summarised multiple experiments done on animals who were impacted on their head and who stopped breathing, and that it was well established that damage to the respiratory control centres in the brain can result in apnoea. 671 With respect to there being no head injury here, JR had scalp swelling, a large skull fracture on the right and a smaller one on the left, which Dr Edwards said clearly indicated that JR’s head suffered an impact. 672 As to whether there were any points raised in Dr Auer's rebuttal report with which she agreed, Dr Edwards said that she found that the arguments and conclusions presented by Dr Auer were fundamentally contradictory to her experience, knowledge and expertise in the highly specialised field of clinical paediatric forensic medicine. The contents of Dr Auer’s rebuttal report did not cause her to alter her opinion. 673 There has, Dr Edwards said, been multiple animal studies which induce concussive head injuries to animals that have shown prolonged apnoea and death can occur via hypoxic cardiac arrest as a result of brain stem mediated reflexes, 306 T 1057. -- 133 of 345 -- [2026] SADC 67 132 and also that with early respiratory support, complete neurological recovery was possible. This opinion is, she said, supported both by the literature and her clinical practice. The idea that you cannot develop disordered breathing as a result of head injury has no support of which she was aware in clinical practice and contrary to what emergency departments in adult and paediatric centres would see. 674 Dr Edwards said that Dr Auer continued to infer that she made decisions in isolation to the process which she had explained to the court. It was not on her ‘say-so’ that there was a skull fracture as Dr Auer had asserted. That finding was based on the report of Assoc. Prof. Linke, on whose opinion she deferred. Coning 675 As to Dr Auer’s comment: 'Dr Edwards invents an instant death of [JR] due to coning right away',307 Dr Edwards described ‘coning’308 as the term used for when the brain stem is compressed by the brain, which she said can happen in scenarios where the brain is very swollen and, as it swells has no place to go within the skull. It puts downward pressure onto the brain stem that goes down towards the spinal cord. She said that this can happen from widespread severe brain swelling, but it can also happen in situations of a large bleed, which is space occupying and compresses the brain. JR did not have coning. There was no evidence on his CT scan of that having happened and would be contrary to what the neuroradiology reports stated. Circulatory system is stimulated not failed by brain injury 676 Dr Auer’s opinion was that 'The circulatory system is stimulated not failed by a brain injury'.309 677 Dr Edwards said that JR was a previously well baby who had a sudden cardiorespiratory collapse which included the description of him being limp. The cause of the cardiorespiratory collapse was a head injury which included primary injury to the brain. The described limpness was a manifestation of his head injury and brain injury can and does cause cardiorespiratory arrest. Brain/lung damage caused by a virus 678 As to Dr Auer’s statement that 'With regards to what actually happened to [JR], it must be recognised that viruses can in fact cause brain damage and in series of thousands of infants and toddlers can also cause lung damage, not always killing the child',310 Dr Edwards said that was obviously true. Viruses can infect the brain, meninges and lungs, but they do not result in subdural haemorrhages or retinal haemorrhages, as seen in JR. Assoc. Prof. Linke and Assoc. Prof. Taranath are, Dr Edwards said, experienced paediatric radiologists who identified the findings to have had a traumatic cause. They would readily have identified if there had been 307 T 1061. 308 T 1061. 309 T 1061-1602. 310 T 1062. -- 134 of 345 -- [2026] SADC 67 133 an infection cause and there were no clinical features that would support that, nor did JR progress to develop encephalitis or meningitis. 679 Dr Auer suggested:311 Causation cannot be divined by Johnson et al312. The head injury allegedly caused the bleeding, may not be a head injury at all, only misrepresentation of hemodynamic intradural - not subdural - bleeding after resuscitation. That is, if there is natural illness causing an apnoea in the first place, what remains is only circular reasoning' and he goes on 'The article with apnoea intubation describes pneumonia not head injury. 680 Dr Edwards said that in response to Dr Auer’s previous report which asserted that head injury does not cause apnoea, she had provided references of multiple publications that described an association between head injury and apnoea and in the paper by Johnson et al, 50% of the infants had a history of apnoea prior to hospitalisation. Dr Auer discounted the validity of this association because he was not convinced that the infants in the published literature had head injuries at all and opined that the apnoea was due to a natural illness. Dr Edwards said that Dr Auer disregarded the clinical findings described in this paper which clearly indicated head injuries, including skull and facial fractures, seizures, unreactive pupils and retinal haemorrhages, neurosurgical drainage of intracranial haemorrhages and that 43% of that population group were left with severe disability. To suggest that all of those were misdiagnosed as pneumonia, was, she said, irresponsible. 681 Dr Auer said: 'Does Dr Edwards truly think that this assault/head injury is happening to the babies by their own parents practising MMA on their baby's small head? And so many that it is an epidemic? Is Dr Edwards to be taken seriously?'313 Dr Edwards said that obviously that was not something that she had ever asserted. She did, she said, make the point that there is no valid comparison between head impacts in highly trained adult MMA athletes and head injury in a six-week-old baby. 682 Dr Auer added, 'So this article by Dr Edwards to support fatal impact apnoea is not honest'.314 Dr Edwards said that in that article, apart from describing the different experiments that have been completed on animals, there were two case reports. One of a motorcycle accident which was witnessed and who immediately stopped breathing who had resuscitation immediately and had a good outcome. Another case was of a person hit by a bus, their head was injured, and they had immediate resuscitation and had a good outcome. Accordingly, they were witnessed examples of the fact that first, you can stop breathing from head injury but, second, that in the rare situation there is an ability to provide effective resuscitation quickly, it is quite possible that people can have a good outcome. 311 T 1064. 312 Exhibit P152. Johnson, Boal and Baule, 1995. Rule of Apnoea in Non-accidental head injury. 313 T 1064. 314 T 1064. -- 135 of 345 -- [2026] SADC 67 134 Biomechanics 683 Dr Auer said:315 There is no evidence for a change in breathing control at 12 months. She also mixes in "non-mobile infantile head injury" (snuck premise) as if this is a traumatic head injury that must have been produced by some person since the infant is non-mobile. The sneaking in of her premise that [JR] had a non-motile head injury with her circular reasoning converts the case into a whodunit. 684 In response, Dr Edwards stated that it was well recognised in the literature that an infantile immature brain is more susceptible to brain injury than an older child and adults. If an infant who cannot generate sufficient forces to move on their own, which is the situation for a six-week-old, has an injury, it must have involved an externally applied force by somebody else because they do not have the ability to generate that to themselves. It is she said, a logical conclusion, which is deductive reasoning, not circular reasoning, that the injury must have involved another person. 685 The term 'inflicted head injury'316 does not mean intent. All it means is the involvement of another person, and there can be circumstances where inflicted injuries happen through mechanisms that you would not consider in any way intentional. 686 As to Dr Auer’s statement that 'There is no intent variable in physics',317 Dr Edwards said that a biomechanical mechanism which involves the actions of another person does not infer a knowledge of intent, nor has this been stated in any of her reports regarding JR. Her opinion relates to the medical and related evidence in relation to onset of symptoms. As a forensic medical expert, she would never give an opinion about intent. Dr Edwards’ response to the opinions expressed by Prof. Ackland. 687 Dr Edwards noted that Prof. Ackland is not a medical practitioner and that his curriculum vitae318 included an extensive list of his keynote papers, books, publications and technical reports which related to adults and adolescents becoming injured in sport and ergonomics. There were no references to papers or publications in relation to infant anatomy or biomechanics, or in relation to head injury in any age group in terms of work that he had undertaken himself. He gave no history of working in a paediatric setting. 688 Dr Edwards said that Prof. Ackland’s report was titled 'Shaken Baby Syndrome Biomechanics Evidence'.319 Dr Edwards said that the term Shaken Baby Syndrome (SBS) was coined many years ago and was not a term that she ever used. 315 T 1062. 316 T 1062. 317 T 1065. 318 Exhibit P44. 319 T 1072. -- 136 of 345 -- [2026] SADC 67 135 She said that she did not think it appropriate to consider this a syndrome. That is, to infer that you can have certain features and that always means that you know what the mechanism of injury was. It was used, and some people still would use that term to refer to situation where a baby had intracranial injuries but no signs of impact. 689 In this case, there was evidence of impact. Accordingly, Dr Edwards said, it was not clear to her why the report by Prof Ackland was requested to address the issue of the evidence for or against SBS. 690 Dr Edwards said that she noted Prof. Ackland was instructed to provide expert biomechanics report in this matter with specific focus on the strength of evidence in the scientific literature pertaining to the biomechanical mechanisms of injury leading to the triad of symptoms known as SBS, or abusive head trauma. Dr Edwards said there is no evidence within Prof. Ackland’s curriculum vitae (CV) of education training and experience in the human functional anatomy and bio ergonomics of infants. 691 Dr Edwards said this was important because infant anatomy is very different to the anatomy of older children and adults. Obviously, the injury biomechanics involved in the causation of injury to a non-mobile infant is very different to the biomechanics of sporting injuries in adults and older children. 692 Prof. Ackland stated that he was provided the literature by the ‘defence team,’320 and had performed his own literature search to elicit other relevant peer review publications.321 Dr Edwards was critical of Prof. Ackland’s apparent failure to outline the scientific method by which he undertook his own literature selection. 693 Prof. Ackland’s reference list contained 25 articles. Dr Edwards said that to undertake a search on the term 'infant head injury' in PubMed, 15,885 articles would be returned. If looking specifically for the term 'abusive head trauma in infants', that identified 2,000 articles. 694 She observed that in the search of the 2,000 articles, the Consensus Statement appears as the lead article in PubMed on that topic, yet Prof. Ackland did not reference that article. She said that some of the articles referenced by Prof. Ackland, are considered within the paediatric forensic community to be the subject of serious methodological flaws. 695 Dr Edwards said that while Prof. Ackland declared this information is not within his sphere of expertise, he nevertheless, said that it is worth mentioning that several authors have reported that there are multiple non-abusive accidental or 320 T 1073. 321 T 1073. -- 137 of 345 -- [2026] SADC 67 136 natural causes that can produce the symptoms associated with shaking only, SBS, Shaken Baby Syndrome/AHT Abusive Head Trauma'.322 696 Dr Edwards said the methodology employed to form a forensic opinion regarding injury causation involves the same process utilised in any medical diagnosis. A clinical history is taken and in paediatrics that history is taken from the parents, generally. The child is then examined, and notes made of any relevant findings, targeting what investigations to order and, in a forensic sense, information is incorporated that may be gathered from the circumstances of what is known to have occurred, including the ambulance reports and police statements, site visits when required, and witness statements. Taking all that information together what alternative explanations there might be are looked at and what tests should be done to include or exclude them, and, at the end of that process, an opinion is formed based on the most likely causation of a child's injuries or presentation. Several medical and related conditions are excluded, so the door is closed on those. 697 With respect to whether anything raised in the materials referred to by Prof. Ackland gave her cause to reflect on her opinion, Dr Edwards again raised that JR’s presentation had not been referred to as SBS. There is evidence of head impact and to focus a literature search around shaking did not appear relevant to this case. 698 Prof. Ackland was said to have acknowledged in his report under the heading 'Impulsive loading and retinal haemorrhaging'323 that 'Much of the literature on this topic is not within my area of expertise'.324 The literature review that he then undertook and reported on was selective. Dr Edwards said that because of the scope of the request for his report being limited to shaking, Prof. Ackland did not look at the biomechanics of head impact to the same degree in his literature review around the so-called shaking only cases. 699 In his report, Prof. Ackland referred to an article that involved live lambs being shaken in an attempt to produce retinal haemorrhages. Dr Edwards said that was not the purpose of that study. The actual purpose, as stated in the paper, was to address the question of whether shaking alone is sufficient to produce brain injury and mortality, and their finding was in the affirmative, with three lambs dying unexpectedly after being shaking, proving that shaking alone can be lethal. 700 In response to Prof. Ackland’s statement that ‘In making these observations and stating my findings, I rely on the information provided to me by [the defence lawyer] and that gleaned from my own literature searches. I must also state that I have had no direct research experience in the field of SBS/AHT, shaking baby syndrome and acquired head trauma, so my observations are based on my 322 T 1074. 323 T 1076. 324 T 1076. -- 138 of 345 -- [2026] SADC 67 137 understanding from these information sources',325 Dr Edwards said that to be able to interpret the biomechanical literature you need to understand the clinical issues and infant anatomy. She said that a lot of the research in this field has been done jointly by paediatricians and biomechanical engineers and that Prof. Ackland does not hold those qualifications. She said that the reason why this research has been done jointly is because it is appreciated that there is value in incorporating real-life examples and scenarios and an understanding of the specific anatomy of infants into any research regarding infants. Dr Edwards questioned Prof. Ackland’s ability to interpret the literature if he did not have that experiential base. In that regard, Dr Edwards said it is not just a capacity to review papers but requires some clinical experience, an underlying knowledge that would be gained from paediatric experience, or an extended review of paediatric materials. 701 Prof. Ackland did identify from the literature that 'Infant head impacts, from a variety of causes, especially those contacting noncompliant surfaces do result in very high angular accelerations. Several studies show that these very high angular accelerations surpass the injury thresholds for SDH subdural haematoma and DAI - Diffuse axonal injury.’326 Dr Edwards said that in monkey studies where there was no impact, there was sufficiently high angular acceleration forces to cause subdural haemorrhages and diffuse axonal injuries. In general, however, there are no reliable injury thresholds, so it is not known exactly what level of force is required in the head injuries of an infant because the research has been done on adult primates extrapolated to adult humans and then extrapolated down to infants. There is real concern that because there are no known injury thresholds, that a lot of the biomechanical research has limited applicability in real life clinical scenarios. While there was a lot of work being done on developing more biofidelic infant surrogates, trying to make them more human or lifelike, but because the properties of the infant neck and the infant blood vessels and the brain are unknown and there are so many differences to adults, it is not possible to replicate the human infant's anatomy with any degree of accuracy in a biofidelic model. For example, in the Duhaime327 paper, to which Prof. Ackland referred, a dummy was utilised that had a hinge for a neck and a head that was full of cotton wool, which in no way replicated a human infant, hence the limitations to the literature in that regard. 702 Prof. Ackland provided an opinion regarding abductive reasoning, concluding that 'Abductive reasoning cannot scientifically and reliably determine the causation of a child's medical findings'.328 Dr Edwards said that in medicine multiple forms of reasoning are used. A doctor's breadth of knowledge and experience are integrated to make informed decisions and diagnoses. Abductive reasoning leads to the generation of a hypothesis from the patient information, so, if you take a history of symptoms and do an examination, that leads to the formation of a differential diagnosis, which then leads to ordering the relevant 325 T 1077. 326 T 1078. 327 Exhibit D121. Duhaime, 1987. The Shaken baby Syndrome. 328 T 1079. -- 139 of 345 -- [2026] SADC 67 138 tests, and to determine the most likely diagnosis based on those symptoms and findings. Deductive reasoning is also used to apply medical knowledge and evidence-based guidelines to specific cases. Inductive reasoning is used to help with pattern recognition and acquiring knowledge from individual patient cases, particularly in the situation of an emergency department where a rapid decision around treatment has to be made that allows you to make decisions on the run. Probabilistic reasoning is also to help assess a likelihood of differential diagnostic outcomes and that is a process that doctors are trained in through medical school and clinical experience. 703 Dr Edwards said that she has specific training in relation to the application of forensic principles to her paediatric opinion. When asked to explain how that impacts on her opinion and the opinion that she was giving in court, Dr Edwards said:329 Well, forensic medicine obviously works at the interface of the law and medicine and so we have to be very aware of the principles of, for example, being objective and putting in place methodologies in our practice to limit bias, such as peer review and keeping up to date with the literature, as is relevant to the specialty that we're in, and we also have to be aware of the importance of chain of evidence, for example, making sure that we document things accurately so that, if a matter comes before a court, we have good evidence to support the opinion that we've formed. 704 Prof. Ackland said in his report that:330 'Having reviewed the biomechanics literature on this matter and after reading her report, I acknowledge Dr Edwards' assertion that the mechanism of [JR]'s injury was likely an impact to his head. She has noted elements of evidence for such an impact, which included scalp haematoma, bilateral skull fractures, subdural haematomas and brain contusions. Biomechanic studies reviewed demonstrated high levels of angular acceleration may occur when a child surrogate's head impacts noncompliant surface'. 705 Dr Edwards said thereby, Prof. Ackland, while noting that he is not a doctor, agreed JR had a head injury caused by head impact, but the balance of his report seemed to be dealing with SBS. 706 As to Prof. Ackland’s assessment that Dr Edwards was dismissing the possibility that JR's serious head injuries could have occurred during a low-force impact reported to have occurred on 30 December 2019, wherein he stated 'Whilst offering an opinion on this assertion is outside of my expertise, I find Dr Edwards' opinion to be at odds with the findings of Prange et al., (Prange)331 and cases such as reported by Geoghegan et al, (Georghegan)332 Dr Edwards said that both of those references related to falls from a height, so that is not the scenario put forward in this case. The Prange article noted that case studies of infants younger than three years have shown that subdural haemorrhage, traumatic axonal injury and death 329 T 1080. 330 T 1081. 331 Article not referenced. 332 T 1081. -- 140 of 345 -- [2026] SADC 67 139 are very rarely caused by impact from falls of less than 1.5 metres. Their experimentation utilising dummies concluded that inflicted impacts against a hard surface may be more frequently associated with clinically significant inertial brain injuries than vigorous shaking or falls from less than 1.5 m. 707 Dr Edwards said that what the article states is exactly in line with what she stated in this matter, in that a simple drop with linear forces does not result in those findings, but a rotational force applied before impact is much more likely to and that is in line with that experimentation that they had done. So, she concluded, it is not at odds with her dismissing an impact which was not a drop, but was a 10-20 cm horizontal movement, with no gravity involved. The impact force was generated by the legs of a six-week-old baby. 708 Dr Edwards said that there is no literature that such a comparatively low- impact force would result in serious head injury and Prof. Ackland had not provided any literature to indicate that is so. The infant pushing off as described would not have involved any angular acceleration forces. 709 Dr Edwards described the case in Geoghegan333 as an ‘interesting case’, described by colleagues in Canada, who, like herself are very keen to find cases that are well documented. This case was captured on CCTV footage and described a five-month-old who was sitting on the lap of a five year old on a swivel chair and an adolescent rotated the chair causing the baby to be dropped headfirst onto their forehead and then on to the right side of their head on a wooden floor. That infant developed a focal subdural haemorrhage and retinal haemorrhages but had no brain injury and had no skull fracture and the fall height was estimated to be approximately three feet. The authors commented that they suspected a rotational component from the turning of the chair prior to the fall was likely to have introduced momentum and more significant deceleration on impact. They stated that they do not propose that these findings can occur after all short falls, but they believe this case to be an ‘outlier’. 710 Dr Edwards noted that a drop with some initial momentum of three feet is not similar to the description of the sofa incident event that was provided in this case. Dr Edwards said that applying common sense, if the baby came off the lap of the five-year-old because of the turning of the chair itself, that would naturally involve some rotational force to launch the baby in the manner described. Dr Edwards said that the article just supports the view that to sustain a life threatening head injury as JR did, it was of greater force than appeared to have occurred in that particular case that was caught on home security footage and that his head injury is, therefore, the result of high force angular acceleration and impact, which is consistent with the findings from the Prange paper. 711 As to Prof. Ackland’s comment that there was 'no scientific evidence put forward by Dr Edwards to support a conclusion that vigorous shaking of the infant 333 Ibid. -- 141 of 345 -- [2026] SADC 67 140 [JR], with or without head impact, might have occurred and could have contributed to such damage based on the lack of damage to [JR]'s neck and cervical spine',334 Dr Edwards said that the lack of neck injuries on imaging, noting that JR did not die so there was no pathological examination of the tissues, does not discount there having been a high force angular acceleration in the context of head impact. Many of the children seen with significant head injuries, whether they have impact sites or not, do not have neck injuries. She said that this is well documented throughout the literature. 712 Prof. Ackland referred to an article by Davison et al,335 who concluded 'Under a pure inertial loading mechanism analogous to shaking, the paediatric neck will sustain injury prior to the development of closed head injury'.336 Dr Edwards said that when you look at that paper, they actually utilised three-year-old equivalent crash test dummies in sled testing runs and again there is no knowledge of what the actual threshold for injury of the spine is and that the neck strength of a three year old is obviously going to be quite different to that of an infant. Dr Edwards did not believe that research had any applicability to the situation of an infant of six weeks of age with an impact head injury. 713 Prof. Ackland stated that 'Dr Edwards does not provide any scientific basis to underpin her assertions, ie, via peer reviewed biomechanical or clinical studies'.337 Dr Edwards said that what Prof. Ackland concedes is that a biomechanical forensic analysis cannot be conducted when the injury thresholds for infant head injury have not and cannot be established experimentally and, in this case, when there is no proposed incident or mechanism of injury it would not be possible to do or apply a peer reviewed biomechanical study to inform her opinion. 714 Dr Edwards said that in Prof. Ackland's response, he limited himself to the biomechanical literature, which is largely based around experimentation on animals and using dummies. 715 Prof. Ackland was said to have provided a further response dated 1 May 2024 which Dr Edwards said did not cause her to alter her opinion with regards to causation of JR's head injuries being the result of rotational acceleration and impact forces. 716 In his review, Prof. Ackland maintained his focus on the lack of scientific evidence in relation to shaking only cases. Dr Edwards said that he did acknowledge that the biomechanical literature aligns with the clinical literature in that head loading with impact can cause intracranial injuries, and the presence of 334 T 1084. 335 Article not referenced. 336 T 1084. 337 T 1084. -- 142 of 345 -- [2026] SADC 67 141 skull fractures in JR's case indicates that there was forceful head impact and which was involved in the causation of his head injury. 717 Dr Edwards said that the clinical and scientific literature does support the view that shaking, can cause intracranial injuries. However, it is not the only mechanism, and, in this case, there is impact, which can also cause the intracranial injuries. She said that it has not been established that you need to have repeated rotations of the head to cause these findings. It certainly is the case that with a forceful rotation and impact you can get the same findings as seen in children that have no signs of impact. 718 Dr Edwards maintained her view that JR’s head injuries provided evidence that they were the mechanisms involved in the causation of his head injury. There is, Dr Edwards said, no relevance in this case to the biomechanical debate in terms of SBS. 719 As to Prof. Ackland’s statememt that he did not contest that JR had evidence of head trauma, but the suggestion that triad symptoms could be caused by shaking alone must be addressed in light of the available scientific literature, Dr Edwards said she had not asserted that anywhere in her reports. 720 Dr Edwards said that biomechanical and animal studies that Prof. Ackland referenced provide an adjunct to clinical studies, but they must be evaluated considering the significant limitations within that body of literature because there are no biofidelic infant surrogates. There has been scaling of thresholds from monkeys to adults to infants, and the approximate injury thresholds are unknown. Therefore, in a particular circumstance, it cannot be said what exact unit of force was involved and, secondly, even if the unit of force was known, it cannot be said whether that would have caused an injury to an infant or not because there are no thresholds. It is not only the anatomy that cannot be replicated, but also things like the lack of myelin in the nerves, the different stiffness of the infant brain, the structure of the neck, the structure of the bridging veins and the fact that how a baby responds to head injury in terms of blood flow to the brain is thought to be different and the brain being softer than it is in adults. There are many differences that cannot be considered and therefore biomechanical literature cannot be used in an individual case. 721 Dr Edwards said that it is established and well accepted by paediatricians across the world that rotational movement of the head around the neck without impact can cause the findings of cerebral concussion, haemorrhages and retinal haemorrhages and that has been found in accidental scenarios as well as inflicted scenarios and with animal experimentation. 722 Dr Edwards noted the limitations of experimental biomechanical literature in relation to infant head injury. A literature review by Schiks et al338 who reviewed 338 Article not referenced. -- 143 of 345 -- [2026] SADC 67 142 47 articles in relation to the biomechanical literature, concluded that none of the published injury thresholds have been scientifically validated for infants and are not based on infant data. There has been scaling from adult primates to adult humans, then scaling to infants. The simple mass scaling employed by many researchers does not allow for the known age dependent differences in the viscoelastic properties of the infant brain and neck. Because there are so many variables, you cannot just simply mass scale from primates to infants. 723 The point also made in that article as to the comparison between linear and rotational acceleration forces, Dr Edwards said, aligns very much with clinical experience, that you can fall from a third floor window and have minimal head injuries, but if you have a punch to the side of the head, which causes rapid rotation you can become unconscious. So, Dr Edwards said, we know that the human brain tolerates linear forces quite well, but it does not tolerate rotational forces, hence why measures are taken to prevent those whiplash-type injuries, because we know that humans are very susceptible to those. The infant brain is even more susceptible than an adult to rotation. 724 Prof. Ackland said: 'It is for those giving expert opinion for the prosecution to provide sufficient argument to reject the possibility of an accidental short fall causing [JR]'s symptoms'.339 Dr Edwards said that the most relevant point is that there was no history of a short fall prior to the onset of his symptoms. If a six-week- old infant, had a fall, she said that she would expect one of their caregivers to have information regarding that, which was not provided. 725 She said that the accidental short fall literature is exceedingly clear that low- distance falls, which is less than a metre, from an elevated surface or a caregiver's arms, does not result in the type and severity of head injury that JR had. Particularly, it does not result in brain injury and the degree of retinal haemorrhages that he had and the constellation of all the findings. It is the rotational force together with the damage caused by impact that provide the explanation to the whole of the suite of symptoms and injuries sustained by JR. 726 In response to Prof. Ackland’s view that 'One would expect an appreciation of the biomechanics literature when a forensic paediatrician seeks to opine on the causation of any observed injuries',340 Dr Edwards said that she does have an appreciation of the biomechanical literature. It is not possible to do an experimentation of a specific event, particularly because there was no event in this case, and come up with a definitive opinion as to the exact amount of force that was involved. 727 In the example of the outlier article where a five-year-old had a baby on their lap and the baby came off the lap and then impacted, that would, as a real-life example, involve both rotation and linear forces and an impact at the same time which, Dr Edwards said, is why it is really important to not just say that every fall 339 T 1091. 340 T 1094. -- 144 of 345 -- [2026] SADC 67 143 is a short, simple, linear fall that just has linear acceleration, because some falls are complex. The fall height might be quite short, but there is initial acceleration and rotation. It is important to look at exactly as much detail as you can about how a fall happened and, therefore, determine whether it accounts for significant acceleration or not. 728 Dr Edwards said that the occurrence and severity of primary head injuries is also influenced by the child's age, their anatomy and acknowledging that there can be underlying predisposing conditions that might make an injury more likely than in another child. The king-hit to the side of the head tells us that human brains of all ages can be injured by rotational rather than linear force. The brains of infants and young children are particularly vulnerable given the relative size of the head to the body, amongst other features, namely the weak neck, the different physiology within the brain itself, tethering of the brain, and a higher water content of an infant brain. 729 Dr Edwards maintained that she is familiar with the biomechanics literature which is a topic about which she is required to update herself in a routine manner. She explained that it was part of her master’s in forensic medicine and she has attended multiple conferences where biomechanical engineers have presented their research. Literature is collected every few months and peer-review journals and biomechanical literature is included in the literature in which she keeps abreast. 730 She said that the most common real-life example is where babies get dropped or fall. If a parent is standing and the baby falls from their arms straight down, that is mainly going to be linear force because the head and the body stay in a line. At impact, there may be a slight bounce of the head, which gives minimal angular acceleration, and we know that babies can be dropped from shoulders of parents, which can be up to five to six feet, and they will have focal injuries, so they will have a skull fracture and a bruise or swelling of the scalp, but they do not get those diffuse injuries of the brain, which Dr Edwards said is the experience of everyone who works in paediatrics. 731 A parent dropping, a child falling off a change table or children falling off beds, happens regularly. There would be several presentations to the WCH emergency department every week with exactly that scenario. 732 Dr Edwards described a case where a child was run over by a car, so their head was completely compressed and they remained conscious throughout. It is very much the case that the rotation, which leads to the stretching of the nerves in the brain, is what affects the level of consciousness. There are, she said, many examples that show that you need free movement of the head to become unconscious. The shearing forces affect the blood vessels, they affect the nerves and if it is sufficient, then they become torn and that is why we get the subdural haemorrhages, the retinal haemorrhages and the brain injuries. -- 145 of 345 -- [2026] SADC 67 144 Dr Edwards’ cross-examination 733 In cross-examination, Dr Edwards said that she recognised the importance of receiving a clinical history from family in a circumstance such as this which might embrace alternative explanations or an explanation for a presentation. She received explanations in the context of this matter, from the parents and grandparents as part of her role to conduct a forensic medical assessment. 734 Dr Edwards said that there was a request from the family for further information and to provide them with opportunity to ask questions, which she facilitated. 735 She understood that the request to meet from the DCP worker, Ms Breuer, was that the family were keen to meet and understand more about the nature of JR's injuries. She said that people can request to bring a legal adviser to meetings, and it would depend on the circumstances as to whether people are told a meeting would be cancelled if they bring a lawyer with them. Clinical Risk would be consulted. 736 Families are made aware before they speak with them that their role is to gather information that will be shared with DCP and the police.341 737 As to the purpose of her giving information rather than someone who is not involved in any forensic capacity, Dr Edwards said that the radiologists do not meet with families to provide reports of results. The general paediatrician provides information about treatment and medical care and when it comes to an opinion around injury and causation and the forensic process, then that would be her unit’s role to speak to family about that. 738 The information that was provided by the family to Dr Noori initially was that no incidents involving BR had caused any injury or any circumstances that they were concerned about in terms of interactions between BR and JR. 739 Dr Edwards said that she had a PowerPoint presentation which she showed to the family, and she explained what the injuries were to them. 740 There was reference in her notes on the meeting with AE and BE with BE asking whether BR could have pressed on JR’s chest, whether the rib fractures were caused by CPR or the car seat being too tight. They queried whether the dogs or BR running over JR whilst on ground could have crushed JR’s ribs. Dr Edwards said there was not a specific incident, it was a query. There was no description that had be witnessed.342 741 Dr Edwards said there were no re-enactments done in relation to the CPR, the dogs or BR running over JR, car seat. She said that unless there is a specific 341 T 1103. 342 T 1115. -- 146 of 345 -- [2026] SADC 67 145 incident to re-enact, it would not really be helpful to have dogs run across a doll, for example. She said that car seats are standard and do not cause rib fractures. 742 Dr Edwards said that injury caused by BR was discounted, because there was no witnessed incident of her being involved in any injuries to JR. The family were specifically asked if any incident had happened or if there had been a situation where JR had been found crying when left alone with her. The parents said that whenever BR was in the lounge room with JR he was in his bassinet or in a bouncer and had not been left unattended. Dr Edwards accepted that BR was quite a bit bigger than JR, as would be expected. 743 When challenged that she was ‘reversing the onus of proof’, Dr Edwards said that she was not making the family prove anything but had asked for that information. They provided ideas, asking 'Could it have been that?' and in her opinion it was no. 744 Dr Edwards said that part of a forensic medical assessment, like any type of medical diagnostic process is to take a history and if there is anyone who is a witness or saw something that might explain a child's injury, then they would like to hear what information they have. 745 On 30 January 2020, no-one had been charged with any crime and they were conducting a forensic medical assessment as per the standard process. 746 Dr Edwards said that parents are aware from the beginning that any information they provide is shared with police and DCP. The parents and family requested the meeting because they wanted to get more information about the medical findings. Dr Edwards denied that she was in any way coercing or forcing the family to give her any information. 747 As to why she did not let them get the information from the treating practitioners, Dr Edwards said that it was her role. The questions were about causation of injury. They could have got information about the injuries from the practitioners, but the understanding was that they were wanting more information around how these injuries could have occurred. 748 As a doctor, she is not a police officer, so does not caution people but rather explains they are given information and it will be shared. 749 Under the Interagency Code of Practice the role is to conduct a forensic medical assessment and then determine whether the injuries are explained or not and part of doing that is to gather as much information as possible. Dr Edwards said that if they did not ask for a history at the beginning of every assessment, they would not be able to draw any conclusions. She added that it is a normal process to seek out as much information as you can, because in a large proportion of cases, -- 147 of 345 -- [2026] SADC 67 146 by doing so they may find that an injury can be explained and it needs no further interagency process.343 750 Dr Edwards rejected defence counsel’s criticism that it was a ridiculous assertion to say that if they did not take a history, they would not be able to draw any conclusion. She said:344 If you have a baby with an injury that can’t tell you what happened, then you are reliant on the caregivers to tell you what they know about what caused the injuries. So of course, it is a crucial part of all medical diagnosis and particularly in this case. 751 Dr Edwards said that the DCP and SAPOL have different priorities, but they need input from medical specialists to interpret injuries. The role is to provide a forensic medical assessment that addresses both safety and it may well lead to SAPOL forming a view about criminality. She said that in this case, Dr Noori did not speak with the parents until after the police had done their interviews and had given approval. She did not meet with the family until after SAPOL had completed their second interview and gave her approval to do so. 752 Dr Edwards said that the main point of meeting with the family was to provide them with information. She was not conducting a formal interview of them at that time. They were wanting to understand why her opinion had been given. She was, she said, giving them the information so that they could have that to form their own opinions, not trying to convince them one way or the other. She was giving them the opportunity to understand why she had formed that opinion. 753 Dr Edwards said that the DCP were very keen for JR to be placed with the grandparents and were of the view that the grandparents did not understand the basis of the medical opinion and that was a barrier for them being able to potentially be carers for JR. Dr Edwards said that she had offered to provide a session, showed them all the images and explained to them why she had formed her opinion. It was not strategic. She was responding to a request via the DCP from the family that they did not understand the extent of the injuries.345 754 She offered to meet after the second police interview had occurred. Police had asked them not to do that before hand and that if there were any other explanations provided that police needed to investigate, they would share that as part of the Interagency Code of Practice. 755 As to an email on 15 January 2020 from DBS Sherratt to her and to Ms Breuer copying in others from SAPOL, which asked 'Are parents offering any new 343 T 1274. 344 T 1274. 345 T 1279-1280. -- 148 of 345 -- [2026] SADC 67 147 defences or alibis?',346 Dr Edwards said they were asked if there were different explanations for the injuries. She did not know what was meant by ‘alibis’.347 756 In terms of alibis, Dr Edwards said that her understanding would mean whether there were there other people that could verify where people were at certain times. It would not be her practice to seek alibis, that would be very much within the role of police. 757 Dr Edwards noted that she had written: 'According to the hospital notes the only new information in terms of explanations the grandparents are putting forward was the circumcision procedure and also SAAS having caused rib fractures and query head injury'.348 758 Dr Edwards said that if there is an explanation put forward, then police will try to gather further information about that. The circumcision procedure, for example, led to them taking a statement from Dr Kirby in relation to that. 759 She said that it is part of the Interagency Code of Practice. It is about an interagency response to a situation of suspicion and gathering of information and sharing of information occurs in that context. 760 Dr Edwards said that she is guided by police about when she can speak with families or not and takes their guidance. She does not seek to manipulate anyone's information but just forms an opinion and feed back in a transparent way whether, given her expertise, that would be a plausible explanation or not. It is, she said, part of the process. 761 As to her email on 30 January 2020 sent through to various members of SAPOL and other agencies associated with the interagency investigation 'I was clear with them that he has inflicted injuries. ‘They seem to have accepted the previous explanations are untenable',349 Dr Edwards said that she was giving them an opinion, telling them that the suggestions they had put forward were not plausible or tenable in her opinion. 762 As to whether she was ‘hoping that they accept that previous explanations are untenable’,350 Dr Edwards said that she was not hoping or otherwise, apart from the fact that it was important from a DCP perspective for them to be able to consider JR going into the care of the extended family, for them to accept that somebody had hurt him.351 346 Exhibit D54 (admitted on Voir Dire as Exhibit VDD3). 347 T 1280. 348 Exhibit P54 (admitted on Voir Dire as Exhibit VDD3). 349 Exhibit P52 (admitted on Voir Dire as Exhibit VDD1). 350 T 1283. 351 T 1283. -- 149 of 345 -- [2026] SADC 67 148 763 Dr Edwards agreed that she was giving them her opinion that the theories they put forward were not tenable and reporting back that they had not provided any further explanations. 764 It was put to Dr Edwards that she was trying to give police information in a bid to undermine narratives consistent with innocence, she said:352 So the theories put forward by the family continued to be put forward, hence the second or the third report that I wrote. So it would seem to me that the family were not put off in terms of putting forward these, and obviously they have the right to put these forward through any subsequent court processes, and which they have done, so I don't think that I was acting in any way to put them off, if that's the question. 765 She said that the family wanted to know about the injuries. There is a process involved, JR was not in their care, and they wanted to understand the opinion that had been given in relation to that. Also, the extended family had not had an opportunity to see all the imaging so she agreed to do that. 766 She said she was just offering to make sure that a lack of information was not what was leading to them not accepting that somebody has hurt JR and that they then could decide on what position they would then take. 767 Dr Edwards emphasised that she is not retained for a second opinion. She is involved in the assessment of children, then forms an opinion, writes a report that gets given to police and the DCP and if they proceed to court, then she is called to give evidence. She is not giving evidence as an investigator. In her role she has compiled all the medical records, interpreted them, formed an opinion and is giving an opinion as an expert in this field. 768 Dr Edwards said that she was aware that there are responsibilities and requirements put on experts giving an opinion in court. She said she must be recognised as an expert by the court to give opinion evidence and that opinion must be within recognised knowledge, and she must have expertise in that recognised body of knowledge. Her responsibility is to the court, and she must, always be objective and impartial. 769 In the context of her work, basic principles are followed. All doctors that work at the medico-legal interface are aware of chain of evidence requirements and the importance of documentation and everything done is in trying to gather all the information to make sure that they have all the information that might inform their opinion before they finalise their opinion. 770 Dr Edwards did not agree that attempting to have witnesses accept her view is to interfere with the integrity of the narrative. She said that they do not have the power to speak to people individually if they don't wish to be spoken to. 352 T 1284. -- 150 of 345 -- [2026] SADC 67 149 771 Dr Edwards said that she was not seeking a narrative. She was not interviewing the family, but rather, was providing them with information. 772 In the process of the meetings, various ideas were put forward, and she provided the family with her opinion with regards to those. Did CPR cause a re-bleed – the sofa incident 773 Dr Edwards denied that the paramedics, in applying force and moving JR’s head around on a floor could have caused some swelling to recur from the earlier head injury, but agreed she was not present. She said that in a normal standard resuscitation, the head remains on the ground, and the airway is applied over the face so there is not a huge amount of manipulation of the head because the training is very much that you do not know if a child or anybody has a spinal injury so you are very careful about not manipulating the head to any degree during a resuscitation. The jaw is just lifted in the position called a ‘sniffing’353 position, so the head is very slightly rotated back and the jaw lifted forward. 774 Dr Edwards said that the information she had at the time was that the swelling had resolved when examined on 3 January 2020 and she agreed that was what she had told the family. She said that she had corrected herself in her final report. 775 Dr Edwards denied that a head injury like that with persistent swelling gives rise to a vulnerability or a fragility. The swelling that was palpable on the scalp was on the outside of the skull, while the subdural haemorrhage was between the skull and the brain. They are, Dr Edwards said, completely different things. The swelling that was palpated by the doctor, is on the surface of the skin and the doctor was very clear that there was no indication of any intracranial injury. On the radiology the swelling was still there but over time the blood can spread over the surface of the brain which means it is very hard to palpate. 776 The paramedics observed no evidence of any trauma or external application of force at all on 5 January 2020, in that they saw cardiac arrest and agonal breathing, respiratory issue, and cyanosis. Typically, if performing resuscitation, the child is lying on their back and she would not have thought that they would have felt the back of the head during that process. It was never recorded that they did specifically examine for swelling of the head. 777 As to defence counsel’s suggestion that there was no evidence of any injury or trauma noted by the paramedics, Dr Edwards noted that as soon as JR was in Emergency Department, they did feel swelling of the scalp. As to the descriptor ‘boggy’,354 Dr Edwards said that is just a description of a squishy feeling when you palpate. She agreed that skull fractures cannot be aged, in terms of bone healing. 353 T 1261. 354 T 1257. -- 151 of 345 -- [2026] SADC 67 150 778 Dr Edwards said that on radiology there is a wide window of healing, but it is always necessary to correlate that with history and with examination findings. She said that the skull fractures here cannot be aged specifically but they were associated with overlying swelling and underlying bleeding that was recent and so correlates with a recent head injury. 779 Dr Edwards was asked about the condition of JR’s brain, post the events of 5 January 2020, when the brain was said to look good. Dr Edwards said that the initial CT scan showed the fractures overlying the swelling and underlying bilateral subdural haemorrhages surrounding the brain. It did not show any swelling of the brain tissue and that is very common on early CT scans because the process of brain swelling and damage evolves over time, so it is very common for an initial CT scan of the brain tissue to not show too much abnormality. JR did however have an abnormal level of consciousness at that time and was having seizures, indicating his brain was not normal at the time of the CT scan. 780 As to whether subdural haematomas can rebleed with minimal force, Dr Edwards said that chronic subdural haematomas that have formed a new membrane around them with fragile blood vessels, can rebleed inside that formed chronic subdural haematoma. They have a specific appearance on neuroimaging, which JR did not have. 781 The research that has looked at the change in appearance of subdural haematomas over time, suggests that when they look bright or white, they are less than seven to ten days of age and beyond that, purely on radiology, you cannot age subdural haemorrhages unless you also see the formation of membranes. 782 Here there is an acute or a recent subdural haemorrhage which is related to the trauma, the tearing of the bridging veins and the release of blood at the dural arachnoid interface. Over time, that recent blood can resolve completely, or if it does not resolve, it can form a chronic subdural which forms a membrane and within that there are new membranes formed, new blood vessels formed and they can rebleed. But they all have very different appearances on scanning. The appearance of the subdural haematomas on the CT scan was bright and the previous head knock was on 30 December 2019. Dr Edwards said the head knock explanation would not account for the subdural haematomas and the association with the brain injuries, and the collapse would indicate to her that they occurred at the same time. 783 Dr Edwards rejected the suggestion that rebleeding can occur in the context of minimal application of force, for example by the paramedics. She said that it could not cause a rebleed and explain the subdural haematoma. The source of the bleeding was damage to the bridging veins. Rupture of bridging veins is the most common cause of bleeding, and trauma is the most common cause of subdural haemorrhages. -- 152 of 345 -- [2026] SADC 67 151 Biomechanics of head injury 784 Dr Edwards said JR’s cardiorespiratory arrest was a result of the head injury which would have been sustained prior to the onset of change in consciousness level and change in breathing pattern and that is way outside of normal handling. There must therefore have been a high force movement of the JR’s head or body that resulted in rotation and angular acceleration that led to damage to the control of the breathing centres which led to the cardiorespiratory arrest. 785 As to what sort of measure is ‘high’, Dr Edwards said we cannot measure force, but they see children with head injuries from varying degrees of force application. A child being dropped from caregivers' arms of approximately a metre, does not give a cardiorespiratory arrest, so it is higher than normal handling and it is higher than a fall and it is a different type of force. It is impossible to quantify but certainly the severity of the presentation reflects the severity of the forces applied. Dr Edwards did not agree that it was a meaningless descriptor to say ‘high force’.355 She agreed that there are no suitable biofidelic models to assess how a six-week-old is going to respond to an application of force. 786 Dr Edwards disagreed that to surmise a level of force when dealing with very young infants where there are no appropriate surrogates, is to engage in conjecture. She said that it is based on experience and that a lot of literature in this area is based on clinical presentations and having an overview as a paediatrician of the type of presentations children have when they come to emergency departments. Most six-week-old infants are fairly similar in their anatomy. There are variants and there are other underlying conditions and children present to emergency departments with falls quite regularly and children come in with various conditions. They do not present with this type of constellation of injuries from normal handling or from low force falls. 787 When asked what peer review process occurred that shows what she was saying was correct when using a term like 'high force', Dr Edwards said there is a large literature base that she refers to, and her experience. High is higher than normal handling and the normal incidents of household falls that happen to young infants quite commonly. 788 In this case JR was in cardiorespiratory arrest. She has seen other children who present with subdural haemorrhages and retinal haemorrhages who do not go into cardiorespiratory arrest and so this is at the higher end of the most severe presentations that is seen of infants presenting with head injuries. 789 The cardiac arrest, the brain injuries, the seizures and the subdural and retinal haemorrhages are the basis for that conclusion. 790 Dr Edwards explained that different types of loading conditions lead to different types of injuries. When the type of injuries that JR had are seen, that 355 T 1265. -- 153 of 345 -- [2026] SADC 67 152 provides the ability to form an opinion on the type of forces. The magnitude of the forces are high outside of normal handling. The way children can be injured is obviously very different and it cannot be definitively concluded exactly what type of forces were applied, but the result was that he suffered a very severe head injury that nearly killed him. 791 Dr Edwards said she did not characterise the process as conjecture, but rather, it was forming an opinion. Unless it is witnessed or videorecorded as to what a person did to a child, then it cannot be hypothesised exactly what was done to the child, but the result is known as are the type of forces that were involved. 792 Dr Edwards said her opinion is based on the fact that there were contact forces because JR had skull fractures and scalp swelling and there were angular acceleration forces because his head rotated around his neck because of the distribution of the brain injuries, the contusion, the axonal injuries and the subdural haemorrhages. 793 She said that looking at the type of injuries allows the formation of a conclusion about the type of forces involved and to correlate that with any history of trauma provided. There was no history of trauma provided in this case. She said that she forms an opinion based on her knowledge of the literature and the clinical presentation of the child in this case. 794 Dr Edwards said the science is in the huge literature base that she refers to and in her experience of over 25 years working in this area. She applied that to the individual circumstance and formulated an opinion. She said that part of the history taking is always to see if there is any explanation provided and if an incident is provided, then there will be a re-enactment done or requested so they can visualise exactly what happened. However, if a family says 'Could it have been, maybe it was this', but there is no incident where a child was upset or anything was seen, it is not possible to recreate something like that. 795 When it was suggested to Dr Edwards that ‘beyond the fact there are no suitable biofidelic models, it is just not possible to recreate circumstances that may give rise to a degree of force full stop’,356 she said:357 It is possible to recreate when there's event that's been provided. However, in this case, there was no incident of any injury to [JR] having been seen or even the aftermath of it having been seen by the parents in relation to the two-year-old sister or the dogs. 796 Dr Edwards said that there was not a specific incident having ever been seen, it was just putting forward various theories. The type of forces that were involved would not account for the injuries. 356 T 1270. 357 T 1270. -- 154 of 345 -- [2026] SADC 67 153 797 When challenged that she was ‘reversing the onus of proof’,358 Dr Edwards said that she was not making the family prove anything but asked for that information. They provided these ideas, asking 'Could it have been that?'359 and in her opinion it was not. 798 Dr Edwards said that her opinion is based on a review of multiple sources of information. It is not a scientific experiment that she conducts but is a recognised process of forensic medical assessment that is done throughout the world in these circumstances. 799 She said that there are paediatricians who undertake forensic medical assessments throughout Australia, New Zealand, America, the United Kingdom and other countries in Europe, as well and some of the Asian countries. There is no incident of injury provided in this case, so the opinion is based on the radiology, the history and the medical records. All medical diagnoses concern history, examination, investigation and findings. Brain injuries 800 When asked how it was that she reconciled her view that there was a brain injury with that detailed by Assoc. Prof. Linke that was there was no need for a contrast study, the brain looked good and the CT did not see differing densities of tissue, it all looked fine, Dr Edwards referred to what was found later on the MRI scan, and the clinical symptoms indicative of brain injury.360 Retinal haemorrhages 801 Dr Edwards said retinal haemorrhages can occur from birth. The research shows that most of the intra-retinal haemorrhages resolve within two to three weeks. Large pre-retinal haemorrhages at the front of the retina just between the retina and the vitreous, can persist for longer. In JR's case, he had multiple extensive intra-retinal haemorrhages at the age of six weeks that would not be consistent with them coming from birth. Nor could they be consistent with the failed tracheal intubation or the process of CPR. 802 Dr Edwards explained that there is traction at the retinal vitreous interface that causes stretching and tearing of the blood vessels that leads to bleeding within the retina. There are alternative causes of retinal haemorrhages and therefore it is important to consider them in the context of the actual case. They very commonly coexist with subdural haemorrhages and brain injuries, and they are explained by the same mechanism of angular acceleration forces. 803 The retinal haemorrhages of the type that JR had were extensive, multilayered to the ora serrata and were not explained by CPR. 358 T 1272. 359 T 1272. 360 T 1258. -- 155 of 345 -- [2026] SADC 67 154 804 She said you cannot end up with retinal haemorrhages too numerous to count by a violent coughing fit. Dr Edwards said that she had not read any evidence to suggest that a viral infection is going to give the complex retinal haemorrhages that were seen in this case. Seizures cannot cause retinal haemorrhages. She said that retinal haemorrhages can come from birth which has been studied, and they resolve over the timeframes that she explained.361 805 Dr Edwards said that performing forensic medical assessments regarding children requires an understanding of the literature and experience in relation to that field. They have meetings with radiology and ophthalmology, who provide photographs of the retinal examination that they do. They describe what they see, and the forensic paediatricians interpret it in the context of the individual case. Lucid interval 806 Dr Edwards said that the concept of lucid interval is based on adults who suffer certain head injuries, particularly that cause a slow bleed, which can expand over time so initially a person can present quite well, but as that lesion expands and starts to compress the brain then they start to deteriorate. Dr Edwards said that does not happen with diffuse brain injuries which are associated with a change in consciousness at the time that they occur. It is also very hard to assess lucidity in infants. She said that they are looking at whether the baby was behaving the same as what they were prior, and so you ask specific questions around feeding, sleeping, and whether they rouse to stimuli that they normally would. Quite commonly in these circumstances questions are asked that will help inform an opinion about whether the baby had a normal conscious state or not.362 807 She explained that infants with head injury can present in different ways. They can present very differently and abruptly with cardiorespiratory arrest, or they can present with slower, or a delayed presentation with an accumulation of symptoms as the brain swelling and oedema develops, and they can present with no symptoms at all until they have a big head picked up on examination. There are, Dr Edwards said, different types of presentations, so each case is slightly different. Timing of JR’s head injury 808 In this case, Dr Edwards said that she considered the statements, the 000 call and also all the relevant information to conclude that JR had not been noted to have any problems with his tone, he had awoken at a normal time and then had suddenly been pale and stopped breathing and that sudden change in conscious level indicates that that is the timeframe within which the head injury was sustained. 361 T 1301. 362 T 1324. -- 156 of 345 -- [2026] SADC 67 155 809 She said that originally you would start with a broader timeframe and as further information is gathered, you formulate an opinion, to the degree that you can, about the timing of the head injury. 363 810 In her communications with police, she had said it was in the hours prior to the attendance of the paramedics, keeping a broad window, preferring not to form a definitive opinion until she had received all the information. She was she said basing her opinion on the accused’s police interview, the information he provided to the first responders and to the hospital personnel and then to Dr Noori, and in all of those pieces of information the baby had woken up, been unswaddled and placed on a change mat on the floor prior to going to the kitchen which was around the corner for one to two minutes to heat up a baby's bottle. The accused had come back, was unpopping the jumpsuit when he noticed that JR was not breathing properly and he progressively became pale and at which point he gave two breaths and then called the 000.364 811 Dr Edwards said that some factors that influence her opinion were that both parents were present up until 11.15 am that morning and neither described any incidents having occurred; that JR had then woken at his normal time for a feed and was grizzling; he was picked up; he was not noted to have any abnormal tone, and nothing was noted to be wrong with him and he was put on the ground and then upon the return, he was noted to be going into cardiorespiratory arrest. Dr Edwards said that she then narrowed her broader timeframe down to a more specific timeframe.365 812 Her timeframe is based on the other important factor that the initial CT scan did not have significant brain swelling or shift of the brain. She explained that the other way breathing can stop is if there is pressure on the brain, either from a large expanding collection of blood or because the brain is pushed down towards the spinal cord. If that had been the imaging finding, that would have significantly affected her opinion. Given that the brain on the initial scan, no significant abnormality was noted, supported the idea that a very recent event had occurred. 813 Dr Edwards was asked about her communication where it was recorded that she could not really say when the respiratory distress and cardiac arrest occurred post the infliction of any trauma to any greater than a couple of hours because there was no blood in the cervical fluid of the spine. Dr Edwards said that the relevant email was written by a police officer in relation to what she had said to him. She thought it was misinterpretation of what she had said because she did not understand what the officer was referring to from his statement.366 814 Dr Edwards said that originally when first considering this case she kept an open window in terms of timing. Then having reviewed all the information, formed 363 T 1323. 364 T 1303. 365 T 1303. 366 T 1323. -- 157 of 345 -- [2026] SADC 67 156 her final opinion that just prior to the significant change in JR’s conscious state and the onset of cardiorespiratory arrest, which was noted to be gasping respirations and becoming pale and floppy, was the timeframe that most likely the head injury was inflicted. Pneumonia 815 Dr Edwards said JR did not have pneumonia, and he did not have a clinical picture consistent with that. In an infant with pneumonia of such severity as to stop their breathing, the initial chest X-ray would have been abnormal. It is also very uncommon for a child to go into cardiac arrest from pneumonia having previously been reportedly well, suddenly to have a complete collapse and then be resuscitated for up to and over 20 minutes. That is not consistent with rhinovirus which is the common cold virus presentation.367 816 She said that there is no causative relationship established between rhinovirus and complete compromise of functioning such as sudden infant death syndrome. 817 Rhinovirus can cause significant infections, particularly in immunocompromised infants. Dr Edwards said that it is a very mild infection in most infants and could not cause the presentation seen here. Vitamin D 818 Dr Edwards said that JR did not have any findings of rickets on his skeleton and disagreed with Dr Gootnick’s opinion. 819 She said she relied on Assoc. Prof. Linke’s interpretation but also, has herself seen children with rickets in her clinical practice and is aware of the appearance. JR did not have any evidence of rickets. 820 Dr Edwards said that an isolated low vitamin D level is not associated with any rickets or propensity to fracturing and that is clearly stated in the South Australian guidelines. 821 The intrauterine bony development of infants is dependent on maternal calcium levels, it is not vitamin D dependent. Postnatally all bones are dependent on having adequate calcium, and vitamin D is part of the body's way of regulating the fact that there is enough calcium in our bloodstream. If there is not, then that is taken from bones. So, it has a relationship, but in this case, there was no evidence that JR had any increased breakdown of his bones. Growth arrest lines 822 Dr Edwards said that growth arrest lines are a non-specific finding, that is, not a finding of rickets. Rickets has a very specific appearance on radiology. She 367 T 1296. -- 158 of 345 -- [2026] SADC 67 157 said that growth arrest lines are seen in very many of radiological scans and reflect a child who has been resting, like in this case in intensive care.368 823 Dr Edwards said that the growth arrest line can be comfortably excluded from the analysis. 824 As to whether the growth arrest line, is potentially a manifestation of an under mineralisation or some form of metabolic bone disorder, Dr Edwards said:369 So if the vitamin D deficiency was affecting the bones, you would say arrays in other blood - on blood tests, that is alkaline phosphatase which goes up if bone's being broken down to increase calcium in the blood and parathyroid hormone similarly works to make sure, because we really need to have the right level of calcium in our blood at all times. So, if it’s dropping low then it has to be taken from bone which is where it’s stored. So you cannot have rickets with those results being normal. So, in this case, those results were normal, he had a slightly low vitamin D level. His bones appeared normal on radiology, so there's no propensity to him fracturing from lesser degrees of force. 825 As to whether the bones appearing normal, may be a manifestation of supplementation, exposure to sunlight, and vitamin D levels improving and a compromise consistent with rickets in the process of resolving, Dr Edwards did not agree because JR did not have supplementation. He was on formula which has a standard amount of vitamin D and he was only six weeks old. If he had severe infantile rickets and had not had supplementation, he would not have had rickets that was resolving. 826 When babies have rib fractures, occasionally they have such displaced fractures, but most will have undisplaced fractures like JR, and even on examination, you cannot elicit any symptoms. There is pain at the time and probably for a few days afterwards but in a baby who is just generally irritable, it is not possible for a doctor or a parent to be able to determine where the irritability is coming from. She said that most GPs would not palpate a baby’s chest, which is not a standard part of newborn examination. Even so, if you have got a baby who is crying because you have undressed them for an examination or to weigh them, it is not going to possible for a doctor to identify rib fractures in those circumstances. Rib fractures from CPR 827 Dr Edwards agreed that there is literature to suggest that you can get rib fractures from CPR in infants, but said that it is extremely rare. 828 The rib fractures had significant healing around them at the time of the first X-ray which was done very soon after JR was in hospital. Dr Edwards said that it was very clear that the majority of the rib fractures were already present prior to the resuscitation. 368 T 1307. 369 T 1319. -- 159 of 345 -- [2026] SADC 67 158 Modelling deformity 829 Dr Edwards said that ‘modelling deformity’370 can be the end stage of healing of acute rib fractures. It is just a very broad descriptive term but does not tell you what the cause of that was. 830 Dr Edwards disagreed that observations in the medical material that the ribs had an unusual appearance, meant they appeared to be unusual in terms of their development. No sign of injury 831 Dr Edwards said that very rarely bruising is seen over the rib cage in association with rib fractures. It is sometimes seen but because it is an indirect force, a squeezing and levering force, the pressure on the skin is dispersed over a larger area, so you can get significant levering of the ribs without causing any damage to the skin. She said that as JR was repeatedly presented with irritability, so it could well be that some of his irritability was related to his rib fractures. 832 There were various descriptions of JR’s irritability and changing formulas. Dr Edwards said that rib fractures are referred to as an occult injury. It is very common that in skeletal surveys for a child who presents with a bruise or a suspicious injury, that rib fractures are found for which no-one has any symptoms or any indication that they were present. In a baby, if there's no overlying skin injury, it would be very difficult for a GP to detect rib fractures in an infant. 833 Dr Edwards said that normal handling of infants does not lead to rib fractures. Here JR’s fractures had callous around the fracture sites. The bones themselves had normal density and mineralisation based on the expert radiology opinion. Subdural haemorrhage from CPR 834 Dr Edwards said that it is not possible that subdural haematomas may be because of the intervention of CPR. Children have cardiac arrest for various reasons. They do not have subdural haemorrhages because of either the cardiac arrest or the resuscitation. 835 Dr Edwards said that Dr Auer’s opinion there was a cessation of blood flow due to compromised respiratory function, and then a restoration of blood flow causing the subdural haematoma is not an opinion supported by any of the literature. She added that if that were the case, as the chair of the Mortality Committee, she would be seeing subdural haemorrhages in all those deaths related to sudden death or drowning and does not. She said that this theory has been very comprehensively ruled out as a theory that Dr Auer continues to promulgate.371 370 T 1305. 371 T 1297. -- 160 of 345 -- [2026] SADC 67 159 Dr Edwards’ re-examination 836 In re-examination, Dr Edwards said that after JR’s arrival at the WCH they noticed some movements that were indicative of seizure activity. She explained that with head injury you get the primary injury, which is the damage to the brain that happens straightaway. Then in response to that you get a lot of changes within the brain, which lead to secondary injury, which can include changes in the permeability of the cells, or an inflammatory reaction in the brain and which can, in itself, cause further damage. 837 The purpose of treatment is to minimise the secondary damage. You cannot change the primary damage. What is commonly seen is that a child or an infant becomes unconscious immediately and then there is a period of some improvement before there is deterioration again. This biphasic presentation is very common, so the fact that JR, after resuscitation, was improving, fits very much with impact brain apnoea such that the parts of his brain that control breathing were affected by concussion. After his breathing and circulation were restored his blood flow improved, he started to improve, but the secondary process in the brain were starting to develop and that would have then led to his seizure activity.372 838 As to Assoc. Prof. Taranath’s evidence that the MRI results showed a low level of overall swelling of the brain, and how that fit with the hypothesis of a lucid interval, Dr Edwards said that the lucid interval is very hard to categorise in infants, but JR did not have a lucid interval. He never returned to a full GCS of 15 out of 15. It was about 6 out of 15, so he still had impaired consciousness, which is not a lucid interval. 839 Over the subsequent night, as his seizures became harder to control, he ended up being intubated and ventilated for approximately 24 hours in the intensive care unit. That all occurred before the MRI scan, which showed areas of the brain which were bruised or contused from primary injury, but also showed areas of the brain which looked to not having an adequate blood supply or oxygenation, so that was called the hypoxic ischaemic injury identified in multiple areas on the MRI scan. Dr Edwards said that type of presentation is not consistent with a lucid interval.373 840 The primary injury would have occurred minutes before the paramedics arrived rather than hours. In addition to the symptomatology the initial scan showed no large bleed that was compressing the brain, nor did it show swelling of the brain that was compressing the brain stem which controls respiration. Dr Edwards said that the symptoms, the sudden onset, the radiology and the clinical progression all fit together. 841 Dr Edwards said that if JR’s cold or another virus was so severe as to impact on breathing, you would anticipate findings on the radiology. 372 T 1327. 373 T 1322. -- 161 of 345 -- [2026] SADC 67 160 842 If children are stopping breathing because their lungs are full of fluid and it is not allowing oxygen exchange and they have stopped breathing which has led to a secondary cardiac arrest, resuscitating the heart is not going to allow them to breathe normally because they still have lungs full of infection. The oxygen level would be very low. They would need to be on a ventilator to try to aerate the lungs and they would need to have a high dosage of venous antibiotics. The fact that JR was able to start breathing on his own and then from that point on could exchange oxygen normally and had a normal oximetry level, points to the lack of any findings on the X-ray and having no problems with his lungs. 843 Dr Edwards said that she has a standard approach in meetings such as the one on 30 January 2020, which is that she explains what her role is, that they work with police and the DCP and that any information that is provided to her will be shared with police and the DCP. Summary of Dr Edwards’ evidence 844 In summary Dr Edwards’ opinion was that: • The collective injuries to JR's head were the result of a recent high force inflicted head injury on the morning of 5 January 2020 which involved head impact with rotational acceleration-deceleration forces. • JR’s subdural haematomas were bilateral and over the surface of the brain which is not explained by a linear acceleration force. Some rotational element was needed. • The inflicted head injury most likely occurred just prior to the onset of the observed breathing difficulties and loss of body tone. • The precise timing of the incident relied heavily on the accuracy of the reported onset of symptoms. • The possibility of two separate head impacts and another separate incident of head rotation could not be excluded. • If not for the prompt resuscitative efforts, it is very likely that JR would have died because of his head injury, and he may suffer long-term cognitive impacts as a result. • Breathing is controlled by the brain, and an injury to the brain can result in an impact to breathing even when the lungs are healthy. • Altered breathing pattern or stopping breathing from a head injury is extremely common. • It is not correct to say that the brain can respond to a head injury by preserving breathing. -- 162 of 345 -- [2026] SADC 67 161 • Comparing professional athletes to a six-week-old infant has limited relevance. • Post-traumatic seizure is an extremely well recognised phenomenon and in infancy, seizures following head injury is a very common presentation. • That there is a skull fracture and scalp swelling is clear evidence that JR sustained head impact. • Hypoxic ischaemic damage is seen as diffuse throughout the whole brain. There was not diffuse ischaemic injury throughout JR’s brain, rather it was limited to certain areas described on the MRI. • JR’s brain looked good on the CT scan. The follow-up MRI showed residual changes and the contusional injury was described as associated with some loss of brain tissue. • There was not widespread loss of brain tissue, which would be expected if there had been global hypoxic ischaemic change. • On the initial scan no significant abnormality to the brain was noted, supporting a very recent event having occurred. • There is no evidence base to support the assertion that a skull fracture can occur spontaneously even in a child with rickets. • JR did not have rickets, so whether the mother had a low vitamin D in pregnancy or not is irrelevant. • JR did not receive vitamin D supplementation other than through the standard amount contained in formula. • JR sustained inflicted skeletal injuries which included rib fractures and a right tibial fracture over the days to weeks prior to the head injury and the prior skeletal injuries are considered to have occurred on at least two separate occasions. • There was no evidence of pneumonia in JR’s case. • While viruses can infect the brain, meninges and lungs, they do not result in subdural or retinal haemorrhages. • She deferred to the opinion of Assoc. Prof. Linke with respect to a diagnosis of craniotabes. adding that there is no evidence of clinically significant vitamin D deficiency. • Low vitamin D does not make a child prone to fracture from lower degrees of force. -- 163 of 345 -- [2026] SADC 67 162 • There is no evidence whatsoever of the involvement of Ehlers-Danlos syndrome in respect of JR. • Dr Edwards said that quite commonly rib fractures are found with no overlying signs of injury. • Infants do not get fractures from normal growth. • JR had a normal white cell count, a normal CRP level and apart from having a cold virus, he did not have any other infection that would explain his sudden respiratory arrest. JR’s lungs were not affected by significant disease. • There is no evidence on the scans to suggest that JR had a stroke. • The scans taken at the WCH showed that JR had a recent subdural haematoma which does not result from from hypoxic ischaemic damage. • JR had scalp swelling, a large skull fracture on the right and a smaller one on the left, which clearly indicated that JR’s head suffered an impact. • There is no association between epilepsy and subdural haemorrhages in the literature. • Retinal haemorrhages do have several different causes, and no one would divine child abuse from retinal haemorrhages alone. • The retinal haemorrhages were not explained by the paramedics’ interventions. • JR did not have a lucid interval. • Complex retinal haemorrhages like those seen in JR are highly associated with rotational acceleration head injuries. • Experienced paediatric radiologists identified the findings to have had a traumatic cause and would have readily identified an infection cause, nor did JR progress to develop encephalitis or meningitis. • A 6-week-old infant cannot generate sufficient forces to move on their own, and any injury must have involved an externally applied force because they do not have the ability to generate that to themselves. It is a logical conclusion, which is deductive not circular reasoning. • Research has been undertaken jointly by paediatricians and biomechanical engineers because it is recognised that there is value in incorporating real- like examples and an understanding of the specific anatomy of infants into any research regarding infants. -- 164 of 345 -- [2026] SADC 67 163 • The term 'inflicted head injury'374 does not mean intent, rather it means the involvement of another person, and there can be circumstances where inflicted injuries happen through mechanisms that you would not consider in any way intentional. • JR’s presentation had not been referred to as SBS as there was evidence of head impact. • It cannot be said what exact unit of force was involved and even if the unit of force was known, it cannot be said whether that would have caused an injury to an infant or not because there are no thresholds. There are many differences that cannot be considered and therefore, biomechanical literature cannot be used in an individual case. • It is established and well accepted by paediatricians across the world that rotational movement of the head around the neck without impact can cause the findings of cerebral concussion, haemorrhages and retinal haemorrhages and that has been found in accidental and inflicted scenarios and with animal experimentation. The defence case The accused’s evidence 845 The accused gave evidence as to his educational history and his work in the family business. He had no history of drug use and was financially stable. TR’s antenatal history and JR’s birth 846 In his evidence, the accused called TR’s pregnancy with JR ‘complicated’375 and ‘another intense pregnancy’.376 He said that there were a lot of scans and medical intervention. 847 JR was born two weeks premature. Labour was induced and JR’s heartbeat was irregular. The accused said that the placenta was starting to detach and everything got ‘very hands-on’377 quickly. There was a conversation between the doctors and the midwives whether to go down a C-section route or to use the ventouse. The ventouse was the method chosen. 848 While the accused said that he had told police the birth was straightforward and quick, having to go back through it all now, he said he would not call it straightforward. 374 T 1062. 375 T 1356. 376 T 1356. 377 T 1357. -- 165 of 345 -- [2026] SADC 67 164 JR’s neonatal progress 849 The accused said JR had a lot of colic and would throw up quite a bit and his formula was constantly changing to find the right kind. 850 He said that before discharge from hospital JR was put on a vitamin D supplement to add to his formula. There were issues in relation to reflux and JR’s inability to keep formula down.378 851 With the assistance of phone messages between himself and TR, the accused recalled that around the Christmas time there was a cold going through the house. BR, TR and JR were sick.379 852 The accused recalled that prior to the six-week check up with Dr Murphy, JR had a jittery leg, where he would push his leg out and then instead of just smoothly retracting it, it would jitter in motion. There was no associated pain or tenderness on handling JR or his leg.380 He saw no external evidence of any bruising or application of force to JR’s chest or abdomen. In cross-examination, the accused agreed that TR had made an appointment for JR to see the GP about a problem with his leg and the issue was raised at the six-week appointment. He remembered Dr Murphy said it was an irregular neurological issue and it should fix itself in time. He agreed that JR’s leg moved in a jerky way for a while but then it passed. Sofa incident 853 The accused said on 30 December 2019 TR was at a doctor’s appointment. He was getting ready to feed JR, sat down with him and put his bottle in the sofa cup holder. The television remote was to his left. 854 The accused described the couch as a two-seater with a console in the middle which can be opened for storage. At the front there are cup holders. There is padding up the side, but where the top of the cup holder meets the side of the console, there is no padding. It is simply fabric, with wood underneath. He was sitting with JR, and he put his hand under JR's back and supported his neck with his right hand. As he rolled and reached for the television remote on the left of the couch, JR pushed off the accused’s legs and drove his head into the sharp corner of the centre console on the back right-hand side of his head. The accused said that it was ‘quite a thud’ and that JR was ‘quite upset’. The accused settled JR and noticed a lump forming on his head. He gave JR some Panadol, applied ice, and then fed him.381 855 When TR returned home, the accused told her what had happened, and they put JR into the car and TR went to the GP surgery where she saw Dr Gillis. 378 T 1359. 379 T 1360. 380 T 1360. 381 T 1361-1362. -- 166 of 345 -- [2026] SADC 67 165 856 The accused described the swelling as being on the back right-hand side of the head which extended to run down the side of the skull. Events on 5 January 2020 857 The accused said that he was at home with JR, BR and their two Maltese Shih Tzu dogs which each weighed approximately seven-and-a-half to eight kilograms. The accused described the dogs as very active, and they would get excited and bark and run around inside the house. 858 BR was in bed asleep and JR was in the bassinet. The accused was lying on the couch watching YouTube. It was coming up to a feed and JR started fussing. The accused said that he may have gotten up and put JR’s dummy back in once or twice. Eventually the accused thought it was about time to feed JR and he got him out of the bassinet and put him on a change pad on the floor. He said that JR was happy laying on the floor. BR and the two dogs had access to the area. He described his emotional condition at the time as ‘calm’. 859 The accused went to the kitchen to make JR’s bottle which he said takes one to two minutes. When he returned, he sat down in front of JR, his legs pointing towards him and noticed that JR was gasping for air and looked like he was not breathing. The accused said that he had done some first aid training. He picked JR up. JR was quite limp and was not breathing. He could not tell whether JR had a heartbeat or not. JR’s lips were starting to turn blue. He rang 000 and gave JR mouth-to-mouth twice but was not sure if he was doing it correctly. 860 The accused said that he panicked and was in shock. He was scared for JR. 861 He performed CPR according to the operator’s advice, using two fingers on top of each other on the breastbone giving compressions, and mouth to mouth as directed. 862 He said he was in a state of confusion with absolutely no idea how it was that JR was not breathing. 863 When the ambulance officers arrived, they took over and he went into the kitchen to call TR to tell her to come home, then returned to the lounge room. He did not recall the specific procedures performed by the paramedics. 864 TR came home within three minutes of his phone call. She still had foils in her hair, and she was visibly shaken and upset. TR’s parents arrived. 865 The accused described TR as someone who would always second guess everything that she did. He reassured her all the time. He described himself as a calm person who had never had issues with anger management and said he had been honest with police. 866 The accused said he had not hurt his son and would never do so. -- 167 of 345 -- [2026] SADC 67 166 The accused’s cross-examination 867 The accused said that it was the usual routine for BR to have her morning nap around 11.00 am and he believed he and TR had put BR to bed that morning. He had no recollection of hearing BR coming down the hallway on 5 January 2020 or being aware that she was awake during the time that he was on the phone to the ambulance. He agreed that she was not in the room with him. 868 From where he was laying on the sofa, he heard JR fuss a little bit. He said that JR was probably not as loud as what he normally was, but he did not think much of it and just placed his dummy back in his mouth. He agreed that there was nothing unusual in JR’s demeanour when he gave him his dummy.382 869 He said that when TR had put JR down that morning, he was not floppy and there was nothing unusual about his presentation. He said that from where he was laying on the couch, he could hear JR and see the bassinet. It was between one and two minutes to get the bottle and it was when he went back to JR that he found him gasping for air. 870 The accused said that when he took JR out of the bassinet, he placed him in between the coffee table and the bassinet on the floor on the change mat. The accused said that he did not put the dogs outside when BR was sleeping, because they went in and out by themselves. When asked if he would put JR on the floor, even if the dogs were running around, he said:383 Well, generally we'd put him on the floor, the dogs weren't running around but that's - yeah, we'd put [JR] on the floor. But if the dogs were going crazy around our feet, I wouldn't just put him on the floor. That would be a no brainer. 871 He could not recall where the dogs were in the house when he put JR on the floor but agreed that had they been excitable at the time, he would not have put JR down there. 872 The accused agreed that when the ambulance arrived it was all a bit of a blur and the rest of the day at the WCH was overwhelming. 873 The accused said that on the evening before 5 January 2020, JR was probably more unsettled. He was fussing. His feeds were roughly between 1.00 am and 2.00 am and 4.00 am and 5.00 am. 874 BR was generally awake anywhere from 6.00 am to 7.00 am, sometimes earlier, sometimes later. They would hear her get up and they would get up with her. On a weekend only one of them would get up to her. 875 On 5 January 2020 he had been up early with BR, and she had been put back to bed before TR left. JR had been put to sleep in the bassinet in the lounge room 382 T 1393. 383 T 1406. -- 168 of 345 -- [2026] SADC 67 167 before TR left. From his recollection, it was at least 30 minutes prior to JR waking. He was hoping that JR would re-settle himself, but he kept fussing some more. 876 The accused denied he was at the end of his tether and had taken JR out and placed him either hard into the bouncer, banging his head on the floor, or onto the floor recklessly. He said he did not hurt his son and would never do so.384 877 In re-examination he said that TR had left the house ‘happy’ and ‘normal’ and she was not upset.385 Dr Gootnick’s evidence Qualifications and experience 878 Dr Gootnick gave evidence via AVL from San Francisco with the assistance of a PowerPoint presentation she had prepared.386 879 She said that she had been reading X-rays for about 50 years. Since her medical residency she has trained in most forms of imaging and completed four weeks with Dr Hooshang Taybi at Oakland's Children's Hospital where there was intensive instruction in paediatric radiology. Every day she reads paediatric films of ‘all sorts’.387 880 She is not certified in paediatric radiology as at the time she was a resident it was not available. She commenced as a radiologist in 1976, and thereafter graduated to positions of Chief of Radiology, both in the public health service in San Francisco, California and then at Ross Valley Medical Group. She then worked as a radiologist and practice owner before working as a general diagnostic radiologist. She held the position of Assistant Clinical Professor of Radiology in women's imaging at the University of California and San Francisco. Thereafter she worked as a radiologist and mammographer. 881 She was the Medical Director of Women's Imaging at the Adventist Medical Centre in California and worked in as a general diagnostic radiologist thereafter. Chest X-ray of 5 January 2020 882 Dr Gootnick’s PowerPoint presentation incorporated X-rays taken of JR at the WCH.388 883 With respect to JR’s chest X-ray taken on 5 January 2020, (see below image) Dr Gootnick noted that the red arrow indicated the endotracheal tube which had been placed into the trachea a little too far, so it blocked the left mainstem bronchus. 384 T 1434. 385 T 1442. 386 Exhibit P98. 387 T 1680. 388 Exhibit D98. -- 169 of 345 -- [2026] SADC 67 168 884 When asked whether interstitial pneumonia was apparent on the X-ray, Dr Gootnick said that she could not see the left lung so could not speak to that. In terms of the right lung, she did not see anything, but added that in somebody who is older who shows up in the hospital, once they get hydrated, suddenly you can see a pneumonia, that may not be seen on the initial entry X-ray. There may, she said, have been something in the right lung, but she did not see it. A few days later it might have been seen.389 Chest X-ray 5 January 2020 885 Dr Gootnick said that JR's vitamin D levels were tested on 6 January 2020390 and provided a result of 33 nmol/L with the normal range being 60 to 160. She explained that the body needs vitamin D to absorb calcium from the gut and calcium is very important for bone strength. The precursor of bone is cartilage, and calcium is placed in the bone by the effect of vitamin D. If there is not enough vitamin D, the cartilage is not calcified enough and so it is more susceptible to breaking under forces that would not break normal bones. In other words, the bone density is much lower because there is not enough calcium and that, Dr Gootnick said, can be seen on the X-ray.391 389 T 1683. 390 Exhibit D30. 391 T 1685. -- 170 of 345 -- [2026] SADC 67 169 Widened Occipital Suture 886 Dr Gootnick said that this image shows a lateral view of JR’s skull. She explained that the multiple bones that make up the skull fuse over time, but in the beginning, they have sutures, which allow growth of the skull. She said that the yellow arrow on the image marks a widened lambdoid suture. In a normal child, the suture would be present but would be much thinner. Cartilage is not well seen on X-ray, but calcified cartilage, that is bone, is well seen. The X-ray showed poor calcification of the growing cartilage of the suture, susceptible to fracture. Here, Dr Gootnick said, there is no fracture, just widening of the suture. 887 She said that rickets is curable, in that with vitamin D supplementation, it goes away. The supplementation provided to the child, would assist in resolving the vitamin D deficiency post birth depending on the amount of vitamin D that is given. The development of the bony structure of the skull is compromised because of a deficiency in vitamin D, which manifests itself in the balance of the skeleton.392 888 With reference to image 9 shown below, Dr Gootnick said this showed JR’s abnormal calcification in the growing end of the rib in contrast to an image showing normal calcification. She said that if it is poorly calcified, it shows on X- ray as a grey line, not a striking white line. Dr Gootnick said the blue arrow in the image points to a light-grey line and the red arrow is a white line and is indicative that JR is low in vitamin D and therefore, low in calcium.393 889 As to image 10, she said this shows a normal neonate where a homogenous whiteness to the upper part of the humerus is seen (red arrow). There is a blue arrow in the mid-portion, which is indicative of a periosteum, which is a membrane surrounding all bones, which blows the long bones wider as they grow longer. Dr Gootnick said you can get a zebra like effect beneath the periosteum where there is a light-grey line followed a by a whiter line, and this can be seen is normal neonates but is also seen in rickets. You can, Dr Gootnick said, see the difference 392 T 1686. 393 T 1687. -- 171 of 345 -- [2026] SADC 67 170 between the abnormal growth plate in JR and the normal growth plate in the stock image.394 Image 9 Image 10 394 T 1687. -- 172 of 345 -- [2026] SADC 67 171 Growth arrest lines Image 12 890 Dr Gootnick said that growth arrest lines occur when there are alternating levels of nutrients and look like a kind of a zebra line as in image 12. 891 She said that the red arrows are marking white lines, perpendicular to the long axis of the bone. The blue arrow marks a grey line, and this is indicative of a time when there was inadequate nutrients to normally calcify the growing cartilage. Growth arrest lines can be seen in chronic illness, which JR does not have, and rickets, which he does have.395 892 Dr Gootnick said that the growth arrest line supports her findings relevant to the analysis of the skull and the evidence of craniotabes. 893 Dr Gootnick said that this was another example that there is metabolic bone disease, which is the inability of the bones to normally calcify. The grey line marks continuing growing cartilage. That is, even though there is not adequate calcium or vitamin D, the cartilage continues to grow and the difference in the colour of the lines indicate that there was a time when there were inadequate amounts of nutrients to normally calcify the cartilage. The end of the bone is where the bone grows, so that is where cartilage is produced and calcium is laid down. 395 T 1688. -- 173 of 345 -- [2026] SADC 67 172 Ribs 894 With reference to the above image of JR’s anterior ribs taken on 10 January 2020, Dr Gootnick said that the red line marks the very faint white-purple linear line, and the blue line marks a sort of rounded blob that is vaginating into that white line. She said this shows rickets, and in third world countries where children are very thin this is called a rachitic rosary, because these grey blobs can be seen or felt through the skin. It is a well-known finding in rickets.396 Image 3 – chest X-ray taken on 10 January 2020 895 With reference to this image, Dr Gootnick said the red arrow on the right- hand side of the image shows a partially calcified blob. This is a healing fracture on the anterior or posterior lateral aspect of the rib. 896 She said that shaking a child would occur by putting hands under the arms and around the chest with the child facing you. Your four fingers are going to be in the back of the chest, and the thumb is going to be in the front, so the fractures in abuse caused by shaking occur in the back. 396 T 1689. -- 174 of 345 -- [2026] SADC 67 173 897 Dr Gootnick said that none of these fractures, are in the back. They are laterally and to a lesser extent anteriorly. She said that these fractures, from whatever cause, were not caused by shaking the child. In addition, if you grab the child with both hands, you expect to have fractures on both sides which is not the case here. Looser zone fractures 898 Dr Gootnick said that looser zone fractures are fractures that occur in rickets, with minimal pressure to the bone, but it does not go all the way across the bone. She said that rickets and osteomalacia are basically the same disease in completely different age groups. Osteomalacia is common in elderly people and rickets in younger people. It is a particular kind of fracture that occurs in those two entities. If you have a looser fracture, you do not have normal mineralisation of your bones. They are consistent with poorly ossified bones and the locations of these fractures are not typically seen in abuse. Modelling deformities 899 Dr Gootnick said that she was not familiar with the term modelling deformity but said that on the right side of the chest (left side on Image 3), the ribs indicated by the four arrows are bulging which is just a callous. 900 She said that when you break a bone you form a haematoma under the periosteal reaction, which grows the bones wider as they grow longer. You form a haematoma and that haematoma in the presence of adequate calcium and vitamin D then begins to calcify. That is, she explained, where we get the bulge in these fracture areas. Dr Gootnick said she presumed that was what is meant by modelling and by the time this child gets to be one year old these will be gone. Image 4 901 Dr Gootnick said that in the ends of the rib bones there was evidence of uncalcified cartilage. Image 4 was a blow up she made of the image seen in image 3. She said that the blue arrows on both sides, are uncalcified cartilage and the red -- 175 of 345 -- [2026] SADC 67 174 arrow marks a very thin curvature at the growing ends of the bones which is indicative of the last time that there was adequate nutrients to calcify the bones.397 902 Going back to image 3, Dr Gootnick said this shows the healing of fractures. Healing of fractures is delayed because we need calcium and vitamin D to heal fractures. If there is an inadequate amount, fracture healing takes much longer. Fracture healing in a normal individual is usually six to seven weeks. In a child who is deficient in vitamin D and calcium it can take much longer, which has an impact on any opining as to the age of a fracture. It compromises the process. 903 Dr Gootnick was asked how, given there was no observation of pain or of external injury that fit with her evidence in relation to rickets, the presentation of these fractures, and their resolution, Dr Gootnick said that ‘this may have occurred at birth because we can’t date the fractures’.398 904 As to Assoc. Prof. Linke’s opinion that flaring would occur at the end of the bones if rickets were evidenced, Dr Gootnick said:399 Well, I appreciate him saying that because we see that in the ribs, go back to image 4. You see how this is flared, this white line is kind of curved. This is called splaying or flaring. So that's what we see here. It was nice of him to back me in. 905 Dr Gootnick said because JR was being treated at the time, the flaring you would normally see in a severe case of rickets, is not available because the child is being treated. 906 As to testing suggesting that calcium levels are normal and whether the vitamin D deficiency still carries significance viewed in isolation, Dr Gootnick said ‘For sure, yes. Because you need the vitamin D to get the calcium into the cartilage’. 397 T 1693. 398 T 1694. 399 T 1694. -- 176 of 345 -- [2026] SADC 67 175 Accessory sutures 907 Dr Gootnick used these images of four lateral views of the skull to indicate the line that goes right through the middle of the parietal bone in both directions, called the intraparietal suture which is a normal finding and occurring frequently. They are, she said, not fractures.400 908 Dr Gootnick said the accessory sutures have no relationship at all to craniotabes other than they may be wider than normal because, once again, the cartilage is not being calcified. 909 As to whether there being no sign of comminution, displacement or depression, supports or contradicts her findings relevant to craniotabes or accessory sutures, Dr Gootnick said:401 …you would like to see some soft tissue swelling if there was trauma. Comminution you can see if there is trauma. I think in my report I said that the widening of the sutures indicates that there is fluid within the subdural space. I use a dictation system, a voice dictation system and I believe what happened was it left out a word. What I believe it should have said was 'It is also possible to be indicative of fluid in the subdural space', not that it was present in this case, but just as an example of something else that could happen. 910 Dr Gootnick confirmed that the evidence was that the presentation of the skull is consistent with the absence of a fracture. Sofa incident 911 Dr Gootnick said that the head knock JR sustained on the sofa could not have contributed to his presentation as there is no fracture.402 912 She said that she saw no evidence of fractures within JR’s skull that are perhaps a product of trauma as opposed to craniotabes. 400 T 1696. Exhibit D98, page 9. 401 T 1701. 402 T 1697. -- 177 of 345 -- [2026] SADC 67 176 Image 7 913 By reference to this lateral image of JR’s skull, Dr Gootnick said craniotabes was evident in that it showed that his skull was not being calcified normally so it does not show up well on X-ray. Rather, it shows up as light grey, like everything else that is cartilage. Image 6 914 With respect to image 6, Dr Gootnick said that the sutures in JR’s skull were wider than they should be. Once again, the growing ends of the bones are not being adequately calcified. 915 Dr Gootnick said that she thought a thin squiggly line on both sides were accessory sutures because accessory sutures narrow as they approach a regular suture. A regular suture is the dark area that is being measured on both sides – the lambdoid suture. The wiggly lines are indicative of these being accessory sutures because the fracture would continue to be wide all the way to the normal sutures.403 916 Dr Gootnick said that the narrowing of the accessory suture assists in drawing her conclusion. 403 T 1698. -- 178 of 345 -- [2026] SADC 67 177 Image 5 917 When asked whether with respect to image 5, which Dr Gootnick had described as showing a widened occipital suture, fits in her evidence on this topic, Dr Gootnick said:404 Well, the sutures that I'm talking about, we can’t see it here but the sutures that I'm talking about, the lambdoid sutures in the back, and because this is a different projection, in other words, well, we can see this accessory suture line up above, but we can’t see it as it approaches the normal suture very well. 918 As to any suggestion that the angle upon which the image is taken gives rise to disparity or potential confusion as regards widening and the content and shape of accessory sutures, Dr Gootnick said:405 Okay. So you can see this line that's traversing the parietal bone, which is the big bone in the middle here, and if you follow that line out all the way to the back of the head, you'll see it is beginning to narrow. So that fits well with what we saw in image 6 where we see this - these accessory sutures narrowing as they approach a normal suture. 919 Dr Gootnick said that she was comfortable in the conclusions that she drew as regards the presence of accessory sutures based on the images provided to her. 404 T 1698. 405 T 1699. -- 179 of 345 -- [2026] SADC 67 178 Images page 13 showing JR’s spine Image page 13, stock image 920 With respect to the image of JR’s lateral spine and the other a stock image of a neonatal spine, Dr Gootnick said that the significance of the comparison between the two was that in the stock neonatal spine, the red arrow is marking normally calcified bone surrounding a grey/light-grey line which is horizontal to the long axis of the vertebral body. The grey line is a normal nutrient foramen found in all children. Dr Gootnick said that while it is present on the lateral spine image of JR, we do not see it because there is not enough contrast between the uncalcified cartilage and the vessel and is another indication of poor calcification of the growing cartilage. She said that properly calcified bone carries a greater density of white colour.406 406 T 1700. -- 180 of 345 -- [2026] SADC 67 179 Image 11 - JR’s proximal hips 921 With respect to this image below, showing JR’s proximal hips, taken on 10 January 2020, Dr Gootnick said that once again there is a thin grey line marked by the blue arrows on both sides. She said that this is a systemic process, and while not to the same degree, it involves all the bone. The red arrows mark lighter lines which demonstrate that there is an attempt to calcify the growing cartilage which suffers compromise and is not adequate. 922 Dr Gootnick maintained that compromise due to vitamin deficiency does not affect all of the skeletal structure equally.407 Dr Gootnick’s cross-examination 923 In cross-examination, Dr Gootnick said that she is a diagnostic radiologist, holding board certification from the American Board of Radiology. Whilst she holds the qualification and the certification of being a radiologist, she does not have to participate in the continuing certification process. She did not agree that paediatric radiology is a separate subspecialty. 924 She said that there is only 3% of the population of radiologists in the United States who are certified as paediatric radiologists, but that everybody must read paediatric X-rays. She agreed that to be a paediatric radiologist, board certified, you would need to additional study but did not know the exact amount of time involved. 925 Dr Gootnick said she thought she read images for maybe ten babies each week. She said she saw the same number of images of babies who were under the age of six months, with the most common problem being in newborn babies with lung problems. She has credentials with several hospitals in the United States which send her images to read which she reports on and sends back to the hospitals. 926 Dr Gootnick said that she had not kept her CV up to date. She had been doing teleradiography, for maybe ten years. The clinicians order the films, and she sends 407 T 1701. -- 181 of 345 -- [2026] SADC 67 180 a report to the clinician who ordered the films based on the X-ray. She does not see patients. The bulk of her work is regular diagnostic radiology. 927 When asked whether it was fair to say that she was not working within a paediatric hospital or institution, she said they send her films and she does not know where they come from. She said that she specialises in X-rays, CT scans, MRIs, and ultrasounds. 928 The first report she had provided was dated 1 November 2024. Wormian bones 929 Dr Gootnick said she made no findings of Wormian bones.408 Rickets 930 Dr Gootnick said that does not affect all the bones equally, but it affects all the bones. It was not true to say that a child with a metabolic bone disease such as rickets, all the bones will be affected in a similar way. There are some bones that are growing faster than other bones and, therefore, they get more affected. 931 She agreed that it would not just be one rib that is affected, and the other ribs not affected, they would all be affected. But, she added, ‘that doesn't mean that the ribs will be affected to the same extent as the femurs’.409 Rachitic rosary 932 Dr Gootnick agreed that one of the examples that we can look to in terms of the diagnosis of rickets is a rachitic rosary, that is, the round blobs at the anterior end of the ribs that joins with the cartilage and becomes quite round and bulbous. As to the prosecutor’s suggestion that in respect of JR, there was no rachitic rosary, Dr Gootnick said that rachitic rosary is a clinical finding. In other words, if you present a child to an emergency room and they find these bumps on the chest, that's Rachitic rosary. 933 She said that it would be seen in all the ends of the ribs and was seen in all of JR’s ribs. 408 T 1705. 409 T 1706. -- 182 of 345 -- [2026] SADC 67 181 934 Dr Gootnick described the below image as figure 3 (which was ultimately said not to have been before the court or available to either prosecution or defence),410 she said this showed the abnormality on both sides of the ribs involving all the ribs. 935 Dr Gootnick said that she did not believe she had the opportunity to review Assoc. Prof. Linke's PowerPoint presentation. She did not believe she was aware of the CT scan performed on 10 January 2020. She did not recall whether she had been provided with Assoc. Prof. Linke's evidence before the court, but said it was possible. 936 It was suggested to Dr Gootnick that by reference to the CT scan, there is evidence of two broken ribs that are healing but not of an abnormality present at the ends of all the ribs. 937 Dr Gootnick gave the following evidence:411 A. Well, what can I tell you? It is present on the plain film. Now, I have no idea why he doesn't see that on the CT scan but I can tell you it is present on this. No problem. Q. And I suggest that if you take a view - have you been provided with the raw data, the X-rays themselves, the CTs themselves. A. I don't know if I've seen the CT scans but I know I have seen the plain films. Q. Okay. Because I suggest that if you put the two of those together, you will see - and, indeed, we see on the chest X-ray - you have seen the chest X-ray with the resuscitation paddle on it, haven't you. A. I don't know. I did not put it in my thing because it does obscure the data. I didn’t put it in my PowerPoint because it obscures the data with the paddles on it. Q. But it does show the ends of the ribs. 410 Copy of the relevant image forms part of Exhibit D 197 – Agreed Position as to figures referred to by Dr Gootnick in her evidence. 411 T 1708-1709. -- 183 of 345 -- [2026] SADC 67 182 A. I don't know. I did not put it in my PowerPoint presentation. But we see the ends of the ribs quite nicely. Q. Not all of it. A. But I did not include all of them. Q. No, you did not. A. Hang on one second, one second. Can you explain to me why you think that - because of the ribs - let's see, the ribs that we see on the 'Anterior ribs, 1/10/20' we see a bunch of these globs and the red arrows and stuff that it wouldn't include the rest of the ribs as well. How is that possible? Q. Because you have only selectively chosen a number of ribs in your diagram and not the whole of the rib cage. A. Okay, so listen to this. If this is the way the growing ends of the ribs look, why would this occur just in the lower ribs and not the rest of the ribs? Do you have any idea about that? Q. Fracture. A. In other words - no. It is not a fracture. These aren't fractures. Q. What fractures were there that you are aware of. A. Okay, hang on a second. Let me go back to image 3. One second. I'm having trouble with this PowerPoint here. Okay, one second. I have got to get rid of some of this stuff. Okay, I'm going to have to - one second, I have got to get rid of this real quick and then get back to it, okay, because it is not behaving properly. Okay. Okay. So there are fractures on the right of the one, two, three, four, five, six, seven, eight, nine and 10, and on the left there is a fracture at one, two, three, four, five, six, seventh ribs. 938 Dr Gootnick said that she had not been made aware of the MRIs in this case as she had been told not to evaluate the brain as someone else was going to do that. She did not look at the MRIs to see whether there was swelling or bleeding in the same areas as the alleged fractures. She had been asked to look at the plain X-rays as to whether there were fractures but not asked to comment on the CT scans or the MRIs. 939 With respect to whether any evidence of bleeding in the region of what is alleged to be a skull fracture, would cause her to change her opinion, Dr Gootnick said:412 A. Okay. I don't know - well, what do you base that on? In other words, I am taking your word for something that I can’t attest to because I don't see the film, so I don't think I'm going to do that. 412 T 1715. -- 184 of 345 -- [2026] SADC 67 183 940 Dr Gootnick was asked to assume there was subdural haematoma in the area of what could be a fracture and asked whether the fact of a subdural haematoma would assist in the diagnosis. She said that this was not necessarily the case because if the child's head was struck, it would not necessarily have to make a fracture but may have caused some rupture of some vessels in the subdural space. She added that it does not necessarily support the fact, especially since there is no evidence of soft tissue swelling over the region of the supposed fractures and that was where she would like to see some soft tissue swelling. If there were soft tissue swelling as well, that might, she said, impact on her view but she could not say because she had not seen the films. 941 Dr Gootnick was taken to her report under the heading 'Findings', where she had noted that 'In the hospital, [JR] had a skeletal survey, CT scan of the head and MRI of the head as well as CT scan of the chest, abdomen and pelvis, an MRI of the head was also obtained. Bilateral parietal skull fractures were diagnosed.’ 413 942 She had written there is also a description in the emergency department of ‘boggy414 swelling over the right parietal bone. Swelling was not confirmed by X- ray.’415 Dr Gootnick said that she was not aware that it was confirmed by CT scan because she did not look at the CT of the skull. 943 She went on in her report to say that the fig.2416 in her report 'Is a lateral X- ray of the skull [JR], conducted on 10 January'.417 The relevant X-ray was ultimately identified as showing a skull with one red arrow. When it was suggested to her that she had referred to the red arrow marking ‘one of the parietal skull fractures’418 she said that she believed she had said ‘marks what is called a skull fracture in the parietal bone.’419 She said that she did not say it was a fracture but rather that ‘it was called that’.420 944 Again, there was some confusion as to the report both counsel and Dr Gootnick were working from. She was referred to paragraph 15 of her report but said that her report had not been numbered. 945 Plainly both counsel and Dr Gootnick were dealing with different documents as Dr Gootnick said that she never numbered her paragraphs ‘ever’.421 It was later clarified that defence counsel had the same document without paragraph numbers. A medico legal consultant appeared to have added the numbers. 413 T 1716. 414 The report had read ‘barking swelling’ which was a typograpgical error. 415 T 1716. 416 There was some confusion as to the references to Dr Gootnick’s report and the referenced figures given that counsel and Dr Gootnick were apparently not working from the same version of her report. 417 T 1717. 418 T 1717. 419 T 1717. 420 T 1717. 421 T 1718. -- 185 of 345 -- [2026] SADC 67 184 946 When the trial resumed some days later, confusion as to the report she and counsel were working from continued. 947 Dr Gootnick was asked to look at Assoc. Prof. Linke’s PowerPoint presentation. Craniotabes 948 Dr Gootnick said that whether craniotabes is a very rare diagnosis, is a difficult question to answer yes or no. She explained that unless a child goes to the hospital for 'fracture' of some sort and there is a concern for abuse, people are not going to take X-rays of the child's skull because that is a lot of radiation and they do not need to do it. She said that she thought neonatal rickets is ‘fairly common’422 and so probably is craniotabes. The problem is that they do not see it because most children don't break their bones or at least the parents do not bring the children in if they do. She agreed that on imaging, it appears in almost geographic areas looking like little maps of greyness or radiolucency. Chest X-rays on 5 January 2020 949 Dr Gootnick was asked to look at the first X-ray taken on 5 January 2020 and assume the film was taken in the resuscitation room within the emergency department and to note the resuscitation paddle. 950 She agreed that the structure immediately behind the resuscitation paddle is JR’s heart and agreed the heart was probably normal but added that the one thing that did not look normal was the size of the thymus, which she explained was an organ that sits on top of the heart. It was small which means that this baby was stressed, most likely at birth. She disagreed that the thymus was normal.423 951 Dr Gootnick agreed that the lungs looked clear and the imaging of the diaphragm, unremarkable. She agreed that in the abdomen on the X-ray darker areas are gas within the bowel loops and the stomach, which looked normal.424 952 She agreed that if viewing the film for the first time, you would look to see if there was free air in the abdomen or gas in a place where it should not be found and would also look to see if there's free air between the lung and the chest wall. She agreed that here there was no free air or pneumothorax. From what she could see of the spine there were no segmental vertebral anomalies. 953 Dr Gootnick agreed that ribs are all joined at the back to the spine and that some of the ribs then come around to the front and are joined to the sternum by cartilage. As to whether the sternum itself cannot be seen on a plain X-ray as cartilage is radiolucent, Dr Gootnick said the sternum at that point should have some calcium, but on this film, it could not be seen because it overlies the spine 422 T 1893. 423 T 1895. 424 T 1896. -- 186 of 345 -- [2026] SADC 67 185 and the heart. When it was suggested that in terms of cartilage of a six-week-old, it is effectively invisible on a plain X-ray, Dr Gootnick said that she did not know. 954 Dr Gootnick asked for clarification as to the age of the baby and whether the baby was premature. As he was ten days to two weeks premature, Dr Gootnick concluded that JR was basically four weeks old. She said that the bones are ossified or calcified in the last three months of pregnancy and that if you remove two weeks or ten days of intrauterine life from a baby, the bones are not going to be as well calcified as they should be if the baby was full term. 955 She agreed that the cartilage is radiolucent and said that you cannot see cartilage unless it is partially calcified, but in general is not well seen. Dr Gootnick said that from the X-ray both sides of the top ribs appeared normal but that down the image, there are two on the right and two on the left with the knuckle or bulbous appearance. She agreed that the knuckle or bulbous appearance is caused by new bone formation and that the most common reason for the appearance of a bulbous formation like that on a rib is a healing fracture. As to whether that new bone formation occurs between five and seven days from fracture, Dr Gootnick said that it depended on the status of the calcium in the body, keeping in mind, in order to heal a bone, which is made of calcium, you have to have adequate calcium, otherwise it takes much longer.425 956 Dr Gootnick agreed that the second chest image of 5 January 2020, showed what looked like healing fractures. She denied that the image showed a black fracture line that has been healing and refractured. She said that the dark line is actually the fracture line which has not completely healed. It has not been refractured and was just poorly calcified healing at that site. She said that if it was a new fracture, you would expect to see a lot larger callus formation. 957 She agreed that in terms of this image, that the fractures occurred at least a couple of weeks beforehand to allow them to form that amount of callus.426 958 She disagreed that the difference in the size of the calluses between left and right indicate that there may be fractures of different ages, because to her eye they looked the same and looked like they occurred at the same time. 959 Dr Gootnick said that she did not recall whether she looked at the written reports that were prepared, reporting on this image. Dr Gootnick was referred to the report of the X-ray which read: 'Bony irregularity involving the posterior, lateral left fifth rib reflects a minimally displaced fracture without discernible evidence of bony callus formation'.427 Dr Gootnick said that she did not see a fracture. She said that an undisplaced fracture without callus formation, would possibly indicate a more recent fracture. 425 T 1899-1900. 426 T 1901. 427 T 1902. -- 187 of 345 -- [2026] SADC 67 186 960 She added that there is a little grey line on the fifth rib and the one above it, which she said has to do with the fact that the heart is behind it. It is a normal thing that you see if there are two superimposed images. It is not a fracture. 961 While Dr Gootnick agreed that if there were fractures with no callus, or more or less callus, was an indicator of fractures of a different age, that was not the case here. If that were noted, she agreed that it would be reasonable to request a skeletal survey to see whether there any evidence of trauma elsewhere in the child and secondly, to turn up any genetic or metabolic abnormalities that might predispose a child to fracture. Pneumonia 962 Dr Gootnick agreed that if there were fluid or pus or blood in the lungs, that would appear whiter on the X-ray because, with infection, the gas would be lost, and the lung itself would become more of a solid object. She agreed that different forms of infection can have different appearances on X-ray, all diagnosable as increased opacity. She agreed that radiologically there is no pneumonia on the X-ray.428 963 With respect to the chest X-ray taken at 8.32 pm on 5 January 2020, Dr Gootnick noted that it showed a nasogastric tube placed too far. Rib fractures 964 She agreed that on that X-ray there was expansion of the anterior ends of the left sixth and seventh ribs raising the possibility of trauma at the costochondral junctions. She said that fractures in abuse are almost always posterior not anterior. She said there were fractures that are healed but said that they were not in the position you like to see them in if you were suspecting trauma. In other words, if you have a child and you are angry, and you want the child to know that you are angry, you are going to grab the child under the arms, and your fingers are going to be in the back. Your thumbs are going to be on the chest and you are going to squeeze and shake, so the fractures that occur are where your fingers are in the back. These fractures on the left are in the front. 965 Dr Gootnick disagreed that the usual place to get fractures from squeezing would be on the side of the rib cage, not at the front or at the back. 966 Dr Gootnick said it would be rare for her to report on infants who have had CPR. She agreed that if there had been CPR on 5 January 2020 that had caused a fracture, there would be no callus formation yet. 967 She agreed that the radiology showed JR did have fractures and there was evidence of healing and on that basis, it was fair to assume that they were nothing 428 T 1904. -- 188 of 345 -- [2026] SADC 67 187 to do with any attempt at resuscitation. She said that fractures present that have no callus formation, could be associated with resuscitation. 968 As to the CT scan of the chest dated 10 January 2020, at 11.36 am, which Dr Gootnick said she presumed she had reviewed, Dr Gootnick agreed it is harder to see a fracture on the backs of the ribs on an X-ray than on a CT scan. 969 Dr Gootnick agreed that there was a fracture line visible on the right sixth and seventh posterior rib and they were healing. As to the ninth posterior rib, she agreed that showed a fracture with minimal degree of bony callus formation evident. She denied these fractures would have occurred on different occasions to the ribs with more significant callus formation. She said that all the ribs looked the same. From looking at the film, Dr Gootnick said:429 So there are two rib fractures on the right, okay, of the ninth and 10th ribs and there is a fracture of the left one, two, three, four, fifth rib on the left posteriorly but that fracture is healing faster but it is almost healed as opposed to the other two fractures on the right side. That fracture has almost completely healed. 970 She denied that the body acts as one entity and ribs would heal at the same rate and said that if you have a more severe fracture on the right and a bigger callus, a bigger accumulation of blood, that one is going to heal slower than one that is not displaced. That is going to heal faster because there is less to heal. 971 As to the CT scan taken on 10 January 2020 titled ‘Bone Windows’,430 Dr Gootnick did not agree that the images demonstrated fractures of different ages. 972 It was suggested to Dr Gootnick that you could tell that they were of different ages because the left image shows a healing fracture, and no fracture line is visible. Dr Gootnick said that in fact there was a fracture line visible on the right. 973 Dr Gootnick agreed that the orange arrow on the left showed what was described as 'Healing fracture - no visible line'.431 She disagreed that on the right- hand side of the PowerPoint, the orange arrow showed what was described as indicating a 'Fracture line and callus - healing'432 'and a repeat fracture'.433 Rickets 974 As to the image labelled 'Rickets - vitamin D deficiency'434 the top image of the rib cage was, Dr Gootnick said, indicative of what is seen in JR. You cannot really see the ends of the rib because there is not enough calcification there. That 429 T 1911. 430 Exhibits P9/P10, image 5. 431 T 1912. 432 T 1913. 433 T 1913. 434 T 1915. Exhibits P9/P10, image 6. See Reasons for Verdict, page 39. -- 189 of 345 -- [2026] SADC 67 188 is, the growing zone of provisional calcification where the rib grows is very poorly calcified, so you end up with a grey blob which is cartilage that continues to grow. 975 When it was suggested that Dr Gootnick was wrong on this issue based on the opinion of Assoc. Prof. Linke, Dr Gootnick said she based her opinion on her 50 years of reading X-rays. 976 She agreed that the image at the bottom showed cupping and fraying of the ends of the long bones. 977 She said that her understanding of rickets is a diagnosis of vitamin D deficiency and its effect on bones. She said she had not heard that endocrinologically rickets is a symptom complex of a number of things and had always heard that it was a symptom of vitamin D deficiency.435 978 She agreed that for a diagnosis of rickets to be made, a number of factors needed to be confirmed, that is, radiological confirmation of a bony abnormality, a low, but according to Dr Gootnick, not very low vitamin D or at least to suspect that vitamin D was low at birth, an abnormality of the parathyroid hormone, and alkaline phosphate, unless according to Dr Gootnick, the child is been treated, and an abnormality of calcium. 979 She did not accept that a low vitamin D reading alone is not enough for a diagnosis of rickets. She said that once you have a low vitamin D, then you cannot absorb calcium from the stomach and you cannot put calcium into the bones. So low vitamin D by itself is very suspicious. 980 Dr Gootnick said that if you have a low vitamin D and abnormalities consistent with rickets, then you have a diagnosis. Because the parathyroid hormone releases calcium from the bones, if you release calcium from the bones because calcium is low, then the parathyroid hormone drops. She said she ‘would go’436 with a low vitamin D and metabolic changes in the bones. 981 She said there are other disease processes that can cause what looks like rickets in bones, but agreed here there was no evidence here of those other disease processes. 982 As to whether you either have rickets or you don’t, Dr Gootnick said you can have varying degrees. You can have terrible rickets or you can have mild rickets because you have mild vitamin D deficiency. She had not heard of the term 'Subacute rickets'.437 983 As to whether there can be a vitamin D deficiency without it impacting on the bones, Dr Gootnick said that was so in other diseases, but not in rickets. There is deficiency, insufficiency and normal. You can have deficiency, you can have 435 T 1916. 436 T 1917. 437 T 1918. -- 190 of 345 -- [2026] SADC 67 189 bone changes, but if you have insufficiency then you are definitely going to have bone changes. 984 Dr Gootnick said it was outside her experience to know whether there can be a vitamin D deficiency on the scale of insufficiency without it impacting on the bones. She said that there was a range for deficiency. She did not know if close to normal was going to impact the bone or if it is closer to insufficiency it is going to impact the bone. She accepted that there can be a vitamin D deficiency without it impacting on growth and development of the bones and it is fair to say that all depends on the degree of the deficiency. She agreed that the potential degree of impact of vitamin D deficiency on bones depends on the degree of that deficiency.438 985 As to whether it is only called rickets when the condition is severe enough in terms of the deficiency on the bloods and can be seen radiologically, Dr Gootnick said she did not know, and you would have to talk to the people who make up the names for these things. 986 Somewhat surprisingly, Dr Gootnick did not appear to be aware that the prosecution was suggesting JR showed no evidence of rickets, as evidenced by the following transcript:439 Q. Okay. Because here I'm suggesting it is not rickets, the bloods are normal. A. You're suggesting it is not rickets? Q. Yeah. A. In Oscar, is that right? Q. Absolutely. A. I disagree with you. 987 The prosecutor asked Dr Gootnick to assume that levels of the parathyroid hormone, alkaline phosphatase and the calcium were normal. 988 Dr Gootnick said that calcium levels were at the upper limits of normal, meaning that if the calcium is at the upper limit of normal in the blood, the parathyroid hormone is going to be normal because the job of the parathyroid hormone is to release calcium from the bones. She said that: 440 If there is adequate calcium, then the parathyroid hormone is going to be normal and the alkaline phosphatase, if you don't have any acute fractures and it takes - I think as I recall three or four days for the alkaline phosphatase to elevate in a fracture, if the alkaline 438 T 1919. 439 T 1919-1920. 440 T 1920. -- 191 of 345 -- [2026] SADC 67 190 phosphatase is normal, that means that these were old fractures. And the child was getting calcium in its feeds. 989 She totally disagreed there was no evidence of rickets in the radiology. 990 Dr Gootnick said that rickets affects all the ribs, but in terms of the healing, it may be slower in one part than the other because a degree of blood surrounding the fracture may be larger on one side than the other. 991 Dr Gootnick said that on the CT scan on 10 January 2020, there is not much seen in the way of cartilage because of the settings. If you had a different setting that was looking at soft tissues, you probably could see the uncalcified, continuously growing cartilage. She denied that on all of the settings available to Assoc. Prof. Linke, rickets and the presentation that she described was not present.441 992 By reference to the CT scan, Dr Gootnick counted from the bottom and went up. In ribs twelve, eleven, ten, nine, eight and seven, there is an indentation on the ends and a splaying at the ends of those ribs because there is a divot in the middle of it. Looking at the other side, ribs 12, 11, 10, nine, eight, seven, you see the divot which is the growing cartilage. Going up to rib two on the left, on JR’s left, it is fairly smooth, without big divots like there are lower down because this is now calcified. 993 It was suggested to Dr Gootnick that the very fact that they are different from 1-11 and on both sides goes against her proposition that rickets is apparent on the bone ends. Dr Gootnick said that she did not say they were different, the divots were symmetric. The lower ribs, which are obviously calcifying slower, have the divots, the upper ribs don't, because they are calcifying faster. So, it is symmetric, meaning this is a systemic process, something that's going on with this child, it is not a localised process like the evidence of abuse. 994 Dr Gootnick said it appears that the top ribs would absorb calcium at a different rate to the bottom ribs, which the prosecutor suggested was a novel proposition and unknown in medicine. 995 She disagreed that the images of the ends of the ribs are normal. Images 6 and 7 - vitamin D deficiency 996 With respect to image 6 of Exhibits P9/P10, Dr Gootnick agreed that the bottom image of a child’s wrist showed cupping and fraying on the ends of the long bones. She agreed that image 7 of Exhibits P9/P10, that of JR’s wrist, showed no cupping, nor three little bones which she said were shown on image 6. Dr Gootnick said image 6 was of a much older child. JR had been given vitamin 441 T 1922. -- 192 of 345 -- [2026] SADC 67 191 D and calcium because he has had formula, so now things are beginning to go back to normal growth.442 997 Dr Gootnick agreed that on image 7 there is no cupping and fraying of JR's wrist. She agreed JR's wrist has a very nice straight line where the growth plate would be. 998 She also agreed there's no cupping or widening of the zone of provisional calcification but said that she believed there is a growth arrest line indicative that previously there was not enough calcification to normally calcify the growth. 999 Dr Gootnick maintained that it would not necessarily be the case that if there were rickets in a six-week-old, it would show up on this image of his wrist. She said that he had been having formula, with vitamin D and calcium, so there is a chance that the bones can improve and calcify.443 1000 As to why that would not also be evident on the ribs which she suggested had evidence of inappropriate calcification, Dr Gootnick said that things calcify at different speeds and so the wrist showed faster calcifying than the rib. She disagreed that was not how the body works. 1001 Dr Gootnick said that she was aware osteogenesis imperfecta was ruled out on deoxyribonucleic acid (DNA) testing and agreed that in that condition there would be other clinical manifestations of that disease. Wormian bones 1002 Dr Gootnick said that she did not see any Wormian bones and did not look at the skull ‘very much either’.444 1003 She agreed that she had not reported on any Wormian bones. She was told not to look at the brain. 1004 With respect to image 9 of Exhibits P9/P10, she agreed JR’s image showed no Wormian bones– adding there was maybe one, but there must be at least ten for it to be significant. Skull fractures 1005 She did not agree that the two blue arrows on image 9 are pointing to what appear to be fractures. 1006 She said that if those two lines that were marked with the blue arrows were related to other investigation findings, such as subdural haemorrhages, that would not support an opinion that they were fractures and not sutures. She said that commonly there are other things that can cause subdural haemorrhages in 442 T 1925. 443 T 1926. 444 T1927. -- 193 of 345 -- [2026] SADC 67 192 neonates. For instance, 30% of neonates have subdural haematomas, most of which are not clinically apparent.445 1007 She maintained that JR was four weeks old. She said that subdural haematomas can re-bleed even if they developed at birth or they can stay around for a while and this was an area within her expertise. She agreed that she had not however had cause to review the MRI or the head CT scan. 1008 She agreed that if there was soft tissue injury associated with the lines marked with the blue arrows, that might impact on her opinion. 1009 As to a case where there was also a minor degree of overlying soft tissue swelling as well as the underlying subdural haematoma, whether that would point towards a fracture, Dr Gootnick said if talking about an acute fracture, if you tear the periosteum, the blood vessels of the periosteum are going to bleed so you would like to see a relatively significant haematoma or soft tissue swelling. 1010 When asked why she was discounting trauma over incidental or coincidental findings, Dr Gootnick said that looking at the image of JR on the right, the larger blue arrows marks what is called a fracture. One of the distinguishing features between a fracture and an accessory suture is that an accessory suture will narrow as it approaches a real suture. This line is approaching the lambdoid suture, which is a normal suture, and you notice that the suture line is narrowing, which is one of the findings that differentiates between a fracture and an accessory suture. 1011 Dr Gootnick disagreed the edges of the sutures were not consistent with them being accessory sutures. 1012 With respect to whether it would be reasonable for a radiologist who sees there is soft tissue swelling and what appears to be a fracture and a subdural haematoma, to say it looks like a fracture, Dr Gootnick said she would have to see the imaging. She had been told not to look for the subdural haematoma.446 1013 She said that she did not recall going through the exercise of comparing the soft tissue swelling to where it is that the fracture occurred and to the subdural bleeding but vaguely recalled not being ‘impressed with the soft tissue swelling’.447 1014 She agreed that the calcified cephalohaematoma has no relevance to JR's presentation on 5 January 2025 and that the bruising for a cephalohaematoma is outside of the skull and not inside of the skull. 445 T 1927. 446 T 1927. 447 T 1930. -- 194 of 345 -- [2026] SADC 67 193 Image 12 skull fractures, X-ray and CT 1015 Dr Gootnick disagreed that the two arrowed features are fractures and said they were accessory sutures.448 1016 She disagreed that asymmetry is a pointer towards the arrowed structures not being sutures as usually accessory sutures and the parietal bones can frequently be symmetric. As to whether the these appeared asymmetric, Dr Gootnick agreed one was wider than the other but did not accept that one started and ended in a different location. She did agree that one is at a different angle to the other as it approaches the primary sutures. 1017 Dr Gootnick said that the CT scan showed thinning of the skull vault and is craniotabes and disagreed that JR's skull had no evidence of craniotabes.449 1018 Dr Gootnick was taken to her report and Figure 2, a lateral X-ray of JR’s skull taken on 10 January 2020. 1019 In her report she had described the red arrow shown on the image as marking ‘one of the parietal skull fractures’.450 She said ‘What I should have said was what they alleged is one of the skull fractures’451 and that it had just been a ‘typo’,452 as had been the case when she was describing Figure 3. 1020 It was suggested to Dr Gootnick that twice in her report she had said not only that it is a skull fracture, but it is the same skull fracture. Dr Gootnick maintained her description of figure 2 in her report was a ‘typo’453 because she did not think it was a fracture and that ‘it should have said 'An alleged parietal skull fracture for both of those images.’454 She said her evidence on this issue had nothing to do with the evidence Assoc. Prof. Linke had given. 1021 Dr Gootnick then referred to an image she described as ‘image 8’, which did not appear to accord with the copy of the report that counsel were both working from and the issue was left until further enquires were made as to the report which Dr Gootmick had referred.455 1022 Dr Gootnick said she had not been provided with the transcript of Assoc. Prof. Linke's evidence. She said she did not recall seeing Assoc. Prof. Linke’s report in reply to the report Dr Gootnick had provided. 1023 It was suggested to Dr Gootnick that Assoc. Prof. Linke had commented negatively on her referring to a fracture in images 2 and 3 of her report and then in 448 T 1932. 449 T 1933. 450 T 1935. 451 T 1935. 452 T 1935. 453 T 1936. 454 T 1939. 455 T 1939-1942. -- 195 of 345 -- [2026] SADC 67 194 a later image calling it a suture. Dr Gootnick said she totally disagreed that had been the reason why she had stepped away from her earlier descriptions of the fracture appearing in images 2 and 3. Craniotabes 1024 Dr Gootnick agreed that craniotabes is a condition where the bones of the skull have inadequate mineralisation. She said the image of JR’s skull showed evidence of craniotabes. 1025 In the report the prosecutor was working from, image 3 the lateral skull film of JR with one red arrow, two blue arrows and a yellow arrow, Dr Gootnick had referred to the red arrow showing the parietal skull fracture, which the prosecutor suggested Dr Gootnick was saying was a ‘typo’.456 Dr Gootnick said that her report read 'The red arrow marks what is called a skull fracture in the parietal bone'.457 1026 Dr Gootnick said the area between the blue arrows are craniotabes. She denied that the grey lines she had marked on the plain X-ray are redundant skin folds. 1027 Dr Gootnick was referred to an excerpt from the Atlas of Roentgen Variants that May Simulate Disease,458 which Assoc. Prof. Linke had provided in her response to Dr Gootnick’s report. Dr Gootnick said she could not comment on whether the images looked similar or different because ‘it never occurred to me. It is basically craniotabes, period’.459 1028 She had marked the image with a yellow arrow to show a widened occipital suture and agreed that the fact that there was no diffuse swelling on the MRI fortified her opinion that it was nothing to do with increased intracranial pressure. Dr Gootnick did not accept that because of the axis on which the X-ray was taken, what would appear normal on one view has appeared broader because of the angle at which the X-ray was taken. 1029 Dr Gootnick had described figure 4 in her report as an ‘AP view of the skull’ from a CT scan done on 1 October 2020. She agreed with that she was mistaken as it was a plain X-ray.460 1030 Further questioning was halted because of difficulties with counsel working from a different report. The cross-examination resumed after Dr Gootnick had provided the report to which she was referring, dated 4 September 2024. 1031 Before the break, Dr Gootnick had been taken to what she had written in the report that was before counsel where she had marked with a yellow arrow a 456 T 1945. 457 T 1945. 458 Article not referenced. 459 T 1947. 460 T 1951. -- 196 of 345 -- [2026] SADC 67 195 widened occipital suture, and suggested that is secondary to increased intracranial pressure.461 1032 Dr Gootnick took issue with what the prosecutor said because she had written it ‘may be’ secondary to increased intracranial pressure. 462 The latest report that had been provided in respect of that image said, 'It is also indicative that there is fluid within the subdural space which is widening the sutures',463 which the prosecutor suggested was much more positive that there is fluid within the subdural space. 1033 Dr Gootnick said that she had ‘no idea why I said that, it just might have been something that - just a mistake. I mean, you said that there was a small amount of subdural fluid, right?’464 Dr Gootnick was reminded that she had been told there was no diffuse swelling. Dr Gootnick gave the following evidence:465 A. So let's put it this way: if this report went to the referring doctor and he said 'Well, there's no swelling, there's no subdural fluid' and I said 'Okay, fine', so then it is related to the rickets. I mean, you know, what I see on an X-ray is not a hundred per cent. I cannot always give a hundred-per-cent diagnosis. So you have to give them, you know, something else. So if I say there might be subdural fluid or swelling and the doctor says 'Nope, there isn't', then I say 'Fine, that's not the cause and there is another cause which is rickets' and that's the way we write reports. Q. So why did you go from might be subdural - might be - no, I withdraw that. Why did you go from it might be, as you explained earlier today, to more positive in your last report which is 'This is evidence of subdural swelling'. A. Like I said, I can’t be sure if there's subdural swelling. If the doctor reads this who's got the patient says 'No, there is no subdural swelling', fine, well, then there is something else. I cannot be - you can’t be completely correct all the time because I don't know anything else about the patient. Is there subdural swelling, is there swelling of the brain? Blah, blah, blah, blah, blah. So there's no way to know. Q. Okay. A. Go ahead. Q. You finish, please. A. No, no, I did finish. Q. Okay, thank you. Earlier today you gave evidence that there is no evidence of fractures in your opinion of [JR]'s skull. A. Correct. 461 T 1947. 462 T 1947. 463 T 1962. 464 T 1957. 465 T 1957-1964. -- 197 of 345 -- [2026] SADC 67 196 Q. In the report that you provided after lunch - just before lunch, at p.7, you said this, quote, bottom of the page - A. Which page? Q. Page 7. A. Thank you. I'm sorry. Yes. Q. Bottom of the page. A. Yes. Q. 'In this case, what started out as parietal accessory suture may have been widened because the fracture in this region would become more obvious due to the presence of both vitamin D deficiency and a small accessory suture. The father states that there was an episode when the child's head hit a solid object accidentally. This could easily have caused the accessory suture to turn into a fracture in this region'. A. Okay. Q. That's what you've reported, isn't it. A. Yes. Is that puzzling to you? Q. Well, it seems to be contrary to what you told her Honour this morning that there is no evidence of fracture in [JR]’s skull. A. Right. And I think that if there is an accessory suture here, which was widened because of some minimal trauma, it’s still not a fracture. Which is, I believe, what I've said. Q. Again, is that another typo or is that just badly put or how do you explain the difference. A. No, if there is an accessory suture, I think this is an accessory suture, but if there is minimal trauma, like, I don't know, the head got, you know, hit in some way, it might have widened the accessory suture, but that doesn't make it a fracture. Q. Then why did you call it a fracture. A. Pardon me? Q. Why did you call it a fracture in your report. A. Hang on a sec. Where did I call it a fracture? Back to p.7? Q. Yes. A. 'What started out at a parietal accessory suture may have been widened because of fracture in this region would become more obvious due to the presence of both vitamin deficiency and a small accessory suture'. Okay, let's see, okay, so what it should have said was 'had been widened because a fracture' not 'the fracture', 'a fracture in this region would become more obvious due to the presence of both vitamin D deficiency and a small accessory suture'. So I think this is an accessory -- 198 of 345 -- [2026] SADC 67 197 suture which may have widened because of the minimal trauma, but I don't think most of this is a fracture. Q. But some of it is a fracture. A. I don't know and you don't either. Q. Is it a fracture or isn't it a fracture. A. It is not a fracture. Q. Then why did you report that the accessory suture may have been widened because the fracture in this region would become more obvious. A. Maybe it just wasn't put as well as I could have put it. In other words, I don't think this is a fracture, so it makes it look like a fracture because it is wider with a minimal trauma, but it is not really a fracture. Q. Doctor, in your last report you reported on it being a fracture twice, in this report, you report on it being a fracture in the presence of an occipital suture. I'm suggesting you're making it up as you go along now. A. Hang on a second. Not an occipital - this is not an occipital suture, it is a parietal accessory suture, it has nothing to do with the occipital suture. So, in other words, this is an accessory suture, but it may have been widened by minimal trauma which may have separated the parietal bone plates more than it normally would have, but - I mean, I can’t tell, it doesn't matter, because basically most of it is an accessory suture. Does that make sense to you? Q. No, but that doesn't - that's not the issue, the issue for you, doctor, is on the face of it you have changed your evidence before lunch to after lunch. Before lunch there was no fracture at all, full stop, after lunch your most recent report seems to report that there is what looks like a fracture in the location of a suture. A. But where is the fracture? That's the whole point. Look at the imaging. There is no fracture. It is an accessory suture. What I was saying was it might have been widened by some minimal trauma. Now, whether or not I said it was a fracture - okay. Okay. Does that make sense? No. I'm not sure I can explain this to you. Q. Is it the case that your evidence is that if there's a suture there and you get a bang to it, that could turn it into a fracture. A. I'm sure - you know, 'fracture' is probably the wrong word because there's no bone there, it is all cartilage, so it is not a fracture. Q. Then why on page - A. In other words - I understand, I understand what I said. So basically what it is is a separation of the cartilage. Usually we don't call separations of the cartilage fracture, but in a certain sense you could call it a fracture because if the cartilage is widened, the skull bones are produced in the same way the rest of the bones in the body are. In other words, first there is cartilage all the way down, and then they become calcified, etc. So, basically, if there's increased widening of the accessory suture, in a certain sense, it is a separation of a cartilage which may indicate a - I don't want to say fracture, I guess a fracture, through the cartilage, but you can’t really see it -- 199 of 345 -- [2026] SADC 67 198 because you can’t see the fracture, all you see is the widening, which just appears to be secondary to the poorer calcification of the growing cartilage. So it could go either way, basically. I don't think it is a fracture, I think it is an accessory suture. Q. Do you agree that if the child's head hit a solid object, let's say accidentally, that could easily have caused the accessory suture to turn into a fracture in that region. A. It’s not a fracture, though, it is just a separation of the cartilage. I have no idea. In other words, how much of a trauma would you need to cause a separation of the accessory suture? Pardon me. I have allergies and that's what's happening. Determined to a widening of a suture. I don't know and there's no way to know that. Q. Then why did you report - why did you say in your report, bottom of p.7, top of p.8, 'Father states that there was an episode when the child's head hit a solid object accidentally. This could easily have caused the accessory suture to turn into a fracture in this region'. You agree that you said that. A. Okay, hang on a second. So after I go from 7 to 8, widening of the suture. Okay. Q. So, firstly, do you agree that you said the quote that I read out to you. A. Correct. Q. Thank you. A. Now, keep in mind I did not look - Q. Go on. A. I did not look at the brain, so I didn’t - fluid in the brain which could have been widening the suture. Q. If you cannot tell whether hitting the child's head accidentally could cause the sutures to widen, why did you describe it or give your opinion that this could easily have caused the accessory suture to turn into a fracture in this region. A. Once again, let me just tell you that as a radiologist you can never say anything completely, so it’s possible it could have actually, you know, caused some damage to the cartilage of the suture just hitting it accidentally, that's why I said it, because it’s possible, it’s part of the differential diagnosis. But I didn’t say that this was definitely a fracture. It’s part of the differential diagnosis, like my saying indicative that there is - it is also indicative that there is fluid within the subdural space which is widening the sutures. So what I probably should have said, which I didn’t say, probably should have said, given the fact that the lawyers are much more concerned with each individual word than I am, that, you know, it’s possible that the sutures could be widened by increased intracranial pressure if there is such an item, and I should have said that. Trust me, I will say that the next time. Q. Okay. And is it - well, I'm suggesting that you've reported again twice in a paragraph on a fracture and now you're walking away from that, is that so. A. No, I'm not walking away from it at all. I'm not walking away from it. I just - you can’t see a fracture in cartilage, you just can’t. Q. Well, I'm suggesting - -- 200 of 345 -- [2026] SADC 67 199 A. Because - HER HONOUR Q. Sorry, could you repeat your answer there, we lost you. A. I'm sorry, yeah, you can’t see a fracture in cartilage because it is not calcified. Q. Thank you. A. And you need calcium to see a fracture in cartilage. But I also said this is indicative that the child does not have enough nutrients to normally calcify the bones of the skull and, as you noticed, there is two words there, this is 'indicated', 'indicative'. So basically the voice dictation system screwed up there and it did it twice in those two words. 'This is indicated/indicative that the child does not have enough nutrients to normally calcify the bones of the skull'. So there are problems with the voice dictation system. I'm not backing out of this. XXN Q. All right. What I'm suggesting to you is that the more straightforward differential diagnosis is in fact a fracture. You're having to jump through hoops, doctor, to say that there is no fracture here. A. No, I'm not. That's your definition of this, but then again I probably have seen more fractures of the skull than you have. Q. Now, you agree that there is no record in the hospital notes of any definitive signs of raised intracranial pressure. A. Like I said, I did not pay much attention to the brain - Q. But if you read the notes - A. - because I wasn't asked to. Q. On what basis did you start hypothesising about raised intracranial pressure then. A. That's part of the differential diagnosis for a widened suture. Without knowing anything about what's going on inside the skull, it’s part of the differential diagnosis. In other words, you can see that in children or adult - or children who have increased intracranial pressure, so that's part of the differential diagnosis. Q. Now, on this I'm suggesting, and I expect you'll disagree, that the gaps in the parietal bone are fractures and not accessory sutures. You disagree with that. A. I do. Q. And you state that having regard of the fact that there is evidence of - on the radiology of swelling above the right area described as a fracture and subdural bleeding in that area. A. I never saw that. Q. You didn’t look to the brain, did you, doctor. -- 201 of 345 -- [2026] SADC 67 200 A. I wasn't - no, I didn’t. I wasn't supposed to. Q. If there is subdural bleeding in the area of or associated with the location of the fracture on the right parietal bone, does that change your opinion. A. It depends on how much soft tissue swelling. I can’t make a comment about something I don't see, I haven't seen. Q. Okay, fair enough, thank you. A. I just can’t. 1034 In her 4 September 2024 report, Dr Gootnick had noted that the: 'Rib fractures are identified, they are of several ages'.466 Dr Gootnick appeared somewhat shocked that was what she had written. She said:467 A. Okay, because I know I was asked to put the page numbers, so I guess I made some corrections before I gave it to them. Okay, so rib fractures. Okay. I said there are several ages. Yeah, I changed that in the other one, in the new one, I believe. Okay, so on the ones with the page numbers on page number 3, the chest X-ray of 1N okay which is the same one that's here with the arrows on it, it says 'The red arrows mark healing rib fractures bilaterally more marked on the right than on the left'. Q. Sorry, go on. A. I didn’t mention it in the repeat one. Q. Okay. So why on your report of 4 September '24 did you say 'They are of several ages' and then delete that altogether. A. I didn’t. 1035 Following an objection by defence counsel, all of what had been written by Dr Gootnick was put to her as follows:468 ….rib fractures are identified. They are of several ages. For instance, the rib fractures on the right still demonstrate the fracture lines though there is callus surrounding fracture line. These are called looser zone fractures. These are typical of poorly ossified ribs. One reason for these being of different ages could be that at some point there was enough calcium to relatively normal calcify the cartilage surrounding the fracture which then became unavailable which makes the rib fractures look of different ages. Healing of bones cannot occur if there is inadequate calcium or vitamin D present. 1036 Dr Gootnick explained her response and was asked whether she should have said 'They are not of several ages'.469 Dr Gootnick’s evidence continued as follows:470 466 T 1965. 467 T 1965. 468 T1965-1966. 469 T 1966. 470 T 1966-1967. -- 202 of 345 -- [2026] SADC 67 201 A. I'm not going to say that, I just know - it was explained in the paragraph why they look like that, okay, so I don't think - go ahead. Q. Do you accept that, on the face of it, they look as if they are of different ages. A. I think we're talking in circles here. I explain why they look like that and that's the end of that. I mean, I have nothing else to say about it. Q. Why explain it if they all look the same. A. Because there is a feeling that people said that these were of different ages and they're not. I'm rebutting what Dr Linke had to say and I'm giving you a reasonable discussion of why they're not of several ages. Q. So it should have read 'They are not of several ages'. A. No, I'm sticking with what I said and the explanation. Q. And do you agree that it doesn't say 'Whilst other practitioners have asserted they look as if they are of a different age, this is not so'. You agree that that's not there. A. Of course not. Why would I say that? Looser zone fractures 1037 Dr Gootnick disagreed that a looser zone fracture would show up on the end of a long bone, not in the middle of a rib. She said it will show up wherever there is a possibility for a fracture with decreased density of the bone. Furthermore, she also disagreed that there is no radiological evidence of decreased density of the bone in the location of the fractures or that a looser zone fracture would in fact show up where the bone meets the cartilage, that is the growing part of the bone. 1038 She denied the X-rays and investigations of JR demonstrate normal bone healing. She agreed looser zone fractures are an indicator of a metabolic bone disease. As to whether all of the skeleton would therefore be impacted, she agreed but said that it would not be to the same extent everywhere. It is, she said, a systematic problem but not necessarily to the same degree in every bone. 1039 Dr Gootnick was taken again to her 4 September 2024 report where she was addressing JR’s chest AP X-ray on 10 January 2020,471 and wrote: 'One reason for these being of different ages could be that at some point there was enough calcium to relatively normal calcify the cartilage surrounding the fracture which then become unavailable which makes the rib fractures look of different ages.'472 1040 As to the suggestion that what she had written did not make sense, because that would then apply to the whole body, Dr Gootnick said she disagreed because it is a systemic process, so it affects the whole body, but not to the same degree. 471 Dr Gootnick said she had sent that report to Mr Knott but had no idea why he had not circulated it. 472 T 1966. -- 203 of 345 -- [2026] SADC 67 202 1041 In her 4 September 2024 report Dr Gootnick had referred to: 'An image of the growing ends of the ribs. The red arrow marks curvilinear light line being splayed by a grey blob, the grey blob is uncalcified cartilage which continues to grow deforming the end of the rib. This is seen in neonatal rickets in Third World countries. The grey blob can be seen through the chest and is called a rachitic rosary'.473 1042 Dr Gootnick denied that the figure that she provided in fact shows normal costochondral junction save for some healing rib fractures, or that the images that she commented on relating to rachitic rosary, showed no rosary. Growth arrest lines 1043 Again, referring to the 4 September 2024 report, Dr Gootnick had said that an image of the wrist showed growth arrest lines. 1044 As to the suggestion that growth arrest lines can occur in any child, Dr Gootnick said that growth arrest lines are when the bones stop growing and you must pretty much ‘stress them out’474 to have that happen. 1045 She did not agree that growth arrest lines could be due to an emotional cause. She said that she had never seen growth arrest lines occurring as a result of a child lying down in hospital for a number of days. 1046 Dr Gootnick disagreed that the absence of cartilage is a non-specific finder of infant stress, caused for example by neglect or inadequate nutrition, except if they get inadequate calcium and vitamin D. 1047 The prosecutor suggested that all the growth arrest line is reflecting is a time of bone growth stasis, because for example, of the broken ribs. Dr Gootnick said:475 I have no idea how much stress is necessary to create a growth arrest line. That's outside my area of expertise. I know what one looks like when I see it. 1048 Dr Gootnick said that growth arrest lines mean a lot – either metabolic bone disease or the child has something like leukaemia or lymphoma or some systemic disease that is causing problems with bone metabolism. 1049 As to whether there would be more than five to seven days of healing in the ribs which could cause a stress causing the growth arrest lines, Dr Gootnick said:476 Once again, neither you nor I know what kind of stressors are necessary other than I am aware in the literature they talk about large systemic diseases like leukaemia, lymphoma, cancers, near the end of life etc., that's what can cause growth arrest lines. 473 T 1971. 474 T 1972. 475 T 1974. 476 T 1975. -- 204 of 345 -- [2026] SADC 67 203 1050 She said she had never heard that the options on creating growth arrest lines are much broader and that growth arrest lines caused by a stress of many and varied types did not include healing bones. 1051 Dr Gootnick denied that the X-ray Exhibit P23 showed a perfectly normal X-ray for an infant and did not raise the possibility of rickets. 1052 As to Exhibit P24 taken on 10 January 2020, and Dr Gootnick’s opinion that the red arrows mark the last time there was adequate nutrients to normally calcify the growing cartilage, and that the blue lines indicate poorly noncalcified cartilage which appears darker grey, it was suggested to her that the blue line in is in fact radiology of a baby who has been in hospital not moving for five days and represents non-use osteopenia. Dr Gootnick said:477 First of all, babies who are growing and they grow rapidly actually, should have calcium in the zone of provisional calcification which is the cartilage. So the fact that the baby - most babies who are four weeks old spend most of their time laying on their back or their stomach, so they're not walking around and they're not moving that much either. So that has nothing to do with the way these X-rays look. So this child is having trouble calcifying the growing cartilage of the hips. 1053 Dr Gootnick agreed she had said the red lines mark the last time there was adequate nutrients to normally calcify the growing cartilage. She disagreed that the cartilage would be sitting on top of that line, on top of the edge of the bone. 1054 Dr Gootnick said if that were just cartilage, we would have trouble seeing it but the reason we see it as a darker grey line is because it is outlined by two white lines, which is the last time there was adequate calcium. She denied that the grey area is bone that can be seen and not cartilage. 1055 Dr Gootnick maintained that you can see poorly ossified or poorly calcified cartilage in the image because it is different from the line above and the line below. If it was a normally calcified cartilage, that whole area should be white, but it is not. 1056 Dr Gootnick explained that calcium is necessary to calcify cartilage. The precursor of bone, bone begins its life as cartilage. In the images of the wrist, there are two white lines separated by a darker grey line. She said the lower red arrow is partial calcification of the cartilage and there was enough calcium to calcify that cartilage. As growth continued, because even though the cartilage is not calcified, it continues to grow, there is a grey area where there is no calcium, or very little calcium, and then at the zone of provisional calcification where cartilage is growing, it is now being calcified in an appropriate way. The reason we see the grey line is because there is a space between the two areas where the cartilage was calcified. 477 T 1977-1978. -- 205 of 345 -- [2026] SADC 67 204 1057 Dr Gootnick denied that represents simply bone with non-use osteopenia. She agreed her evidence was that the red arrows mark the last time there was adequate nutrients to normally calcify the growing cartilage. 1058 As to Exhibit P25 showing JR’s lateral lumbar spine, Dr Gootnick agreed that she had referred to those images to show that these findings are seen in many of the bones and are indicative that this is not secondary to trauma because is a systemic process caused most likely by a lack of vitamin D and calcium. She said the red lines mark the calcification of the outer most portion of the vertebral bodies. The blue line demonstrates poorly calcified cartilage in the interior of the vertebral bodies.478 Dr Gootnick denied what in fact is seen is a vascular bundle that runs through the middle of the vertebral body referred to as the vertebral hilum. 1059 Dr Gootnick disagreed that the image of JR shows normal calcification but a different level of opacity due to different radiographic technique or radiation dose. 1060 As to her evidence in relation to gestational diabetes being caused by hormones produced during pregnancy that can make insulin less effective and gestational diabetes can cause macrosomia, Dr Gootnick said she was not aware of the recently published study in the Journal of Nutrition that found that most women with gestational diabetes had adequate vitamin D status. 1061 She said:479 One of the problems is - the problem is that in gestational diabetes and macrosomia, the child develops increased fat levels and the inactive form of vitamin D is stored in the fat tissue. So vitamin D levels might be adequate but the child doesn't have access to them. 1062 Dr Gootnick agreed that would be so with a fat baby, but JR was an average baby and that macrosomia could be put aside. 1063 Dr Gootnick agreed that she found that JR had multiple radiographic findings consistent with metabolic bone disease, that is, rickets. She disagreed with the suggestion that there are no features of neonatal rickets on JR's imaging. 1064 As to whether in neonatal rickets, you would see it at ends of the long bones, flared like an umbrella, Dr Gootnick said you might see that or looser fractures or prominence of the periosteum. It can be all kinds of different things, but all these findings are seen in neonatal rickets and metabolic bone disease. 1065 She agreed that sometimes, but not always, you would see what looks like a furry margin at the ends of the long bones, depending on how old the child is. 478 T 1981-1982. 479 T 1985. -- 206 of 345 -- [2026] SADC 67 205 1066 In terms of the circumcision of JR and whether she was suggesting that could have broken his bones, Dr Gootnick said:480 If he was restrained, I don't know. I mean, it is possible. I mean, you can imagine children don't really appreciate that being done to them and they can squirm and carry on and somebody's got to hold them still. 1067 She conceded however that she was not familiar with how the procedure is performed and it was speculation on her part. 1068 Dr Gootnick disagreed that there are no features of metabolic bone disease on any of the imaging and that the absence of flaring of the metaphysis on the long growing ends of the long bones is a relevant finding as to the absence of rickets. She said that as to flaring, it depends on the age of the child and how long they have had the rickets.481 1069 She also disagreed that if rickets were present, it would be uniform in its existence and radiology across the joints. 1070 Dr Gootnick said it is systemic, but it doesn't have to be symmetric. In other words, all the bones are involved, but they can be involved to different degrees. 1071 She disagreed that there is no evidence of poorly ossified ribs on the imaging. Dr Gootnick’s re-examination 1072 Dr Gootnick said there is no real radiographic evidence, of a skull fracture. It may have caused some widening of the suture, a loosening of the cartilage, but there's no actual evidence of a fracture. There is an accessory suture. 1073 As to whether she received ‘medical reports, medical data, or Assoc. Prof Linke’s report on police statements or her evidence’, she said:482 Probably more like maybe I did, I just don't recall it. I know I disagreed with pretty much everything she said, and her PowerPoint presentation. 1074 Dr Gootnick said that rickets goes away under appropriate treatment. It is not static and once a child gets out in the sun and runs around, can make vitamin D in their skin so it goes away as the child gets older. And there is no residual. The fractures that are present, you will not ever see them because young children completely remodel fractures. 1075 Dr Gootnick said that clear lungs do not exclude viral pneumonia. When a child first comes into the hospital, they can be dehydrated. She said that once they get hydrated you can all of a sudden then see pneumonia. You may not see it initially, but, once they get some fluid on board, then you can probably see it, if it 480 T 1987. 481 T 1987. 482 T 1990. -- 207 of 345 -- [2026] SADC 67 206 is present. She said ‘you may see it and you may not, if there is a significant viral pneumonia’.483 Summary of Dr Gootnick’s opinions 1076 In summary Dr Gootnick’s opinion was that: • Compromise caused by the endotracheal tube blocking the left lung contributed to hypoxia and to seizure activity. • JR’s left lung could not be seen on the chest X-ray taken on 5/01/20. She did not see interstitial pneumonia in the right lung. • If there is not enough Vitamin D, cartilage is not sufficiently calcified. The X-ray shows that JR’s bone density is much lower because there is not enough calcium. • There is no skull fracture. • The X-ray shows no evidence of skull fracture that are perhaps the product of trauma as opposed to craniotabes. • The lateral view of JR’s skull showed a widened lambdoid suture, which normally would be much thinner. The bony development of the skull is compromised because of Vitamin D deficiency. • Wiggly lines on the X-ray are indicative of accessory sutures because the fracture would continue to be wide all the way to the normal sutures. The narrowing of the accessory suture assists in this conclusion. • JR has rickets. • The X-rays show growth arrest lines which are seen in rickets. • X-ray of the ribs shows abnormal calcification in the growing end of the ribs. • A growth arrest line occurs when there are alternating levels of nutrients and supports her findings relevant to the analysis of the skull and the evidence of craniotabes. • The image of JR’s anterior ribs taken on 10 January 2020, shows rickets, and in third world countries where children are very thin this is called a rachitic rosary, because these grey blobs can be seen or felt through the skin. It is a well-known finding in rickets. • The rib fractures are in the back, laterally and to a lesser extent anteriorly. These fractures, from whatever cause, were not caused by shaking. In 483 T 1993. -- 208 of 345 -- [2026] SADC 67 207 grabbing a child with both hands, you expect to have fractures on both sides, symmetric, which is not the case here. • Looser zone fractures are fractures that occur in rickets, with minimal pressure to the bone, but do not go all the way across the bone. Looser zone fracture means you do not have normal mineralisation of your bones. • The locations of these fractures are not typically seen in abuse. • There was evidence of uncalcified cartilage in the ends of the bones. A very thin curvature at the growing ends of the bones is indicative of the last time that there were adequate nutrients to calcify the bones. • Fracture healing in a normal individual is usually 6-7 weeks. In a child deficient in Vitamin D and calcium it can take longer and therefore they cannot be dated. • There is evidence of flaring in JR’s ribs. • Because JR was being treated the flaring normally seen in a severe case of rickets is not available. • Despite testing suggesting calcium levels were normal, Vitamin D deficiency still carries significance in isolation because you need vitamin D to get calcium into the cartilage. • Craniotabes is not affected by increase in cranial pressure. • The accessory sutures have no relationship at all to craniotabes other than they may be wider than normal because the cartilage is not being calcified. • The head knock JR sustained on the sofa could not have contributed to his presentation as there is no fracture. • The cephalohaematoma is not relevant to JR’s appearance on 5 January 2020. • There is no evidence of fractures within JR’s skull that are perhaps a product of trauma as opposed to craniotabes. • Compromise due to vitamin deficiency does not affect all the skeletal structure equally. • You would like to see some soft tissue swelling if there was trauma. • Once a child is hydrated you may see evidence of pneumonia. -- 209 of 345 -- [2026] SADC 67 208 Prof. Ackland’s evidence Qualifications and experience 1077 Prof. Ackland gave evidence via AVL from Western Australia. His CV is Exhibit D95. 1078 Until he recently retired, Prof. Ackland had been a Professor at the University of Western Australia. His initial studies were in an area of physical education, where he became interested in the biomechanics of human motion and completed a PhD in biomechanics. He taught and researched in the areas of human functional anatomy and biomechanics, having produced multiple peer-reviewed research papers. He supervised post-doctoral research students in biomechanics and sat on editorial boards and reviewers for various journals in that field. 1079 He has produced over 150 reports, primarily for the District Court in Western Australia, but also for Supreme Courts and coronial inquests in multiple jurisdictions. Prof. Ackland said that while his work embraced criminal matters, the majority of his work has been in the civil courts. 1080 Prof. Ackland said that in broad terms he has taught and researched in the areas of human functional anatomy and biomechanics for the past 30 to 40 years. 1081 Prof. Ackland said that in his research since 2001 he has been involved with biomechanical research about the injury occurring to adults, admittedly, from the loading environment, particularly for cartilage, tendon and bone injuries. In this context he looks to matters such as injury tolerance values and associated with observed failure to tissue, trauma and the like. He said there are fairly good injury tolerance values, particularly in adult humans. 1082 Prof. Ackland described biomechanics as the basic science of injury causation. He said that it provides a useful framework to understand the various sources of loading and to look at all possible causes of loading that might give rise to the failure of tissue. The loading could be either static or dynamic or both. Static loading would be something like a crush injury, whereas a dynamic loading involves impacts, either of the body with a surface or another object colliding with that body. Dynamic loading can result from head contact or head motions. 1083 Prof. Ackland said that from his reading in this particular area it is clear that static loading or dynamic loading that is linear generally gives rise to focal strains on the tissue, such as a contusion to the skull or a skull fracture, whereas angular dynamic motion normally gives rise, according to the literature, to diffuse strains in multiple areas of the body. 1084 From his reading and in his experience, traumatic brain injury in adults, children and infants is caused by one of two mechanisms. The first is generally termed, impulsive loading where the head moves because of motion imparted to some other part of the body, for example in a whiplash injury or violent shaking. In this type of loading the unsupported head will be caused to rotate about some -- 210 of 345 -- [2026] SADC 67 209 point on the cervical spine and in such rotation the skull will move at a different rate to the brain, which lags because the brain and the skull are not rigidly linked. 1085 This differential displacement can produce tensile failure of the bridging veins which occur, on average, when they are stretched about 30% beyond their unloaded length. So impulsive loading is the type of loading we would expect in a shaken-only scenario. 1086 The second type of cause is impact loading, where the head either strikes a stationary object or is struck itself by a moving object. The impact produces a contact phenomenon in one or both colliding objects such as a scalp contusion or a scalp fracture. As there is no rigid link between the brain and the skull, there is a transmission and reflection of a pressure wave inside the skull that causes deformation of the brain within that skull. It is the combination, so it is the relative contribution of these accelerations that will determine whether the injury is primarily focal, primarily diffuse or a combination of focal and diffuse. 1087 Prof. Ackland explained the ‘hierarchy of evidence’484 from level 1 through to level 7. He said that in the sciences a means of determining the reliability, validity and the precision of various measures that look at the responses of humans to certain environments, are called the levels of evidence and describe the quality of the research. 1088 Prof. Ackland said that ‘injury thresholds’485 are the application of forces that reach a certain level which go beyond the biological tolerance of tissue and if that force environment exceeds that tissue tolerance, then the tissue will begin to fail. It fails slowly at the start, but if the force environment increases then it will fail more quickly later. 1089 Prof. Ackland said that through his reading it has become quite clear that the scientific community has not established ‘beyond reasonable doubt’486 injury thresholds for infants in terms of the loading environment, because you cannot use, infants in these particular studies. 1090 Prof. Ackland said that in the context of providing his opinion in this matter he acted on an assumption that JR’s injuries are as described. 1091 Prof. Ackland was asked whether it is possible to determine the biomechanical loading environment present during an alleged event that will produce the medical condition in the child (such as subdural and retinal haemorrhages) or alternatively, can it be reliably scientifically determined if any forces would exceed the injury tolerance that the specific, observed medical failure (such as subdural and retinal haemorrhages). 484 T 1521. 485 T 1523. 486 T 1523. -- 211 of 345 -- [2026] SADC 67 210 1092 Prof. Ackland said that there are many research challenges associated with determining tissue tolerance thresholds for such injuries. Currently accepted angular acceleration threshold values were originally derived from non-human primate models, then scaled for human infants based on brain mass. Such an approach has several limitations and requires certain assumptions to be adopted. There are not he said, very clear and universally accepted values for the tolerance of these tissues which, when exceeded, are going to cause injury in all circumstances. Secondly, the measurement of angular acceleration is crucial, and the measurement of angular acceleration can only be performed on a surrogate because of the ethical issues related to instrumenting a live child and performing such actions. Prof. Ackland said that researchers and bioengineers continue to develop anthropomorphic surrogates or biofidelic models, to mimic the biomechanic responses of live humans exposed to these loading environments, but he was not aware of any surrogate models that have achieved universal acceptance. There is, therefore, a problem of threshold and a problem of measurement. He said that if you cannot measure in the real environment what those angular accelerations are, then it is very difficult to try to apply some level of tissue tolerance. 1093 If there is witness or CCTV evidence, the likely force resulting from a fall or a contact can be studied, but without that, there is no evidence to describe the loading environment in a scenario. 1094 Prof. Ackland said that from the reports of Dr Edwards and others, we have a good understanding of the injuries but we do not know how those injuries were caused. In Prof. Ackland’s opinion a medical condition, or conditions, and a history are important, but are insufficient to conduct the forensic biomechanical analysis to elucidate a definitive cause or mechanism of injury. 1095 He said that there are too many unknowns to determine a definitive cause or mechanism of the observed or diagnosed injury, and such an opinion must be qualified due to the many required assumptions and limitations, including no specific knowledge of the acceleration force environment at the time of injury. There is no appreciation of the acceleration of force thresholds required for tissue failure and resultant injuries. There is the possibility of alternate causes of the injury including medical, accidental and non-accidental mechanisms. He said, ‘And finally, even if there is an injury, there is an inability to determine intent. Human tissue is sensitive to force, but it is unaffected by the intent of the generator of that force.’487 Abductive interpretation or reasoning backwards from an event of the child's medical findings cannot scientifically and reliably determine the causation of the child's medical findings. While abductive reasoning, which relies on the diagnosis and the history, yields a plausible conclusion, it is, Prof. Ackland said, not one that is verified. Abductive conclusions do not eliminate uncertainty or doubt. 487 T 1529. -- 212 of 345 -- [2026] SADC 67 211 1096 Prof. Ackland said that while he thought there was an abundance of evidence that there was a collision to JR's skull, we don't know how that impact was caused. There might be multiple causes, there might be multiple occasions where impacts have led to the series of conditions that were reported. It is however not known which one or which combination of scenarios had occurred which might have given rise to those conditions. 1097 Prof. Ackland said that Dr Edwards asserted the totality of JR's head injuries were caused by a forceful impact to the right side of the head associated with rotational acceleration, deceleration forces. There may have been an episode of shaking prior to or after impact. He said that put simply, Dr Edwards has observed signs and symptoms of head trauma that she opines may be associated with a forceful impact with or without concomitant shaking. He said that in terms of the head impact, he had reviewed the biomechanics literature on this matter 1098 He acknowledged Dr Edwards' assertion that a mechanism of JR's injury was likely an impact to his head, and she had noted elements of evidence for such an impact which include scalp haematoma, bi-lateral skull fractures, subdural haemorrhaging and brain contusions. It was Prof. Ackland’s opinion that there are multiple opportunities for impacts to the head. Impacts to the head can occur from a small or short fall and he referred to the studies reported in Prange488 and Geoghegan.489 He said his point is that there is good evidence to show that high levels of angular acceleration can occur when a child or an infant fall from even a small height of 30 cm onto a noncompliant surface. He added that there may in addition be other forms of contact, by other animals, and other people, other objects, or when the child's head is deliberately hit against an object. 1099 He said that here we have a history and some medical conditions, and it is a big leap of faith to say that all these conditions were caused by one particular act on one particular day. Prof. Ackland said that he did not believe that Dr Edwards provided any scientific basis to underpin her assertions. 1100 Prof. Ackland was asked whether there is a reliably accepted scientific methodology to validate the relationship between the forces as noted by Dr Edwards and subdural and retinal haemorrhages or subdural haemorrhages and retinal haemorrhages. He said he knew of no universally accepted scientific methodology that is free from limitations or assumptions to validate the relationship between the forces as noted by Dr Edwards and brain injury or eye injuries associated with head trauma. 1101 As to Dr Edwards’ reference impugning his expertise to provide the evidence that he had given, Prof. Ackland said he claimed expertise in the field of biomechanics and that in particular, since 2001, had developed a line of biomechanics research relating to the effects of mechanical loading on such tissues 488 Article not referenced. 489 Ibid. -- 213 of 345 -- [2026] SADC 67 212 as bone, cartilage, ligaments and tendons. He acknowledged that the responses of infants, children and adults to mechanical loading do vary with respect to the structure and maturation of these tissues, but the fundamental biomechanical principles remain the same. 1102 Prof. Ackland said he had expertise in the following aspects of his knowledge and experience: • demonstrable knowledge on biomechanical principles via formal qualification of PhD and experience as noted in my CV. • demonstrable experience in conducting applied research in biomechanics-related topics and reporting the findings in peer-reviewed journals. • demonstrable experience in the process of critically reviewing, synthesizing and summarising biomechanics and biomedical research in his academic roles as journal editor and reviewer and higher degree by research supervisor and examiner. 1103 He said that to his knowledge Dr Edwards had no formal qualifications in biodynamics. She may, he said, have some experience in the area through her work. 1104 Prof. Ackland, in response to criticism that he had not performed a systematic review, said that was not his task, adding that this would take ‘at least a year to perform a systematic review, so with the limited timeframe, one goes directly to the information that's available on the topic that he was asked to review.’490 1105 Having said that, there is, he said, not much literature around on the biomechanics of the mechanisms of infant injury, and so he was, he said, able to short-circuit that process by looking at the information that was provided to him, seeking out secondary sources, running literature searches through the university library on those particular important keywords on biomechanical or bioengineering topics. It was not his brief to do a systematic review. He reviewed what he believed to be the most important papers over the last couple of decades in this area. 1106 With respect to the Consensus Statement,491 Prof. Ackland said that while it is suggested in that paper that they have considered 2,000 articles that they had gathered through their research, they selected representative works from only 210 of those papers to support their argument. 1107 Prof. Ackland said that it is worth noting that Choudhary's paper in those 210 references only cited six of the 25 references that he had included. These are the 490 T 1537. 491 Exhibit P47. -- 214 of 345 -- [2026] SADC 67 213 biomechanical related studies. He said that if he was accused of ‘cherry picking’,492 then Choudhary et al., can also be accused of cherry-picking papers to support their argument. He said that the Consensus Statement is not based on a systematic review. It has not been peer reviewed, and, in his view, gives little attention to the biomechanics literature on this topic. 1108 Prof. Ackland said he maintained his view that injury thresholds for the infant brain have not been established and that it is fraught with error to try to do so. While certain researchers have proposed these thresholds, he is not aware of any surrogate or a group of surrogates that have achieved universal acceptance regarding their ability to mimic the biomechanical responses of a live human when exposed to area-loading scenarios. 1109 Prof. Ackland said that Dr Edwards' expertise as a clinician to make diagnoses based on a set of observed signs and symptoms from a variety of sources is not in question. However, the ability to diagnose injury whether in infants, children or adults via abductive reasoning only proceeds to a likely plausible conclusion. 1110 He said this form of reasoning cannot scientifically and reliably determine the causation of these medical findings and this is especially pertinent as Dr Edwards dismisses the possibility of JR's head trauma being caused by any other means other than what occurred on 5 January 2020. Prof. Ackland said these other opportunities include, but may be not limited, to a low-force impact reported to have occurred on 30 December 2019. He said that it appeared to him that Dr Edwards is not aware of the peer-reviewed biomechanics literature. She also did not appear to be aware of the literature on paediatric neck injury which should be present in the case of shaking-only cases. 1111 Prof. Ackland said that while case studies provide useful information, they rate poorly on the level of scientific evidence because of their high risk of research bias. Case studies, even if there are multiple cases involved, do not have a controlled group to compare against and are simply ‘these people have these symptoms and these conditions and we believe, using circular argument, we believe that they were caused by abusive trauma, therefore, using the circular argument, if we see these symptoms, then this is evidence, clear evidence of abusive trauma’.493 He said that this is the problem with the many thousands of articles in the medical literature concerning abusive head trauma, that they are in the main case studies. 1112 Prof. Ackland said that he agreed with Dr Edwards, that exact injury thresholds cannot and have not been established due to all the limitations inherent in these experimental approaches, but added that the biomechanics literature has provided useful comparison data about the relative head angular accelerations for 492 T 1538. 493 T 1543. -- 215 of 345 -- [2026] SADC 67 214 infant surrogates that have been subjected to various injury inducing actions including shaking, falls, and inflicted head impacts. One would, therefore, expect that an appreciation of the biomechanics literature be considered when a forensic paediatrician seeks to opine on the causation of any observed injuries. 1113 Prof. Ackland said that in the absence of a witnessed incident, it behoves the forensic paediatrician who seeks to opine on the causation of these injuries to consider all the various alternatives in the light of the peer reviewed literature, including the biomechanics literature pertaining to the matter. It is not sufficient, to say that one's clinical experience is paramount in this endeavour and thereby dismiss the collective attempts of clinical researchers to shed greater light on the possible mechanisms of injury. 1114 Prof. Ackland said that Dr Edwards only pointed to one Consensus Statement as evidence of the ‘abundance of literature’494 to which she referred in her report and ‘at this point we have no means of assessing the research quality, the validity, or the evidence of value of these 2,000 papers’.495 Prof. Ackland said that in his experience, the great proportion of the clinical literature that he read generally contained many case studies and opinions which are of low-evidence value, hypothesising mechanisms that can never be tested. Prof. Ackland’s cross-examination 1115 In cross-examination, Prof. Ackland was questioned as to his expertise. He said that he undertook his PhD at the University of Western Australia in 1989, with the topic of the dissertation to do with the biomechanics of adolescents (aged between 10 and 16 years). He would class an infant from zero to one year of age. 1116 Prof. Ackland said that none of the journal publications, his work in exercise or sports science or commissioned book reviews referred to in his CV, relate to infants. He is not associated with any infant society in a professional capacity. 1117 He said that the request for his report came with the medical reports associated with Dr Edwards' report as appendices, and a bundle of about 25 to 30 papers on the biomechanics of what was then termed 'Shaken baby syndrome' or 'Abusive head trauma'.496 He undertook his own literature review, and he understood he had been criticised for that literature review. 1118 He was asked to focus on the issue of biomechanics and acknowledged there are thousands of reports, lots of case studies reporting on child abuse and on infant head trauma, but there is very little in the literature on the biomechanics. 1119 Prof. Ackland said that he had not provided the search terms for his own search of the literature or kept a record of them. In addition to the materials provided by the accused’s solicitor, he believed that in preparing the report, would 494 T 1545. 495 T 1545. 496 T 1548. -- 216 of 345 -- [2026] SADC 67 215 have looked at some 60 to 70 papers that had the words 'biomechanics or something similar to that in the title and in the abstract in relation to head trauma in infants’.497 1120 Prof. Ackland was, he said, not asked to do a systematic review, but to simply review the literature on this topic and agreed that in failing to provide the search terms, what he looked at could not be checked. 1121 Prof. Ackland said that he had searched both the term 'Shaken baby syndrome' and 'Abusive head trauma'.498 1122 Prof. Ackland agreed that infant anatomy is very different to the anatomy of older children and adults and conceded that the biomechanics involved in the causation of injury to a non-mobile infant is very different to the biomechanics, for example, of sporting injuries in adults and older children. 1123 Prof. Ackland agreed that he had not outlined the scientific method by which he undertook his own literature selection and had not provided the search terms that were inputted and which search engine was used. He agreed that was an important consideration to allow for a review as to whether he had undertaken an unbiased literature review. 1124 He accepted that to review literature meaningfully, it needs to be established that he was not introducing selection bias in terms of the terms that he input into the search engine. He agreed that anyone can find literature to support any proposition in the literature as a whole and that to undertake a literature review on a topic that you have no experience in, it would be very important to make sure that you were not introducing bias into that selection process. 1125 He said the list of his references contains about 25 articles and was ‘led to believe’499 that if you search 'Infant head injury' on PubMed there would be 15,885 articles. While he had not verified that, he said that he understood from Dr Edwards' criticism and pointing to a consensus paper, that there are many thousands using the term 'Infant head injury'. He did not turn his mind to checking whether her evidence which refers to there being 15,885 articles, was accurate or not. He did not dispute that to search under PubMed 'Abusive head trauma in infants' would turn up some 2,000 articles but said that very few of those would have a biomechanics theme, which is what he was asked to review. 1126 He did search the term, 'Abusive head trauma in infants’ and that the term 'biomechanics' was an important term in that filtering process. In undertaking that, his search did not turn up the Consensus Statement of 2018, which was suggested 497 T 1549. 498 T 1550. 499 T 1551. -- 217 of 345 -- [2026] SADC 67 216 to Prof. Ackland is the lead article in PubMed on abusive head trauma in infants. He said he was not aware of the article prior to 2024. 1127 Prof. Ackland said that this was the first matter involving a baby in which he had been involved. He had not had opportunity to work with paediatricians in his professional capacity in the past. 1128 It was suggested to Prof. Ackland that he did not have the knowledge base or experience to interpret the literature in a way in which he could identify that there is a body of knowledge in this area of abusive head trauma, that is the subject of outlier opinion. Prof. Ackland said that through his reading, he had come across articles of outlier opinion. In that regard he agreed that he knew there had been a lot of discussion in relation to methodological flaws and biases within the literature. 1129 Prof. Ackland said that it was worth mentioning in his report that several authors have reported that there are multiple non-abusive, accidental or natural causes that can produce symptoms associated with shaking only, shaken baby syndrome/abusive head trauma' but acknowledged that this information is not within his sphere of expertise. He said that he could not comment as to whether some symptoms can be quite non-specific as it was outside his expertise. 1130 He agreed that if a child presents with symptoms, it is reasonable for a clinician to organise investigations and would presume that it is not simply one symptom that needs to be reviewed by a clinician, but all the symptoms together. 1131 He agreed that he did not hold qualifications in forensic medicine or paediatric medicine and did not disagree that it was reasonable for a clinician to take a history from whatever source they can, and reasonable for a clinician to then review those findings with a view to targeting clinical investigations to be undertaken. 1132 Prof. Ackland agreed that in a forensic sense it is reasonable for the clinician to incorporate any information from any source that may be available to them including everything from, for example, police materials, statements, ambulance officers' accounts and the like. All that information would be considered to reasonably include or exclude matters relevant to diagnosis, and which would inform a biomechanics expert as well as a clinician. 1133 As to the prosecutor’s suggestion that it is reasonable for a clinician to look at all alternative explanations with a view to including them or excluding them in the first instance for a diagnosis, and that that diagnosis may inform the opinion as to the likely causation of injuries or presentation, Prof. Ackland said that he had no issue with what the medical practitioners do in terms of coming up with their diagnosis. The problem is when one moves from the diagnosis of an injury to causation. There are certainly things in the history that need to be considered in terms of causation, but it is not something, in his view, that can be tested. -- 218 of 345 -- [2026] SADC 67 217 1134 He said that while Dr Edwards has done a thorough job in diagnosing several conditions and injuries, taken a history, she then has, without any evidence provided, leapt to a cause of an abusive trauma. 1135 The prosecutor suggested that to cause a shearing of the bridging veins one needs a rotational force. Prof. Ackland said that it appeared from his research in this area that rotational accelerations, and therefore the force that creates, can cause these bridging vein disruptions. He said that he had not been given the opportunity to review the evidence of Assoc. Prof. Taranath. He was not aware of the locations of other bruising to the brain. 1136 He was not aware of the hypothesis that if there was a slow bleed that would be evident, and a slow bleed would compress the parts of the brain that make breathing and the heart work. He said that he was not across the medicine behind Dr Edwards’ opinion as to the timing of the injury. 1137 The prosecutor suggested that Dr Edwards had worked through the alternative causes that could have led to JR's presentation on 5 January 2020. Prof. Ackland was asked whether he accepted that a rotational force together with a direct head trauma could cause retinal haemorrhaging. Prof. Ackland said that from the literature he had read, that relationship is very sound. He said, ‘There are high levels of angular acceleration occurring when there is an impact of head with a non-compliant surface and if we understand that the angular acceleration is a measure or marker of the potential for injury, then I agree with your proposition’.500 1138 He agreed he had cited an article501 where the researchers shook the heads of lambs without impact. Prof. Ackland said that he believed there was no evidence in the literature that shaking alone can cause the magnitude of angular accelerations necessary to give rise to some conditions, including retinal haemorrhage. He said he could not comment that damage to the retinal inner nuclear layer neurons and mild patchy ganglion cells together with axonal injury sounded very much like an injury to the eye. He agreed that if those were the findings in that study that would appear to support that shaking alone can cause damage to the eyes. 1139 As to whether inferentially, if it causes that level of damage to a lamb eye, it could also be considered that that might be supportive of shaking injury causing retinal damage in a baby, Prof. Ackland said ‘It might be - it might be thought that but there are many, many assumptions and limitations in that line of theory’.502 1140 Prof. Ackland said that upon the basis of one paper he would not accept as a general tenet, the fact that shaking alone can cause injuries to a brain. 500 T 1558. 501 Finnie – article not referenced. 502 T 1559. -- 219 of 345 -- [2026] SADC 67 218 1141 He had referred to the article because the author stated that there was no retinal haemorrhaging. Whether other areas of damage are part of retinal haemorrhaging or not, is not for him to say and is a medical question. 1142 Prof. Ackland said that there were no cervical spine injuries is important in a shaking-only scenario. He added, ‘But as I understand, we are not considering a shaking-only scenario but there is good evidence that Dr Edwards has provided of cranial impact. So, the shaking-only scenario, the papers that I have reviewed suggest that the infant cervical spine should also be damaged if there is damage to the brain’.503 1143 As to the prosecutor’s suggestion that a broad review of the literature does not make out that proposition, Prof. Ackland gave the following evidence:504 A. I haven't done a broad review of the literature. I've simply looked at some of the papers involved in that and there was at least one paper that said - and the paper that I cited said that the infant cervical spine is at greater - is at greater risk than for older children because of many factors. The size of the head, the relative size and mass of the head, the structure of the cervical vertebrae, the weak musculature that supports the head. It was their conclusion, therefore, that in any shaking scenario, that one would ought to see damage to the skeletal elements of the cervical spine if, indeed, there was head injury, head trauma. Q. One article, you agree, just one. A. One article, yes. Q. How does that stack up against the consensus statement that was said to have reviewed thousands of articles before coming to a consensus statement. A. It is not - it was not my intention to provide an exhaustive review but merely to point out that at least one study had said that this should be seen in cases of shaking only. But again I'll repeat, as I understand this case is not about shaking only, this case is about an impact to the head. Q. An impact to the head and/or rotational forces. Well, together with rotational forces. A. Possibly, yes. 1144 Prof. Ackland accepted that he had no research expertise in the biomechanics relating to infants. As to whether he accepted that a lot of the research in the biomechanical literature that he reviewed on the topic of injury to infants has been undertaken jointly with paediatricians, Prof. Ackland said that his recollection was that in many cases, there were biomechanists involved and paediatricians involved in the author team. 1145 He agreed that it follows that the research was joint because it accepts the importance of incorporating clinical experience and scenarios, together with specific anatomy and biomechanics. He further agreed that also would apply to an 503 T 1559-1560. 504 T 1560. -- 220 of 345 -- [2026] SADC 67 219 interpretation of the literature in the field, namely, that to have a meaningful opinion, you need to have that experiential base. He agreed he did not hold that experiential base and had no clinical experience in biomechanics dealing with infants. 1146 Prof. Ackland agreed that except on the minor point that testing was done with infant surrogates, not infants, he had identified from the literature that infant head impacts from a variety of causes, especially those contacting non-compliant surfaces, do result in very high angular accelerations. 1147 He agreed that several studies, involving primates show that these very high angular accelerations surpass the injury thresholds for subdural haematoma and diffuse axonal injury and that the studies involved high angular acceleration forces that were sufficient to cause subdural haemorrhages and diffuse axonal injuries. 1148 He agreed that in general, it is fair to say that we do not have any reliable injury thresholds so we cannot say whether you need to drop a baby from 1, 2 or 3 metres to get a particular type of injury. He said that was because there are individual differences in these infants that would cause them to respond slightly differently from one to the other. 1149 As to whether he agreed that a lot of the biomechanical research consequently has a limited applicability to real-life clinical scenarios, Prof. Ackland said:505 that despite all the limitations of the surrogates and the biofidelic models, when those models are subjected to various scenarios of loading, they give a clear separation in the angular acceleration between striking the head, for example, on a non-compliant object, falling from various heights on to different surfaces, and shaking only. There is clear distinction between those angular accelerations under those three broad categories. 1150 He agreed that the difficulty of applying that to a clinical setting is that there will be more than one movement in life, it is not generally in a straight line or in a straight-line curve forward. He said that most of those loading scenarios will involve both translation and rotation and we do not know the specifics of how much of each. 1151 Prof. Ackland agreed that in that respect, there are just so many variables that it is not possible, in terms of the surrogates, to replicate a human infant's anatomy with any degree of accuracy in a biofidelic model. 1152 With respect to his reference to the paper by Duhaime506 Prof. Ackland agreed that in that matter, the dummy just had a hinge for a neck. He agreed that reference to a study like that does not really assist us because it is so very different from even a monkey. 505 T 1562-1563. 506 Exhibit D121. -- 221 of 345 -- [2026] SADC 67 220 1153 As to his conclusion that abductive reasoning cannot scientifically and reliably determine the causation of a child's medical findings, he agreed that a clinician has to use multiple forms of reasoning, both for diagnosis and in forming an opinion on causation, applying their knowledge and clinical experience to form an opinion. 1154 He agreed the abductive reasoning leads to the generation of a hypothesis from, for example, patient information and it would be reasonable that an examination itself and further investigations would lead to a differential diagnosis. He agreed that to get to a differential diagnosis, one might need to order a battery of tests to include or exclude a variety of alternate hypotheses. 1155 Prof. Ackland disagreed that in that respect, the likely diagnosis is based on symptoms and findings and also deductive reasoning. He said the reasoning used by Dr Edwards only gives us her opinion of the likely cause. The hypothesis that she is putting forward cannot be tested. There is so much information that she doesn't know about that she cannot be certain about the likely cause as she suggests. 1156 When asked how Prof. Ackland could hold that view without the medical background to understand the basis of her opinion, in terms of the nature of the injuries that have been reported on, Prof. Ackland said:507 In my response, all I will say is that Dr Edwards has not - does not have information about the loading scenarios that occurred on 5 January or on the days prior to that. She does not have information about the angular accelerations that occurred, the compliance of the surfaces that might have been struck etc. etc. So all she can opine on is the likelihood of a particular cause. 1157 That Dr Edwards knew there were bleeds to the brain was a diagnosis and not a cause. He agreed impact had likely caused the bleeding but the circumstances were unknown. He agreed that we know that the impact is more than the ordinary handling that a baby would endure. 1158 As to the paper by Geoghegan508 referred to by Dr Edwards, with the example of a baby thrown off the lap of another child on a swing chair, Prof. Ackland denied the child was thrown off the lap in that the paper says that the child had the infant on her lap, turned a quarter of the turn and then stopped and then the child fell off sideways. 1159 He agreed that the point of that example is that that infant did not sustain a bleed to the brain. As to whether that meant that we know that JR's impact must have been greater than that example, Prof. Ackland said:509 Again, it is likely that it’s greater but there is an individual difference between infants. [JR] was a very young child so I can’t say with any clarity whether the two circumstances are 507 T 1565. 508 T 1081. 509 T 1566. -- 222 of 345 -- [2026] SADC 67 221 the same. Just that all I can say is that there is evidence of high angular rotations from short distance falls on to noncompliant surfaces, that's all I can say. 1160 Prof. Ackland agreed that inductive reasoning helps with pattern recognition and acquiring knowledge from individual patient cases and that would be particularly so where you see a lot of patients, for example, in an emergency department where you have to make rapid decisions about treatment. He also agreed with the suggestion that it is appropriate for clinicians to use probabilistic reasoning to help assess the likelihood of differential diagnostic outcomes. 1161 As to the prosecutor’s suggestion that a relevant factor in Dr Edwards drawing inferences were because of the severity of the injuries sustained by JR, Prof. Ackland agreed it was a relevant factor and had no objection to the myriad of tests that have been performed to suggest that JR had an impact to the head. 1162 He said he would not contest that if there were such an impact to the head that would be a relevant explanation for the retinal haemorrhaging. 1163 Prof. Ackland was taken to his evidence where he had said that Dr Edwards’ opinion was that the impact must have occurred on the morning of 5 January 2020 thereby dismissing the possibility of injury occurring during a low-force impact reported to have occurred on 30 December 2019. He accepted Dr Edwards had information that a six-week-old infant has pushed off a lap into a sharp edge of a cup rest, but said that apart from that description, we know nothing about the forces and accelerations involved in that push, what the compliance of the piece of furniture that was hit was, whether it hit on an angle or was it hit on a flat surface or what part of the head was struck. Prof. Ackland said that a person who was opining on a particular scenario as not being relevant should have addressed those biomechanical aspects. 1164 Prof. Ackland was asked whether he was aware that Dr Edwards did address those topics and, in particular, whether or not there was swelling at the location and the presentation shortly after that incident to a GP. Prof. Ackland said:510 Again, these are medical areas that you're going to. What I object to is her opinion that this was a low-force impact that occurred on the 30th - there is no basis upon which to say that this was a low-force impact. 1165 Prof. Ackland agreed he had referred to the articles by Prange and Geohegan. What he objected to was Dr Edwards dismissing this as a low-force impact without any basis. Prof. Ackland agreed both of those articles related to falls from height. He agreed the sofa incident was a move under the movement of the infant of about 30 cm and would be considered a low-level fall. 1166 As to the suggestion by the prosecutor that the Prange article notes that studies of infants younger than three years have shown subdural haemorrhage, traumatic axonal injury and death are very rarely caused by impact from falls of 510 T 1569. -- 223 of 345 -- [2026] SADC 67 222 less than a metre-and-a-half, Prof. Ackland said high levels of angular acceleration have been recorded for surrogates landing from low level heights. If it is agreed that the angular acceleration is a measure of the risk of injury, then he is suggesting that the risk of injury is still high from a low-level fall onto a noncompliant surface. He said that what Dr Edwards has not done is given any information about the circumstances of that scenario. Simply to say that it was a low-force impact is not sufficient evidence. 1167 Prof. Ackland said that:511 Notwithstanding all the problems of using biofidelic models, we can get an appreciation of the magnitude of angular acceleration from various scenarios. Shaking only was very low. Activities of daily living is very low. Falls from a height are in the moderate level, you know, sort of 20-50,000 radians per second square but impacts - forceful impacts onto a stationary object, noncompliant, were much higher, around the 160,000 radians per second. So it gives us some ranges to work with but it’s not – it’s not going to tell us what was the force involved in a specific scenario. 1168 He said he could not comment on it having been thought that clinically it was not enough to cause the GP on the day to note any changes consistent with any bleed to the brain. 1169 Prof. Ackland said he did not have issue at all with Dr Edwards’ clinical basis and ‘if she reports the outcome was mild, then that's fine, but what I'm suggesting is the terminology she's using is what I object to from a biomechanics perspective’.512 1170 He said that ‘If, for example, she'd said that the impact did not elicit certain medical outcomes, I would be happy with that but what I'm objecting to is her use of the words 'low force' without any basis’.513 He said he was taking objection to the use of the words, not the eventual medical outcome. 1171 He said he was not able to assist as to whether or not one would anticipate that the legs of a six-week-old baby could or could not push off under their own weight at high force, low force or no force. 1172 As to whether he had identified any literature that shows that a drop or a fall from 30 cm could cause serious head injury, Prof. Ackland gave the following evidence:514 A. So, again, I go to the studies that I was able to review, the majority of those had used infant surrogates and what we can be sure of is the results that they obtained in terms of angular acceleration. Except for the one study by Geohegan as we've spoken about. This is a five-month-old infant, fell off the chair, a short fall, less than three feet, head first onto a wooden deck. Diagnosed with subdural haemorrhaging. 511 T 1572. 512 T 1573. 513 T 1573. 514 T 1573-1574. -- 224 of 345 -- [2026] SADC 67 223 Q. And retinal haemorrhaging. A. And retinal haemorrhaging. Q. But no brain injury. A. Not that I can recall. Q. And no skull fracture. A. Not that I can recall. Q. And in that matter, the authors commented that they suspected a rotational component from the turning of the chair prior to the fall was likely to have introduced momentum and more significant deceleration on impact. A. I find that at odds with the description of what happened when the chair rotated a quarter of a turn and stopped and the child then just fell off to the side. So I don't think we've got any data on what increase in momentum had occurred because of that rotation of the chair. All we know is that the fall was from less than three feet head first. Q. They were in the best position to make that call, though, weren't they, they watched the video of the event as it occurred. A. Yes, I am. I do agree with that. But they're - what they are saying is a little bit ambiguous. Q. Well, they said that it was likely to have introduced momentum and more significant deceleration on impact. A. Yes, that's what they'd said. But that is at odds in my view. That is at odds in my view with their description of what happened as I've just elicited. Q. You've left out what the rider was that they put in their view. They stated that they do not propose that these findings can occur after short falls. A. Yep, that's their opinion. Q. And that they believe the case to be an outlier. A. Yes. 1173 As to whether he agreed that that some initial momentum of three feet is not similar to the description of the console event on 30 December 2019, Prof. Ackland said there were many differences and many unknowns and neither he nor Dr Edwards could tell if it is the same or different. 1174 In response to the suggestion that Dr Edwards is in a position to give more of an informed opinion because of the breadth of her knowledge of both the medical side and her clinical experience, Prof. Ackland said that he did not disagree with her understanding of the medical outcomes following that event, but simply objected to her stating that it was a low-force impact. -- 225 of 345 -- [2026] SADC 67 224 1175 Prof. Ackland agreed JR sustained a life-threatening head injury and that it follows that as a matter of common sense, the forces involved in that incident were greater than the forces that appeared to have occurred in the Geohegan case. 1176 He agreed JR's injuries were the result of angular acceleration and impact, which is consistent with the findings in the Prange paper. 1177 When asked whether it was his evidence that if it is a baby shaking alone case, you would expect injury to the neck in every single case or not. Prof. Ackland said that the papers he had read on the topic suggest that if there was to be brain injury and subdural haematoma as a result of shaking only, then one would expect to see damage to the cervical spine of the infant. 1178 Prof. Ackland said that he was not aware of the evidence given by Assoc. Prof. Taranath. He was not aware that many of the children seen at the WCH with significant head injuries, for example, from car accidents, do not have neck injuries. 1179 As to Prof. Ackland having cited the article by Davison515 who concluded under a pure inertial loading mechanism analogous to shaking, the paediatric neck will sustain injury prior to the development of closed head injury, he agreed they used three-year-old equivalent crash test dummies in a sled testing run and that there are no established agreed biomechanical surrogates for an infant's neck. He further agreed that the neck of a three-year-old is going to be quite different to an infant. Prof. Ackland conceded that research has no applicability at all to a six-week-old infant and head injury. 1180 When asked whether the focus of his attention in terms of the scientific literature that he reviewed, was more on shaking-only cases or general, Prof. Ackland said that the brief was for shaken baby syndrome and abusive head trauma, so it included both inertial damage like shaking only as well as impact. He said he thought that there was more literature available in the biomechanics research area on the shaking only, but more recently there were tests done in biofidelic models on various impacts. 1181 Prof. Ackland agreed that the fact of skull fractures indicates a forceful head impact occurred but it cannot say how many newtons of force was applied and in which scenario. 1182 He could not comment on whether that even without impact you can get intracranial injuries as he is not a medical practitioner. 1183 He could not give any information as to whether it was one force coming to a stop or more than one. 515 Article not referenced. -- 226 of 345 -- [2026] SADC 67 225 1184 Prof. Ackland said that he had read the article by Choudhary but not the supplementary letter that adopts the consensus statement. 1185 With respect to the article, Prof. Ackland said:516 What I say is that they have only referenced six of the papers in biomechanics that I had cited, those six papers, and a very superficial treatment of the biomechanics papers involved. The other parts of that systematic review left me thinking that they really have not exercised good quality assurance in selecting all of those papers that they cited. What I'm suggesting is that one of the major problems is that in many of these papers they use circular reasoning; in other words, that the people who are saying that this was an abusive event are the same people who are doing the diagnosis of the injuries. 1186 Prof. Ackland said that he ‘whole heartedly agreed’517 that the Consensus Statement amounts to a flagpole and that if a constellation of symptoms is seen, the flags go up the flagpole, which will then cause investigations of a particular type to be undertaken. As to whether he thought it important that a number of learned societies across the world have come to a consensus, he agreed this was a very rare situation, and these topics need to be discussed, and consensus reached on the diagnosis and the medical conditions and point to possible causes of those conditions. 1187 In response to the suggestion that insofar as the identification of a constellation of symptoms might give a clinician a heads-up in terms of reasoning, not necessarily being circular, as it would depend on the facts of the case, Prof. Ackland said the circular part of the reasoning is involved in many of the papers that were reviewed and the circular reasoning is that they have found a constellation of symptoms, that they use those symptoms as the test of an abusive cause for those symptoms. Without any CCTV, witness statements or confession statements, many of those papers simply said 'We see this constellation of injuries, therefore, there must have been an abusive cause'.518 1188 While he agreed that there were also a number of papers that they referred to where there were admissions by the perpetrator of what had occurred, it was not many. He said he did not mention those and had not read the 210 papers that were involved. 1189 Prof. Ackland agreed that it is very hard to use modelling because of issues with scaling and very hard to apply the primate research to translate that to adults and then to translate that to infants in any meaningful way. An infant, he agreed has a large and heavy head in relation to the body, weak neck muscles and poor head control. He could not comment on an infant having a larger extra cerebral space, different laxity of the meninges, less tethering of the brain, higher water 516 T 1578-1579. 517 T 1579. 518 T 1580. -- 227 of 345 -- [2026] SADC 67 226 content of the brain, or lack of myelination in the white matter leading to an increased difference in specific gravity between the white and grey matter. 1190 He agreed an infant has a less developed skull cortex and a thinner, more pliable, less protective skull and that the loading response of the brain to applied forces would be dependent on all of those issues which vary with age which why you simply cannot mass scale from primates to infants. 1191 Prof. Ackland said that he had opportunity to read through Dr Edwards' evidence.519 1192 As to whether he was thereby aware of the fact that she has a working knowledge of biomechanics, Prof. Ackland said that he saw no evidence and had not seen her CV but agreed that she was principally concerned to do her job as a forensic paediatrician, and that part of that task is to work out the question of causation. 1193 He did not disagree with the fact that Dr Edwards would have attended conferences to stay abreast of current body of knowledge and made specific reference in her evidence to there being presentations on biomechanics. 1194 He had read that she had attended multiple conferences where biomechanical engineers presented their research and that her unit collects literature every few months and has peer-review journal clubs and biomechanical literature is included and they keep abreast of it. 1195 Prof. Ackland said he did not dispute that Dr Edwards has experience in biomechanics through her work. 1196 In her evidence she had run through the different types, or mechanisms of injury, that is, static versus dynamic impact, contact versus non-contact impact and linear versus rotational acceleration. 1197 Prof. Ackland conceded that if Dr Edwards works in a hospital where there's an accident and emergency unit, that type of unit would be seeing infants who have suffered trauma on a daily basis. He agreed that the type of head injury is an important consideration in forming an opinion, that the type of head injury is established by clinical examination and the type of head injury is also established by neuroradiology. 1198 He further agreed that it is the clinical examination and neuroradiology that allow for a conclusion to be drawn relating or regarding the likely type of force involved in the head trauma, that is, static versus dynamic and so on. He agreed that the combination of clinical examination, neuroradiology and the conclusion relating to likely forces is correlated with all other available information to inform 519 It transpired that he had been given Dr Edwards’ evidence the night before giving his evidence. -- 228 of 345 -- [2026] SADC 67 227 an opinion as to cause and that Dr Edwards is required to consider is a combination of all those factors. 1199 He also agreed that it is that combination of factors that provides the basis for concluding that JR's head injury resulted from contact and impact and dynamic impulsive forces, rotational or angular acceleration. 1200 He agreed that those injuries could have resulted from a single application of force involving rotational acceleration, impact and additional applications of force to the head could also have occurred. 1201 Prof. Ackland said he could not comment on the sudden onset of cardiorespiratory arrest allowing for the conclusion that JR had sustained an inflicted head injury immediately before the onset of symptoms on 5 January because ‘that is going down a medical road’.520 1202 As to his opinion that it behoves those who are giving evidence on causation to reject any other available, reasonable hypotheses, Prof. Ackland agreed that it was fair to conclude that his evidence is coming from a strictly scientific approach, that is, if you cannot reproduce what has occurred then, from a scientific perspective, it is not black and white certain. Prof. Ackland’s re-examination 1203 In re-examination, Prof. Ackland said with respect to the sofa incident, he was objecting to the terminology 'low force', not the medical outcome that occurred. He said that if Dr Edwards wanted to use the term 'low force', then he would have expected there would be some discussion about the degree of force that she was anticipating would have occurred at that time. He said that he was not saying that the outcome is incorrect, just objecting to the term 'low force'.521 1204 He said that as he understood it, on 5 January 2020, when JR stopped breathing, resuscitation was attempted by his father. There were ambulance officers who also attempted to resuscitate him. Prof. Ackland said that all of those are opportunities for forces to be directed towards JR's body, and those forces have not been scrutinised in terms of the amount of force. 1205 Even with a fall onto a particular point on the head, there are both linear and angular accelerations involved. He agreed that it was simply not a case of considering a linear application of force, there are many variables. 1206 Prof. Ackland said that he felt his expertise is in speaking about the many factors that are unknown in all these opportunities for energy exchange that have occurred in JR’s life. 520 T 1586. 521 T 1573. -- 229 of 345 -- [2026] SADC 67 228 1207 As to whether his lack of research expertise relevant to infants, and whether that provided a complete impediment to providing an opinion in this matter, Prof. Ackland said notwithstanding that there are differences between infants, children and adults our physiology is the same and our tissues respond under load in a similar way, even though the inference may have a different response to a child than an adult, there is still the same biomechanic factors involved in the mechanisms. Summary of Prof. Ackland’s opinions 1208 In summary Prof. Ackland’s opinion was that: • Biomechanics as the basic science of injury causation, provides a useful framework to understand the various sources of loading and to look at all possible causes of loading that might give rise to the failure of tissue. • Static loading or dynamic loading that is linear generally gives rise to focal strains on the tissue, such as a contusion to the skull or a skull fracture. • Injury thresholds are the application of forces that reach a certain level which go beyond the biological tolerance of tissue and if that force environment exceeds that tissue tolerance, then the tissue will begin to fail. It fails slowly at the start, but if the force environment increases then it will fail more quickly later. • The scientific community has not established ‘beyond reasonable doubt’ injury thresholds for infants in terms of the loading environment, because you cannot use, infants in these studies. • In the context of providing his opinion he acted on an assumption that JR’s injuries were as described. • There are many research challenges associated with determining tissue tolerance thresholds for injuries. There are not very clear and universally accepted values for the tolerance of tissues which, when exceeded, are going to cause injury in all circumstances. • The measurement of angular acceleration is crucial, and the measurement of angular acceleration can only be performed on a surrogate because of the ethical issues related to instrumenting a live child and performing such actions. • If you cannot measure what those angular accelerations are, then it is very difficult to try to apply some level of tissue tolerance. • Without a witness or CCTV evidence there is no evidence to describe the loading environment in a scenario. -- 230 of 345 -- [2026] SADC 67 229 • Medical condition, and history are important but insufficient to conduct the forensic biomechanical analysis to elucidate a definitive cause or mechanism of injury. • There are alternate causes of the injury including medical, accidental and non-accidental mechanisms. • Human tissue is sensitive to force but is unaffected by the intent of the generator of that force. • Abductive reasoning backwards from an event of the child's medical findings cannot scientifically and reliably determine the causation of the child's medical findings. While abductive reasoning, which relies on the diagnosis and the history yields a plausible conclusion, it is not one that is verified. • While he thought there was an abundance of evidence that there has been a collision to JR's skull, it is not known how that impact was caused. • Impacts to the head can occur from a small or short fall. • High levels of angular acceleration can occur when a child or an infant falls from even a small height of 30 cm onto a noncompliant surface. • There may in addition be other forms of contact by other animals, and other people, other objects, or when the child's head is deliberately hit against an object. • From his research in this area it appeared that rotational accelerations, and therefore the force that creates, can cause bridging vein disruptions. • Dr Edwards had not provided any scientific basis to underpin her assertions. • He accepted Dr Edwards has experience in biomechanics through her work. • He knew of no universally accepted scientific methodology that is free from limitations or assumptions to validate the relationship between the forces as noted by Dr Edwards and brain injury or eye injuries associated with head trauma. • The Consensus Statement is not based on a systematic or peer review and gives little attention to the biomechanics literature. • Other opportunities for impact include, but may be not limited, to a low-force impact reported to have occurred on 30 December 2019. • While case studies provide useful information, they rate poorly on the level of scientific evidence because of their high risk of research bias. -- 231 of 345 -- [2026] SADC 67 230 • In the absence of a witnessed incident, it behoves the forensic paediatrician who seeks to opine on the causation of these injuries to consider all the various alternatives in the light of the peer reviewed literature, including the biomechanics literature pertaining to the matter. It is not sufficient, to say that one's clinical experience is paramount in this endeavour and thereby dismiss the collective attempts of clinical researchers to shed greater light on the possible mechanisms of injury. • The great proportion of the clinical literature that he read generally contained many case studies and opinions which are of low-evidence value, hypothesising mechanisms that can never be tested. Dr Auer’s evidence 1209 Dr Auer gave lengthy evidence on a wide range of topics. He was highly critical of the prosecution’s medical witnesses, in particular Dr Edwards, and wholly rejected the conclusion that JR had sustained traumatic injury. He attributed JR’s condition to various alternative causes, all of which were non-traumatic in origin. Qualifications and experience 1210 Dr Auer gave evidence over several days via AVL from Canada. His CV recorded that he worked at the Royal University Hospital at the University of Saskatchewan in the Department of Pathology and Laboratory Medicine.522 1211 He described himself as a medical doctor, a scientist of brain damage and a specialist in neuropathology. He has authored 137 peer-reviewed articles with 13,341 citations and is a member of the American Board of Pathology, Neuropathology. 1212 He has a teaching role with respect to medical students, graduate students and post-doctoral fellows. He serves on various committees both provincial, national and international and has given invited presentations on 29 occasions. He serves on editorial boards reviewing various manuscripts and written forensic neuropathology books. He has given evidence in many legal proceedings including in Australia. 1213 He said that he had worked particularly in the area of children and infants. He described working in Montreal in 2013 when ‘police brought me the microscope glass slides of the ‘Palumbi’ child, and they asked me to look over them, which I did and I issued a report and that began quite intense involvement with unexplained child illnesses and child deaths.’523 1214 He said that he had been ‘contacted over my career by prosecution and defence in various countries ranging from Canada to the US, to Germany, to United 522 Exhibit D96. 523 T 1598. -- 232 of 345 -- [2026] SADC 67 231 Kingdom, New Zealand, and Australia’524 and that ‘Infants with unexplained deaths and unexplained illnesses have been referred to me over the last 12 years at a rate of roughly four per year and I have looked at the tissues of deceased infants as well as the histories of living and deceased infants’.525 Cardiorespiratory arrest due interstitial lung infection- not trauma 1215 Dr Auer said that JR did not stop breathing because of a traumatic head injury. Rather, JR suffered an interstitial lung infection which caused his breathing to stop. 1216 Dr Auer said that even the worst head injuries do not involve instant cessation of breathing due to a head strike. 1217 While bronchopneumonia can produce sputum and cannot be silent, interstitial lung disease is characteristically silent until there is collapse. 1218 Dr Auer gave evidence regarding the interval between head trauma and the eventual swelling or bleeding that can kill a child. He said these periods are usually hours to days to one week and that it is not common to see it over one week later but that it can happen.526 1219 Dr Auer said the description of JR not breathing, as provided by the accused to the 000 operator, is a history of pulmonary insufficiency, a ‘lung attack’.527 As to Dr Edwards’ opinion that this was not a recognised medical diagnosis, nor conventional clinical terminology. Dr Auer said:528 Yeah, well, we have 40 of these cases where the collapse, like a stroke which is now called a brain attack, or a heart attack is due to lung causes so we're going to use that as an easy way to make the public aware that you can collapse, also because of lung disease suddenly. And we've seen that with COVID-19 and sudden infant death syndrome is the same, sudden unexpected collapse from a lung cause. Now, Dr Edwards is quite correct, it's not general terminology but that's what Dr Green and myself are going to introduce as a simple public word that people can understand. Because we have heart attack, we have brain attack, but we don't have lung attack but we have to have the three causes of collapse are brain, heart and lung. So lung deserves its time in the sun too in this scheme of collapses. 1220 Dr Auer described Dr Edwards’ opinion that 'Breathing is controlled by the brain so problems in the brain can lead to a person stopping breathing and hence developing cyanosis when their lungs are perfectly healthy'529 as a mistake, because the brain disease does not cause failure of the circulation, and in fact, usually stimulates the circulation. He referred to a case ‘where a chicken was without a brain at all and survived for over a year because part of the medulla was intact, it 524 T 1598. 525 T 1598. 526 T 1608. 527 T 1622. 528 T 1622-1623. 529 T 1623. -- 233 of 345 -- [2026] SADC 67 232 was a farmer who didn't cut off the head properly and you don't need a brain to survive if you can breathe. So, yeah, breathing can be stopped by a brain cause.’530 1221 Dr Auer said that he was aware of the parts of the brain that keep you breathing but most of the brain is not necessary for breathing and certainly lung failure and circulatory failure does not come about from brain disease. 1222 Dr Auer had reported that ‘having stopped breathing is not a feature of head injury’531 and that ‘having a head injury preserves breathing’,532 adding that was so even if a person is struck on the head and later dies and whether the person loses consciousness or not. He said:533 …you wouldn't see severe head injuries coming into emergency all the time because they would die on the spot, if a severe head injury stopped the breathing. I mean, everybody knows that ambulances take head injuries to hospitals and people don't die on the spot before the ambulance arrives, because breathing is preserved in a head injury. And we know that from personal experience too. If we watch boxing or if we watch mixed martial arts or if we watch, really, any of the head injury inducing sports, even when the person is knocked down and loses consciousness they're still breathing. In fact, the worst head injury I know is Jeffrey Dahmer who had a crowbar taken to his head by Christopher Scarver in prison and his head was virtually pulped by the bar from the barbell. But Jeffrey Dahmer was breathing and was taken to hospital where he died an hour later. But this idea that you instantly strike someone on the head and you selectively stop their breathing is wrong. It doesn't accord with personal experience, observation, and the pattern of severe head injuries regularly being survived for that moment anyway. Boxers when they're knocked out, they're always breathing. So it's because the medulla oblongata is where the breathing is controlled and that isn't affected in a head injury. That's the reason. 1223 As to Dr Edwards’ reference to the article by Rungruangsak et al,534 and her opinion that 'It is common knowledge that some people die as a direct result of severe isolated head injury and many die immediately or within the first 12 hours because the damage to the brain leads to a cessation in breathing',535 Dr Auer said with respect to that article536: It's just not true that many die immediately as Dr Edwards says. None of them died immediately. And you have to go five hours until some die. So I could share the screen, or just say it, but it's a false statement that she's made about the articles she's quoted. Figure 4 shows none of them died immediately. 1224 He added, referring to the article:537 So here's the curve of survival in Dr Edwards' cited article and one is everybody survives. And zero is they're all dead. So this is called a Kaplan-Meier block, and here is 20 hours, 530 T 1624. 531 T 1626. 532 T 1626. 533 T 1626-1627. 534 Exhibit P100. Rungruangsak et al, Pathology of fatal diffuse brain injury in severe non-penetrating head trauma. 535 T 1627. 536 T 2062. 537 T 1627-1628. -- 234 of 345 -- [2026] SADC 67 233 10 hours. So you don't get any deaths until five hours. So I was a little surprised that she would say that many die immediately when none die immediately in the article that she quotes, which is what we know. 1225 In response to Dr Edwards’ opinion that 'The cardiorespiratory control centres responsible for controlling breathing and circulation are located within the brain and the brain stem. The damage to the brain may be primary or secondary from brain swelling and coning of the brain stem through the narrow foramen magnum at the base of the skull',538 Dr Auer said:539 The coning occurs when the medulla is wedged into the foramen magnum down here . So this is the medulla oblongata, MO, and it's wedged like an ice-cream cone here which is why it's called coning with the tonsil of the cerebellum, this is not the tonsil in your throat, and this takes hours to develop after a head injury. Again, it doesn't happen right away because the brain needs to swell and it takes hours for this to happen. That's why the patient is awake and then they go secondarily downhill when you herniate. So I'm puzzled by what she says. It's just not true. 1226 As to Dr Edwards’ comment that 'It is therefore logical that severe brain injury can impair breathing and, in some cases, terminate breathing leading to death',540 Dr Auer said:541 Yeah, well, that's not logical at all because the breathing centres are not what's first affected in a head injury. So I've mentioned Mike the headless chicken who survived without a brain and was breathing for a year and I've mentioned the most severe head injury that I know, Jeffrey Dahmer, but all the head injuries don't die on the spot with an awake person stopping breathing. It's quite the opposite. An awake person hit on the head will selectively preserve their breathing and that's how they make it to hospital all the time before someone gets there. If that wasn't true and Jane Edwards was right, we wouldn't see a plethora of people surviving severe head injuries come to hospital. We just wouldn't see that. It flies in the face of everything we know and we see. 1227 In response to Dr Edwards’ observation that JR's failing circulation was the result of his brain injury, Dr Auer said that is not how brain injury works. It does not cause a failing circulation. 1228 Referring to the article by Plunkett, 2001,542 Dr Auer observed 'This cessation of breathing is not the clinical picture of a head injury which preserves breathing selectively. Traumatic head injury, as in fatal playground falls and household falls in children, teaches us that breathing is selectively preserved'.543 As to Dr Edwards’ observation that none of the children in the series were under twelve months old, therefore the applicability to non-mobile infantile head injury is limited, and one 538 T 1628. 539 T 1628. 540 T 1628-1629. 541 T 1629. 542 Exhibit D116. Plunkett, 2001. Fatal Paediatric Head Injuries Caused by Short-Distance Fallas. The American Journal of Forensic Medicine and Pathology. 543 T 1630. -- 235 of 345 -- [2026] SADC 67 234 of the cases in the study showed that there was an apnoea as a result of the head injury, Dr Auer said:544 Well, nothing happens differently at 12 months of age to the control of breathing. It's still in the medulla oblongata. And it's in the medulla oblongata in older children as well. So it's really not material that none were under 12 months. We do know, however, that the very young, they respond to hypoxia not by hyperventilating, but by hypoventilating, when you're very young. So that's the only way I could think she's thinking of but she doesn't actually say that. And she mixes in the premise of nonmobile infantile head injury which sneaks in the premise that this is a traumatic head injury only. But all bleeding is not trauma, as we've mentioned already, but is due to leaky blood vessels and pressure. And we have those here. But certainly the playground falls all kept breathing but she's picked out one of the cases that stopped breathing for a few seconds, only seconds, not a minute, and restarted right away which is also in another article trying to make a big deal about stopping breathing after head injury. But, it just doesn't occur as an important feature of head injury. It's quite the opposite. So my response is that, yeah, the one case that stopped breathing in the Plunkett article, I know it very well because I wrote the biography of John Plunkett, one of the 18 fall-related - and these are deaths so these are more severe head injuries than [JR], these are deaths. He didn't have a traumatic head injury and he didn't have a death but even these didn't stop breathing, except one of them for a few seconds and spontaneously restarted, so that's my response there. 1229 Dr Auer said that Dr Edwards was attempting to:545 …make a big deal out of the few seconds and picks the part of the sentence without the fact that the breathing actually didn't stop permanently, it went on without resuscitation. It recovered spontaneously in a few seconds. You see that with night-time sleep as well. People stop breathing for a few seconds when they're sleeping but it conflates something that isn't happening is that breathing stoppage in head trauma isn't occurring as a mechanism of brain damage. It doesn't work that way. In head injury, it's the head injury itself when there is a head injury, not like in [JR], and when there's lung disease, it's the heart stoppage that causes the brain to be damaged. It's ischemia which means lack of blood flow. So it's not really honest to say the child had breathing stoppage due to the fall because it didn't last more than a couple of seconds. It wasn't material to the case. But Dr Plunkett is scrupulously honest and puts every detail on each of these 18 cases. But, no, none of them died due to breathing stoppage including case three that Dr Edwards actually misrepresents as a breathing stoppage that caused anything at all. It didn't. 1230 As to Dr Edwards’ observation 'Furthermore, in this discussion section of Dr Plunkett's paper, it is written apnoea and catecholamine release have been suggested as significant factors in the outcome following head injury',546 Dr Auer said:547 Yeah, well, people have written just about anything without evidence. Apnoea isn't a feature of head injury. It can be transient but it kickstarts itself. And catecholamine release is a big thing that restarts the heart and breathing in any form of circulatory arrest and there's no way to have any major life threatening event. [JR] has been called A-L-T-E, his type of stoppages, an acute life-threatening event. Another word is a B-R-U-I, brief unexplained event and B-R-U-E so all of these release catecholamines which just means 544 T 1630-1631. 545 T 1631-1632. 546 T 1632. 547 T 1632-1633. -- 236 of 345 -- [2026] SADC 67 235 adrenaline and more adrenaline and [JR] was given adrenaline by one of the ambulance people and, of course, that's necessary to survive an acute life threatening event, whatever the cause is to have a heartbeat and catecholamines stimulate the heart and they also open the bronchi for breathing via those bater receptors I mentioned before. The lung opens as well with catecholamines. So I don't see actually what this has to do with apnoea, the catecholamines. It has nothing to do with actually what she's maintaining. 1231 Dr Edwards had observed that one of the references described 28 infants with severe head injury in whom 57% had apnoea prior to hospitalisation. Dr Auer said they were not head injuries at all. They had apnoea first and then intubation and that describes not a head injury but a pneumonia. 1232 He added:548 And the keyword in that article, I pointed it out, is presumptive child abuse. It's a presumption. There's no actual evidence for it. It's just a presumption and, of course, once the doctor makes that presumption, there's no alternative but guilty verdict because child abuse is deplorable but there's no actual evidence for it. It's presumptive in that article that Dr Edwards quotes. 13 are said to be shaken impact and 15 are shaken only. We know that shaking only doesn't do anything because the brain follows the fluid that surrounds the brain and does not bobble around inside the skull for that reason. For the same reason that a boat goes down a river, same thing, the brain follows the fluid and the neck would break first if shaking was a mechanism of infantile brain damage and that fragile neck does not transmit upward from the thorax, a lethal brain trauma. It can't. It would fracture or the neck would dislocate or the neck would have both a fracture dislocation and we don't see that in these cases of alleged shaking, so her second part, the 15 shaken only doesn't make sense at all because it's been discounted by physics. 1233 In response to Dr Edwards’ evidence that the other article referenced by Dr Plunkett stated ‘Apnoea is a known response to concussive head injury hypoxic or ischaemic brain injury has been documented in a high percentage of severe head injury deaths. Apnoeic patients found at the scene of head injury are common',549 Dr Auer said:550 Yeah, well, that article, it's reference 5 in what she writes, it doesn't have any primary data. And there's no supporting data. It's a review of animal experiments. If that were true in humans that respiration stops on a severe head injury, we wouldn't have ambulances reaching hospitals with all these people with severe head injuries, because they would die on the spot. But that's actually the rule, that the ambulance picks up the person with a severe head injury and they haven't stopped breathing and that's why they're salvageable sometimes, the head injuries. There would be no such thing as chronic traumatic encephalopathy if a strike to the head would knock your breathing. We have so many sports injuries where there is repetitive head injury and if the breathing stopped on each one of them, you wouldn't accumulate the chronic traumatic encephalopathy. So none of this actually makes sense when you really dig deeper, what Dr Edwards is saying, that it just stops the breathing and that's it, nothing else. It does quite the opposite. It gives you lots of other things, head trauma, but not stoppage of the breathing. It's quite the inverse of what Dr Edwards is alleging. 548 T 1633-1634. 549 T 1644. 550 T 1644. -- 237 of 345 -- [2026] SADC 67 236 1234 As to Dr Edwards’ assertion that 'Dr Auer's misrepresentation of published literature in a medico-legal expert report, the purpose of which is to inform a court as to the current state of medical knowledge is of significant concern',551 Dr Auer said that the concern related to Dr Edwards’ report and that her statements were ‘demonstrably false’. He said that he was a brain damage scientist who had done trauma experiments with a ranking in the top 1% of scientists on Google Scholar and on ResearchGate and yet was being told he should not be testifying in court by someone (Dr Edwards):552 … who hasn't done brain trauma research or has examined brains in trauma and published on trauma… 1235 When asked by defence counsel whether Dr Edwards’ reports displayed critical thinking or analysis relevant to the articles cited, Dr Auer described them as ‘weak because she does circular reasoning, for example, it's head trauma because it's bleeding. And it's bleeding because it's head trauma and you go round in circles. So that's called circular reasoning. And it's a problem with a lot of the child abuse literature. It's circular and self-reinforcing.’553 1236 He described Dr Edwards’ opinions as ‘basically armchair theorising about brain trauma from a perspective that has an interest in it'.554 He added that he had a disinterest in trauma in that if it is ischemia or lung disease or heart disease or brain disease, he did not have a vested interest and just called it the way it is. He said he thought Dr Edwards had a tendency of bias to call it child abuse. 1237 He said that he could not find Dr Edwards’ Google Scholar profile, on Orcid or on any of the scientific database where doctors usually publish and register themselves.’555 Head injury selectively preserves breathing - boxing/MMA 1238 Dr Auer had opined that 'Careful reflection will reveal that this principle obtains as well in adult head injury from boxing and MMA, none of which selectively affect breathing, instead selectively preserve breathing'. Dr Edwards’ was said to have noted that Dr Auer had provided no reference for this statement, that is, that adult head injury from boxing and MMA selectively preserves breathing. 1239 Dr Auer said in response that:556 Yes, well, after being forced to watch hours and hours of boxing myself, which I wasn't actually interested in, and mixed martial arts I'm also not really interested in, but I have to look for cases where they go down and what happens to the breathing in severe head 551 T 1634. 552 T 1635. 553 T 1635-1636. 554 T 1636. 555 T 1636. 556 T 1638. -- 238 of 345 -- [2026] SADC 67 237 injuries because the idea of boxing is to cause a head injury. So it's the sport you have to watch and, to a lesser extent, MMA which can do it also via a kick to the liver which can end a match, but basically the two sports are head injury desirous sports. That's probably not good English. So I already had a big experience of passively watching these two to see if breathing is stopped or the corticospinal tracts are stopped first and how the head injury actually works in humans, and you don't come up with any apnoea from the head injury. And of course they have gloves in boxing and bare knuckle, which would be the allegation in [JR], but bare knuckle hit to adults preserves breathing and in a bare knuckle hit to the head of [JR], I mean it's bizarre just to discuss it because it would smash the head in and this is not a bare knuckle strike to the head of [JR]. It has nothing to do with bare knuckle fighting, which does exist, there is a resurgence of it nowadays, and everything was bare knuckle before the 1890s. But it has nothing to do with [JR], it's not trauma in the first place. 1240 Dr Edwards’ opinion was that 'It is well recognised that death can result from one-punch attacks in young otherwise healthy people due to damage to the brain (either directly from the punch or from the punch rendering a person unconscious such that they fall, strike their head on a hard surface) causing the victims to stop breathing so that their brain is starved of oxygen'.557 1241 In response, Dr Auer said that this had led him specifically to look up one- punch attacks. He said there are such attacks in violent street fighting and a few such attacks in boxing where the match is over due to one punch. He added that it is however very rare. He described having provided several relevant YouTube links. Dr Auer went on further to say that neither the street fighting nor the boxing one-punch attacks, despite being violent, feature apnoea. It was therefore the case that ‘it actually supports the opposite of what Dr Edwards is trying to promulgate, is that the one-punch knockout causes apnoea’.558 He said the three YouTube links did not feature apnoea at all, despite being one-punch violent knockouts. 1242 He said:559 So real life invalidates the imaginative argument of Dr Edwards by not featuring apnoea. And I don't think she really knows head injury that well because she just makes it up that these head injuries regularly stop breathing and lead to 911 calls. No, the breathing is what's going, what's continuing, and even the fatal head injuries with one punch, such as that of a person called Patrick Cronin, in Wikipedia didn't involve cessation of breathing. So she has invalidated her own argument by bringing up the one-punch attack. And the idea that [JR] suffered a one-punch head injury is pretty far removed from the reality of everything we know about head injury. Head injury does not work like that. 1243 Dr Auer’s opinion was that:560 Impact head injury, even when it occurs however does not selectively knock out breathing. This is apparent not only from adult injury seen in boxing and mixed martial arts but also in paediatric head injury including infants with none of these hundreds of infants having had an actual traumatic head injury showing apnoea. It is fictitious and inconsonant with 557 T 1639. 558 T 1639. 559 T 1639-1640. 560 T 1640. -- 239 of 345 -- [2026] SADC 67 238 the way a head injury works to assert that [JR]'s breathing difficulties were due to a head injury. Head injury does not selectively knock out breathing'. 1244 Dr Edwards’ response to what Dr Auer had said was as follows:561 Not all people with head injuries die and there is a spectrum of injury severity depending on how many factors, including age, individual vulnerabilities, and the mechanism of injuries, specifically the amount and type of forces imparted on the head, low force, common mild head injuries which do not cause brain injury, particularly those resulting from predominantly linear forces, would not be expected to result in any breathing difficulties. However, cessation of breathing, apnoea is a very well-recognised consequence of severe and fatal head injury resulting from rotational forces applied to the head, especially in infants. The greater the rotational forces the more likely and more severe the resultant apnoea will be. Apnoea can be centrally driven (due to primary injury to the nerves within the brain that control respiration or secondary due to brain swelling and coning with compression of the brain stem), or obstructive as a result of the result of loss of airway tone in the person who is profoundly unconscious due to the primary brain injury. 1245 Dr Auer said that the reference that Dr Edwards provided did not support the assertion she made. The reference described 53 cases of non-accidental head injury in children, but, Dr Auer said, no-one can know in the first place that they were not accidental. A head injury would look the same whether intentional or not. There is he said, a fundamental problem in the literature that Dr Edwards is quoting that you cannot know they are non-accidental in the first place, yet that is the input criteria for the study. 1246 Dr Auer was asked to comment on Dr Edwards’ observation:562 In those situations of immediate apnoea after head injury cardiopulmonary resuscitation is required, otherwise this failure of respiration will lead to death. Witnessed examples of this have been published and personal paediatric clinical experience in the emergency and forensic context over the past 20 years also corroborate this established fact. In those whose head injury leads to impaired respiration but not complete apnoea and survive for a period of time reduced oxygen delivery to the brain leads to a condition called hypoxic ischaemic encephalopathy with secondary brain swelling and injury. 1247 He said that hypoxia is not the same as ischaemia, adding that ‘you climb Mount Everest with severe hypoxia and you might get retinal haemorrhages and bleeding but you do not get encephalopathy, you actually come back from the mountain and write books, as Jon Krakauer did or as the pathologist Beck Weathers did’.563 He said:564 …the ‘whole idea of hypoxic encephalopathy the way she describes it is wrong. Hypoxia increases brain blood flow and retinal blood flow, that's why you get the haemorrhages. It's the ischaemia that causes the brain damage and Dr Edwards is conflating the ischaemia with trauma, and if you look at her reference, No.7, it doesn't support her assertions about fatal impact brain apnoea, despite being right in the title. And this is what some authors do, they want to write an article, they put something in the title, and this happens a lot in 561 T 1640-1641. 562 T 1642. 563 T 1642. 564 T 1642-1644. -- 240 of 345 -- [2026] SADC 67 239 medicine and even science, and they want to say the statement very badly, but you read the entire article and you don't find support for the assertion. 1248 Dr Edwards’ had opined that acute respiratory compromise in infants is one of the leading symptoms along with altered conscious levels and seizures associated with severe rotational head injury. Dr Auer responded as follows:565 Well, she put in a little diagram of the three axes around which injury can take place. The third one is the head flipping back and forth in the shaking paradigm, which was devised by doctors to explain dural bleeding that they couldn't explain for want of an external injury on the head, as in [JR]'s case. So that's the only one that really obtains is the third part of her diagram ….and this would require the neck to break to transmit lethal brain injury up through a fragile baby's neck at six weeks of age. And if you think of the second one called rotational here, this would require the assailant of the six-week-old baby to somehow gain purchase on the chin or side of the face in a very violent one punch, as Dr Jane Edwards says, to cause this severe rotational injury and indeed that would cause a rotational neck fracture, just as this would cause a fracture or dislocation. So the other one here in this diagram is translational, which doesn't actually obtain because the brain follows the fluid in translation. Translation just means movement through space. So none of these really obtained as a mechanism of baby brain injury and it's quite obvious why not. The physics shows that you get one 100th of the angular acceleration that you need to cause a head injury in shaking. But I won't go into all the studies of shaking here, but it's two logs or one 100th that is 1% not 10% of the angular acceleration necessary to meet head injury criteria HIC thresholds. But she invokes it nevertheless, it's been dead by physics for 20 to 25 years, but she puts it in, so there it is, that's my answer to that one. 1249 In response to Dr Auer’s opinion that ‘breathing difficulties were more likely due to an infection that resolved,’ Dr Edwards had said the paramedics found him JR not breathing, apnoeic and unconscious. There was no evidence to support Dr Auer's attribution of JR's apnoea to an infection as JR's initial chest X-rays showed no abnormality and his initial blood tests showed a normal white cell count, normal CRP level of 4.2 (inflammatory marker) and blood and urine cultures did not identify any infection.566 Dr Auer said that Dr Edwards was ‘exactly wrong’567 because JR was not breathing because of the lung disease that rhinovirus causes and the ‘near miss’ is not ruled out by a chest X-ray that is normal. 568 1250 Dr Auer referred to an article by Jain et al569 ‘where in thousands of kids, 89% show an abnormality on chest X-ray and the other 11% do not. Chest X-ray showing no abnormality, is quite characteristic of many cases with lung disease as there are not enough water and cells to block the X-rays and you do not always get an abnormal white blood cell count because viruses are like stealth. They do not always produce a big inflammatory response and a fever. But you know there's a virus because of the isolation of rhinovirus from JR’. 565 T 1644-1645. 566 T 1656-1657. 567 T 1657. 568 T 1657. 569 Exhibits D112 and D173. Jain et al, 2015. Community-Acquired Pneumonia Requiring Hospitalisation among U.S. Children. -- 241 of 345 -- [2026] SADC 67 240 1251 He also referred to an article by Auvray et al570 which he said recognised that viral infections are now recognised to cause collapse and death in children ‘increasingly as the literature accumulates’.571 1252 Dr Auer said that the 000 call by the accused sits consistently with his opinion in that the initiating thing here is ‘air hunger’,572 which is not produced by a head injury, gasping and grunting which is not produced by a head injury and struggling to breathe, which is lung disease. He added that JR is an awake child who has a cardiopulmonary arrest and is near death. 1253 As to Dr Auer’s observation that JR's blood gases showed that he was hyperventilating with a pCO2 of 52 (normal 40) and despite eight litres of oxygen per minute he had oximetry of 97%, which indicates lung disease, Dr Edwards had said that when the ambulance arrived at the home two minutes after receiving the 000 call, JR's father was doing CPR. JR was found to be in cardiac arrest. He was not breathing at all, and his heart was not pumping blood around his body. He was completely unconscious, with a Glascow Coma Scale 3. He was artificially ventilated and given fluids and adrenaline. JR did not start breathing again until 13 minutes after resuscitation commenced and when his circulation and breathing returned and his conscious level improved, the airway was removed. His oxygen saturations were then 100% whilst enroute to the hospital indicating that his lungs were working normally to oxygenate the red blood cells circulating in his blood. JR’s blood gas results clearly indicated a metabolic acidosis (high lactic acid/lactate due to an imbalance between cellular oxygen demand and supply) which she said is the expected finding after a cardiorespiratory arrest. 1254 Furthermore, Dr Edwards said that Dr Auer incorrectly interpreted JR's venous blood gas, inaccurately stating that a normal pCO2 must be exactly 40 mmHg. However, there is a normal range for carbon dioxide and a venous blood sample of between 41 to 51 mmHg. JR's CO2 level was therefore only very mildly elevated. Hyperventilation leads to a low carbon dioxide level, not high level as Dr Auer suggested. Dr Edwards said that an oximetry of above 94-95% is normal in infants. JR's oximetry and normal chest X-ray and blood test did not support the presence of lung disease.573 1255 Dr Auer responded to Dr Edwards’ as follows:574 Yeah, as the principal investigator of a laboratory that worked for 25 years measuring blood gases in all of my rats, as I was trained to do in Sweden to have physiologic control of all the blood gases, the pH, the pCO2 and the pO2, the anion gap being a secondary or derived measurement, it is quite remarkable to be lectured on this topic, when the chief advances 570 Exhibits D111 and D128. Auvray et al, 2024. Sudden Infant Death Associated with Rhinovirus Infection. 571 T1600. 572 T 1658. 573 T 1658-1659. 574 T 1660-1661. -- 242 of 345 -- [2026] SADC 67 241 we made while I was doing by PhD was just such physiologic monitoring of pH, pCO2 and pO2. Firstly I want to point out Dr Edwards is correct, I have a mistake, hypoventilating not hyperventilating gives you a high carbon dioxide, and that's what happens when the lung is not getting rid of the carbon dioxide. And the lung has two jobs with respect to gas exchange. One is getting rid of the carbon dioxide which it was not functioning to do, and that accounts for the high pO2 of 52. I never said it has to be exactly 40. But 52 is a notch up especially when there are eight litres of oxygen being ventilated and the oximetry is 97% on 100% oxygen. If you put anything in 100% oxygen you're supposed to get 100% PO2 if there's any circulation at all. It doesn't mean the lungs are working perfectly and you just need a transient decrease in lung function to have a 000 call and to have the heart fail because the heart is dependant on oxygen for minute-to-minute, or more accurately, second-to-second oxygenation. So there's no way you can say that the lungs are working well just because 100% oxygen over came the oxygenation deficit and the carbon dioxide elimination deficit of the lung disease. There's just no way you can say that it's all okay on 100% oxygen because it's going to be. Now the other thing here, Dr Jane Edwards has said that he was completely unconscious with a Glasgow Coma Scale of 3, which is 1 for eye movement, 1 for motor response and 1 for verbal response and then he turned normal when the oxygen and circulation returned. That's not a head injury. That's not how head injuries work. If you look at countless episodes of hypoxia, the Hillsborough soccer crush in England or read - if she reads my chapter on hypoxia in 'Greenfield's Neuropathology', she'll see that hypoxia is reversible and that's exactly what happened to [JR]. And the reversibility is due to the fact that oxygen lack hypoxia doesn't give brain damage. It stops the heart. And if you can get the heart going again you're okay. And that's how oxygenation and the heart work. Not manufacturing it all into head trauma. No, the anion gap is normal but the lactate is elevated because the heart was in trouble and the body starting producing lactic acid or milk acid, that acid that's produced when our legs feel like rubber when we run too fast, when we go for a run. But this absolutely is compatible with lung disease because the ventilation profusion doesn't match for a minute and then you got a 000 call. It's classic. And there are other things she mentions like carbon monoxide poisoning which I've written about in my chapter and sedative drugs but they play no role here. This is not carbon monoxide or sedative drugs. This is completely explained lung disease with a near miss sudden unexpected death in infancy almost happened. And it's only attributable to all the people involved that this child came out unscathed from this because hypoxia is a knife edge, you either stop the heart and you die or you recover and you're good. There's hardly anything in between if you don't ischemia added to your hypoxia. So it's really a knife edge. It's been said that fainting, be it hypoxic or cardiac, is the same as dying. It's just that when you faint, you come back. And when you die, you don't. But you really have a cardiopulmonary arrest and that's what happened to [JR]. This has nothing to do with head injury. And Dr Edwards working through it, the way she did, and the question you read out, actually finds that herself but she still concludes head trauma. It's quite a remarkable baseless conclusion that this is head trauma. This is rhinovirus all the way. 1256 In response to Dr Edwards’ observations that the paramedics described JR as ‘blue’575 which she said follows from when breathing ceases and the blood becomes deoxygenated and that JR did not have any evidence of pneumonia, Dr Auer said that there may not be any evidence of pneumonia until collapse occurs and the idea that you need evidence of pneumonia before you collapse is ‘dead wrong’576 and 575 T 1665. 576 T 1666. -- 243 of 345 -- [2026] SADC 67 242 that COVID has taught us that. He said it was known in babies since a seminal series of articles in the 1950s by Jacob Werne and his wife Irene Garrow that children suddenly stop breathing due to pneumonia.577 The idea that an awake infant suddenly turns blue and stops breathing from a head injury is wrong because when an infant does stop breathing due to a head injury, they are in coma. They do not stop breathing from an irritated awake state. That is not how head injury works. He said that The New England Journal of Medicine article tells us that a normal chest X-ray is perfectly compatible with interstitial pneumonia. 1257 Dr Auer had said that Vitamin D deficiency is associated with pneumonia due to immune deficiency associated with lack of this vitamin. Dr Auer maintained that JR had vitamin D deficiency and added that a head injury does not collapse in an awake infant. This was a sudden unexpected collapse on a period of irritability of an awake child and it is how pneumonia works as a silent killer. He added that happily, that did not happen in this case because most of these cases that he sees is where he is looking at the lung under the microscope. The lung gets thick and the human dies. It's very easy to die from this disease and it was almost what happened in JR’s case. 1258 He said it is known that rhinovirus can kill. While it was thought to be just a common cold virus, it is known to cause death. He described Dr Edwards’ assessment of a head injury as an ‘class error’578 commonly made, because of bleeding and that doctors often have no causes of bleeding other than trauma. Apnoea and circulatory collapse – severe rotational head injury 1259 Dr Auer described Dr Edwards’ opinion that ‘apnoea and circulatory collapse are typical manifestations of severe rotational head injury in infancy'579 as a hypothesis that's been debunked, adding that apnoea being due to a rotational head injury in infancy has never been observed once in 50 years. He said:580 You know, there has never been a video despite all the nanny cams and cameras we have at day care centres, of a collapse due to shaking. None. This whole thing is made up. And it's persistently made up into the year 2025 now when it was proposed in '73 by Caffey debunked by the turn of the millennium and now we still see this in the courts, apnoea and circulatory collapse are typical manifestations of severe rotational head injury in infancy. That's just out and out a false statement. That doesn't obtain. It's been debunked by a series of physics articles. Banner Goldsmith, John Plunkett, they wrote a very good review on it. Ommaya, Ayub is his first name. And many other biophysicists including Duhaime, who in her first paper, D-U-H-A-I-M-E, debunked it. There's not enough angular acceleration to cause what Dr Edwards says happens. It's just a mythology idea. It's a hypothesis that has no substantiation in physics. 577 Exhibits D123, D124 and D125. Werne & Garrow, 1953. Sudden Apparently Unexplained Death During Infancy (I, II, & III). 578 T 1647. 579 T 1665. 580 T 1665. -- 244 of 345 -- [2026] SADC 67 243 1260 Later in his evidence Dr Auer said:581 Yeah, I know the literature, I read it in detail. I don't make free-wheeling statements that are unsupported, I'm a researcher of brain trauma and hypoxia. I have a top 7% scientific reputation, that includes all fields of science, and Dr Edwards made a class error, classification error. She is attributing everything to trauma and with a certitude that is misplaced, that doesn't fit with the clinical picture at all that this was a severe head injury, that the child immediately recovered and is normal now from. That's just not how severe head injuries work and she has got all this one punch - one punch, sorry, it's getting late here. One-punch head injuries and it's a fictional narrative, actually, and it's very disturbing to be made by someone that has no experience in brain damage research or in looking at the tissues to provide such a strong opinion, ungirded - it's not undergirded by evidence, and it's a fallacy. I mean, Dr Plunkett wrote that such errors can have the significant potential to terribly mislead other physicians, child protection workers, the public and the courts and I actually quoted Dr Plunkett in my biography of him in my 'Science Direct' article in 'Forensic Science International'. So that's the danger here, is making a mistake and I want to tell the court I made the same mistake in my early days when I was rapidly signing out and I saw retinal bleeding and I made this mistake. It's an easy one to make, but it's so serious and it needs a hard-nosed critical thought to assess all the evidence and put it together. Lucid interval 1261 A PowerPoint presentation used by Dr Auer for teaching purposes was tendered.582 He described the document as a summary of the literature authored by neurosurgeons from the 1950’s onwards on actual paediatric head injury. He said that by reviewing the literature we see the evidence that paediatric head injury does not cause instant death and cardiac arrest. 1262 Dr Auer said it is not the exception, but rather the rule that children are usually quite clear in consciousness after a head injury, and the literature showed that lucid intervals are common.583 Dr Auer described an article by Molloy et al.,584 that studied lucid intervals, found it present in most of the children involved and that it could last up to 3 weeks.585 1263 He said however that in 1997, the child abuse literature published something entirely new by Willman et al.,586 that there are no longer lucid intervals. Dr Auer said that this was a brand-new assertion, not from neurosurgeons but from paediatricians. Only one child out of 95 had a lucid interval. Dr Auer said that when you read this paper you must note the number of babies that were eliminated from the study, possibly introducing bias. He said that read carefully, the article concludes, despite the bias of eliminating so many infants, that lucid interval in a fatal head injury is likely false. Dr Auer said it also overreaches in stating it is likely inflicted, which implies child abuse as a knowable entity with certitude. The 581 T 1674-1675. 582 Exhibit D99. Lucid intervals are the rule, not the exception. 583 T 1785-1786. Exhibit D99. Restricting the time of injury in fatal inflicted head injuries. 584 Exhibit D99. Extradural haemorrhage in infancy and childhood. A review of 35 years experience in South Australia. -- 245 of 345 -- [2026] SADC 67 244 article also states that the injury can be restricted to the time after the last confirmed period of wellness. The brain swelling is not helpful for timing. This, Dr Auer said runs against the previous many decades of neurosurgical experience and is from a centre for child protection, not from a centre of neurosurgery. The children were admitted having serious medical conditions underlying this, which, Dr Auer argued, contradicts their assertion that these are pure fatal head injuries. 1264 Dr Auer said:587 The idea that the children are both medically sick and were then assaulted causes cognitive dissonance in anybody reading this article. Serious medical conditions are referred to several times in the article and the authors do not describe what those serious medical conditions are, which may have caused the collapse and arrest. This converts all of these child cases into a whodunit rather than a what happened, and a whodunit is of course a murder presented to a court, and that is the underlying thesis of this article in 1997, which runs counter to the previous half a century of neurosurgical experience. 'The parents must be lying' is the conclusion of this article. The question 'Can an infant or young child who experiences a fatal head injury look and act well?', the answer was long known to be 'Yes' and here the answer becomes 'No' because serious medical conditions causing bleeding are mixed in and included. 1265 Dr Auer added that Dr John Plunkett stated that severe forces causing a subdural bleed, which are proposed by Dr Edwards in the present case, are thought to preclude a return to consciousness in fatal cases. This statement, Dr Auer said cannot be true because if true, you would never see an old chronic or subdural haematoma because the children would die on the spot. Dr Auer closed his analysis by saying that trauma does not always lead to immediate collapse when trauma occurs. Seizures causing haemorrhage/retinal haemorrhages 1266 Dr Auer said that hypoxia can produce seizures and that hypoxia can give rise to haemorrhages. He described hypoxia being noticed in mountain climbers and retinal haemorrhages come about because of the stretching of the blood vessels with hypoxia and the increased blood flow. It is, he said, not at all surprising that you get leakage and atraumatic haemorrhage when you have hypoxia.588 Dr Auer said that retinal haemorrhages occur when there is increased intracranial pressure. He said that there are many causes of retinal haemorrhages, some of which related to normal human activity. The seizures JR experiences were as a result of pneumonia. 1267 Dr Auer had said 'Seizures are caused by hypoxia due to inhibition of GABA, the workhorse neurotransmitter of the brain. This seizure activity is not an index of trauma and is seen in infant pneumonia. As an adjunct to that when JR was admitted to the paediatric intensive care unit, he was noted to have eye deviation from hypoxic seizures and was given Midazolam. Seizures in very young babies 587 T 1788. 588 T 1609. -- 246 of 345 -- [2026] SADC 67 245 most commonly have an hypoxic or ischaemic origin, not a traumatic origin'.589 Dr Edwards had responded that seizures can result from a number of different causes, including traumatic, infectious, metabolic and genetic and that a clinical medical assessment considers all of the circumstances of the presentation, examination findings and the result of investigations to determine the most likely cause of seizures in a particular patient. She said that:590 When there are findings of a significant primary head injury (skull fractures, brain contusions, subdural haemorrhages) as in [JR]'s case associated with sudden onset of seizure activity, it is most logical to conclude that the head injury is the underlying cause of the seizures, particularly in the absence of indicators for other seizure-causing conditions. Seizures following severe head injury in infants is extremely common, supported by literature and extensive clinical experience. 1268 Dr Auer described Dr Edwards as ‘fixated on trauma’591 having no differential diagnosis, other than trauma. He added that there was no evidence of trauma according to the paramedics and to have the violent knockout punch required, would be seen on an infant skull. He said that it was illogical to conclude a head injury is the cause of the seizures because we have hypoxia due to a virus which caused a near life-threatening experience from which, due to proper resuscitative measures and attention of the caregivers, got the child to the hospital and the child escaped scot-free without any damage whatsoever. Atraumatic cause of subdural haemorrhages 1269 Dr Auer said that JR’s bi-lateral skull haematomas were caused by a lack of oxygen or reperfusion during resuscitation, rather than by trauma. 1270 Dr Auer said that the paramedics gave JR adrenaline which increases the force and rate of contraction of the heart and constricts the blood vessels, which also increases blood pressure. It is, he said, a very powerful way to resuscitate by those three mechanisms. The side effect is that if the vessels are permeable in the body, either because of the arrest itself or because of an infection, which increases permeability, then the permeability will allow red blood cells, not only white blood cells, to escape and you will then have a traumatic bleeding, haemorrhage, bruising or oozing when that happens. 1271 He said subdural haematomas are commonly seen in babies and toddlers who are resuscitated with adrenaline because of the marked pumping of blood across leaky vessels. The vessels are being rendered leaky by the arrest itself that stimulated the resuscitation and also being rendered leaky by the infection and inflammation. If there is a virus in the body, then that permeability that is normally present increases even more and you get leakage of red blood cells and white blood cells. Viruses can have haemorrhage as part and parcel of their clinical picture. The number one cause of thin blood is infections. In addition to the leaky vessels 589 T 1646. 590 T 1646-1647. 591 T 1647. -- 247 of 345 -- [2026] SADC 67 246 is thin blood and high pressure and, in fact, the three together, the leaky vessels, the high pressure and the thin blood are the three basic set-ups for bleeding. You only need one of them and if you have more than one, there will be atraumatic haemorrhage. He said that all haemorrhages are not trauma. 1272 Dr Auer said that subdural haematoma by most physicians is reflexively associated with trauma and venous trauma, but subdural bleeding is also associated with arterial pressure and the arteries supplying the dura. Bridging veins 1273 Dr Auer said that ‘bridging veins are the only things that doctors usually know that can cause subdural haematoma, so they go straight to bridging veins and stick to them’.592 He said that bridging veins in fact are very hard to tear. Retinal haemorrhages 1274 Dr Auer said that retinal haemorrhages occurred from raised intracranial pressure or other atraumatic causes and some concern normal human activities that give rise to increased retinal blood flow and pressure. He said:593 The quickest way to explain it is by the great opthalmologist, Duane, who noticed that anything that causes a Valsalva manoeuvre will cause retinal haemorrhages, thus you have them in normal children exercising, cartwheels, yoga, tug of war, even sex in adults causes retinal haemorrhages. So they are almost a normal finding. They are often not noticed, and they can be due to seizures and hypoxia. [JR] had both seizures and hypoxia so ‘of the panoply of causes of retinal haemorrhages, we have two of them there in the form of seizures and hypoxia and we have a third in the form of increased intracranial pressure which happens in cardiorespiratory collapse. So there is a fulsome explanation of the retinal haemorrhages in the pathophysiology specifically of [JR]. 1275 When asked whether the Valsalva manoeuvre and tracheal intubation can give rise to increases in intrapulmonary pressures and give rise to retinal haemorrhages, Dr Auer referred to an article594 in which CPR was associated with retinal haemorrhage, compression of the thorax and general anaesthesia and intubation. He said that his view was that the CPR is not the guilty party, but the disease for which the CPR is given is the major player in the retinal haemorrhage, because it is that underlying the disease that causes the vascular permeability to go up and causes the resuscitation to take place with adrenalin in the first place. 1276 He said that seizures cause a massive increase in cerebral blood flow and this causes haemodynamic haemorrhages in the eye and the dura. 1277 He said that it was possible for retinal haemorrhages, to have a birth origin relevant to vacuum delivery. He added ‘there have been several studies of retinal 592 T 1604. 593 T 1612-1613. 594 Article not referenced. -- 248 of 345 -- [2026] SADC 67 247 haemorrhages and birth. One of the most comprehensive is by Rooks,595 who found that over 50% of children after birth have retinal haemorrhages, so they are almost a normal phenomenon in birth and mountain climbing.’596 1278 Dr Auer was asked whether vacuum delivery was a plausible origin given that JR was six weeks old at the time the retinal haemorrhages were diagnosed. He said:597 Yes, vacuum delivery increases the tendency to retinal haemorrhage by increasing the dynamic forces and pressures of the scalp and all the vessels are connected, as we just discussed, so it’s the fluctuations in pressures, not only from birth but also from the ventouse. Skull fractures – craniotabes – pseudofractures 1279 Dr Auer said that JR’s skull fractures were not caused by trauma and that the lesson is that all spaces between bones does not mean fracture and all fractures are not necessarily due to violent trauma. 1280 Dr Auer said JR potentially had craniotabes because his vitamin D level was 33 nmol/L which is deficient. 1281 Dr Auer said the skull in a child of JR’s age needs a lot of vitamin D to calcify otherwise bone cannot be laid down. He said that fractures in the context of vitamin D deficiency, in an infant of six weeks, can occur spontaneously in that a fracture is often mistaken for any space between the bones, and the intraparietal suture is the most common suture mistaken for a fracture. 1282 Dr Auer said that when the paramedics find no trauma and then bleeding occurs later, it is likely that there was no trauma as the initiator of the bleeding. 1283 Dr Auer said that Dr Edwards’ opinion that there was no definite relationship between newborn benign craniotabes and maternal vitamin D had been contradicted in an article in the Canadian Medical Association Journal that said that benign craniotabes is associated with vitamin D deficiency. Dr Auer described as ‘really breathtaking’598 misquoting the article by saying the opposite of what the article says. Dr Auer said that he thought that ‘Dr Edwards is stuck like a posted stamp on an envelope to trauma, but then strangely she admits that low maternal foetal vitamin D levels can produce spontaneous fractures.’599 He added that in JR’s case Dr Edwards ignores the fact that these could possibly be an anatomical variant, or pseudo-fractures that are easily mistaken for true fractures. 595 Exhibit D114. Rooks et al, 2008. Prevalence and Evolution of Intracranial Haemorrhage in Asymptomatic Term Infants. 596 T 1614-1615. 597 T 1615. 598 T 1648. 599 T 1648. -- 249 of 345 -- [2026] SADC 67 248 1284 He said that occipital pseudo-fractures, are actually anatomical variants and you can compare JR's skull to the skull in Eklund et al.,600 (Eklund) which looks quite like JR. He said by reference to both JR’s skull and that depicted in Eklund, the intraparietal suture does not reach the occipital parietal suture, making them identical. The Eklund article utilises the relevant image as evidence of a parietal pseudo-fracture, which Dr Auer said are easily mistaken by the ‘unwashed’601 for a fracture. 1285 As to Dr Edwards’ opinion that based on the radiology, it can be definitively stated that JR did not have craniotabes, Dr Auer said that ‘In the low vitamin D clinical setting of JR, it makes craniotabes quite likely and craniotabes is the first sign of vitamin D deficiency in the opinion of some writers’.602 He added that craniotabes has nothing to do with a parietal pseudo-fracture. Rather, craniotabes is the state of vitamin D deficiency of the bone in the cranium. It appears as soft bone, easily indented bone, parchment-like bone, easily fractured bone but parietal pseudo-fracture is an anatomical variant of normal at that stage of ossification of the skull. 1286 Dr Auer said that the broken bones were rendered weak due to likely vitamin D deficiency ubiquitous in babies and the biparietal skull fractures are typical for craniotabes, the skull manifestation of rickets. The fractures appear because the calcification cannot keep pace with the brain growth period thus when growth abates, rickets subside. He said that it is generally not seen in the skull at two years or beyond an that rather, it is a temporary kinetic disorder that children grow out of. Rib fractures 1287 Dr Auer said that a child’s chest is being vigorously pulled on by its own muscles, not only with every breath, but also with crying. Pathological fractures must be considered with vitamin D deficiency and JR’s rib fractures may be the result of normal growth or normal handling. 1288 Dr Auer said that the ribs broken without overlying bruising, as in a punch, is not compatible with the fractures present. He said that the chest wall and the ribs are much too small to be accounted for by an open-handed or a fist causing these fractures. They would require a very delicate small instrument and leave no trace on the overlying skin if these were externally traumatically caused. For that reason, he said he thought that with the vitamin D deficiency, they are most likely simply due to normal infant breathing and crying. 1289 As to Dr Edwards’ opinion that in his report he had not considered that trauma should be a differential diagnosis for any of JR's fractures, Dr Auer said that he did consider trauma but that it did not look like trauma in that there is no 600 Exhibit D109. 601 T 1651. 602 T 1652. -- 250 of 345 -- [2026] SADC 67 249 depression of the skull fracture and, secondly, it was a ‘dead ringer’ for parietal pseudo-fracture as seen in the comparison with the skull from Eklund603. 1290 Dr Auer said that:604 …fractures are not due to trauma, just like bleeding is not due to trauma. And it's not even established it's a fracture, I've called it a fracture but it's really a space between the bones and you cannot call every gap between bones at this stage of life a fracture. Otherwise you fall into a logical trap, like if all policemen wear blue suits, I put on a blue suit, I must be a policeman. It's a logical error called affirming the consequent. So severe head trauma gives gaps between bones, [JR] has gaps between bones, so [JR] must have severe head trauma is not a valid argument. It's a fallacy. It's a logical fallacy. But I do have trauma in the differential, it just doesn't look like trauma in any way, shape or form. 1291 Dr Auer had observed that the thorax is another region of rapid growth in a baby of JR’s age and when growth abates, the tendency to rib fractures disappears over time. Dr Edwards had described Dr Auer’s observation as unreferenced and not substantiated by any scientific evidence. She had added that specialist paediatric training in clinical experience recognises that developmentally when children begin to ambulate, certain fractures in typical locations can occur when sufficient forces can be self-generated. Normal infant growth patterns and developmental milestones do not predispose to rib fractures in the absence of externally applied forces or predisposing medical conditions affecting bone. 1292 Dr Auer said that Dr Edwards’ statement was not true at all. He said that you do not need externally applied forces to a baby. There have been reports of fractures of the foetus in utero coming just from kicking. He said it was just not true that the absence of externally applied forces means you are not going to get fractures and that you do not need a scientific reference to say toddlers have big heads and big chests compared to their limbs and bodies. It was, he said, entirely unnecessary to reference common knowledge. 1293 Dr Auer had said that producing the rib fractures would require a highly selective focus breakage of ribs without leaving a trace in the overlying skin, which he said was hard to conceive and may be a ‘fictional narrative’. 1294 In response to Dr Edwards’ opinion that:605 Infant rib fractures can result from direct focal impact or from chest encirclement and compression (squeezing). Clinical experience and extensive literature have described the common occurrence of fractures including multiple infant rib fractures in the absence of associated skin bruising. This can be explained by the presence of clothing, delay in presentation (such that bruising has resolved but healing rib fractures are still visible), and by the latter mechanism of injury. Chest encirclement and compression by adult hands can cause fracturing of the ribs in multiple locations as a result of applied forces, bending and levering the ribs underneath. The underlying ribs underneath. And at a distance from the 603 Ibid. Exhibit D167. 604 T 1653-1654. 605 T 1655. -- 251 of 345 -- [2026] SADC 67 250 externally applied forces. In this mechanism, the forces applied to the skin may not result in damage to the blood vessels within the skin so no bruising will be seen. 1295 Dr Auer responded to Dr Edwards as follows:606 Yeah, well, then she's implying hugging, carrying, chest encirclement. Children are often carried and if carrying them is trauma, then we can't carry our babies any more if their bones are weak enough. The other thing is breathing. Everybody forgets the hardest thing pulling on bones via the tendons is the muscles. And the breathing muscles are really powerful. We mentioned how loud a baby can cry and that's the internal intercostal muscles and a baby also inhales with the external intercostal muscles. To breathe, the muscles pull on the ribs pretty hard and she's fixated on external forces which in pathological fractures, and we do have vitamin D deficiency here, we don't know if we have another condition that makes fractures a virtual certainty that occurs in 2 to 4% of the population EDS607, but we for sure have vitamin D deficiency. So to discount that and abusive squeezing, you know, that's just a fictional narrative because the bones are not considered to be pathological and I don't think she's ever looked at them under the microscope. But the kind of bone we're talking about in young children in the foetus is woven bone, it's not cancellous bone or strong lamellar bone, that comes later. So I think she's just underselling how weak the ribs are, especially in vitamin D deficiency and the only thing in her differential is child abuse, which is actually illegal accusation and I've had cases where I don't make the diagnosis because the courts are supposed to do that, but I do give the evidence. And the evidence here is that the bones are weak, the fractures and the ribs could be spontaneous. There are studies of rib fractures in kids that are just found on X-rays and there are about 50% and they're call a normal finding. A study in Sweden, and I will supply that reference as well, considers rib fractures a normal finding in babies because they're so common. It's a stage of rapid growth. The child will grow out of them but by that time it's usually in a foster home or somewhere else. But this is a natural illness and it's hardly an illness because it leaves no trace in the older child. 1296 Dr Auer had observed that TR said JR was always unsettled, possibly indicative of JR being sick. Dr Edwards’ response was that many babies who are not sick appear unsettled and in JR's case we know he had healing rib fractures and a healing tibial fracture which would no doubt have caused him pain and hence he would have appeared unsettled. Dr Auer said that there were a number of errors in what Dr Edwards had written. He said that to say we know JR had healing rib fractures and a healing tibial fracture which would no doubt have caused him pain is ‘just false’608 as the pain comes from the displacement of a fracture. Fractures, do not cause any pain until you move them. JR has vitamin D deficiency and has pathological fractures and the most sensitive person to whether a child is normal is usually the mother. He said that Dr Edwards probably should know better as a paediatrician that most babies are not always unsettled. They can be consoled and in JR's case, the rib fractures did not necessarily cause pain. He added that to Dr Edwards, ‘everything is trauma, trauma, trauma with intent.’609 He said there could be trauma, but it does not fit with the whole picture. 606 T 1655-1656. 607 Later referred in evidence to as Ehlers-Danlos Syndrome. 608 T 1663. 609 T 1664. -- 252 of 345 -- [2026] SADC 67 251 Tibial fracture – stroke? 1297 Dr Auer accepted that Dr Edwards could be correct in saying that JR had a healing spiral fracture to his right distal tibia which explained TR’s observations of JR not moving his right leg properly, but that there was also the spectre of stroke in young people because viruses often cause a vascular disease in the brain. He added however that he did not know for sure and was not being dogmatic on the issue. Dr Auer’s cross-examination Qualifications 1298 In cross-examination, Dr Auer was questioned at length regarding his qualifications and experience. He agreed that he works as a pathologist at the College of Medicine at the University of Saskatchewan; does not work in the department of paediatrics; is not a paediatrician; is not a certified child abuse paediatrician and that his board certifications are not in the area of paediatrics. 1299 When it was suggested to him that his research papers do not include paediatrics, Dr Auer said that was not correct as he had published on children. He said that he would have to check his CV to see whether that related to dead children. He said that his research papers do not ‘yet’610 include abusive head trauma but that there are four papers which have been in preparation for a number of years because of other commitments. When asked whether in his practice he treats ‘live children’, he said that he was hesitating because ‘we play a major role in the treatment of children with brain tumours. We have neuro-oncology rounds where our findings and recommendations are determining the treatment of the children but that's in the arena of brain tumours not head trauma’.611 1300 Dr Auer said he had experience in paediatric neurology in his training where he was looking after children while training clinically under Dr George Hinton and had published a paper with him. 1301 He agreed that he does not treat patients when they come into Emergency. 1302 When it was suggested to Dr Auer that other than in the oncology setting, dealing with child patients or infant patients, is beyond the scope of his clinical expertise, Dr Auer said:612 Again, not really. I'm responsible for the muscle biopsy service here which involves children and often infants with early onset muscle disease, usually dystrophies, muscular dystrophies and we see babies and children with weakness. These are presented at rounds. We have clinical rounds in neuroscience, neurology, where these people can be presented and sometimes we have videos of them and older patients as well. So what you're saying is 610 T 1794. 611 T 1794. 612 T 1795. -- 253 of 345 -- [2026] SADC 67 252 by and large true that I'm not responsible for direct treatment, although because the only thing I do is make a diagnosis, that often is determinative of treatment. 1303 He agreed that he is a pathologist but said that he does not only look at slides. He looks at histories, then at the physical exam and then at the imaging, and then at slides. He agreed that he looks at slides and that his review of slides is certainly a matter within his field of expertise. He denied that the question of histories, looking at imaging and clinical matters are not within his field of expertise. 1304 He said:613 We have expertise in the clinical matters, but the clinical doctors don't have expertise in the microscopic matters. They don't look at cells, but we do look at histories and physical exams and we can interpret them in the light of the pathology. We're the only doctors that do the clinical and the pathology and that's one reason we exist to make diagnoses which is really our only function as clinical pathologists. 1305 When asked whether he is a biomechanical engineer, Dr Auer said:614 Well, that's another good question because I have a mistress called physics. I received a number of physics awards in high school. I was fourth in the province and I continue to have a lasting interest in physics. I was invited to go into physics. I had a few awards but I wanted to stay general, but I'm not a physicist professionally. I am not a professional biomechanics engineer. I do not design crash test dummies or use anthropomorphic test devices to design safety in children but I can give you the equations of a fall and I can discuss the physics of a fall with you. 1306 Ultimately, he agreed that he was not a biomechanical engineer. 1307 In response to the suggestion that he did not hold specialist qualification as a forensic paediatrician, Dr Auer said:615 That's a good question, because I don't hold formal forensic certification in anything, yet I've written a forensic book called 'Forensic neuropathology and associated neurology'. So, in answer to your question, I'm not certified in forensics, but I have a vast four-decade experience in forensics and forensics only was certified - I'm not sure about Australia, but in Canada it was only recently certified I think 15 years ago. So there wasn't any forensic to be certified in, and there certainly isn't any forensic neuropathology, and I'm not sure there ever will be that subspecialty and certification. So the answer is no to your question. 1308 Dr Auer agreed that he did not hold specialist qualifications as a forensic paediatrician or in paediatric radiology. As to qualification in radiology, Dr Auer said:616 I'm sorry for the qualification, I've published on radiology in my hypoxia chapter in 'Greenfield's Neuropathology' on how a CT scan is made, an MR scan is made and a PET scan is made. Despite that, I'm not board certified in paediatric radiology or adult radiology. 613 T 1796. 614 T 1796. 615 T 1796-1797. 616 T 1797. -- 254 of 345 -- [2026] SADC 67 253 1309 He agreed he held no qualification in nuclear medicine. As to qualification in reading MRIs, Dr Auer said:617 Well I have to qualify briefly again. I read MRIs every day when I do neuropathology. It would be crazy not to because the gross pathology, in other words, the macroscopic pathology, is the MRI scan. We receive only microscopic portions of the brain when it's looked at for infection or tumour or demyelination. So we must look at the radiology and do so on a daily basis. Sorry for that long qualification. 1310 As to opthamology, Dr Auer said that he and a colleague look at all the eyes in the province of Saskatchewan. He said that while he is not certified as an ophthalmologist but sees all the eyes in the domain of neuropathology. He sees eyes from the dead and from enucleated eyes of the living. 1311 As to qualifications in endocrinology, Dr Auer said:618 Again, we do the paediatric tumours, the pituitary adenoma and adult pituitary adenomas, and we have endocrinology attend our rounds weekly. We have two endocrinologists who we regularly interact with, and the answer is no, I'm not an endocrinologist. 1312 He said that he is presently reviewing for a number of journals but is not sitting on any international editorial boards. 1313 Dr Auer said that he had published in the Canadian Journal of Neurological Science on shaken baby syndrome in 2015 which was a peer-reviewed abstract which commented on some of his cases. He said:619 By 2015, I had a number of cases that started in Montreal when I was working there 2010 to 2015 and it started when the police brought me just over one tray of slides on a young girl who had died and, since then, I opened the floodgates, unfortunately, to other referrals which have continued unabated since then and, by 2015, I had already experience to realise that this idea of head trauma based on inference was false, so I wrote the abstract, and I also realised I better not publish it 'til I get a large number of cases and get every sentence right. So that's what's going on. 1314 When asked whether his working hypothesis as a defence expert was that head trauma is based on inference, Dr Auer said:620 No. The working hypothesis is that Dr Caffey and Guthkelch could not explain subdural bleeding in the 1970s, so they basically made it up, that this was head trauma. They were flummoxed by the lack of external evidence of trauma with a preponderance of internal bleeding. 1315 Dr Auer denied that his hypothesis is that if there is subdural bleeding, that cannot be because of trauma where there is no obvious fracture and there is no such thing as shaken baby syndrome. He said the literature shows where many of 617 T 1798. 618 T 1798. 619 T 1799. 620 T 1799-1800. -- 255 of 345 -- [2026] SADC 67 254 the babies have no fractures and it is not essential to have a fracture to have a head injury. 1316 When asked whether he was ‘agenda driven’,621 Dr Auer said that he had no agenda. He would he said:622 …like these cases to stop coming to me because I spend a lot of time doing them very carefully and I don't have an agenda other than to boring down to the truth, and I have an experience with blood flow and bleeding and, hence, I bring to the table scientific bents with a background formally in the science of blood flow and not in the science of biophysics, as you've pointed out, and that's why I want to put this to bed to rest because it's been going on for 50 years without resolution, in the courts and in the literature. 1317 He agreed that his biography on the College of Medicine website which he had written says:623 He has been called upon over the years to expert witness duty in 50 medical/legal cases testifying roughly equally between plaintiff and defence or prosecution versus defendant. This has changed recently with his testimony in cases of shaken baby syndrome (or not) resulting in more testimony for defence for families and caregivers wrongly accused. 1318 He agreed that his biography makes it very clear that his testimony is for those who he believes are wrongly accused. He added however that he had ‘a few cases, although I don't say it directly to the court, it's for the courts to decide, of child abuse myself’. 1319 When asked how having no preconception fit with his acceptance that he is giving more evidence for defence of families and caregivers wrongly accused, Dr Auer said:624 Yeah, it fits because there is no socialism in science that distributes the cases 50/50. In fact, many times someone either committed a murder or they did not. There is no in between. And that at the statistical level or epidemiological level, there is no socialism either. If children are dying, or getting sick from viruses, en masse, then I can't change that with any sort of intake criteria that would give me a 50/50 distribution. That sort of socialism in science just doesn't happen. It's often either true or it's not true. So I can't help that or fix it. It's not something I need - that needs fixing in my view. It's just whatever happens out there in the world. 1320 When the prosecutor went on to say that he was challenging Dr Auer’s earlier evidence of no preconceptions, given his acceptance that more recently he gives evidence for defence of families and caregivers wrongly accused, Dr Auer said:625 Yes, well, if most people referred to me have medical illnesses in their children and yet are going to gaol or traumatising specifically their heads, then, as a head injury expert, I'm going to rise to the occasion and accept those cases. And please note, Dr Salu, that I have 621 T 1800. 622 T 1800. 623 T 1801. 624 T 1801-1802. 625 T 1803. -- 256 of 345 -- [2026] SADC 67 255 found two cases where there has been injury by the parent or caregiver and I opine as such. But I do not take over the role of yourself in determining guilty verdicts or not guilty verdicts. I only stick to the facts, whether they fit who is contacting me or not, and I leave it to judge and jury to make the final determination. I do not, therefore, use the words 'abusive head trauma, non-accidental' because that is overstepping the bounds of what I can say and what I can know. 1321 Dr Auer agreed that his CV was out of date in that there are more publications. He agreed that his work had been tilted towards defence since 2013. He said that before that, he was equally representing mostly medical malpractice lawsuits against the Mayo Clinic for example. Dr Auer said that there are very few people who work for both sides. Cardiorespiratory arrest due to interstitial lung infection - not trauma 1322 When asked why he had avoided any working hypothesis or critical analysis of any trauma on 5 January 2020, Dr Auer said that was because JR did not show signs of trauma, but, rather, showed signs of respiratory collapse, which trauma does not cause. 1323 He added that if trauma does not cause breathing to stop, he was ‘not going to go there as a hypothesis’. He had raised that JR had a boggy scalp and had a previous injury to the head, so did not discount it entirely, but said that when a child stops breathing and goes pale, and has nothing in his mouth but is taking a breath now and then and is gasping for air, that is not a head injury in an awake child. 1324 When asked why he said JR was awake, Dr Auer said that JR was rousing and the father interpreted that as hungry, which indicates an awake child. 1325 He said that for a head injury to cause the agonal breathing observed when the father came back with the bottle, you would have a period of unconsciousness and herniation. That did not happen. He said that this was a child who was awake and stopped breathing with air hunger, which is not a head injury, but rather, is a pneumonia. 1326 Dr Auer said there does not need to be evidence of pneumonia on the radiology. In the article by Jain et al,626 in 11% of thousands of children there was no evidence for pneumonia on the radiology because the pneumonia can be invisible on chest X-ray. When Dr Auer was challenged on what the article said, he agreed that there were 2,638 of 3,803 eligible children enrolled for the purposes of the article. The prosecutor noted that the enrolment was based on the clinician's initial interpretation of the chest X-ray but that the final inclusion in the study required independent confirmation by the radiologist, and anyone who did not have pneumonia was excluded from the study. 626 Exhibits D112 and D173. Jain et al, 2015. Community -Acquired Pneumonia Requiring Hosptialisation among U.S. Children. -- 257 of 345 -- [2026] SADC 67 256 1327 It was suggested to Dr Auer that the outcome of that article was that 'The detection of pathogens in nasopharyngeal or oropharyngeal swabs with the use of a PCR assay could represent infection limited to the upper respiratory tract or convalescent phase shedding and thus detection may not denote causation'. Which it was suggested to Dr Auer, was a completely different proposition to the proposition he had put. Dr Auer said in response:627 No, it's not actually. They're looking for bacterial pathogens in the nose because that's the only place you're going to go in a baby, is in the nose. You're not going to go into the lung with a swab. You're not going to do a lung biopsy, that would be over-investigation. And because viruses go into the lung and the nasal fairings, such as Rhinovirus, you take the nasopharyngeal swab as a surrogate for the lung. The viruses do not care if it's upper or lower respiratory and they often don't even care if they're living in the bowel either which is why a lot of them are called enterovirus. 1328 Dr Auer agreed that the fact of pneumonia was clinically confirmed so there was either fever or altered white cell count. He agreed that in JR’s case there was neither of those things, adding that viruses do not necessarily cause a fever. He denied that JR had no clinical markers for pneumonia, in that there was air hunger or gasping for air. 1329 He said that the description of agonal breathing by the clinicians who attended was not accurate. JR did not die. 1330 Dr Auer said that he absolutely disagreed that the article did not make out the fact that 11% of pneumonia will not show up on an X-ray. Dr Auer said that he had ample experience on this matter. The definitive X-ray technique is not a chest X-ray, rather, it is a CT of the chest and there you can see the thickened lung that causes the collapse. 1331 Dr Auer said that the objective facts on which he based his diagnosis of pneumonia were:628 1. a cardiorespiratory collapse with breathing respiratory more than cardiac; 2. the fact that this is so common that about a million children a year have this collapse and die according to Kyu et al;629 3. with a million children around the world dying of this, a much larger number collapse of this disease; 4. pneumonia, like many other diseases, is absolutely quiet and quiescent and doesn't cause any symptoms. We've learned that from COVID but we've known that for decades. 5. hypoxia doesn't cause brain damage with immediate resuscitation despite collapse. It's the ischaemia, the lack of blood flow that causes brain damage and consistent 627 T 1807. 628 T 1814. 629 Exhibit D166. Kyu et al. Global and National Burden of Disease and Injuries Among Children and Adolescents between 1990 and 2013. -- 258 of 345 -- [2026] SADC 67 257 with [JR]'s recovery. Dr Auer added that he has published on that in his Greenfield Neuropathology chapters and in his article with Miyamoto630 in 2000. He said he is a published expert on hypoxia not causing brain damage and that is precisely what we see in [JR]. 1332 Assoc. Prof. Linke’s opinion that if there were pneumonia of a type that would impact on breathing, it would be there to be seen, was, Dr Auer said, a false statement in that ‘We have many cases where children have clear X-rays, those are plain X-rays, and then they have a CT of the chest and you can see the pneumonia that was missed’.631 1333 He agreed that he was not a practising clinician, does not review thousands of images in a year; was not a paediatrician, and that his day-to-day was not to X-rays and CTs looking for pneumonia. 632 1334 When Dr Auer was asked in those cases where he had been hired by a defence team to testify in what was being called an abusive head trauma, what percentage of those cases concerned undiagnosed pneumonia, Dr Auer said:633 Well, that's a good question. Of my cases, I have a case of liver disease in the form of Alpha-1 antitrypsin deficiency where the liver disease caused brain oedema in hepatocerebral degeneration or hepatic encephalopathy and that had no lung disease because the liver disease was affecting the brain directly and we know ammonia plays a major role. There are other cases where the child fell and has no pneumonia, although I have to qualify that in that sometimes pneumonia in toddlers causes them to fuddle even more and fall. But some kids with accidental falls, not syncope, show no pneumonia as you would expect if a very well child simply falls or is traumatised in an accidental fall. So I do have a minority of cases that don't show pneumonia and the answer to your question is these are other diseases such as liver disease or a straight fall without pneumonia, which also occurs. There was one in Alabama, a case where the child just was in hospital, fell off a wagon and died. 1335 Dr Auer agreed that in the vast majority of his matters involving children under five, he had found undiagnosed pneumonia, because pneumonia is a silent disease and because ‘about a million kids a year under five perish. So I can't help that and make it some other statistic, it is what it is’.634 1336 He agreed that those were matters where the infant or children were dead, with slides to review, but added that he was often asked to look at living children who have cardiorespiratory collapse and he had ‘trouble saying no to these cases’.635 1337 He agreed that in the vast majority of defence matters that he does, he had slides and autopsy as the foundation for his opinion of a silent pneumonia but 630 Exhibit D118. Miyamoto & Auer, 2000. Hypoxia, Hyperoxia, Ischemia and Brain Necrosis. 631 T 1816. 632 He said he reviewed ‘more like a few hundreds’. 633 T 1816-1817. 634 T 1817. 635 T 1817. -- 259 of 345 -- [2026] SADC 67 258 added that he had given five objective criteria as to why in this case, JR likely collapsed because of silent pulmonary disease. 1338 Dr Auer maintained that to say that if there were pneumonia of a type that was significant enough to stop breathing, it would have been seen on the radiology was a false statement. He added that pneumonia is not always visible on chest X-ray when a child collapses. He said that he had ‘several cases where the CT of the chest, which is much more sensitive than a mere X-ray, shows the disease and the X-ray missed the disease. In other words, if we really want to establish the radiology as the gold standard, we would have to do CT of the chest of these babies and we do not’.636 1339 He denied that if the pneumonia was sufficient to stop the breathing and the baby was revived, the lung load would continue and there would be ongoing problems with breathing. He said that most pneumonias recover and in the article by Jain et al.637 only three children died, attesting to the seriousness of the pneumonia, but most children recover. So, while a million children die around the world, most recover. When challenged with the suggestion that recovery would have been spontaneous, going from stopping breathing and going to hospital, with apparently no further problems with breathing, Dr Auer said:638 …when you faint you have a pulmonary cause and if you are resuscitated and given oxygen and your heart has not stopped, you will be normal thereafter. This is hypoxic, not ischaemic brain damage, and it accounts for [JR]'s recovery. 1340 Dr Auer said that there were symptoms of pneumonia noted on admission in the form of air hunger and collapse, but putting those aside, JR could still have pneumonia and be asymptomatic because pneumonia at the outset is asymptomatic, and in lung disease it rapidly becomes symptomatic when the ventilation doesn't match the blood flow. So, the air flow and the blood flow match and you have no symptoms, even though you have severe lung disease. 1341 As to what changed between JR’s revival and his subsequent admission to hospital to avoid further collapse, Dr Auer said that the answer is not in the anatomy but in the physiology. With most resuscitations, there is some blow-by oxygen and oxygen has two effects. One, it reverses the vasoconstriction of the blood flow. In other words, it opens the blood flow to the lung. And the second, the very act of breathing oxygen, activates the ventilation side. In the ventilation perfusion equation, resuscitation, especially with human breath that has 4% carbon dioxide, opens the bronchi and opens the vasculature, so the baby pinks up. The physiology of resuscitation, introducing oxygen and often carbon dioxide to physically resuscitate, changes everything in the physiology of the lung, unless you don't do anything further and in a few hours the child will collapse, but that doesn't happen if the child enters hospital. 636 T 1817. 637 Ibid. Exhibits D112 and D173. 638 T 1818. -- 260 of 345 -- [2026] SADC 67 259 1342 Dr Auer said that the logic is that carbon dioxide opens the bronchi, hypoxia constricts the blood vessels of the lung, oxygen opens the blood vessels of the lung. 1343 Dr Auer said he was aware of Assoc. Prof. Linke’s report of JR’s chest being clear. He said he did not include that in his report because while it is an objective piece of evidence, it does not rule out pneumonia at all, especially not a viral pneumonia. 1344 As to why he did not go through the analytical process of referring to evidence that he disagreed with, Dr Auer said:639 Yeah, that's a good question. The main answer is my report is already 23 pages long. Another answer is I don't have time to write a 50-page report or a 100-page report every time, because when I write a 25-page report, prosecution often wants more and more in the report and I just can't write a paper every time I write one of these reports, so I limit myself to 20 or 30 pages with references. It's a good question, why don't I have everything in here. I can't put everything in my reports. 1345 Dr Auer said that the bloods being clear for infection was also not a matter that troubles him and the fact that the blood is clear of rhinovirus is not disturbing at all, as it is not living there. Viruses live inside and inhabit the intracellular space of the lungs and the nose. 1346 He agreed that it was a bare coincidence that on plain X-ray JR’s lungs were clear and there is no blood picture that would confirm an infection. He added that viruses do not always give an inflammation in the blood, they can in the lymphocytes and monocytes and in neutrophils, but not always because they are so clever hiding inside the cells. 1347 Dr Auer did not agree that generally on a blood picture there would be evidence of infection, as in viral infection it is not the rule that you must have white blood cell abnormalities. Rhinovirus 1348 As to his reference to an article by Auvray et al.,640 he agreed that article concerned an infant who was less than one month old, who had died unexpectedly in his sleep, and who had enterovirus positive in their cerebral spinal fluid. CT scan of the infant’s body revealed no lesion or fracture. 641 There were areas noted on the lungs of frosted glass and condensation which are radiological findings of an issue with the lungs. Dr Auer agreed the infant died of a condition that was apparent on the radiology. 1349 Dr Auer agreed that the definition of SIDS, is: 'Sudden and unexpected death of an infant under one year of age with onset of fatal episode occurring during sleep that remains unexplained after a thorough investigation, including 639 T 1820-1821. 640 Ibid. Exhibit D 128. Evidence at T1600 641 Rhinovirus is an enterovirus. -- 261 of 345 -- [2026] SADC 67 260 performance of a complete autopsy and review of the circumstances of death and the clinical history'.642 He agreed SIDS is a diagnosis of exclusion. As to the prosecutor’s suggestion that there must be no other available cause before you can call it SIDS, Dr Auer said that if the available cause is missed and it looks like the slide shown in the article, then a mistake has been made. He said that the problem in SIDS research, is that it is a diagnosis of exclusion, but people cannot see the disease in the lungs, which they have shown in Auvray et al. Dr Auer agreed that you do not need the slide to show that, if it is visible on the radiology, but said that the radiology is non-specific. 1350 Dr Auer agreed that all Auvray et al., stands for is that viral infections can cause collapse and death in children and in that case, there were in fact findings on radiology because the condition was so bad. He agreed that was not the case with JR and there was a CT of JR on 10 January 2020 which showed clear lungs. 1351 Dr Auer agreed that you can have a positive finding of Rhinovirus for up to 30 days after an infant is symptomatic, adding that it can however persist inside the cells. 1352 Dr Auer referred to an article by Horie et al.,643 where he said they found that 8% of the human genome is made up of retroviral sequences that have embedded themselves into the human genome. He said that viruses have been incorporated into our DNA, and we have 380 trillion viruses, and we get infected as babies, which is what happened to JR. 1353 Dr Auer agreed that from the hospital records that there were no respiratory symptoms described during JR’s hospital admission. When the prosecutor suggested that on that basis it was likely JR no longer had an infection at the time of his admission, Dr Auer said:644 Yeah, well, I had a viral infection too and I got out pretty quick. I mean, these diseases can cause death and collapse or you can go home - if your immune system can handle them. Lucid interval 1354 When asked how his PowerPoint fit in with the notion that lucid intervals are the rule and not the exception, Dr Auer said it would have had to have been the fall eight days prior that caused JR’s presentation as it was the only head injury conceivable to fit with the lucid interval. 1355 In response to the suggestion that his PowerPoint presentation does not accord with the injuries that JR sustained, Dr Auer said:645 642 T 1867-1868. 643 Exhibit D169. British Analogue of Science Journal 2010, January 7, vol.463, No.7277, p.84 644 T 1875. 645 T 1824. -- 262 of 345 -- [2026] SADC 67 261 Well, it gives a thorough view to your trauma theory and that of your experts. You have requested that of me previously and I actually did that. I know about real head injury and how to differentiate it from the bleeding we see here. 1356 Dr Auer agreed that the PowerPoint confirmed that the series was limited to infants with acute subdural haematoma apparently due to minor head trauma without loss of consciousness, and not associated with cerebral contusion, that is, if the infants with subdural haematoma had a loss of consciousness, they were excluded from this article. 1357 It was suggested to Dr Auer that therefore, this article had no relevance at all to his hypothesis and that all the articles that he referred to other than one by Nobuhiko, all referred to ‘extradural haemorrhages’.646 Dr Auer said that was because trauma in infants produces extradural haemorrhages more commonly than subdural. He agreed that if there is an extradural bleed, the space is being occupied by blood and slowly compressing the brain, ultimately impacting on consciousness and/or breathing, but that ultimately takes a long time. 1358 Dr Auer agreed that the articles that he referred to related to how long it might take for a slow bleed to manifest and with slow bleeds, you get a lucid interval. 1359 As to that not being the case if there are bilateral, small-volume subdural haemorrhages, Dr Auer said that can be the case because they can ooze. When it was suggested to Dr Auer that there is no evidence of that in JR's case, Dr Auer agreed, saying that it was because JR's bleeding was ‘due to resuscitation’.647 Response to Assoc. Prof. Taranath’s opinions 1360 He said that it is not the case that if there is a primary brain injury, including brain contusions and the diffusion restriction noted on MRI, that could also lead to loss of consciousness and not breathing. He said herniation would be required to stop the breathing, and diffusion restriction, refers to the freedom of water molecules in imaging. In other words, the brain has 15-20% extracellular space for water molecules to move around in, and cerebral swelling reduces the diffusion of water molecules, that is the basis of diffusion imaging. It was, Dr Auer said, for those two reasons the statement made was incorrect. 1361 The prosecutor suggested that the failure of breathing in this case is by reason of the insult to the brain as reported on the MRI by Assoc. Prof. Taranath. Dr Auer disagreed, saying that there is no breathing control in the cerebral hemispheres. The breathing is controlled in the lower brain stem. 1362 Dr Auer agreed with Assoc. Prof. Taranath, that the imaging that he reported on is consistent with breathing stopping, but not as to the cause of the stoppage. That, he said, would be putting the cart before the horse. The breathing stoppage 646 T 1825. 647 T1825 -- 263 of 345 -- [2026] SADC 67 262 was what gave rise to the diffusion-weighted imaging abnormality, not the other way around. 1363 Dr Auer described Assoc. Prof. Taranath's evidence that there were shearing forces or rotational forces on JR's brain as ‘pure out-and-out speculation because axonal abnormality can be due to many causes, including hypoxia, and genetic abnormalities.648 He said that he published a case of axonal disease in 2015 and to say that he knows there is rotational abnormality when it's so difficult to get even purchase on a baby's face to turn it and cause that rotational abnormality is ‘out- and-out fiction’.649 1364 He said that he disagreed with the Consensus Statement in 2016 and the letter to the editor that adopts it by ‘other learned societies’.650 Dr Auer added that ‘these societies are called learned but they're not scientific research societies. They're organisations of doctors that group together and agree on something. And we once agreed the earth was flat. So the grouping of these learned organisations, they could be wrong, they're not doing scientific experiments’.651 1365 He agreed that it was his view that the Consensus Statement reflects no more than 'Group think'652 involving people invested in what they are writing, with none of them being ever having been practising scientists and doctors. He said that:653 …they often think they're scientists because they went through medical school but none of the people in that authorship, and there are 16 of them, have any science degree, have practised experimental or clinical science, the two kinds of science and they're just promoting a hypothesis. And they're promoting it in the strongest way they can, by banding together and writing an article and it's just like saying the earth is flat hundreds of years ago, it could be dead wrong and it is. 1366 While Dr Auer said that he accepted that impact from hitting a child's head on something could cause injury to the child and that acceleration is significantly higher when impact is involved, that a rotational acceleration followed by an impact would involve even higher forces was ‘made up’.654 He said that ‘they've added rotation because linear shaking doesn't do it in physics…..So this whole shaking theory, they have to add the rotation to make their sentence seem credible.’655 1367 He disagreed that in JR's case, there was inferential evidence of the shearing of the bridging veins, describing this as: 656 648 T 1827. 649 T 1827. 650 T 1828. 651 T 1828. 652 T 1828. 653 T 1828. 654 T 1828. 655 T 1828-1829. 656 T 1829. -- 264 of 345 -- [2026] SADC 67 263 The only theory they come up with for subdural bleeding. They have no other theory. And the theory of bridging veins is borne of their abject bereft explanation of the bleeding in the dura and the subdural space. If you actually take a bridging vein and stretch it, as you can do in autopsies and as I regularly do to teach residents, the bridging veins are so stretchable, they're like a brand new, out of the package, elastic band. You can stretch them to many times their original length and they just don't break, even in the tissue at autopsy that's weaker than the tissue during life. This bridging vein theory is all they have, and they've doubled down on it and it's all they mention. They have no other hypothesis, and it is just a hypothesis. 1368 Dr Auer said that shearing forces were not at play here and ‘this idea that there are shearing forces somehow coming about in [JR], from an uppercut to the jaw which is the only way to rotate that head that quickly is a fiction. It's a fiction because it's 100 times too little. The neck of the infant would break. It didn't happen’.657 1369 It was Dr Auer’s view that you cannot get any injury by shaking at all. He said that the neck would break meaning the neck would undergo a fracture of the cervical vertebrae and if it did not lead to a fracture, it would lead to a dislocation. 1370 In response to the prosecutor’s suggestion that a rotational acceleration followed by an impact would involve higher forces, Dr Auer said:658 That's like cooking, adding rotation to linear acceleration. The reason they invented shake slam, and this is what you're describing, is shake slam, I hope you accept that. Your question is shake slam because shaking doesn't do it. Shaking is two orders of magnitude short of causing head injury criteria threshold, and the neck would snap, and we don't see the neck snapped in these allegedly shaken babies, so we have to add slam. So Dr David Chadwick invented shake slam. The idea now, since shaking doesn't work, that the parent must have slammed after shaking. So it's called shake slam, and that's really your question to me, and yes for slam, no for shaking. 1371 He agreed that striking an infant's head may result in potentially different injuries than shaking. He said you cannot injure an infant's brain by shaking alone without causing neck damage and he had never seen a case of neck damage. Dr Auer’s views on ‘abusive head trauma’ 1372 Dr Auer was asked whether his views on abusive head trauma are in the minority in the medical community. He gave the following answer:659 That's a good question, because it depends which medical community. My views would be in the absolute minority, nobody would agree with me, in child abuse paediatrics. In general paediatrics, a minority of people would agree with me. In forensic pathology, about half the doctors would agree with me. In neuropathology, more than half would agree. And in biophysics, all would agree, but those are not medical doctors, so I'm not trying to evade 657 T 1830. 658 T 1831. 659 T 1832. -- 265 of 345 -- [2026] SADC 67 264 your question, but the answer to your question lies in the domain of medical doctors you're referring to. 1373 Dr Auer agreed that the majority of paediatricians believe in and support the diagnosis of abusive head trauma. He said that he did not because ‘abusive’ supplied the court with a guilty verdict, but the majority of paediatricians have to ‘buy into this’.660 1374 When asked whether he agreed that he was outside of the mainstream of both general and child abuse paediatrics, Dr Auer said:661 I'm similar to Galileo, I'm no Galileo, don't get me wrong, but I'm against the whole world in child abuse paediatrics and I'm against a lot of the practitioners of paediatrics, but many of them haven't thought about this much and don't have these cases pass through their practice. 1375 I set out below Dr Auer’s evidence in response to questions asked regarding his views with respect to abusive head trauma within the medical community:662 Q. Moving then to the broader group, the medical community, I'd suggest your views as to abusive head trauma don't accord with those held within the broader medical community. A. Well, science is not a democracy and medicine is not science. Q. Let's start with Canada. Looking to Canada, the Canadian government has recognised abusive head trauma as a valid medical diagnosis, hasn't it. A. The Canadian government has had submissions by organisations with a vested interest in keeping this alive and doubling down on it, that shaking and child abuse can be inferred by physicians through bleeding, yes, you're quite correct. Q. And in Canada they refer to it as THI-CM, is that right. A. Yes. There's a new fourth acronym in the Canadian Medical Association Journal, you're quite right. Q. What does that stand for. A. I'd have to check the article. I have the other three acronyms in my head, but I don't have that one, but I can bring it up if you like. Q. I'd suggest traumatic head injury due to child maltreatment, you'd agree with that. A. Yes. Q. Okay. Now, that notion in Canada started with a statement issued by the government of Canada in 2001, is that right. 660 T 1832. 661 T 1832-1833. 662 T 1833-1844. -- 266 of 345 -- [2026] SADC 67 265 A. I believe so, yes. Q. And that was reissued and reaffirmed in 2021. A. Yes. Q. And that statement was issued by Health Canada and the Canadian Paediatric Society. A. That is correct. Q. In that statement they suggested that shaking can cause significant injuries and death. A. Yes. They went against the article by Christian et al that shaking was not to be used anymore after 2009 and Cindy Christian's article, but you're quite correct, they stick to their guns on shaking and have doubled down on it in fact. Q. Indeed, the government of Canada recognised that bleeding to the brain, retinal haemorrhages and rib fractures or bone fractures can be signs or markers of abusive head trauma. You agree with that's what they've put in Canada, the government. A. Well, the government of Canada doesn't do head injury research or blood flow research, but yes, they've been - they've been made to say that by various organisations making representations to the government but the government themselves doesn't actually know, in fact we just had a change of government, they don't actually know anything about this. Q. I'm suggesting that the double-down, as you've put it, was supported by the Canadian Paediatric Society. Q. So I was suggesting that the acceptance of THI-CM was supported by the Canadian Paediatric Society, you would agree with that. A. Yes, it was. Q. And it was also supported by other medical organisations and societies in Canada. A. Yes. There are a total of 17 organisations and societies that support what you are promulgating. I won't let them here. Q. And that Canadian position is that shearing of the blood vessels can occur from shaking. A. Yes, the government of Canada position is that shearing of blood vessels can occur from shaking. Q. That is from a rotational force. A. That is correct. Although shaking gives you both linear and angular acceleration. Q. Now, I've taken you and you've agreed that the THI-CM was reaffirmed in 2021, you've agreed with that. A. It was reaffirmed by the words of a position statement, yes. -- 267 of 345 -- [2026] SADC 67 266 Q. Now, you're being a bit, I'd suggest, a bit cute on that, Dr Auer. You know that that was created by Public Health Canada and that a heap or very many statements were called for and a great deal of research was done before they reaffirmed the position in 2021. A. So that's not true. No research was done, unless you call research looking something up in another paper. But there was no actual scientific research done in the form of neither of the two forms of science, neither laboratory bench science, nor clinical trial. Those are the only two forms of science and in the sense of scientific research, nothing was done. But in the sense of looking up papers, you're correct. Everything was researched. But I'm using the word 'research' in a strict scientific and objective sense here. Q. I see. A. I'm not being - Q. I'll rephrase. A major review of the literature on the topic between the years 2001 and 2021 was undertaken. A. Yes, well, another major literature review was undertaken by Linert et al at the Karolinska Institutet in 2016 and got a quite different result that there's no evidence for shaking as a mechanism of brain damage. Q. That's the Swedish study. A. So there you go. I mean, the two reviews disagree completely. Q. But in terms of Canada, let's stick with Canada for the moment, the experts from multiple disciplines were involved in the review of the research. A. Yes, well, none of these multiple disciplines will go against a child abuse paediatrician because they would then appear to be promoting child abuse. Q. You would agree that the 2021 Canadian statement reaffirmed the 2001 Canadian government position. A. Yes, a government which does even less science research than the people making the statement, yes. Q. And the effect of the THI-CM government statement was that blunt force impact and/or compression or crushing force and/or internal forces and/or inertial forces, such as shaking, whiplash and rotational forces can lead to these types of injuries. A. Well, you've got everything in there, you've said about five different things and they've thrown everything in to the mix and you're quite correct. Some of them do cause injury. Some of them do not. Q. But the government position was that those are the - that's the corpus, that's the group that they consider. A. Well, head injuries are very different but lumping them all together, the government has said that, yes. -- 268 of 345 -- [2026] SADC 67 267 Q. And that the same statement indicated that you can see a variety of head, eye and bony injuries, that those are markers towards abusive head trauma-type cases. A. That's what they've said, yes. Q. And you would agree that, on the face of it, we have head, eye and bony injuries in [JR]’s matter. A. Well, when you use the word 'injury', it's a loaded word and I'm supposed to say 'Yes' to it, so I'll say 'Yes', but bones can break without an injury, bleeding can occur without an injury. Q. Now, the Canadian government statement from Health Canada also cited the 2018 consensus statement by Choudhary. A. Of course they did. Q. And that's a consensus statement from multiple medical professionals in 2018. A. It is, but no scientists. Q. And it notes that abusive head trauma is a widely accepted diagnosis in the medical community in the United States, that's correct, isn't it. A. You can't fool all the people all the time but I think it is widely accepted. Q. So your position and opinions are not only outside the mainstream position in Canada, but also the United States. A. Well, if I can give you some ammunition, the Centre For Disease Control like the Canadian government has bought into this, but about half of the court decisions in the United States have been about 50/50 on this matter. In the Nevus decision in Maryland they just don't support it at all. You can't even say shaking in that state. So the answer to your question is guarded. It's been partly accepted in vast areas, but courts are starting to wise up to this in various places, including Texas, where Robert Roberson is to be executed for this. Q. Getting closer to home for you, the Saskatchewan Health Authority website has a page about abusive head trauma, doesn't it. A. They do, yes. Q. And that website says 'Abusive head trauma is a brain injury that occurs when someone shakes a baby or throws a baby against an object, it is a form of child abuse'. You agree that it says that. A. I agree that it says that, and it conflates shaking with throwing a baby. Not dropping a baby, throwing a baby. Q. It puts them in the alternative. A. It does. Q. And, to be fair, you would agree that shaking a baby is a form of child abuse. -- 269 of 345 -- [2026] SADC 67 268 A. Well, I've shaken all my children taking them on bicycle rides, on carriers going over gravel roads, they've all been shaken. There are videos of babies on shaking machines that adjust to their own voice and hear their own voice change as they're shaken. There's no evidence that shaking alone causes anything at all. Q. Thank you. So throwing a baby against an object, you would plainly agree is a form of child abuse. A. Yes. And often the allegations are throwing a child against the wall or ceilings, that was the allegation in a New Zealand case I was involved in. Of course, throwing a baby down gives more force because you have acceleration of gravity helping you but that never seems to be what's proposed. It's always walls or ceilings. Q. So - A. Incredible. Q. Sorry, to cut across you. A. No. Q. I'm suggesting, and you don't disagree, that that quote that I've put to you is on your own employer's website. A. It's on my employer's website, but a judge agreed with me in this province recently. So it's not agreed on by the courts but it's a due rigour statement put out there by the Saskatchewan government, yes. Q. And the Saskatchewan Health Authority does not consult you about cases of suspected abuse, do they. A. They don't. But the Saskatchewan Family Justice Services do and have done so repeatedly, three times. Q. You work for the Royal University Hospital. A. I do. Q. You've reviewed their website. A. I have. Q. You'd agree that the Royal University Hospital accepts abusive head trauma as a valid diagnosis. A. They do. Q. I'm going to suggest that your own hospital's website has this, and I'll quote, 'Babies heads are easily damaged and their neck muscles are not strong enough to control the movement of the head' and then in bold 'Shaking or throwing a baby', end bold, 'can cause the head to jerk back and forth. This can make the skull hit the brain with force causing brain damage, serious vision problems or even death'. You'd agree that there are words to that effect on your own hospital's website. A. I agree there are words to that effect, yes. -- 270 of 345 -- [2026] SADC 67 269 Q. Now, that's consistent with a position taken from both the American consensus statement and from the National Centre for Shaken Baby Syndrome, and other such organisations. A. Yes. Q. And there are multiple organisations in Canada and the US that accept abusive head trauma as a valid diagnosis. A. There are multiple organisations, yes, and there is also a flatter society now. Q. And you'd agree that there are a number of other countries in which abusive head trauma is accepted as a valid diagnosis. A. Yes. But, interestingly, a whole swathe of countries where it is rejected and straight up doesn't exist, countries where you would expect violence against children. Q. For example, India and China. A. India, China, Saudi Arabia, Qatar, Russia, United Arab Emirates, Ukraine, where my wife is from. None of these countries accept this. And there is more child abuse, I can tell you personally, in those countries than there is here. Go figure. Q. In terms of your own hospital, it has a child abuse paediatrician. A. It does. I know him personally. Q. He supports the existence of child abuse head trauma as a diagnosis, doesn't he. A. Yes, he does. Q. Now, you spent 25 years at the University of Calgary. A. That's correct. Q. The University of Calgary teaches that shaking children can be harmful and cause injury, don't they. A. They have to say that. Of course they say that. Q. And, again, the University of Calgary teaches that abusive head trauma is a valid diagnosis. A. Despite being a legal accusation, it is a medical diagnosis. That is correct. Q. And I'm suggesting that it's a valid diagnosis throughout almost all of the Western world. A. That's right. This medical diagnosis of murder exists throughout all the Western world. You're quite right. Q. And abusive head trauma is taught and accepted in medical schools throughout the United States and Canada. -- 271 of 345 -- [2026] SADC 67 270 A. Yes. It has gotten into the medical school curricular, although they are backing off in many medical schools including this one. I teach a lot of medical students and they are not teaching it the way they did previously. They're teaching the more measured approach to the mechanisms of brain damage but the lectures aren't given by people who are well versed in brain damage, they're merely repeating the position statements given to them. Q. And would it surprise you if it wasn't taught in medical schools in Australia. A. That would surprise me, yes, but I don't know Australia that well. I've only been there four times. Q. Now, your position - A. Apologise for that. Q. Your positions and opinions are not taught in medical schools or residency programs in the US or Canada, are they. A. Well, my positions on subdural bleeding are, but as part of the general context of the origin of dural bleeding and it's not just me doing that, there's many, many people talking about dural bleeding being haemodynamic and atraumatic, and that's widely taught in neurosurgery. One of the first things a neurosurgeon learns is that all subdural is not due to trauma and they have to look for other causes. Q. In terms of abusive head trauma, I suggest that your views are not accepted as representing current medical thinking. What do you say to that. A. Yeah, I agree with that for medical thinking, but scientific thinking it's complete opposite. The division between medicine and science is best shown by the questions you are posing. But you're quite right in medicine and you're wrong in science. Q. And in terms of medicine, abusive head trauma and the consensus statement is what's taught. A. By and large, yes, in western countries. Q. And including in your own medical school. A. Yes, although as I've said, the latest crops of medical students have told me it wasn't taught as dogmatically as it was 10 years ago. I've been here 10 years. Q. But in that 10 years you've not been invited to teach your views on this topic at your own medical school, have you. A. Well, no, because that would go against the entire investment of child abuse paediatrics and paediatrics in general that you can infer murder from haemorrhage. It's too incendiary to have someone like me teach it. Q. And just moving broader still, the World Health Organization recognises abusive head trauma as a valid diagnosis, doesn't it. A. Yeah. -- 272 of 345 -- [2026] SADC 67 271 Q. And if we moved to the leading institution in paediatrics, that's the Royal College of Paediatrics and Child Health in the UK, they accept abusive head trauma as a valid medical diagnosis, don't they. A. Yes, any paediatrics association and any paediatric radiology association will accept this unreservedly in its entirety. Q. And, indeed, that is also so of the Royal College of Radiologists in the UK and the Royal College of Ophthalmologists in the UK, isn't it. A. Yes. As I mentioned, radiology societies, especially paediatric radiology societies, uncritically accept this and you're quite right about ophthalmology as well. My own ophthalmologist believes in shaking. Q. Okay. And the American Academy of Family Physicians - I'll list them off - American College of Surgeons, American Association of Neurologic Surgeons and the Paediatric Orthopaedic Society of North America all teach that abusive head trauma is a valid diagnosis, don't they. A. I'm not sure about the last two, the Paediatric Orthopaedic Society and the Paediatric Neurosurgical Society. I wasn't aware of that. Q. You've previously agreed to that proposition in another trial, I'd suggest. A. Well, it's hard to keep track of all the societies that promote and support this hypothesis of shaking causing an epidemic of child injury. There is, in fact, no epidemic of shaking. Q. In any event, you agree that the preponderance or the majority of the societies, medical societies, accept this as a valid diagnosis in Canada and the United States. A. Of course I agree with that fact, but that doesn't make it correct and science is not a democracy. Q. Now, the Swedish Paediatric Society, Norwegian Paediatric Association, Japanese Paediatric Society, all subscribe to and accept abusive head trauma as a valid diagnosis, correct. A. Yes, but there are many paediatricians in those societies that do not, and there are paediatricians testifying as I do, so it is not at all universally accepted. Q. Indeed, there are studies from China suggesting that abusive head trauma is a valid diagnosis, isn't that so. A. Yeah, I think I know the study you're referring to. They're trying to be western and advanced, so yes is the answer. Q. Thank you. Now, you would agree with me that, in the past, Dr Plunkett and currently yourself travel around testifying on behalf of defendants in abusive head trauma cases. A. No, I don't travel around anymore. I don't even have a passport at the moment. Q. But you give evidence in those type of matters, both in Canada, the United States and elsewhere. -- 273 of 345 -- [2026] SADC 67 272 A. I do, yes. Q. And I'd suggest there's a very small number of people giving the type of evidence that you give. A. That is correct. Science is not a majority though. Q. You made a passing comment in respect of the Swedish position, that was a report or rather a paper, that backed away from abusive head trauma, you agree. A. Well, they didn't back away from it. It did a fresh new literature review of over 1,000 papers. Q. And Sweden's own Paediatric Medical Society rejected that report, didn't they. A. The Swedish paediatricians tried to get a copy of it before they saw it published and they tried to alter the content of the paper. And the same was true of the Norwegian Paediatric Societies. So a number of letters where it's changed between these societies and they tried to meddle in the content actually, these letters were written in Scandinavian, the Norwegian language that's close enough to the Swedish language which I'm familiar with because I lived in Sweden for four years. It was nothing short of trying to alter the content of the findings and, yes, you're quite right, there was extreme nonacceptance, but the Swedish courts have generally accepted this study and it's very difficult to prosecute shaking in Sweden now. Q. I would suggest that the Swedish report represents the minority view in the world on these cases, you would agree or disagree. A. I would agree, but these people are from the Karolinska Institutet and these people are often on Nobel committees and they're a lot better scientists than me, but these people generally don't accept this, yeah, that's correct. This is the article you were referring to, I think. Skull fractures- craniotabes/Wormian bones/pseudo-fractures/vitamin D deficient rickets 1376 Dr Auer agreed that his evidence was that vitamin D deficiency is ubiquitous and this was supported by an article by Bower et al.663 1377 He agreed that the article described a vitamin D level of 25 nmol/L as deficiency and that the factors associated with maternal vitamin D deficiency in that article were maternal birthplace outside of Australia, dark-skin phenotype, wearing a veil, and younger maternal age. 1378 When it was suggested that those factors were not necessarily relevant to JR, Dr Auer said that indoor living was relevant to JR. Dr Auer said that classifying 33 nmol/L as insufficient and not deficient, were just words and that it was inaccurate to say that one is a level at which there are going to be problems and one is not, because different people have different requirements for vitamin D. 663 Exhibit D115. Bower et al, 2009. Vitamin D, PTH and calcium levels in pregnant women and their neonates. -- 274 of 345 -- [2026] SADC 67 273 Vitamin requirements are vastly different between individuals and hard-and-fast numbers as absolute cut-offs do not exist. 1379 As to Dr Edwards’ evidence that there is an agreed threshold in South Australia that 30-50 nmol/l is insufficient rather than deficient, Dr Auer said was ‘playing with words’664 and that any test must take into account the individual and that varies greatly from individual to individual. He agreed there were these ranges and JR at 33 nmol/L is ‘insufficient’665 but ‘these are not written in the sand like a hard and fast line that you can - we just need to do this to give ranges’.666 1380 As to his clinical experience with infants and vitamin D, ultimately Dr Auer said that:667 …dozens of these babies that get referred to me have either no vitamin D measurement and unexplained broken bones with indoor living or they do have vitamin D measurements that are low and still ignored. 1381 When pressed as to his clinical experience, ultimately Dr Auer said that he did not treat vitamin D deficiency. He added:668 I take it myself, as should everyone who lives indoors, but I don't have clinical experience, in answer to your question, of giving a baby under the tongue vitamin D drops so they can't spit them out, I did that with my own children, but I don't count that as clinical experience. So the answer is no, I'm not a paediatrician. I'm not a clinician who treats vitamin D deficiency except in my own children and grandchildren now. 1382 It was suggested to Dr Auer that in the Bower article ‘indoor living’669 was not a factor associated with maternal vitamin D deficiency that was raised in the article.670 Dr Auer said that he ‘threw it in’671 when he was referring to the article because the pandemic of vitamin D deficiency around the world is due to indoor living which he described as the core and the common factor responsible for the epidemic in the first place. 1383 Dr Auer said that because JR had a low vitamin D reading, therefore, his bones were more easily broken. 1384 In response to the suggestion that on the plain X-rays and CT scans, there is no mineral deficiency or deficiency in mineralisation of any of JR's bony structures, Dr Auer said that X-ray is the last way you would want to diagnose vitamin D deficiency, supported he said, by an article from a radiologist that X-rays are the worst form of examination of bone densitometry in vitamin D deficiency. 664 T 1846. 665 T 1847. 666 T 1847. 667 T 1847. 668 T 1848. 669 Ibid. Exhibit D115. 670 T 1849. 671 T 1849. -- 275 of 345 -- [2026] SADC 67 274 1385 Dr Auer agreed that JR’s alkaline phosphatase and parathyroid hormone levels were normal, but said that they would not necessarily be elevated if rickets were present. He disagreed that for rickets to be diagnosed, there needs to be elevated alkaline phosphatase and parathyroid hormone levels and abnormal radiology. He said that they were criteria that some people want all the time, but broken bones themselves can be a manifestation of vitamin D deficiency and placing those three criteria out as the gold standard for rickets is simply wrong. 1386 When asked whether he was aware that was the way paediatricians diagnose rickets, he said:672 Well, yes, paediatricians also diagnose murder by the bleeding. I mean, it could be wrong, we have to accept that what you've said could be wrong. 1387 Dr Auer accepted that his opinion in this respect was that of an ‘outlier’.673 Ehlers Danlos syndrome 1388 Dr Auer said that rickets often occurs together with other risk factors for bone fragility. He said the commonest other factor is Ehlers-Danlos syndrome which can be completely silent in a baby and an adult because they have never been tested for it and don't know they have it. He said that there are a number of factors giving a score for Ehlers-Danlos and it is relevant because it is 2-4% of the population, it has no genetic test, and it is a common second factor together with vitamin D deficiency that is commonly missed due to the commonality of Ehlers -Danos syndrome. 1389 While Dr Auer agreed that there was no suggestion of Ehlers-Danlos in this case, he said that may be because no one was looking for it ‘and they're all going head-long into child abuse, it's one of the defects of these cases’.674 1390 He disagreed that if JR suffered from Ehlers-Danlos, you would expect that he would have had multiple attendances for broken bones. 1391 Dr Auer was later challenged with respect to his evidence regarding the possibility of JR suffering from Ehlers- Danlos syndrome and stating that this condition affects 2-4% of the population, Dr Auer disputed the Ehlers-Danlos society’s website figures of the approximate prevalence of Hypermobile Ehlers- Danlos to be one in 3,100 to one in 5,000. He said that the article to which he had referred perhaps cited a minimum prevalence of one in 5,000, but the problem with that is many people simply do not know they have it. 1392 Dr Auer maintained that although the article cited one in 5,000 of the population which would be .02%, his increase by a factor of a thousand, to 2-4% of the population was correct. 672 T 1852. 673 T 1852. 674 T 1853. -- 276 of 345 -- [2026] SADC 67 275 1393 Dr Auer said:675 If you do a Beighton score on mothers and biologically related parents to children who allegedly have been abused, you will find an astounding incidence of Beighton scores higher than six and the incidence given by an expert on Ehlers-Danlos syndrome, Dr Michael Holick, is around 2%, that is one in 50 people of the population, and he runs an Ehlers-Danlos clinic in Massachusetts in Boston. And there's also the article by Tinkle et al, which I'm not sure you're referring to. And this is not as rare as was once thought. Many people have hypermobile joints and are good in gymnastics. There are the bone breakers on YouTube, four gentlemen, who probably don't know they have Ehlers-Danlos, and it is much more common than realised. So I take exception to your maligning my views as artificially inflating the incidence of Ehlers-Danlos. I am not. 1394 Dr Auer said that he took .02% from an article and inflated it to 2-4%, because he had seen world experts in Ehlers-Danlos syndrome such as Dr Holick give evidence and seen his slide shows and his clinic evidence that this is not at all rare. He said that Ehlers-Danlos consists of many subtypes and the common hypermobile form which has no genetic test. 1395 Dr Auer said it was a ‘false statement’676 to suggest there was nothing in the literature linking Ehlers-Danlos to an increased risk of rib fractures and referred to the article by Holick,677 which he agreed was an article based on a population of infants referred for a second opinion as they were originally diagnosed with child abuse. While Dr Auer conceded that on that basis alone, there was a significant selection bias in that study, he added that ‘and courts of law are a concentration of cases that doctors don't understand’. 1396 When asked whether he was aware of the more recent articles by Rolfes et al.,678 and Yeung et al679 that found no infants with a confirmed diagnosis of the common forms of Ehlers-Danlos syndrome had any fractures in infancy in the first year of life, Dr Auer said he was not immediately aware of them but the names triggered recognition. He said those papers did not have a concentration of cases that appear in courts of law and would be closer to population-based studies. 1397 As to the prosecutor’s suggestion that if the studies confirm that no infants with a confirmed diagnosis of the common forms of Ehlers-Danlos had any fractures in the first year of life, that would be even more compelling, Dr Auer said he would have to read the articles to comment on them and was not going to do that without reading them and being provided with at least their location. He added he could look them up himself. 675 T 2027. 676 T 2028. 677 Article not tendered. 678 Exhibit P131. Rolfes et al, 2019. Fracture Incidence in Ehlers-Danlos Syndrome – A population based case-control study. 679 Exhibit P132. Yeung et al, 2024. Fracture Prevalence in Children Diagnosed with Ehlers-Danlos Syndrome and Generalised Joint Hypermobility. -- 277 of 345 -- [2026] SADC 67 276 1398 It was pointed out to Dr Auer that in evidence he had referred to the occurrence of Ehlers-Danlos syndrome as between 2-4%. He was asked whether he had been ‘caught out just making up numbers.’680 Dr Auer said that he was not intentionally making things up for the court to mislead but rather, was trying to lead the court to the truth which is that Ehlers-Danlos is quite common in children. Dr Auer said:681 Paediatricians are making the grossest of errors and, if I make a 1-2% and a 3-4% error, that's made a big deal of. I can be taken to task and dressed down in court for a 1% error and they're in the wrong galaxy of trauma for everything fitting a square peg into a round hole and they have no consequences at all. They keep doing that, and I think there's some prejudicial unfairness in the way the experts are treated, I'm pretty certain about that. 1399 Dr Auer said that he was not surprised about the negative result for osteogenesis imperfecta, which he described as ‘a distant bronze medal in the missed diagnoses for infant broken bones’.682 1400 Dr Auer disagreed that absent a diagnosis of rickets, there was no predisposition to easily broken bones, Dr Auer said that with a vitamin D level of 33 nmol/L there a low vitamin D level and multiple broken bones and when you have multiple fractures, it speaks more to a metabolic bone disease affecting the entire skeleton than it speaks to polytrauma because polytrauma would not be expected with so many broken bones. 1401 With respect to the Consensus Statement and the fact that multiple unexplained broken bones is an indicator towards abuse, Dr Auer said that 'unexplained', therefore it is child abuse, is the error in that Consensus Statement.683 1402 When it was suggested to Dr Auer that if breathing or crying was a routine cause of rib fractures, it would be a common observation by clinical paediatricians on all babies presenting for X-ray or investigation at emergency, Dr Auer said that rib fractures are common and almost an incidental finding. He cited the Journal of Paediatric Endocrinology and Metabolism,684 vol.34, pp.363-373 which he said showed that ‘rib fractures are almost normal, and they lead to false positive cases of child maltreatment’.685 1403 Dr Auer agreed that if they were, in fact, as common as he asserted, they would not be of any diagnostic benefit or weight in terms of the forming of the Consensus Statement. 1404 As to the article by Eklund686 and pseudo-fractures, Dr Auer agreed that his evidence was that they are common. With respect to the author’s comment that 680 T 2099. 681 T 2100. 682 T 1854. 683 T 1854. 684 Article not tendered. 685 T1856. 686 Ibid. Exhibit D167. -- 278 of 345 -- [2026] SADC 67 277 'Partial complete division of the parietal bones resulting in anomalous cranial sutures is a rare entity', Dr Auer said:687 So I'm not sure you've heard this before, but rare things are common. By that, we're not trying to be cute or anything, but if you take rare things in aggregate in certain arenas, such as courtrooms, you find rare things are not rare at all, they're quite common, and we find that in rare metabolic diseases, we find that in anatomical variants that nobody is looking for and you can say they are rare at the same time as you can say that they're common, and that's not a oxymoron. If you look at court cases, you have a distillation of the unexplained by doctors and rare things become common in courtrooms for that reason, because the doctors can't explain it. 1405 Dr Auer said he did not know the incidence in the general population by age of intraparietal sutures but had ‘seen it many times.’ As to the author quantifying the finding as in three in 25,000 skulls examined by cranial radiograph, and the opening line, of the article reading, 'Division of the parietal bone by accessory sutures is a rare occurrence with few case reports published in the medical literature,’688 Dr Auer said:689 Yeah, you're quoting me this sentence here. That has actually no meaning if you're the one with the intraparietal suture. So saying something is common, as you've done here with this sentence in this article, has no meaning if you have all of that disease, or all of that anatomical variant, then your whole life will be upended by it, not three out of 25,000, but a hundred percent. So this idea that something is rare or common really has no meaning for the individual who actually has it. I think you're referring to this phrase, are you? 1406 He went on:690 Three out of 25,000 skulls examined by cranial radiograph', but if you're one of those three and you're going to prison because some doctor mistakes it as a fracture, that rarity has no meaning for you, or as David Chadwick said, short falls kill one in a million children, but if you're that one in a million, it's all of a childhood deaths, but not part of a childhood death. So this rarity thing, yeah, you give the incidence, but it doesn't mean it doesn't happen. 1407 While Dr Auer agreed the findings were bilateral and symmetrical on both the right and left which was not the case with JR, he said that asymmetric findings were entirely expected in JR given he fell on one side, referring to the sofa incident. Dr Auer agreed that it was not a short-distance fall but that the skull of a six-week- old baby at autopsy is just 2 mm thick, ‘it has the consistency of parchment more than bone and those cup holders and that impact is entirely sufficient to cause asymmetry in the parietal bones that you mentioned.’ 1408 When challenged with respect to that answer, Dr Auer said he did not know if pushing by JR into the centre console of the sofa did not cause a skull fracture, 687 T 1856-1857. 688 T 1857. 689 T 1857. 690 T 1857-1858. -- 279 of 345 -- [2026] SADC 67 278 but that it could. It was he said, not his evidence that would also lead to the intracranial bleeding that JR sustained. 1409 When challenged as to the relevance of his PowerPoint, on the topic of delay, Dr Auer gave the following evidence:691 A. Well, that was given to you because I teach with that regularly and it negates the idea that you hit a kid on the head and you stop their breathing. Q. But that's only in respect of a slow bleed. A. Yeah, I know. The allegation of Jane Edwards is there is a one-punch knockout. I don't know if you subscribe to that, but that's what she said, there's a one-punch knockout that stopped his breathing. Q. But there's either shaking followed by an impact or a rotational force followed by an impact, yes. A. I think the adrenaline given by the paramedic Brittany Walls when a hypoxic state was present, pumping blood through the dura in large quantity by the adrenaline from paramedic Brittany Walls and a hypoxic condition has a lot more to do with the bleeding than what you just said a one-punch knockout. 1410 Returning to Eklund,692 Dr Auer said he did not agree with the conclusion that 'In cases where histopathological confirmation is not possible, clinicians may need to depend on the presence of associated injuries such as overlying scalp injury or intracranial haemorrhage in order to make the diagnosis of fracture'.693 Dr Auer said:694 No. It's very shaky if you don't have the bone under the microscope to go on other things then because under the microscope, you will see the fracture and the bleeding and the cells reacting to that and you can't see those on radiology. So I slightly disagree with that sentence for those reasons, but not completely. 1411 Dr Auer said that it is very difficult to tell a fracture where there is usually an accessory suture. All gaps in the bones are not fractures. 1412 In response to the suggestion by the prosecutor that a well-practised radiologist in the paediatric field would be able to pick the difference between an accessory suture which has the interlocking features and the straight line of a fracture, Dr Auer said that there are no interlocking features in accessory sutures. The accessory sutures presented in Eklund were straight lines. Dr Auer disagreed that the interlocking features were an indicator of a suture. The CT reconstruction also showed straight lines without interlocking features. He said his disagreement was based on looking at ‘[JR]'s reconstruction of the skull and I've placed it next 691 T 1859. 692 Ibid. Exhibit D167. 693 T 1859. 694 T 1859. -- 280 of 345 -- [2026] SADC 67 279 to Eklund and they look virtually identical and it's my experience, not just a reading of an article, that makes me say that’.695 1413 When asked why it was that he did not then put both sides of the skull from the article next to the other side of JR's skull for that comparison, Dr Auer said he had. Dr Auer was reminded that there are two skull fractures one on the right and left, and that the point in the Eklund article is that there are bilateral and symmetrical parietal sutures in respect of the infant's skull. 1414 It was then suggested to Dr Auer that with respect to JR the gaps do not look anything like symmetrical at all and to show the other side would not give the same impression as that which Dr Auer had concluded. Dr Auer said:696 Well, this is all I had from the article and demanding more and more from me just produces hundred-page reports that nobody reads. I think this is quite convincing that [JR] resembles a pseudo-fracture. 1415 As to whether that was despite the fact it was not symmetrical, Dr Auer said:697 Well, no, no, because one parietal bone can have a pseudo-fracture and the other cannot and a real fracture can also be asymmetric, so we're no further ahead, that's why I don't give it any weight. 1416 When then challenged as to what the point had been of Dr Auer referring to the article if he did not accept one of the tenets of what they were saying, Dr Auer said:698 Because pseudo-fractures are misdiagnosed in courtrooms all the time and it's important to get the Eklund article and others like it into the courtroom so this anatomical variant does not get misdiagnosed as a fracture and a high level of trauma, which would produce a depression of the skull bone and would produce a different appearance than what we see here. 1417 With respect to evidence that children with a low vitamin D in the absence of radiographically confirmed rickets are not at risk of increased fractures, Dr Auer said that it depended where you look and a lot of the literature is just ‘dead wrong’ because they are looking in the wrong place. 1418 As to the suggestion there was no evidence of rickets on any of the MRI or CT scans, Dr Auer said that MRI is not a way to measure bone densitometry, and X-rays are also insufficient. A DEXA scan is required to measure bone densitometry. When challenged as to how rickets is diagnosed in Canada, Dr Auer said that the only way to diagnose rickets is a microscope and that radiology gives a false impression. While radiology would show the shape of the bones and 695 T 1860. 696 T 1861. 697 T 1861. 698 T 1861. -- 281 of 345 -- [2026] SADC 67 280 whether the ends of the long bones are flaring, it would not show the cells and how they are calcifying into bone. He said radiology can diagnose only severe rickets. 1419 Dr Auer referred to an article he said was in the Journal of Paediatric Orthopaedics titled ‘Vitamin D deficiency rickets simulating child abuse’.699 Dr Auer was challenged by the prosecutor as to reference to the article as evidence that subacute rickets can be misinterpreted as child abuse when the article said that there were rachitic changes actually noted in subject infant. Dr Auer said he ‘just put up an article of vitamin D deficiency can be conflated with child abuse’.700 1420 Dr Auer was taken to the evidence he had given at T 1656, from line 26 where he had said:701 There are studies of rib fractures in kids that are just found on X-rays and there are about 50% and they're call a normal finding. A study in Sweden, and I will supply that reference as well, considers rib fractures a normal finding in babies because they're so common. 1421 Further, he was taken to his evidence at T.1856, line 10 where he said:702 I'm just sharing rib fractures are common and they're almost an incidental finding. If you look at the Journal of Paediatric Endocrinology and Metabolism 12, vol.34, p.363-373 in 2021, you can see that rib fractures are almost normal, and they lead to false positive cases of child maltreatment'. 1422 After some confusion on as to from which article the prosecutor’s following questions in cross-examination had been derived, the prosecutor referred Dr Auer to the article by Ulf Hogberg.703 1423 While Dr Auer agreed that study looked to the same nation population as the study in 2021, Dr Auer said they differed. The 2020 study in contrast, was a population-based study on all infants born in Sweden. He agreed that study found there were 2.9 fractures per thousand live births, including the five infants with an abuse diagnosis and the prevalence of any type of fracture in the first year of life was .0029%. Dr Auer added that it must be remembered that fractures are more common the more you look for them and normal children are not X-rayed. 1424 Dr Auer agreed that the conclusion of the 2020 article was that birth-related and other neonatal fractures are rarely diagnosed and that difficult birth is the main contributor to birth-related fractures, to which the article relates. 1425 When asked whether he still maintained that rib fractures in children found on X-ray are about 50% and they are a normal finding, or a much lesser amount because we don't go looking for them, Dr Auer said it is a lesser amount if we do 699 T 1865. 700 T 1867. 701 T 2013. 702 T 2013. 703 Exhibit P151. Hgberg et al, 2019. Difficult birth is the main contributor to birth-related fracture and accidents to other neonatal fractures. -- 282 of 345 -- [2026] SADC 67 281 not look for them. He added that the articles were quite different papers and the two should not be conflated. 1426 The prosecutor suggested to Dr Auer that the gravamen of his evidence had been that fractures in infants are so common as to be irrelevant. Dr Auer said:704 Well, they're not irrelevant if they lead to false diagnoses of child abuse and they are quite common because of indoor living with children having low vitamin D and they're also common because the bones are being pulled on by the breathing muscles and they're especially relevant to courts of law because they are adduced to infer grievous bodily injury by someone nearby when mothers tell me in many cases they can hear popping and crackling and they can feel crackling in the infant rib cage. So they are very important, I'm not downplaying their importance at all, because they can lead to prison and I agree they're important and this discussion is extremely important. 1427 Dr Auer agreed there is no literature on the topic of rib fractures caused by breathing in young infants. It was he said not a ‘hypothesis’ that the muscles pull very hard on the ribs in a child who is breathing and especially crying against a closed glottis. 1428 As to Dr Auer’s evidence that the mechanism or causation of rib fractures could not have been caused by an open hand or fist and would require a very delicate small instrument, Dr Auer said this was his view as he would expect there to be bruising of the skin overlying the fracture location, adding that you should see some evidence of impact in the skin overlying fractures. 1429 Dr Auer agreed that there was no question that CPR, which the prosecutor had duplicated with a ragdoll, with his thumbs pressing on the front of the ragdoll, can cause fractures. He agreed that squeezing an infant in that way can cause fractures, but added that does not explain pathological factors, or intra-uterine fractures. 1430 When asked why he had then disagreed when the prosecutor suggested that there is a well-established mechanism of chest encirclement and compression which can cause rib fractures to the middle of the ribs, Dr Auer gave the following evidence:705 I disagreed because there are countless convictions of people for squeezing their child too hard when the parent didn't realise the child was so delicate they couldn't be squeezed and they end up in prison for life because of it. When that mechanism certainly occurs in cardiopulmonary resuscitation, but to extend that mechanism to normal parents hugging and holding their children is simply wrong. 1431 Dr Auer agreed that overenthusiastic squeezing of a child, possibly contributes to rib fractures at the sides, but most of the child abuse allegations 704 T 2018. 705 T 2020. -- 283 of 345 -- [2026] SADC 67 282 maintain the rib fractures should be at the back, at the posterior ribs where they join the spine, to surmise abuse. 1432 As to why Dr Auer had discounted a squeezing hypothesis over the mechanism of a very delicate small instrument breaking particular ribs, Dr Auer said that was because external assault is usually what is implied in the attacks on the children by their parents or caregivers, not a hug. It is implied usually in courts of law that parents are assaulting the head and the chest of their children, they're not hugging them, that's not usually the allegation. Dr Auer said that the allegations are often very ill formed and amorphous and include surmising shaking, slamming, squeezing and focal trauma. He said there are at least four mechanisms that are usually proposed in a melange of accusations, adding that he could not ‘make head or tail’706 of precisely what is asserted to have happened in most of these cases, including this one. 1433 Dr Auer agreed that it is not unusual to find central rib fractures without bruising. 1434 Dr Auer agreed that in his evidence he had described vitamin D deficiency as a kinetic disorder in infancy, in other words, as infants are growing quickly, they are more likely to get fractures in the fastest growing bones. In support of that he had referenced Dr Colin Patterson and held him out as a world expert in the field. Dr Auer said that he himself subscribed to Dr Patterson’s theory of transient brittle bone disease and that Dr Patterson had given evidence in many trials on transient brittle bone disease. Dr Auer said that he was not aware that about 20 years ago, Dr Patterson was struck off the Register of Medical Practitioners in the United Kingdom because he diagnosed a number of children with transient brittle bone disease, despite medical evidence which did not support his findings. 1435 Dr Auer likened Dr Patterson having been struck off the register similar to the way that ‘Dr Waney Squier’ was struck off the register, which Dr Auer said was entirely unjustified. 1436 An excerpt from the British Medical Journal in 2004 was read to Dr Auer as follows: 'A Scottish chemical pathologist is facing charges before the general medical council of misrepresenting medical evidence as an expert defence witness in child abuse cases. Dr Colin Paterson frequently testified that seemingly non- accidental injuries were caused by temporary brittle bone disease, a condition that he himself first described and whose existence is disputed by many experts.’ 1437 Dr Auer said:707 Well, yes, shaking and slamming by parents is also hotly disputed and this whole field is needlessly incendiary and career ending for many who testify in favour of natural illness, pathological fractures, infectious illness and medical explanations. And if you read Dr Paterson's articles, you find that he has studied vitamin D deficiency and fractures in 706 T 2021. 707 T 2023. -- 284 of 345 -- [2026] SADC 67 283 childhood and he has published in the Journal of Orthopaedics, paediatric orthopaedics for example, and I have read his literature and I find it logical, underpinned by a lifetime of knowledge of bone chemistry and bone pathology and cogent, but because he went against the groupthink of child abuse, he was struck off like Dr Squier but I wasn't aware that he was actually struck off - it seems part of the war against experts. 1438 Dr Auer said that he was not aware of various comments made by the Chair of the GMC's Professional Conduct Committee, which had included that Dr Paterson's actions posed 'An unacceptable risk to the safety of children' and that he had appeared ‘to have acted as an advocate for transient brittle bone disease and ignored the significant clinical evidence which was at variance with your published view on the clinical signs of transient brittle bone disease'.708 Dr Auer said he disagreed with the comments. Dr Auer said of Dr Patterson that he was not ‘aware of his life’ or it seems that he was a chemical pathologist. 1439 When it was suggested to Dr Auer that he had held Dr Patterson out as an expert in the field without providing the qualification that he is the author of, what the prosecutor called ‘a fringe belief’, Dr Auer said:709 No, it was a fringe belief by Galileo that the earth was round and fringe belief doesn't cut it in science. I held him out to be an expert because as early as 1981, before the child abuse movement started in full swing, he published on vitamin D deficiency simulating child abuse and I found that a prescient article because his later publications go into the millennium, into 2011 for example. 1440 Dr Auer disputed that Dr Patterson’s theory of temporary brittle bone disease is not a mainstream belief at this time, saying that it was now recognised that vitamin D deficiency is important and brittle bone disease is a generic term which includes many things. Dr Auer said that trying ‘to get’ Dr Patterson on the non- enduring diagnosis of brittle bone disease is simply a restatement that we now understand better all the causes of brittle bones in infants such as Osteogenesis imperfecta and other diseases. He said brittle bone disease is a very large umbrella term which, Dr Auer accepted, has not stood the test of time. He said that he no longer uses the term himself anymore because it's not pathophysiologically specific. 1441 As to why it was that he had held Dr Paterson's article out as being that of a world expert in the area, Dr Auer said:710 Because he is a world expert on bone metabolism and fractures in childhood and has articles spanning from 1981 to 2011, and probably beyond, those are the articles I have from Dr Colin Paterson and that's why I consider him a world expert because he's highly published cited, although I haven't done an analysis of him on Google Scholar. 708 Exhibit P102. 709 T 2025. 710 T 2026. -- 285 of 345 -- [2026] SADC 67 284 Pneumonia 1442 Dr Auer said that pneumonia is characteristically asymptomatic because the air flow and the blood flow, are adjusted by the lung to avoid symptoms. They are adjusted by matching air flow to blood flow. So, if air flow goes down and oxygen transfer goes down, blood flow to that area of the lung also goes down and you get no symptoms. That, Dr Auer said, is how the lung is designed to match air flow and blood flow, and lung disease can be completely asymptomatic for that reason. There are, Dr Auer said, people who have collapsed with pneumonia as their first sign or symptom and ‘such as the comedian on stage who collapsed with COVID-19 called D.L. Hughley’.711 1443 Dr Auer disputed that he would not know that was not the experience of clinical paediatricians because he is not a clinical paediatrician, because he talks to a lot of paediatricians. He said that while they see the symptomatic ones, they don't see the asymptomatic children that die or collapse. 1444 Dr Auer said that he based his opinion that pneumonia is characteristically asymptomatic on his knowledge of lung physiology and the fact that lung disease is characteristically asymptomatic, not only at its inception, but through its progression. 1445 Dr Auer denied the suggestion that to call pneumonia asymptomatic in an infant was beyond his expertise in that he looks at a lot of lungs of these babies and also reads the literature of SIDS, which often has no symptoms prior to the death. Dr Auer referred to literature which ‘starts well before my time in the 40s and 50s and you can see that the medical examiner of New York, Jacob Werne, and his wife, Irene Garrow, published already in 1953 that these children show pneumonia and they collapsed asymptomatic’.712 1446 Dr Auer was reminded of his evidence that SIDS is a diagnosis of exclusion. He responded as follows:713 So that's a really good question, because the diagnosis of exclusion leading to SIDS implies that nothing is found at autopsy. The problem with that is that things are missed at autopsy, and Werne and Garrow showed the disease in sudden infant death syndrome in 1953 in the American Journal of Pathology, vol.29, p.633-675, and again in p.817-831. So this has been described in 1953 and has been missed and, if you ask me why, I really don't know why, but it's patently obvious in the lungs of the children who no - not merely collapse, but who die. 1447 The prosecutor suggested that Dr Auer’s answer on SIDS was irrelevant as pneumonia was in fact confirmed as the cause of death in the earlier studies to which he referred. Dr Auer responded:714 711 T 2029. 712 T 2030. 713 T 2031. 714 T 2031. -- 286 of 345 -- [2026] SADC 67 285 Yes, those early studies have not been heeded by the forensic community, however, and SIDS has remained a diagnosis of exclusion due to missing the interstitial lung disease that causes SIDS. 1448 Dr Auer continued to disagree that the literature on the topic of SIDS did not support his hypothesis. He said that for example, Hannah Kinney has written that Dr Larry Becker, who studied SIDS, one of the people who trained him in paediatric neuropathology, did find evidence of ischaemic brain damage in the brain stem in SIDS cases. So, he said, there is evidence that SIDS has near misses and that there is pathology often to be seen if carefully looked for by the trained eye. 1449 The prosecutor again returned to his point that if pathology is identified, then it is not classed as SIDS, which Dr Auer said was ‘precisely the problem in SIDS research...the lack of identification of pathology in SIDS’.715 1450 Dr Auer agreed that the only factor that he could point to for the presence of pneumonia was JR’s cardiorespiratory collapse. 1451 Dr Auer was referred to his evidence where he had cited Kyu et al716 and noted that about a million children a year have this collapse and die according to that article. 1452 He agreed that the paper by Kyu et al., found that the vast majority of deaths from pneumonia occurred in developing countries, for example, Sub-Saharan Africa and Asia, adding that it was ‘a common mode of attack of that article as being relevant to the United States where I'm testifying often, and that is a spurious argument because thousands of children do have this disease and are admitted for it in non-Third World countries’.717 1453 While Dr Auer accepted that it was fair to say those deaths in Third World countries occurred likely in a setting of no access to treatment, he said that in the Jain et al,.718 article three of the children died despite being in hospital, intensively treated in paediatric intensive care units. So, Dr Auer said, it is not true to say that these children do not die in the West. 1454 The prosecutor asked Dr Auer several times to confirm whether he agreed the article did not speak of silent pneumonia. Ultimately, Dr Auer gave the following evidence:719 This article is an epidemiological article, not an article about individual children's symptoms and signs of which there are millions of children. This is a global article, about 6.28 million children and the individual histories, Dr Salu is quite correct, cannot be 715 T 2031-2032. 716 Exhibit D166. Kyu et al, 2016. Global and National Burden of Diseases and Injuries Among Children and Adolescents between 1990 and 2013. JAMA Pediatrics;170(3) 267-287. 717 T 2032. 718 Ibid. Exhibit D112 and D173. 719 T 2034-2035. -- 287 of 345 -- [2026] SADC 67 286 gleaned from that article. The purpose of the article is to state how common it is for young children to die of lower respiratory tract infections and it does that well. It makes the case that many children die of pneumonia, and I'm not sure if it's in this article but it used to be 2.1 million in 1993, but the vaccination against pneumococcus has reduced the number of childhood deaths considerably to under a million worldwide in all the major countries. 1455 Dr Auer agreed that the article gave no breakdown at all as to infants. He also agreed that to utilise a non-applicable population-based study has a rationale for a case-based reasoning process, and application to JR, is not the recognised process by which a medical diagnosis is made. 1456 When asked why then he had referred to this article in support of his contention that ‘About a million children a year have this collapse and die according to Kyu et al’,720 Dr Auer said:721 Because that happened epidemiologically. These million children are not assaulted by their parents. These million children die a natural death due to medical illness of lower respiratory infections and [JR] collapsed from breathing difficulties. That's why I quoted it. 1457 Dr Auer said his answer did not mean that he had moved away from having just said the reasoning methodology was flawed. He said:722 In [JR], he had breathing difficulties and his heart was still beating. He was taking a breath every now and then. He was given mouth to mouth. It's like a real gasp for air. This is case-based reasoning. The general reasoning is that this happens all the time in children. So those two reasonings, I'm aware of case-based reasoning, versus general reasoning, and they both agree that this is common and happened in [JR]. 1458 Dr Auer was asked whether he agreed that agonic breathing is not in fact breathing. He said:723 Well, that's a question designed for a gotcha. So if you're not breathing any more, in agonal breathing, that stopped, then you're not breathing, but if you're still breathing, you have breathing. I'm not sure I understand the question even. 1459 Dr Auer said he agreed JR had breathing difficulties based on the 000-call made by the accused. When asked whether he preferred the accused’s account to that given by the paramedics, Dr Auer said the paramedics were not there until a little later and he did not prefer one over the other. Dr Auer agreed that he was suggesting that between gasping for air, JR stopped breathing and that would account why the paramedics noted agonal breathing. Dr Auer denied that he was taking a biased view. 720 T 2035. 721 T 2035. 722 T 2035-2036. 723 T 2036. -- 288 of 345 -- [2026] SADC 67 287 40 cases of lung attack 1460 Dr Auer was referred to his evidence that he had himself seen 40 cases of lung attack and agreed that he was intending to refer to all of those cases of lung attack in the process of educating the public about the condition. It was, he said, not quite the case to assume that those 40 cases were cases referred to him by defence where treating clinicians had attributed cardiorespiratory arrest to head injury, as some of them were referred by police and prosecution. 1461 He agreed all 40 of the cases had died and he agreed that cohort would therefore indicate a significant sample bias, adding that he is consulted, as in this case, on children who don't die. 1462 Dr Auer was unable to say in terms of those 40 cases whether some or all had skull fractures as he was ‘not that far along in the analysis, but that a significant number did. A larger number had subdural haemorrhages than skull fractures but his ‘data analysis is impeded by time’.724 A substantial proportion of them also had retinal haemorrhages and in some of those cases there was bruising and other fractures also present. He said that all of the 40 cases went to trial. Dr Auer was unable to say how many accused had been found guilty beyond a reasonable doubt, other than it was a substantial proportion who were found not guilty and ‘many of them took plea bargains to avoid longer terms in prison because they were already in prison for, say, a year or two and they were offered five years or three years if only they would plead guilty. So many did that’.725 1463 When asked why he would include anyone in that group of 40 who had been found guilty beyond a reasonable doubt, Dr Auer said:726 Well, because as we know from OJ Simpson, guilty is not necessarily guilty. There were two trials of OJ Simpson, one was guilty, one was not guilty. I'm going on the medical and scientific evidence, but I will give the proportion that are found guilty and not guilty because despite the identical medical illnesses, the verdicts are uneven, shall we say. 1464 It was suggested to Dr Auer that there was no basis in JR's case to diagnose pneumonia given there was not a single clinical feature of pneumonia. Dr Auer said that there was a clinical feature that is singularly important in JR’s case and that was that he was an awake child, where the father was out to feed him. JR suddenly stopped breathing and that was not a head injury, as that is not how head injury works. An awake child who suddenly just stops breathing is characteristic of lung disease. Dr Auer said that as an expert in hypoxia, having written the standard textbook chapter on hypoxia in Greenfield's Neuropathology, he knows the parts of the brain that control breathing. He has published on multiple sclerosis affecting those parts of the brain and causing sudden death in multiple sclerosis due to breathing stoppage. 724 T 2038. 725 T 2038. 726 T 2038-2039. -- 289 of 345 -- [2026] SADC 67 288 Brain injury 1465 Dr Auer agreed that he had maintained throughout his evidence that primary head injury does not affect breathing and that when it does, it does so after a lengthy period marked by herniation and coma before the breathing stops. 1466 He agreed that the brain stem, specifically the medulla, is the part of the brain that controls breathing and the heart rate. He agreed that it follows that an injury to the brain stem can stop breathing and can impact the cardio system. 1467 Dr Auer said however, that it was ‘fantastical’727 to say that a concussive injury to the brain, which affects the respiratory control centres in the medulla, would also affect breathing. He said the symptoms of JR were that ‘he was awake, he didn't have a head injury… and he had irregular breathing, gasping for breath… He had carbon dioxide retention to 58 and this is not a sign of a brain injury. This is a sign of lung disease.’728 1468 He disagreed that there was a stretching of the axons which occurs on rotational acceleration impacting on the medulla. He said there is no rotation of the medulla. The rotation in a true head injury is in the cerebral hemispheres. They undergo rotation while the acceleration angularly causes the axonal shearing in the cerebral hemispheres, not in the medulla which does not move because it is so deeply seeded and is not subjected to trauma. 1469 While Dr Auer said that he was aware of Dr Edwards’ opinion that both experimental and clinical studies demonstrated that severe head injury can result in a cessation of breathing, he said that it was not undergirded by the references she had stated, and they do not say what she said they say. 1470 It was suggested to Dr Auer that multiple animal studies, including concussive head injuries have shown that prolonged apnoea and death can occur via hypoxic cardiac arrest as a result of brain stem mediated reflexes and that with early respiratory support, complete neurological recovery was possible. She had not done hypoxia experiment and was quoting the literature without understanding it. 1471 Dr Auer was referred by the prosecutor to the 5 articles referenced by Dr Edwards, namely: • Denny-Brown;729 • Walker et al;730 727 T 2041. 728 T 2041 729 Exhibit P133 – Experimental Concussion. 730 Exhibit P134 – The Physiologic basis of concussion. -- 290 of 345 -- [2026] SADC 67 289 • Humbert et al;731 • Adelson et al; 732 and • Atkinson et al.733 1472 In response to the suggestion that the articles indicated that concussive head injuries have shown that prolonged apnoea and death can occur by a hypoxic cardiac arrest as a result of brain stem mediated reflexes, Dr Auer said, that was a ‘false statement’.734 1473 As to the suggestion that with early respiratory support complete neurological recovery was possible, Dr Auer said that hypoxia alone does not cause brain damage so it is entirely expected that if there is a hypoxic insult alone, there would be complete recovery. Hypoxia, he said, does not cause brain damage in the first place so it is not surprising that if you have a transient hypoxic insult, that you recover completely. When asked to explain further, Dr Auer said that hypoxia is not the same as ischaemia which shuts off the blood supply to the brain. Hypoxia is anti-ischaemic and increases the blood supply to the brain, so the two are quite different. Dr Auer said that even though in forensics they are often lumped together as hypoxia ischaemia, they are quite different insults. Hypoxia stops the heart and then the heart can cause the brain to have lack of blood flow. But JR still had a pulse when the accused was on the phone, so he had hypoxia but not yet ischaemia of the brain. 1474 Dr Auer was asked about a study to which Dr Edwards had referred in her report, of early resuscitation of children with moderate to severe traumatic brain injury of any cause.735 1475 Dr Auer agreed the article said that a study of early resuscitation found that hypoxia or apnoea was documented in 44% of the 299 children but said that it was due to hypertension, with the study teasing out the importance of hypotension and its treatment, not hypoxia and its treatment. Dr Auer said that conflating low blood pressure and brain ischaemia with brain hypoxia is exactly the error Dr Edwards made in citing this article. He added that untreated hypoxia was not significantly associated with death and disability, except in the setting of low blood pressure, or hypotension. 1476 He denied that the setting was of severe traumatic brain injury because, he said many children coming to a trauma brain injury centre don't have trauma at all 731 Exhibit P135. Humbert et al, 1976. Fluid-percussion model of mechanical brain injury in the cat. 732 Exhibit P136. Adelson et al, 1996. A model of diffuse traumatic brain injury in the immature rat. 733 Exhibit P137. Atkinson et al, 1998. The early critical phase of severe head injury: Importance of apnoea and dysfunctional respiration. 734 T 2043. 735 Exhibit P138. Zebrack et al, 2017. Resuscitation of Children with moderate to severe brain injury. -- 291 of 345 -- [2026] SADC 67 290 because they're ‘all going to be taken to a trauma centre’ especially if they have life-threatening collapse of their cardiovascular and cardiopulmonary system. 1477 Dr Auer did not agree that the documentation of hypoxia/apnoea occurs most often at the scene. He said:736 Hypoxia at the scene and stopping breathing at the scene is not a feature of head injury, we all know that, from all the head injuries around the world, and if it was not true what I'm saying, then ambulances wouldn't be able to bring people to emergencies because they would have collapsed and died on the scene from hypoxia. 1478 When challenged as to whether his opinion that head injury selectively preserves breathing, is not mainstream, Dr Auer said:737 It is entirely mainstream even though I'm not averse to going against the mainstream, or the stream, and it's entirely in line with mainstream because of all our experience with head injury in children and adults, it does not pick off the breathing when you hit someone on the head, full stop, and you and I and everyone in the courtroom knows that from boxing, from MMA and from the study of John Plunkett of all the children that hit their head, even if they later died, they didn't stop breathing and die from that. That's not how a head injury works. 1479 Dr Auer was asked whether he had regard to three articles by Hymel et al.,738 where the prosecutor suggested researchers identified the presence of apnoea as being significantly associated with infants having severe traumatic brain injury as a result of an inflicted mechanism. 1480 Dr Auer said:739 …. the Kent Hymel articles … are based entirely on circular reasoning, in that these are known to be inflicted head injuries based on bleeding which is unexplained so it's termed 'inflicted'. Inflicted implies knowledge of a mens rea of a third party in these articles. These may not be trauma at all, Dr Salu, these may be misreadings of bleeding as due to trauma when the bleeding actually has an atraumatic cause… Inflicted head injury is the input and it's also the factor that's being studied, and this is entirely circular, and that's the problem with the data that you are quoting me and it's by Kent Hymel, who is trauma over everything. There is no room for medical illness in these articles. 1481 It was suggested to Dr Auer that his reasoning in respect of JR was entirely directional. Dr Auer said that his reasoning is based on the data. JR had trouble breathing, his heart was still beating at the time when he was turning blue. His carbon dioxide was increased at 58 and these are signs of pulmonary disease. 736 T 2046. 737 T 2046. 738 Exhibit P141 -Clinical presentations, injuries and outcomes from inflicted versus non-inflicted head trauma during infancy: results of prospective, multicentred, comparative study [not an exhibit] and Exhibit P140 Hymel et al., Paediatric brain injury research network investigators, derivation of a clinical prediction rule for paediatric abusive head trauma, [estimating the probability of abusive head trauma after abuse evaluation]. 739 T 2048. -- 292 of 345 -- [2026] SADC 67 291 1482 Dr Auer agreed that he had discounted the evidence of the paramedics that the heart was not beating effectively at the time of their attendance and needed to be restarted, or assisted, by CPR. Dr Auer went on to say that what Dr Edwards had said regarding breathing being controlled by the brain, so it must be the brain that is stopping breathing, is a standard logical error. Just because the brain can stop breathing doesn't mean breathing stoppage is always due to the brain. All severe head injury can stop breathing, you have stopping breathing, therefore, it must be a severe head injury. 1483 Dr Auer agreed that it was ‘mostly true’740 that he routinely finds pneumonia in cases where no-one else finds pneumonia. He denied however that his clinical experience in relation to identifying nascent or silent pneumonia clinically is limited. He said:741 I talk a lot to the pulmonary paediatrician here, I won't give his name because he wouldn't appreciate being dragged into the court system by name, but we talk extensively about babies, breathing, their response to hypoxia, and he shares clinical information on babies who recover and who do not recover in his hands due to their propensity to stop breathing due to lung disease, and he is a paediatric lung specialist, and I'm not giving his name. 1484 When challenged as to how talking to someone in the field made him an expert in that field, Dr Auer said:742 Well, because I share a lot of my lung findings with him, including the clinical findings, and it stands to reason he tells me that children die of this because children, especially at a young age, respond to hypoxia paradoxically by reducing their breathing rather than increasing their breathing, as older children and adults do. 1485 Dr Auer said that he would not give the name of this person ‘because this causes undue distress to have any association with the courts on the defence side and I'm not going to do that to a colleague of mine. It happened to Dr Squire, it happened to Dr Paterson and I'm not doing that to a colleague of mine’.743 1486 Dr Auer was asked to comment on the following opinion expressed by Dr Edwards:744 When presented with references from published authors in peer-reviewed publications that describe the known association between head injury and apnoea in infants, 57% had a history of apnoea prior to hospitalisation, Dr Auer continues to discount the validity of this association as he is not convinced that the infants in the published literature had injuries at all and opines that the apnoea was due to natural illness. 1487 Dr Auer responded that he calls it that way because there is natural illness in these lungs and he denied that his opinion it is based solely on his opinion that JR 740 T 2049. 741 T 2050. 742 T 2050. 743 T 2050. 744 T 2051. Exhibit P152. Johnson, Boal & Baule, 1995, Role of Apnea in Nonaccidental Head Injury. -- 293 of 345 -- [2026] SADC 67 292 stopped breathing due to undiagnosed asymptomatic pneumonia. Rather, it was based on the examination of the lungs of children that die. 1488 Dr Auer was referred to the article Johnson et al.745 Dr Auer said that the article typifies the problem because circular reasoning was used to define the head injury in the first place, saying that a head injury causes apnoea, which is not true and then use that apnoea to study it in the very head injury that they define by apnoea. He agreed that what he was saying was that the authors of that article do not know what they are saying because they are still talking about shaking. He said:746 I mean, shaking was discredited and debunked by the physics around the turn of the millennium and here they are still talking about shaking and shaking with impact right here (INDICATES). I mean, how do you handle this? And then they say 'There's a history of apnoea prior to hospitalisation has been common'. Yeah, that's because the children have pneumonia, and they're obtuse to all of this. It's just an amazing article, thank you for correcting it, though. 1489 Dr Auer accepted the article made no reference to pneumonia and said that most pneumonias are missed and silent until they cause a crisis. When asked how that could be his view given that most pneumonias are well known because people run a fever, they're unwell, they cough a lot, Dr Auer said:747 Well, it comes from clinical experience and it comes here from reference 8 that 'Early hypoxia-ischaemia is predictive of a poor outcome in head-injured patients'. What if it's not head injured, then early hypoxic-ischaemia is predictive of poor outcome in subsequent hypoxia-ischaemia? It's exactly what you'd expect in missed pneumonia, exactly. It's no secret that pneumonia is commonly missed until it causes a huge crisis. I mean, you just have to look at the literature and people collapsing. They collapse with pneumonia. It happens quite commonly. 1490 Dr Auer maintained that the article to which he was referring referred to pneumonia. He said ‘it’s COVID pneumonia’. When asked whether he accepted that most people with COVID felt unwell, he said:748 Yeah, you know, you can go that route, but then you'll miss the walking pneumonias, the hypoxic - happy hypoxia it's called, the walking pneumonia. I could tell you, I had a pneumonia myself in my 40s and I wasn't doing testimony, but I was doing on-call service and finally I went to emergency, the nurse told me after my finger was in the oximeter she said I'm coming back into hospital I'm not going to go anywhere. And I protested and I said 'Well, why?'. And she said 'You've got a pneumonia'. I said 'Maybe that's why I don't feel like eating so much'. She said 'You're coming into hospital'. I said 'Well, I can't'. It's a pretty simple clinical experience. It happened in me and I wasn't feeling anything. And if you look at COVID has caught us so much about pneumonia, you can just not know you had it. It's a silent killer. Sudden infant death syndrome is a silent killer and there's just no question that pneumonia kills and there's no question it does it silently, unexpectedly and suddenly. There's nothing weird or funny or outlandish that I'm saying. We actually have known this, 745 Exhibit P152. Johnson, Boal & Baule, 1995. Role of Apnoea in Non-Accidental Head Injury. 746 T 2103. 747 T 2104. 748 T 2015. -- 294 of 345 -- [2026] SADC 67 293 but we're not paying attention, because everything is pigeonholed into trauma, which I find incredible. 1491 Dr Auer agreed that there was no evidence before the court of any investigative findings consistent with pneumonia in JR’s case. 1492 Dr Auer went on to detail his own experience, showing the result of his blood gases to be a pO2 of 50 and going on to show a photograph of himself at a Christmas party. 1493 As to Dr Edwards’ opinion that he had disregarded clinical findings which clearly indicated head injuries including skull and facial fractures, seizures, unreactive pupils and retinal haemorrhages, neurosurgical drainage of intracranial haemorrhage and that 43% were left with severe disability including four deaths and suggested all clinicians involved in the care of those infants must have 'misinterpreted the findings', Dr Auer’s evidence was as follows:749 A. Well, I say to that that it's very easy to misinterpret the findings, the bleeding, as trauma. The bleeding has three factors that are not traumatic. One is a leaky vessel, two is thin blood, which is often seen in infections, and three is high pressure. The high pressure comes about when Epinephrine is given or adrenaline as was given to [JR]. So pressure, leakage and thin blood are the factors, really atraumatic factors, that give rise to the bleeding. So bleeding does not equate to trauma for those reasons and it's very easy for physicians to conflate bleeding with it necessarily being trauma. It happens all the time - Q. Let's break that down - A. - the three factors of bleeding are not taken into account. Q. Let's unpack that. Thin blood, there is no evidence of thin blood in the case of [JR], is there. A. Well, it wasn't looked for. So if you don't look for something, you don't find it, but if you have an infection, then you can have thin blood in that the commonest cause of DIC, which is thin blood, is an infection, but if you're not looking for these things, you will be open-mouthed and you won't find it, you know. Q. I'm open-mouthed, doctor, because you are aware, are you not, that the blood platelet levels were normal. A. Well, platelets isn't the measure of DIC. DIC is measured by prothrombin time and partial thromboplastin time and the international normalised ratio. Those weren't done in [JR]. Q. But the coagulation levels were done both at the base level and the extended coagulation levels, weren't they. A. So, again, you're going into demanding all three factors be present to explain the bleeding and you don't need every factor to be present to have bleeding. You have adrenaline given many times, that's in the affidavit by the ambulance personnel, and 749 T 2052-2053. -- 295 of 345 -- [2026] SADC 67 294 you have leaky vessels, which are normal, so you have pressure across leaky vessels, they are hypoxically dilated, so it stands to reason that you have bleeding. Q. Just starting with the thin blood though, are you now accepting that there was not thin blood in light of the evidence of the platelets and in light of the evidence of the two different types of coagulation studies that were undertaken. A. Of course I'm accepting that and I'm also stating you don't need that to have bleeding, you don't need thin blood. It's one of the three factors that often comes up in these infected children, but not always, and you've got the other two factors. Q. Then why, a moment ago, did you say you need the three factors: pressure, leakage and thin blood. A. You need to understand the three factors. Trauma is the only thing in lines of these positions, and they don't have the three factors, the leaky vessels, the bleeding and the pressure. They are going only down the road to trauma. So that's why I said you need to understand the three factors. You don't always have all three factors in all bleeding. Q. So you would withdraw your evidence to her Honour a moment ago that the relevant three factors of pressure, leakage and thin blood because we can pick whichever one you want. Is that your evidence, doctor. A. No, it's not evidence of convenience the way you have now portrayed me. It's evidence that's in [JR]. That evidence is hypoxia, it is adrenaline, given I believe six times, and that is the evidence that is case based here, not hand waving evidence of Dr Auer. 1494 Dr Auer denied the suggestion made by the prosecutor that it seemed that if faced with an absence of symptoms or empirical evidence as to one of the three things required, Dr Auer ‘tweaked’750 his evidence to fit whatever suited. 1495 As to whether Dr Auer had disregarded the article by Byard et al.,751 Dr Auer said this was a retrospective, not prospective study. He described the article as being ‘used to try and support these cases in the courts where the child has resuscitation after stopping breathing, whereas that's not what happened at all…’752 1496 Dr Auer was taken to his evidence at T 1635 where he said: 753 The reference that Dr Edwards provides does not support the assertion she has made. The reference describes 53 cases of non-accidental head injury in children, but no-one can know in the first place that they're not accidental. A head injury would look the same whether it's intentional or not, so we immediately get into the fundamental problem of the literature that she is quoting that you cannot know whether they're non-accidental in the first place, yet that is your input criteria for the study, so the children only have neuropathology, they didn't have their lungs examined, so we have no idea if these children had any lung disease that caused them to fall or have trauma. 750 T 2054. 751 Ibid. Exhibit P142. 752 T 2054. 753 T 2055. -- 296 of 345 -- [2026] SADC 67 295 1497 In response to the suggestion that whether the head injury is accidental or not, does not refute the evidence that apnoea is part of the head injury, Dr Auer said again that apnoea is not characteristic of head injury, even severe head injury. Dr Auer again referred to the case of ‘Jeffrey Dahmer’ who he said was beaten with the crowbar ‘until his head was pulped and he did not stop breathing’.754 Dr Auer referred again to the examples from sports designed to cause head injury, such as boxing and MMA, and to studies in children with head injury severe enough to cause fatality where on the spot the child did not stop breathing. He described Dr Edwards as still clinging to the notion that you hit a child on the head, or an adult and you stop their breathing selectively which is not true. 1498 When it was suggested to Dr Auer that Dr Edwards’ evidence was that a blow to the head can stop breathing immediately, not that it necessarily will, Dr Auer said:755 No, she says that [JR] is subjected to head injury - and that stopped his breathing. She says that quite definitively and quite dogmatically and that's not how head injury works. 1499 With respect to Dr Auer’s reference to ‘Jeffrey Dahmer’, it was suggested to Dr Auer that it was not known whether Dahmer’s medulla was impacted at all. Dr Auer said:756 Yes, we do. We can be fairly certain that it wasn't impacted because there is no evidence that head injury selectively affects the medulla and causes breathing. We have all the evidence from the children who died with head injuries, that didn't stop breathing, and there are 18 of them and we have all the evidence from common knowledge that ambulances wouldn't be able to bring people to hospitals if a head trauma stopped the breathing instantly. It just doesn't happen. 1500 Dr Auer said that he did accept that if the breathing is not stopped instantly, it might be revived or assisted by the attendance of paramedics. He said this was so in lung disease and in head trauma, but in head trauma, you usually have a situation of other things than stoppage of breathing. 1501 Dr Auer agreed that the brain stem is part of the brain, adding that it was just above the spinal cord and ‘pretty remote’757 from brain trauma which is why the breathing doesn't stop in trauma to the brain. 1502 Dr Auer denied again he had ignored the Byard article758, because it did not fit with his narrative and said he had read the article intensively. 1503 When asked whether it was his evidence that all the children in that article had neuropathology or not, and whether he accepted he misspoke when he had 754 T 2056. 755 T 2056. 756 T 2056-2057. 757 T 2057. 758 Exhibit P142 -- 297 of 345 -- [2026] SADC 67 296 stated that ‘all the children had neuropathology’, Dr Auer gave the following evidence:759 A. Well, they had neuropathology in the sense of something wrong with their brain. Q. Only four of them died. A. I mean, there are various meanings to neuropathology. If someone has any disease at all, you can call it neuropathology, whether or not they've had an autopsy. Q. So you're being selective with what you mean neuropathology to mean, is that your evidence. A. Well, it has various meanings. I didn't create that situation or change it. I had one author who wanted to put multiple neuropathologies in the title for different effects of an infection and they said 'Well, that's actually a specialty, neuropathology'. So it has many meanings. It's not my fault. Q. Now, at p.1635 you said this 'So the children only have neuropathology. If they didn't have their lungs examined, so we have no idea if these children had any lung disease that caused them to fall or have trauma'. I'm suggesting only four of them died so the rest of the cohort in that study, we have no idea whether there was anything on the lungs at all or not. What do you say to that. A. Well, we're going to have to go deeply into the article. These are 35 babies, the children, 35 weeks to three years and if you want to debate the fine points of the article, we can open it and do that. I can share it on the screen, if you wish. Q. What I'm suggesting is that earlier in your evidence you've given the impression to the court that their lungs would have been looked at and that that was a relevant factor. I'm suggesting that there were no slides other than the four potential slides for the deceased infants. You disagree with that. A. Well, even if the lungs are or are not looked at, this interstitial pneumonia is routinely missed by forensic pathologists. So it's not going to make a difference if they were or were not examined. If they were examined, the lungs are routinely missed in their contained interstitial pneumonia and if they weren't examined, it also won't be seen. Q. I see. So, again, all the clinicians involved in the care of those infants must have misinterpreted the findings, is that your evidence. A. Yes. 1504 Dr Auer was asked about Dr Edwards’ reference to a paper by Wilson et al.,760 In his evidence at T 1643, Dr Auer had said: 761 If you look at her reference No.7, it doesn't support her assertions about fatal impact, brain apnoea, despite being right in the title and this is what some authors do. They want to write an article, they put something in the title. This happens a lot in medicine and even science 759 T 2058-2059. 760 Exhibit P143. Wilson et al, 2016. Impact brain apnoea – A forgotten cause of cardiovascular collapse in trauma, Resuscitation, European Resuscitation Council. 761 T 2059. -- 298 of 345 -- [2026] SADC 67 297 and they want to say the statement very badly but you read the entire article and you don't find support for the assertion. 1505 It was pointed out to Dr Auer that the title of the article did not read 'Fatal impact brain apnoea'.762 After a lengthy debate between Dr Auer and the prosecutor, Dr Auer ultimately agreed that in referring to that article as 'fatal brain apnoea'763 and then making a point about what is in the article, he misspoke. 1506 Furthermore, Dr Auer agreed that the article in fact described two people who had cardiorespiratory arrest following a head injury and described two people who were very fortunate to receive rapid onset CPR allowing them to recover. 1507 Dr Auer said that he disagreed with Dr Edwards that impact can and does cause cardio collapse in trauma. Furthermore, he denied that on the face of it, the article supported Dr Edwards' opinion as to brain apnoea. Kaplan-Meier plot 1508 Dr Auer was taken to his evidence regarding Dr Edwards' reference to the paper by Rungruangsak et al.,764 at T1627, when he had said:765 Yeah, so I got figure 4 from the article she's quoting, and I've got it on my screen actually. It's just not true that many die immediately as Dr Edwards says. None of them died immediately and you have to go five hours until some die. So I could share the screen or just say it, but it's a false statement that she's made about the articles she's quoted. Figure 4 shows none of them died immediately. 1509 Dr Auer had taken the court to a Kaplan-Meier plot in the article, which he explained is an accumulative survival curve, estimating the probability of an event such as death not occurring up to a certain time, showing the probability of survival and time on the Y axis. Dr Auer agreed the finding of the article is that many died quickly of polytrauma in less than six hours. 1510 Dr Auer agreed that Figure 4 provided no breakdown of the times of death other than within blocks of time, adding that the article did not state that any of them died on the spot. Dr Auer denied that it just said that there were different groups who died within that six-hour block. He said it was not true that if doing a Kaplan-Meier survival curve and you have deaths at zero, you are going to put them in under zero, not going in under five hours. 1511 He did agree that figure 1 indicated that most infants, 72%, died in less than six hours and the number of those that died within the first six hours is set out. There was, Dr Auer agreed, no breakdown of infants and no breakdown of infants within six hours at all. 762 T 2059. 763 T 2061. 764 Exhibit P100. 765 T 1627. -- 299 of 345 -- [2026] SADC 67 298 1512 Dr Auer agreed that the graph on figure 3 makes plain that most with severe isolated head injury died quickly and in figure 4, shows that only 25% were still alive at 20 hours. 1513 Dr Auer denied that the article did not support any delay phenomenon in that the authors do not say any of these traumatic injuries caused instant death. When challenged, Dr Auer accepted it was silent on whether they died immediately or not but added that does not mean you can insinuate ‘that they are hiding something and that they did die immediately.’766 1514 Dr Auer agreed that he knows how to read a Kaplan-Meier plot. 1515 He agreed the survival plot analysed each survival period but said that they had they put them in bins, not times. He agreed that the first designated period was death within six hours and that there was no breakdown in the survival periods in that first bin at all. 1516 He agreed that of the 627 patients who died in the first designated time period, the article does not record at all when they died, but he said, that doesn't mean you can say they died instantly, on the spot. He agreed that it also meant that you cannot say that they did not, but added that Dr Edwards said that many died instantly and that is not just in the article. 1517 Dr Auer maintained that Dr Edwards had said that many died instantly and said ‘She calls it a one punch attack’.767 1518 Dr Auer agreed that in the article the author states 'The resultant pattern supports a unimodal distribution',768 meaning that most patients who are going to die, died in the first six hours. 1519 Dr Auer strenuously maintained that fig.4 shows none of the subjects died immediately. It was, he said, not false to say that it was five hours until some die, because we don't know the times that they died because that is the first time it shows up in their curves. He denied he had entirely misrepresented the tables to the court to improperly bolster the defence case. 1520 Dr Auer agreed that he had said 'and you have to go five hours until some die'.769 He said that was because five hours is the first bin. They put the cases in drawers and - five hours, 10 hours, 20 hours, there is no definition less than five hours. 766 T 2064. 767 T 2066. 768 T 2065. 769 T 2066. -- 300 of 345 -- [2026] SADC 67 299 1521 In response to the suggestion by the prosecutor that Dr Auer had given a false statement or gloss to that article, Dr Auer gave the following evidence:770 A. Yeah, if you're calling me a liar in court, you can say that, but I didn't say anything wrong about the article. They didn't have finer time periods in the first five hours, that's it. Q. Doctor, I'm suggesting that you entirely misrepresented the tables to improperly bolster the defence case, and you disagree. A. I disagree because this has nothing to do with [JR]. These are retrospective autopsy studies in severe closed head injury with Glasgow Coma Scale less than nine. It has just nothing to do with the case at hand. 1522 Dr Auer was taken to his evidence at T.1660 where he had said, 'Dr Jane Edwards has said that he was completely unconscious with a Glasgow Coma Scale of three, which is one for eye movement, one for motor response, one for verbal response and then he turned normal when the oxygen and circulation returned. 1523 Dr Auer agreed that it was clearly documented that during transit in the ambulance and on arrival at emergency, JR still had a reduced consciousness level of six out of 15 and that within five minutes, he started having seizures. 1524 With respect to Dr Auer’s evidence that JR ‘turned normal',771 Dr Auer said that he did subsequently turn normal, and the oxygen greatly helped him. He said that JR’s O2 still was not normal because of his lung disease. It was 96% saturation, but it still was not normal, and he had CO2 retention of 52 which is due to the lung disease. Dr Auer agreed that anything over 96% is normal, but JR was on 100% oxygen at high flow rates, and it should be up to 100%. Dr Auer then said JR did not turn normal instantaneously. 1525 The prosecutor persisted and reminded Dr Auer of his evidence that JR started with a Glasgow Coma Scale of three and had continued to say, 'and then he turned normal when the oxygen and circulation returned'.772 Dr Auer accepted that was not true ‘at that instant, but he got better and turned normal, sure’.773 Dr Auer said the prosecutor was ‘splitting hairs’774 with the exact second and minute. 1526 Dr Auer did not accept that if JR was able to breathe normally on his own, that would indicate pneumonia was not the cause of his cardiorespiratory arrest. This he said, was because the breathing is stimulated by hypoxia and by hypercarbia which is a stronger stimulus to breathing. JR had hypercarbia, a partial pressure of carbon dioxide of 52 or 53. The carbon dioxide retention, Dr Auer argued, is a sign of lung disease and that is carbon dioxide that's going to stimulate 770 T 2067. 771 T 1660. 772 T 2069. 773 T 2069. 774 T 2069. -- 301 of 345 -- [2026] SADC 67 300 his breathing. He said that it stands to reason that JR could breathe. It is because his medulla is unaffected and it's responsive to CO2. 1527 Dr Auer agreed that if JR had not been revived, he would have died, adding that ‘his father saved his life, and here we are, in court’.775 Hypoxia-ischemia related to subdural haematoma 1528 Dr Auer was asked about his opinion that hypoxia can lead to leaky blood vessels and that the leaky blood vessels are an explanation in this case for the subdural haemorrhages. 1529 He said that haemorrhage occurs due to three factors, namely, high blood flow, permeable vessels and thin blood. The last having been discounted. 1530 Dr Auer did not accept that the notion of the ‘unified theories of Geddes’, that hypoxia ischaemia of the brain can cause subdural haemorrhaging, has been completely refuted by research conducted on children who have suffered severe hypoxia without trauma. 1531 It was suggested to Dr Auer that the research in the area shows that none of the children who suffered hypoxia or ischaemia of the brain were found to have macroscopic subdural haemorrhages and the references Dr Edwards had given were Byard.,776 Hurley et al.,777 and Punt et al.778 Dr Auer said he was aware of the articles and felt that the interpretation in those articles was flawed. 1532 When it was suggested to Dr Auer that even Dr Geddes herself acknowledged that this was only a theory meant to stimulate debate, Dr Auer said:779 Well, Geddes is a very gentle woman. She was eliminated entirely by all the brouhaha of attacking her and she only meant it to stimulate thought because these kids, in her view, certainly weren't traumatised and it seemed to her, and it was supported by studies by Scheinberg in the UK, that many of these children in intensive care have atraumatic haemorrhages related to hypoxia so she quite reasonably said it must be the hypoxia but she didn't develop her theories any further and there's no full theory, fulsome theory to be able to refute, but the people promoting shaking piled on to her with the articles that you have mentioned to try and discredit any notion that hypoxia causes subdural. And, of course, what Geddes was missing was the adrenaline and the other factors that cause bleeding besides hypoxia. You see, she made a theory which is partly correct because we know pure hypoxia does give you haemorrhages, but she missed the adrenaline part, she missed the vascular permeability part and she missed the fact that some of these children could be infected as well as hypoxic. So her hypothesis was incompletely developed and I agree with you, she was discredited by these other authors, Hurley and Byard, but they were using drownings and other things than these kinds of resuscitated kids with adrenaline. 775 T 2070. 776 Exhibit P142. Byard et al, 2007. Lack of Evidence for a Causal Relationship between Hypoxic-Ischemic Encephalopathy and Subdural Hermorrhage in Fetal Life, Infancy, and Early Childhood. 777 Exhibit P144. Hurley et al, 2010. Is there a causal relationship between the hypoxia-ischaemia associated with cardiorespiratory arrest and subdural haematomas. 778 Exhibit P145. Punt et al, 2004. The ‘unified hypothesis’ of Geddes et al is not supported by the data. 779 T 2072-2073. -- 302 of 345 -- [2026] SADC 67 301 So it's apples and oranges. But she's a very meek individual and she whisked through it on the court, in the witness stand, and that's widely circulated that everything she said was garbage. But it's not quite right and it's not quite fair to her. 1533 It was suggested to Dr Auer that the articles of Richards et al., 780 Shaken Baby Syndrome, 2006 Archives of Disease and Childhood and Karim et al., 781 Cranial CT scan findings in a large group of children with drowning, also supported the notion that the Geddes hypothesis was inconsistent with the lack of subdural haemorrhages and retinal haemorrhages in the majority of clinical circumstances in which sudden rises of central venous pressure and intracranial pressure occur in the context of acute severe hypoxia and raised or unstable arterial pressures such as strangling and drowning. 1534 In his response, Dr Auer said that strangling and drowning are two very distinct insults. He said:782 …drowning cools the brain as the heart slows and eventually often goes arrhythmic and you can survive amazing periods of hypoxia as documented in The Last Breath on Netflix, of a diver who was hypoxic and almost written off for dead, but whose heart never stopped and whose brain was cooled by the North Sea water and he was almost written off when the overhead boat was severed from him and his line was severed. These drownings and hypoxias are very different because they involve cooling and not complete stoppage of the heart. I could go on about those but - and then strangling is a completely different thing and these are all compared to these babies in search for an answer, but the quest for an answer in different insults that don't resemble what you're studying aren't going to give you an answer. They don't get epinephrine or adrenaline, sorry, they don't get cooling. They don't have strangulation of carotid and venous and trachea as you do in a strangulation. So it's comparing apples to oranges and that's why the answer doesn't come out clearly. 1535 Dr Auer disputed that the notion that hypoxia and ischaemia of the brain can cause subdural haemorrhaging has been completely refuted by the research because there has not been physiologically controlled research. 1536 When asked if he was aware that ‘the Law Lords in the UK’783 stated that the unified hypothesis could no longer be regarded as a credible or alternative cause of the retinal haemorrhages, subdural haemorrhages and hypoxic encephalopathy, Dr Auer said:784 …it's not entirely non-contributory, the hypoxia. It does increase the blood flow a lot and it does increase the vascular permeability and the stretching of the blood vessels which then leak because they're stretched. 780 Exhibit D174. 781 Exhibit P147. 782 T 2074. 783 T 2075. 784 T 2075. -- 303 of 345 -- [2026] SADC 67 302 1537 He said he would not discard it entirely, but that it is not worthless and it does not explain everything and it was just an incompletely developed hypothesis to explain the bleeding. Resuscitation with adrenaline 1538 In response to the suggestion that there was no literature to support Dr Auer’s evidence that 'Subdural haematomas are commonly seen in babies and toddlers who are resuscitated with adrenaline',785 Dr Auer said, ‘Yeah, that's a good question and I'm not going to send you a preprint of my article. But it's just not true what you said.’786 1539 As to whether he could assist with whether this was not the experience of clinicians in Australia, Dr Auer said: I would, actually. If you look at the clinicians in the article by paediatric and developmental pathology in 2013 called 'Non-traumatic intradural and subdural haemorrhage and hypoxic- ischaemic encephalopathy in foetuses, infants and children up to three years of age', that analysis goes against what you have just said in your contained question. They find intradural as well as subdural haemorrhage because the haemorrhage is coming from the dura, as I put in my report on [JR]. The haemorrhage doesn't come from the subdural space, it comes from the high blood flow leaking in the dura and it spills over into the subdural space, and that's what these authors found in that article, 2013, vol.16, pp.149-159. They found intradural inside the dura bleeding, as well as subdural on the brain side of the dura bleeding, and the degree of hypoxic and ischaemic encephalopathy was studied as a factor and they found that there was an association between hypoxia and intradural haemorrhage. 1540 As to whether if it were the case that there is an increase of pressure, leaky vessels and the like, you would expect to see subdural haemorrhages and retinal haemorrhages frequently after hypoxic deaths both with and without resuscitation, Dr Auer said it depends how hard you look as to whether you find these haemorrhages, but they always look very hard in autopsies of babies in these medico legal cases, so they are always there and they are attributed to shaking in those cases, but that's wrong. 1541 As to the suggestion that if 'Subdural haematomas are commonly seen in babies and toddlers who are resuscitated with adrenaline',787 then one would expect to see subdural haemorrhages frequently after hypoxic deaths, both with and without resuscitation, Dr Auer said it would be definitely so ‘with’788 and not sure at to ‘without’789 because without adrenaline, you do not have the pressure and flow that drives the bleeding. 785 T 1602. 786 T 2075. 787 T 1602. 788 T 2077. 789 T 2077. -- 304 of 345 -- [2026] SADC 67 303 1542 Dr Auer said he disagreed that subdural haematomas in babies and toddlers who are resuscitated with adrenaline are not commonly seen in clinical experience or in the literature. 1543 Dr Auer was reminded of his earlier evidence that ‘six lots’ of adrenaline were administered to JR and it was suggested to him that he was mistaken in that there was one lot of intraosseous adrenaline at 12.38 pm administered by the paramedics who attended. Dr Auer agreed he was possibly mistaken, adding that adrenaline was given and, there are only a few cases that bleed without adrenaline. 1544 He was referred to his evidence of an article that linked subdural haematomas commonly seen in babies and toddlers who are resuscitated with adrenaline. Dr Auer agreed that the article was by Dr Irene Scheinberg and denied the prosecutor’s suggestion that the article did not go to subdural haematomas in babies and toddlers resuscitated with adrenaline. 1545 He agreed that Dr Scheinberg does not accept shaken baby syndrome. He denied her views were thought to be ‘extreme’790 adding that ‘the reason nobody accepts cases in the UK is because they will have their licence removed and come under GMC threat if they defend anybody.’791 1546 He said that he was aware that Dr Scheinberg wrote a letter to the British Medical Journal in support of Dr Squier after Dr Squier had been struck off. In her letter, Dr Scheinberg was making the point that 'Silencing the experts that have a different hypothesis based on their research and expertise is a greater risk that miscarriages of justice will be committed'.792 Dr Auer said that he had no issue with the letter. 1547 It was suggested to Dr Auer that Dr Scheinberg’s article linking subdural haematomas being commonly seen in babies and toddlers who are resuscitated with adrenaline is not generally accepted. Dr Auer’s evidence was:793 A. So it's not accepted by child abuse paediatricians, but it is accepted in the general - I mean it's been cited a number of times. So I don't know what you mean by 'accepted'. Who's doing the accepting is my question and then I can answer it? Q. I'm suggesting that it's not accepted by clinical paediatricians, that view. A. Well, John Galaznik is a clinical paediatrician, he accepts it, but the shaken baby doctors don't accept it. Q. Is it fair then to say that it's not accepted by what could be considered the more mainstream clinical paediatricians. 790 T 2086. 791 T 2087. 792 T 2087. 793 T 2087-2088. -- 305 of 345 -- [2026] SADC 67 304 A. Well, it's a good question what you're asking me. To answer it, you'd have to see who is citing the article, if it's been cited. I think it's been cited 50 times. Q. And can you assist us with whether it's been cited by the cohort of defence people who write self-citing or cross-pollenating articles. A. Yeah, that's mostly occurred in the child abuse community who have a plethora of articles and there are not so many articles challenging them because they do this full- time, so I can check the citations according to your question and that will take - Q. Let me put it to you this way, Dr Auer: do you accept that the hypothesis of subdural haematomas are commonly seen in babies and toddlers who are resuscitated with adrenaline would not be accepted by those paediatricians that accept the consensus - what we've called the 'consensus statement'. A. So I think you're spot on with that because the paediatricians who wrote the consensus statement are an isolated group who are writing these articles to promulgate child abuse and therein lies your answer. The paediatricians have been divided. There have been paediatricians such as Dr John Cox who have been charged with child abuse and they certainly doubt the narrative of the consensus statement and it's all divided, so I'm not trying to evade your question, but it truly is divided. 1548 Dr Auer said that it was his evidence that bruising will be caused by giving a baby adrenaline as well. Bridging veins 1549 Dr Auer’s evidence was that he had noted when doing autopsies in both children and adults, that bridging veins are very hard to tear and are very elastic. 1550 He said that he pays attention to bridging veins assiduously now because of the armchair theory of bridging veins explaining subdurals in these babies. 1551 When asked what sort of numbers of postmortems on infants he had examined the brain in situ and removing it from the skull, as opposed to just slides. Dr Auer said that he examines all the brains of all the infants that die in his location and that he is asked to look at the brain at autopsy. He said that he is always looking at bridging veins because they are the only explanation the doctors have for subdural haematomas. He said that every two weeks he is responsible for removing the brain from the skull in postmortem examinations. 1552 He said that he was aware of a recent article on bridging veins, by Cheshire et al.794 When asked to explain why his observations of infant bridging veins differed so significantly from that paper which found that bridging veins were very difficult to remove without tearing, Dr Auer said that you have to tear or cut the bridging veins to take the brain out, otherwise you have not taken the brain out. 1553 Dr Auer said that what was said in the article regarding bridging veins being fragile and easily disrupted by applying excessive stretching force during 794 Exhibit P101. Cheshire, 2018. Systemic autopsy survey of human infant bridging veins. International Journal of Legal Medicine. -- 306 of 345 -- [2026] SADC 67 305 manipulation and under the force of gravity was ‘just not true’.795 He disagreed with the article’s findings that bridging veins, ‘appear to be delicate as they're easily disrupted on reflection of the dura’.796Dr Auer showed photographs to demonstrate his experience with bridging veins as very thin walled, and which do not tear easily.797 1554 It was suggested to Dr Auer that he had been showing the larger bridging veins, of which he said there were: 798 …about 13 or so, 10, 16. It's very variable. It can be up to 20 on each side and they go parasagittally and you can see them at autopsy, but the tiniest ones you don't see because you move something around and maybe the smallest ones tear, but the big ones don't. 1555 It was suggested to Dr Auer that the Cheshire article finds that the mean number of infant bridging veins was 54. He said that he found it interesting that they found so many, but they did that by modelling. When asked whether he agreed with their findings that the mean diameter is less than a millimetre, he said his pictures showed many of them are more than a millimetre, but, agreed ‘they’re small’.799 He agreed that eventually you must tear them to get the brain out, adding that: 800 …you'll notice that Cheshire says characterisation of infant bridging veins will contribute to understanding vascular sources of subdural bleeding and could also be used to further develop computational models of infant head injury. So they're just fixed on this idea that dura bleeding comes from the bridging veins. 1556 Dr Auer’s attention was drawn to a sentence in the article that 'This data could also provide biomechanical engineers with the opportunity to create more detailed computational models of human infantile head trauma or otherwise'.801 Dr Auer said:802 Yeah, traumas kind of look the same. Whether it's accidental or inflicted, still trauma, just as your cell phone will look the same if you drop it in anger or you accidentally drop it, it is still going to crack the same way. Explanation for cortical bruising 1557 Dr Auer was asked how cortical bruising could be explained. He said:803 Cortical bruising, there you're getting more into traumatic to get cortical bruising, but imaging often cannot distinguish intracortical blood is the small baby brain from the 795 T 2079. 796 T 2079-2080. 797 T 2080. 798 T 2081. 799 T 2081. 800 T 2081-2082. 801 T 2082. 802 T 2082. 803 T 2089. -- 307 of 345 -- [2026] SADC 67 306 subdural or leptomeningeal blood, so there is a problem there using imaging to support your statement, but in general, contusions or intracerebral bleeding is more often traumatic. 1558 As to cortical bleeding having been noted on JR’s MRI at two locations, Dr Auer said that the ‘cortical MRI doesn't have the resolution to make that statement.’804 When asked whether, having given evidence that if there was cortical bruising, it's more traumatic related, he was stepping away from that view, Dr Auer said:805 Well, bruising is more likely to be trauma in the cortex, but it has to have certain patterns, like the superficial gyri are more affected and MR often overcalls, especially trauma and intent, from imaging. You can't divine intent from imaging, but if there is bruising, the haemorrhage in the brain is more common in the brain. 1559 He agreed that he was saying if it is traumatic, it is more likely to be bruising in the brain. He said that he was aware of the MRIs undertaken in respect of JR. 1560 When asked whether he was then aware that they are consistent with actual bruising of the brain in two locations, Dr Auer said:806 Yeah, 'consistent with' implies the imaging knowledge that the brain is bubbling around striking the skull inside the CSF, which it does not do, and hence that is an imaging overreach. 1561 When it was suggested to Dr Auer that there was actual bruising within the brain (not on the surface) in two locations which would be more consistent with trauma, 1562 Dr Auer said:807 Well, it's also consistent with reperfusion haemorrhage. So you mentioned trauma as the only thing, but when you reperfuse ischaemic brain, you can also get bleeding. 1563 Dr Auer disagreed with the suggestion that the observations of the bruising of the brain were not consistent with JR suffering a stroke. He said that it was ‘an overcall that’s commonly made by radiologists who don't really know the field of brain ischaemia and brain haemorrhage.’808 1564 As to how he would explain the axonal shear injuries described by Assoc. Prof. Taranath in JR's brain, Dr Auer said there was no shear or trauma, but rather it was ischemic and that you cannot see axons on imaging as they are microscopic. 1565 As to how he was qualified to comment on what an MRI specialist can or cannot say, Dr Auer referred to his writing in his hypoxia chapter in Greenfield with a research radiologist Helene Beneviste, and said he had himself published 804 T 2089. 805 T 2089. 806 T 2090. 807 T 2090. 808 T 2091. -- 308 of 345 -- [2026] SADC 67 307 on axonal disease and axonal swellings in around 2015. He said that axonal swellings cannot even be seen by MRI but if they were, they would not be necessarily traumatic, but trauma is the single-minded explanation for anything the MR imager thinks is axonal swellings. When asked whether reading MRIs was his expertise, Dr Auer agreed that he was not a radiologist, but he reads MR scans and presents MR scans every day. 1566 He said that in his view the evidence of Assoc. Prof. Taranath, in terms of his clinical findings or his findings on the MRIs, is a ‘pathophysiologic overreach in that he doesn't know the cause and he's pretending it's traumatic if he's calling this brain trauma. So axonal injury can be ischaemic, it doesn't have to be traumatic, and you can't see axons in the first place.’809 Furthermore, he disagreed with Assoc. Prof. Taranath’s rejection of Dr Auer’s hypothesis that this could be a stroke based on the location and nature of the bleeds. Dr Auer added that JR had a collapse of the cardiopulmonary system and to say that is not ischaemia, just defies reason. 1567 Dr Auer agreed that his list of causes of retinal haemorrhages did not involve normal activities for an infant but added that having resuscitation with a swollen brain that is having seizures with adrenaline is also not normal and produces the haemorrhages. In response to Assoc. Prof. Taranath’s finding that JR did not have a swollen brain, Dr Auer said that you can have a swollen brain for a couple of minutes when there is a seizure. He gave an analogy of hypoxia causing an epileptic seizure, where there is a temporarily swollen brain. He said that by the time the MR scan was done, it was gone. 1568 It was suggested to Dr Auer that there is no evidence to indicate that seizures which are not the result of head injury have been found to cause retinal haemorrhages. Dr Auer referred to an article by Dr Joseph Scheller810 regarding infantile retinal haemorrhages in the absence of brain and bodily injury. Dr Auer said that the retinal haemorrhages were:811 …multilayered, the kind that usually sends people to prison. They are intra-retinal scattered and here you can see cases one, three, four, five and eight and nine are all multilayered. And that's usually said to indicate child abuse, which is difficult to fathom, but that's the inference that child abuse paediatricians make. 1569 Dr Auer was asked whether the article had excluded trauma as the source of the seizures, to which he replied:812 Well, the fixation on trauma, again in the question, is belied by the fact that these kids just presented with macrocephaly, which is a big head, a seizure and vomiting, irritability but they never presented with trauma. So to make this article into missing trauma, you'd have to say all 10 parents are lying about presenting the kid and then they somehow create seizures, emesis and macrocephaly as a cover up for trauma. It just doesn't make any sense. 809 T 2093. 810 Exhibit D176. Scheller, 2017. Infantile retinal haemorrhages in the absence of brain and bodily injury, p.1902-1904. 811 T 2098. 812 T 2098-2099. -- 309 of 345 -- [2026] SADC 67 308 You asked me about the 1-3% and here it is in the article, in the summary by Tinkle et al, Ehlers-Danlos syndrome is common representing up to 1-3% of the general population. So I was not lying to the court or making numbers up. And this is Tinkle et al 2017. 1570 Dr Auer accepted that his reference to an article by Rooks et al.,813 as relevant to retinal haemorrhages, was in error. He agreed that JR’s extensive multilayered retinal haemorrhages, could not have persisted since birth. Rather, he said, they were due to seizure. Dr Auer’s re-examination 1571 In re-examination, Dr Auer was asked why he had provided an anecdotal example of a comedian who had collapsed and details of his own experience. He said: Yes, I used an anecdotal format because it's more easily understood when a comedian falls over asymptomatic on stage it is clear to anyone that he is intact enough mentally to do comedy, and I used my own anecdotal pneumonia to show that I was also persisting and being on medical call without symptoms, and it's more easily relatable, so I said that rather than the slew of articles. 1572 I then allowed Dr Auer to provide articles which he said supported his evidence regarding silent pneumonia in young people.814 1573 Dr Auer said there was evidence of a staphylococcal-type infection and this had a relationship to the rhinovirus because once you have one infection, the immune system is so busy fighting it that you are prone to a secondary or superinfection. 1574 Dr Auer was asked whether JR now being described as ‘healthy’815 supported the opinion he had given. He said:816 Yes, the child being healthy aligns with the notion that pure hypoxia does not cause brain damage and ischaemia does not cause brain damage, if it's of sufficiently short duration. Thus, one can only conclude that the father and the first responders saved this child from any significant brain damage. You often get cerebral palsy as a consequence of these episodes and events and that was not the case here. Summary of Dr Auer’s opinions 1575 In summary Dr Auer opinion was that: 813 Exhibit D114 – Prevalence and Evolution of Intracranial Haemorrhage in Asymptomatic Term Infants, 2008. 814 Exhibit D179.Tobin et al, 2020. Misconceptions of pathophysiology of happy hypoxemia and implications for management of Covid-19; Ventura et al, 2010. Two Fatal Cases of Hidden Pneumonia in Young People; Brouqui et al, 2021. Asymptomatic hypoxia in Covid-19 is associated with poor outcome; Simonson et al, 2021. Silent hypoxaemia in Covid-19 patients; Dhont et al, 2021. Conceptions of the pathophysiology of happy hypoxemia in Covid-19; and Auer, 2002. Personal blood gases. 815 T 2120. 816 T 2120. -- 310 of 345 -- [2026] SADC 67 309 • JR stopped breathing because of a silent interstitial lung infection. • Pneumonia is not ruled out by a normal chest X-ray and that there may not be any evidence of pneumonia until collapse occurs. • Pneumonia is characteristically asymptomatic. • Head injury does not involve an instant cessation of breathing and impact head injury does not selectively knock out breathing. • Children are quite clear in consciousness after a head injury and lucid intervals are common. • JR’s seizures were because of pneumonia. • The paramedics did not observe signs of trauma, which would have to have been seen to have the violent knockout punch required. • There are many causes for retinal haemorrhages, which occur when there is raised intracranial pressure; through other atraumatic, normal, human activity; or ventouse delivery. • The bi-lateral haematomas were caused by a lack of oxygen or reperfusion during JR’s resuscitation when adrenaline was administered. • JR’s skull fractures were not caused by trauma. JR was deficient in Vitamin D and potentially had craniotabes and it cannot be definitively stated he did not. • Shearing forces were not at play here. • Biparietal skull fractures are typical for craniotabes, the skull manifestation of rickets. • The Consensus Statement reflects no more than ‘group think’. • Evidence that there were shearing or rotational forces on JR’s brain were purely speculative. • Fractures in the context of a vitamin deficiency can occur spontaneously in that a fracture is often mistaken for any space between the bones. • The intraparietal suture is the most common suture mistaken for a fracture. Pseudo fractures can be easily mistaken for fractures, as can Wormian bones. • JR’s rib fractures may be the result of normal growth or normal handling. The rib fractures would require highly selective focus without leaving any trace on the overlying skin. -- 311 of 345 -- [2026] SADC 67 310 • Pain comes from displacement of fractures, which JR did not have. • While it could be correct to say JR had a healing spiral fracture to his tibia this could be due to stroke. • Rickets often occurs together with other risk factors for bone fragility, the commonest other factor being Ehlers-Danlos syndrome. • In general, contusions or intracerebral bleeding is more often traumatic. • Bridging veins do not tear easily. • Bruising within the brain (not on the surface) is also consistent with reperfusion haemorrhage. When you re-perfuse ischaemic brain, you can also get bleeding. • Subdural haematomas in babies and toddlers who are resuscitated with adrenaline are commonly seen in clinical experience and in the literature. Assessment of the medical expert evidence Assoc. Prof. Linke 1576 I found Assoc. Prof. Linke to be a very impressive witness. Consistent with the breadth of her experience, her evidence disclosed a depth of knowledge with respect to paediatric radiology that allowed her to give helpful and comprehensive yet straightforward explanations of what she had reported in JR’s case and the underlying basis for her opinions. She was at pains to keep her evidence within the scope of her expertise as a radiologist. She gave her opinions in what I found to be balanced and matter-of-fact way. While at times she appeared to be mildly frustrated with defence counsel and had apparently refused to meet with him on one occasion, she maintained her professionalism with respect to the defence experts with whom on certain topics she plainly disagreed. Assoc. Prof. Taranath 1577 Assoc. Prof. Taranath was the only specialist paediatric neuroradiologist called to give evidence in this trial and consistent with his level of specialisation and expertise, was a very impressive witness. His professional standing was obvious. He appeared authoritative and inspired confidence in that he was able to clearly explain complex areas of medicine and the basis for his ultimate opinions. Assoc. Prof. Taranath addressed the criticisms that he understood Dr Auer had made against him in a reflective and measured way. Dr Edwards Further application to exclude Dr Edwards’ evidence 1578 In defence counsel’s closing address, the objection to Dr Edwards’ evidence was re-agitated along much the same lines as had previously been put forward and -- 312 of 345 -- [2026] SADC 67 311 incorporating criticisms of Dr Edwards’ evidence in the trial. It was submitted that if the application for exclusion of the evidence was further refused, the defence submissions were relevant as to the weight, reliability and credibility of Dr Edwards’ evidence. 1579 In his final address defence counsel placed particular emphasis on Dr Edwards playing the role of an investigator in this case; failing to properly investigate or consider the alternative hypothesis of an involvement of the dogs or BR; her reliance on the adequacy of the parents answers resulting in a reversal of the onus of proof in a criminal matter; her exclusion of the possibility that the leg injury was caused on 5 January 2020; her ‘misrepresentation’ of the head swelling noted from the sofa incident- said to be symbolic of her adopted approach, her lack of objectivity as regards no evidence of trauma having been identified by the paramedics; and, her failure to apply scientific methodology. 1580 After hearing Dr Edwards’ evidence, I remained firmly of the view that during her involvement in this case she had maintained appropriate impartiality. There was no basis to find that she had acted improperly in either her meetings with the family or in her communications with SAPOL or the DCP. I accept that she made all aware that any information that was provided would be shared, in accordance with her obligations. 1581 Dr Edwards was imparting information to the family as they had requested and offering them her opinion for them to consider. As she explained, it was important for the family to be across her opinion given the ongoing role that family were to play in the care of JR and BR. 1582 Clearly Dr Edwards had considered the issues that were raised by the family. That she dismissed them all as ‘possible but highly unlikely’817 does not equate to a failure on her part. 1583 I do not accept that Dr Edwards’ having mistakenly communicated as to the resolution of the swelling from the sofa incident demonstrated any lack of objectivity on her part. 1584 Dr Edwards’ evidence made very clear to me that she understood the responsibilities of an expert in court proceedings. She understood the scope of her role as a forensic paediatrician and stayed within the appropriate parameters of her role. To assert that she undermined the accused’s right to silence, had reversed the onus of proof, acted ‘in concert with police to break down resistance to her speculative hypothesis’ is to misunderstand her obligations and her role. 1585 The defence submits that Dr Edwards’ evidence in and around the topic of the degrees of force was confusing and inconsistent. It was described as representing a desperate grab at justification for her conduct in the context of this matter. In my view Dr Edwards’ evidence on this topic was both logical and 817 T 492. -- 313 of 345 -- [2026] SADC 67 312 compelling. She described what is clearly extensive experience in working with babies with skull fractures and while the fractures cannot be dated, the medical evidence was overwhelmingly in support of her opinions. 1586 Dr Edwards’ opinions as to causation and timing were based on the investigations and findings that had been presented to her for her analysis and were based on her extensive and relevant experience. 1587 Dr Edwards readily accepted that it was not possible to quantify force and that there was limited evidence-based trauma force literature. She acknowledged the limitations biofidelic infant surrogates presented. It is of note that Prof. Ackland ultimately accepted that Dr Edwards had experience in biomechanics and confirmed that she had accurately explained the differing modalities. 1588 I have assessed Dr Edwards as a highly qualified expert in her field. She provided a genuine, logical, credible, and reliable basis for her opinions, which she expressed without a hint of bias and with the appropriate level of independence and professionalism in the face of what can only be described as an attack on her integrity both as an expert and a clinician. 1589 I found Dr Edwards has the relevant specialised experience and expertise to provide her opinion on both clinical and biomechanical issues in this matter, which she conveyed with the utmost professionalism, clarity and focus. Dr Gootnick 1590 My impression was that Dr Gootnick at times appeared confused and not totally across all the details of the topics upon which she was commenting. Certainly, she appeared unfamiliar with the content of the various editions of her reports and the material with which she been provided. It remained unclear what information she had accessed and what her views were with respect to the relevance or impact the CT and MRI scans may have had on the evidence she gave. 1591 There were aspects of Dr Gootnick’s evidence on the topic of skull fractures that were puzzling. Her opinion was that there was no evidence of skull fractures however when asked whether she had looked at the reports of JR’s plain X-rays, Dr Gootnick said she had and ‘I thought those were fractures, but I disagree for the reason I stated previously’.818 When asked to refer to her report, where she had said that swelling was not confirmed by X-ray, she noted that she had not looked at the CT scan of the skull. This was surprising given Assoc. Prof. Linke’s evidence was that the CT scan showed that blood and soft tissue swelling was at the site of the fracture. 1592 In Dr Gootnick’s report that was before the prosecutor, in reference to JR’s skull X-ray, Dr Gootnick had written ‘the red arrow marks one of the parietal skull 818 T 1716. -- 314 of 345 -- [2026] SADC 67 313 fractures’.819 It became apparent that the report to which Dr Gootnick had been referred by the prosecutor was a different version of her report than that to which Dr Gootnick was referring in her evidence. Ultimately, Dr Gootnick agreed that there were two occasions in her reports where she should have said that what was being referred to was ‘alleged’ to be skull fractures. 1593 In her cross-examination, the prosecutor observed that Dr Gootnick had written that the sofa incident could ‘easily have caused the accessory suture to turn into a fracture in this region’.820 Dr Gootnick said that what her report should have said was, ‘a fracture in this region would become more obvious due to the presence of both vitamin D deficiency and a small accessory suture’.821 Dr Gootnick’s evidence at pages 1957-1964 was unhelpful in assisting me to understand why she had reported as she had, or the credibility of what her ultimate opinion was said to be. 1594 Dr Gootnick’s explanations as to her references to skull fractures as an error in the dictation system or a ‘typo’822 were unimpressive. At the very least, it showed carelessness and a lack of attention to detail and more concerningly, a lack of conviction as to her opinions. These issues were critical to those opinions and to have overlooked such errors, if that is what they were, was in my view an unconvincing explanation. While I accept draft reports are just that and are not necessarily reflective of a fully considered, concluded and final position, I have been left with no satisfactory explanation as to why it may have been that her view changed. 1595 In finding that I cannot accept Dr Gootnick’s evidence as where it differs from that of Assoc. Prof Linke and Assoc. Prof Taranath, evidence, I have considered whether some of her difficulties arose from not having been provided with all the relevant material, namely the CT and MRI scans and had been told that she was not to give her opinion on the issues relating to the head; that there was some involvement of a ‘medical advisor’ of some kind who had reviewed and perhaps edited her reports apparently without her knowledge; and that she was giving evidence remotely and sometimes in the evening. Certainly not having had access to the CT and MRI scans placed her at some disadvantage. 1596 Most importantly, and leaving aside my concerns regarding her reports, clearly Dr Gootnick is best described as a generalist, who although may report on paediatric patients in her current role, cannot be said to have specific training in paediatric radiology. This was best demonstrated with respect to her understanding of paediatric anatomy, issues concerning non-use osteopenia, and growth arrest lines. Her evidence regarding comparisons between an image of JR and that of a child somewhat older than JR is in my view best explained by the limitations in 819 T 1717. 820 T 1958. 821 T 1959. 822 T 1686-1687, 1935-1936, 1938. -- 315 of 345 -- [2026] SADC 67 314 her paediatric expertise. It was plain that Dr Gootnick’s knowledge and expertise on the issues relevant here was not as comprehensive as that of Assoc. Prof. Linke. Prof. Ackland 1597 The defence submitted that it was apparent that Prof. Ackland had considerable forensic experience, and that he was suitably qualified to provide evidence in relation to the area of biomechanics. 1598 While I do not doubt that Prof. Ackland had considerable expertise in biomechanics, as he accepted, there were limitations in his expertise as regards medical clinical issues and infant physiology. That he had apparently been asked to give some focus by the defence to review ‘shaken baby’ literature was unhelpful. 1599 Importantly in my view, Prof. Ackland accepted the medical findings upon which Dr Edwards based her opinions. He accepted the importance of incorporating clinical experience with specific anatomy and biomechanics and that to have a meaningful opinion you would need that experiential base, which he did not hold. 1600 Of relevance was his acceptance that from his review of the literature, rotational accelerations can cause bridging vein disruptions. He was unaware of Assoc. Prof. Taranath’s findings, or of other bruising to the brain. He accepted that he was not ‘across’ the medicine behind Dr Edwards’ opinion that the totality of JR’s injuries occurred on 5 January 2020. Prof. Ackland described the relationship between rotational force with a direct head trauma causing retinal haemorrhaging as ‘very sound’. 1601 Certainly, Prof. Ackland took issue with Dr Edwards’ use of the term ‘low force impact’ with respect to the sofa incident but did not dispute her understanding of the medical outcomes following that event. 1602 He agreed that JR had sustained a life-threatening injury and that it followed, as ‘a matter of common sense’ that the force in JR’s case would be greater than that described in the article by Geoghegan823 and were the result of angular acceleration and impact, consistent with the article by Prange.824 He agreed that impact to JR’s head was more than ordinary handling. 1603 While, as the defence submitted, Prof. Ackland opined that the cause of JR’s injuries was ‘left hanging because we have no full understanding of what happened either on the morning of 5 January or times or days preceding that’, this submission ignores the evidence in relation to the observations of JR’s parents and the medical evidence of the GPs subsequent to the sofa incident, the timing of both JR’s collapse and the attendance of the paramedics on 5 January 2020. 823 Article not referenced. 824 Article not referenced. -- 316 of 345 -- [2026] SADC 67 315 1604 Prof. Ackland ultimately accepted that Dr Edwards had experience in biomechanics through her work. Furthermore, he agreed that it is clinical examination and neuroradiology that allows for a conclusion to be drawn regarding the likely force involved in head trauma and that the combination of factors provided the basis for concluding that JR’s head injuries resulted from contact and impact and rotational or angular acceleration. Dr Auer 1605 The defence argued that Dr Auer’s specific knowledge in relation to the area of neuropathology, and thus his insight into the conditions of the skull, alleged applications of trauma, and assessing symptomology in that context, put him in a sphere of his own in the context of these proceedings. 1606 It was submitted that the prosecution did not rely upon an expert who had ability, experience and expertise that was even close to that enjoyed by Dr Auer. In my view, the defence have thereby identified the difficulty I have in accepting the evidence Dr Auer gave in that he did not confine himself to his specialty. 1607 While I accept that Dr Auer is an expert in the field of neuropathology, I have not found him to be either a credible or reliable witness in relation to whether JR suffered a head injury on 5 January 2020 which then caused his cardiorespiratory collapse. 1608 Dr Auer’s view as to JR’s presentation and the potential cause of his collapse on 5 January 2020 covered a wide range of medical specialisation. I found his preparedness to give an authoritative opinion on areas which are outside his relevant field troubling. I note Assoc. Prof Linke’s evidence that there were statements made by Dr Auer where he had been ‘anatomically incorrect’. His evidence concerning JR’s breathing difficulties from infecting having ‘resolved’ as Dr Edwards observed, made no sense. 1609 Dr Auer appeared to equate speaking or working with colleagues who have expertise in relevant areas of medicine such as radiology, ophthalmology or paediatrics, somehow elevated his authority in those specialties and entitled him to dismiss outright the views expressed by the prosecution medical witnesses. I viewed his attack on the authors of numerous medical articles, and the prosecution expert witnesses, primarily Dr Edwards, as disrespectful of colleagues about whom he appeared to know little. 1610 Dr Auer referred to a paper by ‘one of the two world experts’,825 namely Dr Colin Patterson. Dr Auer said that he subscribed to Dr Patterson’s theory of transient brittle bone disease. He said that he was unaware that Dr Patterson had been stuck off the Medical Register in the United Kingdom in relation to opinions he had expressed as an expert defence witness in child abuse cases. Dr Auer said that he found Dr Patterson’s literature ‘…logical, underpinned by a lifetime of 825 T 2026. -- 317 of 345 -- [2026] SADC 67 316 knowledge of bone chemistry and bone pathology and cogent…’.826 Dr Auer said that he disagreed with the comments made by the General Medical Council’s Professional Conduct Committee (the GMC) that Dr Paterson’s actions posed ‘an unacceptable risk to the safety of children’. Despite Dr Auer being an apparent devotee, was not aware of Dr Paterson’s qualifications. In re-examination Dr Auer appeared to try and justify his position, saying that he did not rely only on Dr Paterson in aid of transient brittle bone disease and that it was a term he never used. 1611 The defence submission that while Dr Auer was criticised for having placed reliance upon others whose careers have been compromised, his own career was entirely without blemish, is not to the point. The relevance lies in Dr Auer’s adherence to compromised views. 1612 Dr Auer tended to insert into his evidence cases of some notoriety, or his own personal life experience, perhaps to make his evidence more relatable, but in my view, more likely to try and divert attention from the relevant issues being discussed at the time. In re-examination Dr Auer was asked why he had given an answer that related to his personal experience. I did not find his explanation helpful in addressing either the issue which he had initially been asked about in cross- examination (there being no evidence consistent with pneumonia), or satisfactory as to why such evidence had been given in that way. 1613 While I give credit to Dr Auer in acknowledging that the views he expressed regarding abusive head trauma did not accord with mainstream paediatrics, he tended to give dismissive, rather than well considered responses as to why it might be that various paediatric societies around the world accept abusive head trauma as a valid diagnosis. For example, his response to Chinese studies suggesting that abusive head trauma is a valid diagnosis, was dismissed as the Chinese ‘trying to be western and advanced’.827 Similarly, his explanation that the Swedish Paediatric Medical Society had rejected a paper that had backed away from abusive head trauma came after them having tried ‘to meddle in the content of the findings’.828 1614 The inference in his dismissal of views that were contrary to his own was that those views were arrived at through either incompetence and or an obsession with a traumatic cause for brain injury. For example, with respect to the suggestion by the prosecutor that paediatricians diagnose rickets from findings of elevated parathyroid hormone levels, and abnormal radiology, Dr Auer said ‘Well, yes, paediatricians also diagnose murder by the bleeding’.829 1615 Dr Auer was cross-examined in respect of the medical literature which he said supported his opinions or discredited those of others. He frequently resorted to generalised criticism of the authors of medical literature and there were 826 T2024. 827 T 1843. 828 T 1844. 829 T 1852. -- 318 of 345 -- [2026] SADC 67 317 occasions in cross-examination which revealed that he had either misrepresented the support the literature provided or, at the very least, had mis-spoken as to that support. 1616 As an example, Dr Auer described pseudo fractures as easily mistaken by the ‘unwashed’ for true fractures, which can be mistaken for child abuse and send someone to gaol. He described Dr Edwards’ thinking she was ‘infallible’ and he appeared to have had little regard to any radiological opinion such as that expressed by paediatric radiologist Assoc. Prof. Linke or even Dr Gootnick, who said she did not see Wormian bones on the scans. 1617 Dr Auer drew a comparison between JR's skull and the skull shown in the paper by Eklund et al.,830 which he described as ‘identical’. The Eklund article referred to the relevant image as evidence of a parietal pseudo-fracture. In cross-examination, Dr Auer was asked about the conclusion of the Ekland article, which was that in cases where histopathological confirmation is not possible, clinicians made need to depend upon the presence of associated injuries. Dr Auer described that conclusion as ‘very shaky’. 1618 When asked why he had not compared both sides of JR’s skull with that in Eklund, which would not give the same impression, Dr Auer’s response ‘Well, this is all I had from the article and demanding more and more from me just produces hundred-page reports that nobody reads. I think this is quite convincing that JR resembles a pseudo-fracture,’831 highlighted his attempt to divert away from the relevant issue. 1619 While Dr Auer went on to maintain that he had not given any weight to the conclusion because one parietal bone can have a pseudo fracture and the other cannot, and a real fracture can also be asymmetric, when asked why then he had referred to the article given he did not accept one of the tenets of what was being said, Dr Auer gave what to my mind was a disingenuous and evasive response. He said that it was because pseudo-fractures are misdiagnosed in courtrooms all the time and that it was ‘important to get the Eklund article and others like it into the courtroom so this anatomical variant does not get misdiagnosed as a fracture and a high level of trauma, which would produce a depression of the skull bone and would produce a different appearance than what we see here’. 1620 Dr Auer’s opinion was that the rib fractures are most likely simply due to vitamin D deficiency due to normal infant breathing and crying. He said that breathing or crying was a routine cause of rib fractures and would therefore, be a common observation by clinical paediatricians on all babies presenting for X-ray or investigation at emergency, going on to say that ‘rib fractures are common and they’re almost an incidental finding’.832 Despite agreeing there was no literature on 830 Ibid. Exhibit D109. 831 T 1861. 832 T 1856. -- 319 of 345 -- [2026] SADC 67 318 the topic of rib fractures caused by breathing in young infants, nor himself being a clinician in a paediatric emergency setting, he remained steadfast in his view. 1621 Dr Auer’s opinion that JR’s low vitamin D made craniotabes ‘quite likely’, did not appear to have been made with any reflection upon JR’s radiology. 1622 In cross-examination, Dr Auer agreed that the cohort of the 40 patients he referred to had all died and that he was not far enough along in the analysis to say whether all or some had skull fractures but agreed that a ‘significant’ number had. He explained that a large number had subdural haemorrhages and retinal haemorrhages and some had bruising. He said that his ‘data analysis is impeded by time’.833 He explained that many of the alleged perpetrators had taken plea bargains to avoid longer prison sentences and did not know how many had been found guilty at trial. His answer as to why he would include anyone in that group of 40 who had been found guilty beyond reasonable doubt, ‘Well, because as we know from OJ Simpson, guilty is not necessarily guilty. There were two trials of OJ Simpson, one was guilty, one was not guilty,’ gave insight into Dr Auer’s agenda and lack of objectivity and revealed his tendency to give glib responses when challenged.834 1623 When it was suggested to Dr Auer in cross-examination that there was no basis for suggesting JR had undiagnosed pneumonia where there was not a single clinical feature of it, Dr Auer said the clinical feature was that JR was awake and suddenly stopped breathing. He said that was not a head injury but characteristic of lung disease. When challenged as to this being a matter upon which a clinical paediatrician would need to give evidence rather than a pathologist, Dr Auer said he was an expert in hypoxia and had published on the topic, having written the standard textbook chapter on hypoxia in Greenfield's Neuropathology (therefore presumably in a neuropathological context), and had published on multiple sclerosis affecting those parts of the brain and causing sudden death due to breathing stoppage. It was difficult for me to see the relevance of that response. 1624 Dr Auer said that in the cases where he has been hired by defence teams in what is being called an abusive head trauma, a minority of cases do not show pneumonia. He agreed that in the vast majority of defence matters he does, he had slides and an autopsy as the foundation for his opinion of a silent pneumonia. 1625 Dr Auer said that while it was not ‘quite true’ that he routinely finds pneumonia in cases where no one else does, he said it was ‘mostly true’. When challenged as to his clinical experience in identifying silent pneumonia as being clinically limited, Dr Auer said that he talked ‘to the pulmonary paediatrician’,835 where he works but declined to name that person. 833 T 2038. 834 T 2038-2039. 835 T 2050. -- 320 of 345 -- [2026] SADC 67 319 1626 When asked as to the objective facts upon which he based his diagnosis of pneumonia, Dr Auer referred to the article by Kyu et al836 to support his evidence that almost a million children die each year from this collapse. Dr Auer argued in cross-examination that he had not misrepresented the article. He appeared unwilling to directly address the prosecutor’s question as to whether the article was entirely silent on ‘silent pneumonia’. Ultimately, he said that this was a ‘global article’ involving about 6.28 million children and the individual histories cannot be gleaned from that article. He said that the purpose of the article was to state how common it is for young children to die of lower respiratory tract infections and ‘it does that well’. While he agreed that to utilise a nonapplicable population-based study as a rationale for a case-based reasoning process and application to JR is not the recognised process by which a medical diagnosis is made, he continued in his efforts to justify his use of the article, which I found unconvincing. 1627 Dr Auer’s lack of objectively was plainly made out when he was questioned as to why he had not referred to JR’s lungs having been radiologically clear. He said that it was because his report was already 23 pages long and he did not have time to write more lengthy reports. His attempt to then go on to justify the radiological findings and the blood picture results was not to his credit. 1628 Dr Auer was taken by the prosecutor to certain articles including that by Hymel et al837 which the prosecution submitted showed that researchers had identified the presence of apnoea as being significantly associated with infants having severe traumatic brain injury because of an inflicted mechanism. Dr Auer dismissed the articles and in particular, Hymel, as based on circular reasoning in that these are known to be inflicted head injuries based on bleeding which is unexplained, so it is termed ‘inflicted’.838 Dr Auer maintained that his reasoning was based on the data, including that JR’s heart was still beating, in conflict it seems with the paramedic evidence that CPR was initiated to restart JR’s heart. An issue which Dr Auer did not directly address in his response. 1629 Dr Auer was asked in cross-examination about Dr Edwards’ opinion that he had disregarded clinical findings described in the article which included head injuries including skull and facial fractures, seizures, unreactive pupils and retinal haemorrhages, neurosurgical drainage of intercranial haemorrhage and that 43% were left with severe disability including four deaths and that he had suggested all clinicians involved in the care of those infants must have ‘misinterpreted the findings’.839 In response, Dr Auer argued that it was ‘very easy to misinterpret the… bleeding, as trauma’840 and that bleeding has three factors that are not traumatic. That is, leaky vessels, thin blood (often seen in infection) and high- pressure associated with adrenaline administered to JR. He said bleeding does not equate to trauma and that it was very easy for physicians to conflate bleeding with 836 Exhibit D166. 837 Exhibits P140 and P141. 838 T 1035. 839 T 2055. 840 T 2052. -- 321 of 345 -- [2026] SADC 67 320 it necessarily being trauma. He said, ‘it happens all the time’.841As the prosecution identified in submissions, Dr Auer ‘stepped back’ with respect to the relevance here ‘of thin blood’842 given evidence of JR’s coagulation test results. Dr Auer went on to address ‘the adrenaline given six times’843 about which he conceded he was mistaken. In evidence in chief, he did not provide any reference to support his view that subdural hematomas are commonly seen in babies and toddlers resuscitated with adrenaline. 1630 Dr Auer believed a head injury preserves breathing. Dr Edwards disagreed and described the statement as ‘fundamentally incorrect’,844 that it did not accord with accepted paediatric knowledge, and that there was no relevance to head injuries sustained from boxing and MMA in a paediatric setting. Dr Edwards observed that having worked in her current role in emergency departments and in her role of the chair of the Mortality Committee, reviewing all child deaths in the hospital, nothing of Dr Auer’s views on this topic was correct. 1631 Dr Auer was asked about Dr Edwards’ observation that he had not provided a reference to support his statement that head injury from boxing and MMA selectively preserves breathing. His lengthy answer845 was a good example of what concerned me about much of what Dr Auer said regarding Dr Edwards’ responses. When challenged and asked to be specific as to Dr Edwards’ observation that he had not provided a reference for his statement that adult head injury from boxing and MMA selectively preserves breathing, he continued to avoid the issue, saying that it was simply that ‘everybody can see it, everybody knows it's in the public domain and nobody has written anything different. Everybody can see it for themselves’.846 1632 In examination in chief, Dr Auer was asked about Dr Edwards’ opinion that it is well recognised that death can result from one punch attacks in young but otherwise healthy people due to damage to the brain causing the victims to stop breathing so that their brain is starved of oxygen. Dr Auer’s response, that it is rare in boxing and street fighting for there to be one punch attacks and that he had ‘provided several YouTube links for those and in boxing’ which ‘don't feature apnoea at all, despite being one-punch violent knockouts,’847 was not reassuring as to the credibility of his opinions. 1633 Dr Auer said that neither the street fighting nor the boxing one-punch attacks, despite being violent, feature apnoea and thereby this supported the opposite of what Dr Edwards was ‘trying to promulgate’. He then went on to say that ‘real life’ invalidated Dr Edwards’ ‘imaginative argument’ and referred then to a case he said was described in Wikipedia. That an expert of such a reputedly high 841 T 2052. 842 T 2053. 843 T 2053. 844 T 1031. 845 At T 1638. 846 T 1639. 847 T 1639. -- 322 of 345 -- [2026] SADC 67 321 standard as Dr Auer responded to the challenge to his opinion in such a way was in my view extraordinary. 1634 Dr Auer appeared to be of the view that because Dr Edwards said that JR was subjected to a head injury meant you stop them breathing. He did not seem to recognise that her view was that a blow to the head can stop breathing immediately, but that is not necessarily the case. 1635 Dr Auer was challenged as to having ignored the article by Byard,848 as it did not fit with his narrative. In evidence, Dr Auer had said that the article described 53 cases of non-accidental head injury in children and that as no one can know if the injuries were truly accidental, there was immediately a fundamental problem with what Dr Edwards was quoting. He had said that the children had neuropathology, but their lungs were not examined and so there was nothing to say that they had any lung disease. 1636 Dr Auer said that he had read the article ‘intensively’849 and had not ignored it. He said the clinicians had misinterpreted the bleeding as trauma. When it was suggested to Dr Auer in cross-examination that whether or not the head injury is accidental does not refute evidence that apnoea is part of the head injury, he said that we know apnoea is not characteristic of head injury, even severe head injury and referred to a case involving a Jeffrey Dahmer who he said was beaten with a crowbar and did not stop breathing. When asked whether he ‘misspoke’850 when he stated all the children had neuropathology, he said, ‘Well, they had neuropathology in the sense of something wrong with their brain’.851 Dr Auer said that there are various meanings for neuropathology and that even if the lungs were not looked at, interstitial pneumonia is routinely missed by forensic pathology, and it was not going to make a difference if they were or not examined. If they were examined, the lungs are routinely missed and if they were not examined, they will not also be seen. Dr Auer then again resorted to criticism of the clinicians, adding that they ‘must have misinterpreted the findings.’ 1637 Dr Auer’s attempts to justify the evidence he gave in relation to an article referred to by Dr Edwards by Wilson et al, titled ‘Impact brain apnoea – A forgotten cause of cardiovascular in trauma’,852 was not to his credit. In evidence, Dr Auer had said that the article did not support Dr Edwards’ assertions about fatal impact of brain apnoea:853 …despite being right in the title. And this is what some authors do, they want to write an article, they put something in the title, and this happens a lot in medicine and even science, 848 Exhibit P142. 849 T 2057. 850 T 2058. 851 T 2058. 852 Exhibit P143. 853 T 1643. -- 323 of 345 -- [2026] SADC 67 322 and they want to say the statement very badly, but you read the entire article and you don’t find support for the assertion. 1638 Dr Auer went further and said:854 And most of the information that we get is wrong for the reason that there’s a flood of information and people want to create more of it by writing articles such as impact apnoea but it hasn’t followed up and it’s the first one and it’s the only one that I can find and there’s no evidence within the article of what is claimed in the title. 1639 Ultimately, Dr Auer agreed that the article’s title was in fact ‘Impact brain apnoea – A forgotten cause of cardiovascular in trauma’.855 When asked why he had called the title fatal impact brain apnoea, he said it was because ‘it’s trying to explain death’.856 Ultimately, Dr Auer agreed he had misspoken and agreed the article described two people who had cardiorespiratory arrest following head injury. He denied however, that the article supported Dr Edwards’ opinion as to brain apnoea. 1640 The evidence that Dr Auer gave in re-examination regarding silent pneumonia and what had been learnt in COVID was said to be supported by the articles he listed. On my review of these articles the common theme appeared to be that there were aspects of COVID disease that were puzzling clinicians who were coping with the management of patients who were profoundly hypoxic yet exhibited no abnormality in their breathing pattern. I found the link between these articles and the cause of JR’s cardiorespiratory collapse was neither apparent from Dr Auer’s evidence, nor in my view, from the articles themselves. 1641 As to Dr Edwards’ reference to the article, Rungruangsak et al, Dr Auer said that while Dr Edwards had said that many died immediately, ‘None of them died immediately. And you have to go five hours until some die…Figure 4 shows none of them died immediately’.857 1642 The figure was a graph described as a Kaplan-Meir plot which Dr Auer described as an accumulative survival curve. He agreed it estimates the probability of an event such as death not occurring up to a certain time. He agreed that the finding of the article is that many died quickly from probably trauma in less than six hours. When asked whether he agreed that the figure provided no breakdown of the times of death, other than there were different groups who died in the first six-hour block, Dr Auer maintained that was not true. Ultimately, however, he agreed the article showed the number of those who died within the first six hours were set out, but not the breakdown of infants. He also agreed that figure 3 in the article made plain that most with severe, isolated head injury, died quickly and that figure 4 showed that only 25% were still alive at 20 hours. 854 T 2059. 855 T 2060 & Exhibit P 143. 856 T 2060. 857 T 1627. -- 324 of 345 -- [2026] SADC 67 323 1643 Dr Auer maintained that his evidence supported a delay phenomenon as the authors did not say any of the traumatic head injuries caused instant death. He ultimately accepted the article was silent on whether infants died immediately or not but maintained he had not misrepresented the article by asserting that ‘you have to go five hours until some die'.858 1644 In my view, Dr Auer plainly misrepresented the article’s findings to bolster his view. Perhaps most relevantly with respect to my assessment of his credibility, he attempted to divert attention away from having made such a misrepresentation by resorting to stating that the article had ‘very little to do with [JR]’.859 A similar misrepresentation was made as regards his evidence with respect to JR having ‘turned normal when the oxygen and circulation returned’.860 He ultimately accepted that that was not accurate as JR did not return to normal ‘at that instant, but he got better and turned normal’.861 He described the prosecutor as splitting hairs. 1645 Dr Auer’s preparedness to stray beyond the limits of his own expertise was perhaps best illustrated with respect to his opinions on neuroradiology. 1646 As to Dr Auer’s evidence regarding atraumatic arterial versus venous subdural bleeding Assoc. Prof. Taranath said that he had never come across an arterial subdural haemorrhage in a paediatric patient. 1647 Clearly, in Assoc. Prof. Taranath’s view, Dr Auer was mistaken with respect some fundamental aspects of MRI imaging. I note Dr Auer’s opinion as regards to fusion restriction referring to the freedom of water molecules moving within the cerebral tissue, which is not an index of trauma, ‘let alone intentional trauma’ and described Assoc. Prof. Taranath as engaging in ‘diagnostic overreach’.862 Assoc. Prof. Taranath said that the MRI reports on the inability of diffusion to happen which is an indicator of the fact that there is swelling in the cells which can be seen with contusion trauma. 1648 Dr Auer’s opinion with respect to MRI angiogram having showed that superior sagittal sinus did not demonstrate bridging veins into it was ‘…a diagnostic overreach. It’s unknowable to a neuroradiologist if there has been trauma or ischaemia’.863 Assoc. Prof. Taranath had explained that it is the location that matters. Trauma related diffusion restriction is going to be superficial whilst ischaemic follows a certain pattern. He said, ‘So certainly a radiologist can differentiate between trauma-related diffusion restriction and ischaemia-related diffusion restriction’ and explained the difference in presentation. 858 T 1627. 859 T 2066. 860 T 2069. 861 T 2069. 862 T 886. 863 T 888. -- 325 of 345 -- [2026] SADC 67 324 1649 Dr Auer did agree in cross-examination that in general, contusions or intracerebral bleeding is often more traumatic. When asked about the two locations of cortical bleeding that Assoc. Prof. Taranath had noted on the MRI, Dr Auer again resorted to his expertise in radiological issues, saying that ‘MRI doesn’t have the resolution to make that statement’.864 When taken to Assoc. Prof. Taranath’s evidence of there being bruising within the brain in two locations, Dr Auer said it is also consistent with reperfusion haemorrhage that is, stroke. He disagreed that the observations of the bruising in JR’s brain were not consistent with stroke and again resorted to generalised criticism that ‘It’s an overcall that’s commonly made by radiologists who don’t really know the field of brain ischaemia and brain haemorrhage’.865 When challenged to his expertise in reading MRI scans, Dr Auer agreed that he is not a radiologist but said he reads and presents MRI scans every day. Dr Auer described Assoc. Prof. Taranath’s clinical findings as ‘Pathophysiologic overreach in that he doesn’t know the cause and he’s pretending it’s traumatic if he’s calling this brain trauma’.866 1650 Dr Auer denied there was injury to the bridging veins, describing them as not easy to tear and that they can be stretched. His evidence stood in direct contrast to that described in the article by Cheshire867 in a systemic autopsy survey of human infant bridging veins which described the bridging veins as fragile and easily disrupted. Dr Auer said that what was reported was ‘just not true’868 and that the whole bridging vein theory ‘is a load of bunkum’.869 He explained the article as an example of being ‘fixed on this idea that dura bleeding comes from the bridging veins’.870 1651 I note that Assoc. Prof. Taranath’s evidence was that MRI does not have sufficient resolution to show the tearing of bridging veins. He said that the presence of trauma is to be inferred from the MR venogram which is meant to pick up signals from the veins and which could not show the veins, suggesting trauma to the veins. He explained that if there is a rupture to the bridging veins, a subdural haematoma will accumulate and will create a space that is not normally there. He said that bridging veins can only get injured when there is a front to back movement because it is going to be perpendicular to their access. Therefore, an acceleration, deceleration type injury is what they considered happened in the context of bridging vein trauma. Assoc. Prof. Taranath agreed in cross-examination that subdural bleeding can arise from causes other than trauma but not in this case and that traumatic origin is able to be readily inferred. 1652 Dr Auer described Assoc. Prof. Taranath’s opinion that there were shearing forces or rotational forces on JR’s brain as ‘Pure out-and-out speculation because 864 T 2089. 865 T 2091. 866 T 2093. 867 Exhibit P101. 868 T 2079. 869 T 2081. 870 T 2082. -- 326 of 345 -- [2026] SADC 67 325 axonal abnormality can be due to many causes, including hypoxia, genetic abnormalities’.871 He described the learned societies who had adopted the Consensus Statement by Choudhary872 as ‘So called learned but they’re not scientific research societies’.873 In my view, Dr Auer’s answers provided denials but were not demonstrative of a genuine reflection of the radiological evidence. 1653 Clearly Dr Auer spoke with an agenda, which is demonstrated by the evidence he gave at T1833-1844. He was focused on disabusing the court of any suggestion that JR might have sustained an injury and without regard to the possibility something traumatic had occurred. He resorted to generalizing cases of alleged child abuse as ‘these cases’ and appeared fixated on ‘intent’. While he was clearly passionate about his various hypotheses and spoke with conviction, I was left uncertain as to whether his opinions were genuinely held with respect to this case or were simply part of his routine agenda regarding abusive head trauma. An example of which was his reference to Ehlers-Danlos Syndrome, which simply had no relevance to JR’s condition and demonstrated his indiscriminate and unfocused approach to the particular circumstances in this case. 1654 It was noteworthy that despite his passionate views he had not yet published on abusive head trauma. As the prosecution submitted, Dr Auer’s evidence demonstrated him to be a dogmatic adherer to marginal view, rather than objectively able to review the facts. 1655 I did not find Dr Auer’s evidence to be either credible or reliable. Decisions in R v Baxter 1656 The defence argued that the decisions in the Queensland Court of Appeal in R v Baxter 874 and the subsequent re-trial875 are of particular assistance as they bear considerable similarity to the issues engaged here.876 The defence emphasized that Dr Auer had given evidence in the forensic context on many occasions, including in the case of Baxter. 1657 In that case, the appellant was acquitted of murder by the jury but convicted of the manslaughter of his six-week-old son. The prosecution case was circumstantial and depended on expert medical opinion that the infant’s collapse and death were caused by inflicted trauma, including shaking and/or impact to the head on 3 November 2011. 1658 The medical findings included subdural and subarachnoid haemorrhage, generalised brain swelling, and retinal haemorrhages. There was no direct evidence 871 T 1827. 872 Exhibit P47. 873 T 1828. 874 R v Baxter [2019] QCA 87 875 R v Baxter [2021] QSC 70. 876 Of note however is the finding of contusions in JR’s brain on MRI and my finding as to the conclusion by Assoc. Prof. Taranath that bridging vein injury was evidenced on the MRI. -- 327 of 345 -- [2026] SADC 67 326 of assault. A major feature of the trial was the admission of evidence that the infant had sustained rib fractures between one and three weeks prior to the fatal collapse. 1659 The appellant appealed, arguing that the verdict was unreasonable and that the trial judge erred in admitting the rib fracture evidence, which unfairly prejudiced the jury’s evaluation of causation. 1660 The prosecution case required the jury to be satisfied beyond reasonable doubt that the appellant caused the death by physically acting on the infant in a way that produced internal cranial injuries. Although the prosecution acknowledged uncertainties in the precise sequence of physiological events, it maintained that trauma inflicted by the appellant was the only rational explanation for the death. 1661 The prosecution also relied on evidence of earlier rib fractures as contextual support for its trauma theory. The Court recorded that the prosecution intended to use that evidence as ‘a compelling graduation in the injuries… with the end point of the death of the deceased from the event or events of 3 November 2011.’877 1662 The defence case was that the appellant did not shake, strike, or impact the child’s head and did not cause the injuries or death. On appeal, the defence emphasised both scientific uncertainty and impermissible reasoning in the prosecution case, highlighting inconsistencies and uncertainty within the prosecution’s own expert evidence as to the mechanism of injury. The Court of Appeal acknowledged that there were unresolved questions about whether death was caused by shaking, impact, or both. The defence also relied on the absence of external injury consistent with violent shaking or impact. The Court noted that despite the trauma theory, there was: ‘no visible manifestation of bruising or other injury externally, in particular to the structures and tissues of the deceased’s neck or to the extra-cranial tissues of the head.’878 Secondly, and critically, the defence argued that the rib fracture evidence distorted the biomechanical analysis by encouraging impermissible propensity reasoning. The Court accepted that this risk materialised at trial, pointing to expert testimony where rib fractures were explicitly relied upon to support conclusions of traumatic shaking and which were used as propensity evidence. 1663 The Court of Appeal allowed the appeal, quashed the conviction, and ordered a retrial. The Court held that the rib fracture evidence should have been excluded under s 130 of the Evidence Act 1977 (Qld) because its prejudicial effect outweighed its probative value. Central to that conclusion was the risk that the jury (and experts) would use the rib fractures as a stepping stone in reasoning towards guilt without being satisfied beyond reasonable doubt that the appellant caused them. 877 At [24]. 878 At [61]. -- 328 of 345 -- [2026] SADC 67 327 1664 In the retrial before Justice North, sitting as judge alone, the prosecution alleged that the infant’s death was caused by trauma involving angular acceleration–deceleration forces which, it was said, tore bridging veins and led to intracranial haemorrhage, brain swelling, cardiorespiratory collapse, and death. Proof of torn bridging veins was therefore an indispensable intermediate fact in the prosecution’s causal chain. 1665 Justice North observed that both of the prosecution’s expert witnesses Dr Lamont (paediatric radiologist), and Dr Skellern (paediatrician), opined that the cause of the infant’s collapse and death was entirely inferential, proceeding upon the hypothesis that a traumatic act, being either a throw down or a shaking as described, produced shearing forces which in turn caused a tearing of bridging veins which in turn caused bleeding and an irritation of the brain causing it to swell. Justice North noted that neither expert could identify a torn bridging vein (or some source of bleeding) and that the prosecution expert Dr TE Robertson, described as an experienced neuropathologist who examined the infant’s brain, said that upon examination:879 (a) There was no evidence of bruising or contusion within the brain itself; (b) There was no evidence of any tears within the brain; (c) There was no evidence of any laceration to the brain; (d) Apart from what appeared to be ischemic damage there was no evidence of any haemorrhage within the brain; (e) There was no evidence of any torn bridging vein or venous source either on the surface or localised subarachnoid haemorrhage. 1666 Justice North made a critical factual finding ‘that there were no torn bridging veins within [the infant’s] brain is contrary to one of the essential links in the circumstantial case propounded by the Crown.’880 1667 His Honour emphasised that the criminal standard requires proof, not reconstruction or assumption:881 Satisfaction of guilt beyond reasonable doubt must be based upon evidentiary proof to the required standard not upon speculation. 1668 It is apparent that Justice North was not concerned with an inability to describe force mechanics in granular detail, nor did his Honour require proof of the precise magnitude or direction of force. The prosecution case failed because it depended on a causal narrative that assumed, rather than proved, critical 879 At [237. 880 At [355]. 881 At [255]. -- 329 of 345 -- [2026] SADC 67 328 intermediate steps — including the existence of torn bridging veins and the identification of a specific unlawful act. 1669 While I note that in the trial Dr Auer had given evidence on many of the topics relevant in JR’s case, Justice North, rejected Dr Auer’s opinion that the alleged infant victim was suffering from a serious undiagnosed condition.882 1670 The decisions in Baxter and in The Queen v Stuart Lee,883 to which the defence also referred, reflect a consistent judicial approach that biomechanical and medical expert evidence may be used to demonstrate that certain mechanisms are capable of producing injury, but may not be used to quantify force with precision, prove exclusivity of causation, substitute scientific plausibility for proof or fill evidentiary gaps. 1671 Where, as in Baxter, the prosecution case depends on proof of a specific biomechanical or anatomical fact as an essential link, failure to establish that fact defeats the prosecution case. However, the identification of the precise magnitude of direction of force is not required, particularly where traumatic injury is independently established, and the remaining issues concern unlawful causation and attribution. 1672 These authorities do not prohibit a finding of guilt where the precise biomechanical mechanism cannot be identified, rather they prohibit findings founded on speculation, assumption, or unproven indispensable steps. Analysis 1673 I must decide whether on the evidence before me I am satisfied beyond reasonable doubt that JR sustained head injuries and if so, whether those injuries were caused by the accused. 1674 It is of course not for the accused to satisfy me that JR did not suffer a head injury or that the accused was not responsible for such an injury. 1675 I have heard a great deal of expert evidence regarding alleged fractures to JR’s ribs and tibia. Certainly, this evidence was part of the history of JR’s diagnosis and treatment at the WCH, and the basis for conducting further examinations. The disputes between the experts as to the potential for these fractures to have an atraumatic cause provided ground for an assessment of the experts’ evidence as to whether an underlying conditions caused JR’s cardio-respiratory arrest. 1676 For the reasons I have discussed, I have concerns as to both the credibility and reliability of the evidence given by both Dr Gootnick and Dr Auer. I reject their opinions as to the underlying causes for the radiological findings and the presentation and symptoms associated with fractures. 882 At [260]. 883 [2001] ATSC 133. -- 330 of 345 -- [2026] SADC 67 329 1677 I accept the evidence of Assoc. Prof. Linke and Dr Edwards and am satisfied beyond reasonable doubt that: • JR had multiple healing rib fractures which may have been of different ages. • The rib fractures had not happened in the five to seven days before 5 January 2020. • Rib fractures are commonly found with no overlying signs of injury. • Rib fractures are painful and symptoms can usually just be one of irritability. • JR did not have of Ehlers-Danlos syndrome. • Infants do not get fractures from normal growth. • JR did not have rickets. • JR did not have osteogenesis imperfecta. • While the observations of JR’s ‘jittery leg’ are consistent with the tibial fracture, it was possible that the tibial fracture occurred around the time of JR’s admission to the WCH. • These fractures are only relevant to JR’s temperament, making him difficult to settle. Has the prosecution proven beyond reasonable doubt that JR sustained traumatic head injuries? 1678 The defence case is that JR did not sustain injuries and that his collapse and the observations made of him at the WCH can be attributed to atraumatic causes as detailed in the evidence of Dr Gootnick and Dr Auer. I note that each gave evidence seemingly without regard to the opinions expressed by the other. 1679 The defence is of course not required to hypothesise alternative causes for JR’s cardiorespiratory arrest or appearances on radiology. 1680 I reject the opinions of both Dr Gootnick and Dr Auer as to an atraumatic cause for JR’s collapse and the radiological findings made at the WCH. I accept the evidence of Prof. Ackland insofar as it is the clinical examination and neuroradiology that provided the basis for drawing a conclusion as to the likely type of force involved in JR’s head trauma. 1681 I accept beyond reasonable doubt that JR sustained traumatic head injuries on 5 January 2020. 1682 I accept the evidence of Assoc. Prof. Linke, Assoc. Prof. Taranath and Dr Edwards in relation to the causes of JR’s cardiorespiratory collapse on -- 331 of 345 -- [2026] SADC 67 330 5 January 2020 and their findings in relation to a traumatic cause for what was demonstrated on the radiology. I am satisfied beyond reasonable doubt that: • JR did not have osteogenesis imperfecta, Wormian bones or craniotabes. • The cephalohaematoma, which was outside the skull, was attributable to JR’s ventouse assisted delivery and had no relationship to the skull fractures. • JR did not have pneumonia. • JR had two skull fractures with subdural haematoma occurring directly below the identified skull fractures. • The right sided fracture to JR’s skull was acute. • There was trauma to JR’s bridging veins. • Swelling noted in the perirolandic area of JR’s brain suggested hypoxic ischemic injury or an axonal shear injury. • Scan diffusion restriction supported an axonal shear injury which is usually the result of an acceleration, deceleration-type of injury. • The injury to JR’s brain on 5 January 2020 caused cardiorespiratory arrest. • The skull fractures would require a fall from height. • The injuries to JR's head were the result of a recent high force inflicted head injury on the morning of 5 January 2020 which involved head impact with rotational acceleration-deceleration forces. • There is no literature quantifying how much force is required to cause a fracture to a child, and it cannot be said what exact unit of force was involved to cause JR’s head injuries. • The Consensus Statement represents a guide to practitioners working in the area of ‘abusive head trauma’ in Australia. • A 6-week-old infant cannot generate sufficient forces to move on their own, and any injury to JR’s head must have involved an externally applied force. • The term 'inflicted head injury' does not mean intent. • Without prompt resuscitation JR would have died because of his head injury. • An injury to the brain can result in an impact to breathing even when the lungs are healthy. • JR did not have a stroke. -- 332 of 345 -- [2026] SADC 67 331 • Subdural haematoma does not result from hypoxic ischaemic damage. • There is no association between epilepsy and subdural haemorrhages. • JR sustained extensive bilateral, multiple retinal haemorrhages. • Complex retinal haemorrhages like those seen in JR are highly associated with rotational acceleration head injuries. • JR’s presentation had not been referred to as SBS as there was evidence of head impact. Has the prosecution excluded that innocent explanations account for JR’s head injuries? 1683 Having found that JR sustained traumatic head injuries, I turn to consider whether the prosecution has excluded innocent explanations for those injuries. The defence case is that in the event I were to make a finding that JR sustained head injuries, the sofa incident on 30 December 2019 or the resuscitative actions by the paramedics cannot be excluded as a reasonable possibility for the head injuries identified on 5 January 2020. 1684 The defence contends that Dr. Edwards was unable to reconcile the absence of bruising at the location of the purported impact.884 All that was evident was described as boggy swelling. The defence claims the boggy swelling likely resulted from the head injury on 30 December 2019, about which, Dr. Edwards agreed.885 1685 The defence argues that it is of significance that there was minimal swelling evident on 5 January, the skull was not depressed and the fractures showed nothing illustrative of an external application of force. Furthermore, the location of the fractures is proximate to the location of the earlier head knock. 1686 The defence submits that while the subdual haemorrhages are utilised as an attempt to justify the recent infliction of a traumatic injury on 5 January 2020, the problem with aging subdual haemorrhages frustrates the prosecution’s attempts in this regard and the intracranial injuries are not capable of establishing Dr Edwards’ theories, which could have been sustained or exacerbated in the context of the efforts of the paramedics. The defence submitted that the process of CPR, intraosseous resuscitation and the use of the defibrillator pads ‘would all but invariably have caused some injury to the 6-week-old infant’ and is a conclusion that is readily available on the evidence. 884 I note Dr Edwards’ evidence that sometimes with an impact you might see bruising, but sometimes you do not. 885 Dr Edwards’ evidence was that she was unable to say whether the swelling noted on 5 January 2020 was swelling from the sofa incident. -- 333 of 345 -- [2026] SADC 67 332 Sofa incident 1687 While the defence submitted that the compounding effect of the head injury sustained from the sofa incident is a commonsense, obvious inference, I note that while Dr Hargreaves’ evidence was that it was a reasonable assumption that JR’s head measuring smaller two weeks after birth is indicative of an injury during birth, she would not be drawn into a discussion with respect to subdural haematoma and head circumference as it was outside her expertise. Dr Hargreaves said that in her experience, ‘instrumental delivery that results in significant head trauma will generally result in a baby who’s depressed and requires resuscitation at the time of the delivery.’886 On her review of the hospital’s note and GP’s notes, there were no observations consistent with head trauma. 1688 Dr Edwards said that she would not expect a skull fracture from the mechanism of the impact described by the accused of 10-20 centimetres with the infant under their own power. She explained that it is very common for infants to have their head bumped on door frames, particularly getting a child in and out of a car, and those incidents do not result in skull fractures. She said that skull fractures do not develop visible bone healing on X- rays and it is only possible to age them radiologically in relation to whether there is recent swelling above them or recent bleeding below them. Here there was obvious swelling over the right- side fracture, and it was reported to be minimal swelling on the CT scan on the left side. Clinically, on examination, no one documented feeling any swelling on the left side of the head. She said that the right sided fracture was recent because there was swelling over that side and there was recent subdural blood associated with that fracture. The boggy swelling was not noted on the notes 24 hours later after admission on 6 January, which Dr Edwards said, told her that sometimes these swellings, can dissipate across the scalp so that they spread and therefore the swelling cannot necessarily be appreciated. An explanation may be that JR had been unwell in a supine position. Another explanation is that increased fluid in the tissues that had now resolved. 1689 Dr Edwards said that it is impossible to age skull fractures and that the skull fracture could have occurred earlier. She explained that while there was swelling described in association with a fracture on the CT scan and subdural blood, which was bright on the CT scan adjacent, the longest that bright blood is shown on CT, is 9 days and therefore it is not possible, based on the radiology, to be specific about the timing of the skull fracture. Dr Edwards went on to say that if there was a fracture, that would require a higher force impact than that which was described by the accused. 1690 The accused described nothing unusual in JR’s behaviour when he was put to sleep on 5 January 2020, nor when he woke for a feed and was placed on the ground. Dr Edwards explained that the sudden change when the accused returned 886 T 123. -- 334 of 345 -- [2026] SADC 67 333 to feed JR, indicates the most likely time frame for the head injury to have occurred and to which the cardiorespiratory arrest can be attributed. 1691 Dr Edwards said that a short distance fall by an infant of JR’s age could suffer a skull fracture and described several factors that determine whether a fracture would occur, such as whether there is initial acceleration; the surface they fall on, and whether it is a small surface area or larger surface area. She said that there is a lot of information needed to be gathered to arrive at a conclusion. It is the whole mechanism of injury. She said that the approach is to look at each injury individually and then look at them together. When you have a skull fracture that is recent and you have recent brain injuries, you need to consider them together when you are forming an opinion about the mechanism of injury. Dr Edwards said that when looking at a skull fracture her approach is that she cannot just make any specific statement. She must look at the circumstances of any reported incident that is purported to have caused the skull fracture. 1692 In arriving at her opinion, she had regard to the description of the event given by the accused to police and saw close-up photographs of the sofa. She described the forces involved in the sofa incident as ‘a trivial low impact’ that could cause bruising but would not be sufficient to cause a fracture or other significant head injury. The injury on 30 December could not be explained by simple angular force and rotational acceleration needed to be involved, as opposed to the injury sustained on 5 January 2020 which was at the higher end of the most severe presentations seen of infants presenting with head injuries. A short fall of approximately a metre would not result in cardiorespiratory arrest. 1693 Prof. Ackland’s opinion was that that there were other opportunities for forces to be directed towards JR’s body and those applications had not been scrutinized. As I have discussed, Prof. Ackland’s issue with Dr Edwards’ description of the sofa incident as a ‘low force impact’ was from a biomechanical perspective, rather than the medical outcome. He agreed the severity of JR’s injuries was a relevant factor to the inferences Dr Edwards had made and that JR’s head injury was the result of angular acceleration and impact which can cause bridging vein disruption. The skull fractures indicated to him that a forceful head impact occurred, and he did not contest that an impact to the head would be a relevant explanation for JRs’ retinal haemorrhages. 1694 Leaving aside the nature of the force involved, on 30 December 2019 and for the following six days, there was no alteration to JR’s level of consciousness observed by the parents. 1695 Dr Gillis said that they reported JR was behaving normally and there were no additional concerns apart from having a swelling to his head. He said there was no indication of any loss of consciousness or internal haemorrhaging. His view was that the injury was minor and did not require any further assessment or examination at hospital. He reassured TR that it was highly unlikely there were any intra cranial -- 335 of 345 -- [2026] SADC 67 334 issues because of the injuries he observed, and the mechanism of injury as provided. 1696 Dr Murphy said that the sofa incident was discussed on 3 January 2020, when he observed that some time had elapsed between the knock to the back of the head and when he saw JR. The danger for any significant intercranial injury would, he said have passed by then. He said that JR’s parents raised nothing that gave him cause to believe that there was anything sinister about the head knock a few days before. He checked JR’s head and there was mild swelling which meant there was no cause to be concerned about it. He said that a mild trauma to the back of the head can result in swelling between the scalp and the skull. It is not inside the skull. 1697 Dr Edwards’ description of the sofa incident as involving a force with a trivial low impact is consistent with the evidence. 1698 As to Dr Auer’s evidence regarding a re-bleed, in cross-examination, Dr Edwards was asked whether she agreed with Assoc. Prof. Linke’s evidence that subdural haematoma can re-bleed with minimal force. Dr Edwards explained that chronic subdural haematoma that have formed a new membrane around them with fragile blood vessels can rebleed inside that formed chronic subdural. This, as with a slow bleed, would have a specific appearance on neuroimaging which JR did not have. Here there was an abrupt presentation, with no symptoms prior to JR’s respiratory collapse. JR was exhibiting agonal breathing at the time of the arrival by the paramedics, suggesting that head injury had occurred very recently. Dr Edwards said that she had formed the view that the correlation of the fractures, the recent subdural haematomas and the acute presentation and acute brain injuries, are all most likely to occur at the same time on 5 January, rather than 30 December 2019. 1699 Dr Edwards observed that her evidence in this case aligned with the article by Prange887 where case studies involving infants younger than three years of age (admittedly using dummies) showed that a simple drop with linear forces of less than 1.5m does not result in subdural haemorrhage, traumatic axonal injury and death, however a rotational force applied before impact is much more likely. This, Dr Edwards noted, is not at odds with her dismissing an impact which was not a drop but rather a 10-20 cm horizontal movement with no gravity involved, the force of which was generated by the legs of a six-week-old baby. 1700 While the skull fractures cannot be aged, here they were associated with overlying swelling and underlying bleeding that was recent, correlating with a recent head injury. The initial CT scan showed the fractures overlying the swelling and underlying bilateral subdural haemorrhages surrounding the brain. Assoc. Prof. Linke’s evidence was that radiologically, regardless of any history, there was evidence of an acute skull fracture. 887 Ibid. Article not referenced. -- 336 of 345 -- [2026] SADC 67 335 CPR 1701 As to whether action by the paramedics could have caused bleeding, Dr Edwards said that while she was not there, in a normal standard resuscitation the head remains on the ground, and the airway is applied over the face so there is not a huge amount of manipulation of the head. This is because the training is very much that as you do not know whether there is a spinal injury, care is taken to not manipulate the head to any degree during a resuscitation. 1702 I have no doubt that Ms Preece perceived the scene to have been ‘chaotic’. The accused was described as hysterical and the situation involving a very young baby who was exhibiting agonal breathing was no doubt alarming to even the most experienced paramedic. While the time of his arrival at the scene is unclear, I note Mr Kretschmer’s evidence was that had there been something unusual in terms of the care being provided to the baby by those performing CPR, when he was present, he would you have intervened and made notes accordingly. 1703 In cross-examination Dr Edwards said she did not accept that subdural haematoma may be because of the intervention of CPR. She explained that children do not have subdural haemorrhages because of either cardiac arrest or resuscitation. Dr Auer’s opinion in relation to a cessation of blood flow due to compromised respiratory function and then a restoration of blood flow causing the subdural haematoma was, she said, not supported by any of the literature. In my view, Dr Auer’s evidence on the issue did not appear to directly address the issue. 1704 In any event, to attribute the subdural haemorrhages to the paramedics overlooks JR’s abrupt cardiorespiratory arrest prior to their arrival. Findings 1705 I accept Dr Edwards’ opinion that skull fracture and scalp swelling is clear evidence that JR sustained head impact and that the collective injuries to JR's head were the result of a recent high force injury on the morning of 5 January 2020, of a rotational nature onto a solid surface, just prior to the onset of the observed breathing difficulties and loss of body tone. 1706 I exclude as a reasonable possibility, the injury JR sustained on 30 December 2019 was causative of the head injury and cardiorespiratory arrest he sustained on 5 January 2020. I also exclude as a reasonable possibility, the head injuries that JR sustained were caused by the paramedics in administering CPR from either a re-bleed of the sofa incident injury or the resuscitative measures themselves. Has the prosecution excluded any reasonable possibility that the injuries were caused by someone or something other than the accused 1707 The defence raised the potential involvement by BR, the family dogs or TR in causing JR’s injuries. The prosecution bears the onus of excluding the -- 337 of 345 -- [2026] SADC 67 336 reasonable possibility that an act by another or by BR, the family dogs or TR was responsible for those injuries. BR and the dogs 1708 The accused described BR as a child who was very involved. She was described as an excitable child who loved to be ‘up in everyone's business and help where she thought she was helping out’.888 She loved to dance and would constantly be dancing around the lounge room. BR loved to hold JR. 1709 There was, the accused said, significant interaction between JR and BR and BR always craved attention. BR would throw tantrums if she wasn't getting her way. The accused described BR as inquisitive. He agreed that if she woke up after a morning nap, she would come and find people. BR was not just one to sit quietly and play in a corner. She was more likely to get up, find the dogs, or find mum or dad. 1710 The accused said he had never witnessed BR being rough with JR. 1711 He said that there was one occasion where BR had grabbed JR's dummy and was not giving it to him, he was upset and that is when they stepped in on that occasion. That was the only occasion he recalled. As to whether TR had ever raised BR being rough with JR he said:889 No, I mean, she was always excited to be around [JR], always dancing, as I said numerous times. She - she was excited to have [JR] in the family but she was - she wouldn't think that [JR] was right there either. Like she might be dancing but she didn't understand that if she fell over she might hurt [JR]. 1712 The accused said that BR had a habit of running in the lounge room and dropping to her knees and sliding on the floor. She would literally just fall to her knees. 1713 AE said that when BR was younger, she used to drop to her knees from standing up. She had done it to him several times and it really hurt. He said that the dogs had the run of the house. They were quite excitable. He had seen them collide with people’s legs and jump on your lap. He said they were crazy little dogs. He said family members had ‘wandered up to the hallway to keep BR at the other end of the house so she didn’t get involved’.890 1714 AR described BR as ‘a lovely girl but loved dancing all the time and sometimes with her dancing she would fall on her knees which would worry me because it would hurt her, but she did that quite a lot. She was happy, always dancing’.891 She thought that BR was a little bit jealous, but that she loved JR. She 888 T 1375. 889 T 1431. 890 T 774. 891 T 1485. -- 338 of 345 -- [2026] SADC 67 337 said that ‘[BR] was just wanting mum's attention more sometimes when mum was feeding JR but that was just normal what happens in families’.892 1715 The accused said that on 5 January 2020 he was at home with JR, BR and their two Maltese Shih Tzus which weighed approximately 7-and-a-half to 8 kilograms each. The dogs were very active and got excited. They barked a little bit and ran around inside the house. BR and the two dogs had access to the area where JR was in the lounge room. The usual routine was that BR would have her morning nap around 11am. The accused believed he and TR put BR to bed. 1716 The accused said he could not recall hearing BR coming down the hallway on 5 January 2020. He said that he was unsure as to whether he was aware that she was awake during the time that he was on the phone to the ambulance but agreed that she was not in the room with him. 1717 The accused said that he did not put the dogs outside when BR was sleeping, because they had free roam of the house and come and go from inside to outside by themselves. 1718 When asked if he would put JR on the floor, even if the dogs were running around, he said:893 Well, generally we'd put him on the floor, the dogs weren't running around but that's - yeah, we'd put [JR] on the floor. But if the dogs were going crazy around our feet, I wouldn't just put him on the floor. That would be a no brainer. 1719 He could not recall where they were in the house when he put JR on the floor but agreed that had they been excitable at the time, he would not have put JR on the floor. 1720 In submissions, defence counsel argued that BR’s ‘capacity’ was ‘made plain’ by photographic evidence and that there was evidence as to her ‘propensity to drop to her knees into others and to be boisterous’. It was submitted that ‘the photographs…show that [BR], even in the presence of others, manhandled the complainant, her infant brother’. Further, it was suggested that the text messages between TR and the accused suggested that BR was capable of inflicting trauma. The accused had only assumed she was asleep. The dogs had ‘propensity’. They were not restrained and were ‘capable of colliding with the child, causing the child to collide with an item of furniture, the coffee table for example’. BR may have ‘attempted to lift her brother and dropped him and/or fallen upon him. To have run for refuge post an event of that nature makes perfect sense, as opposed to a claim that the father has made an attempt on his son’s life where there was no history of disturbance or animus, or issues as between them’. 892 T 1485. 893 T 1406. -- 339 of 345 -- [2026] SADC 67 338 1721 The defence reliance on the photographs showing BR and JR together as ‘manhandling’ was plainly a misrepresentation of the evidence. The photos demonstrate nothing of the sort. I note that in the photograph showing BR sitting on a couch with JR on her lap with her arm around his neck, an adult hand is seen supporting JR. There was no evidence that anyone had seen BR or the dogs interact with JR with any degree of force and importantly, the accused had not seen BR be rough with JR. The accused’s evidence was that had the dogs been going ‘crazy’ he would not have put JR on the floor and logically, nor would he have done so if he had concerns about BR. 1722 Dr Edwards said she had considered all the information provided to her as to what might have happened to JR and had discounted those. She noted that there was no description that JR had been found crying in pain when left alone with either BR or any incident witnessed involving the dogs. In her opinion the right sided skull fracture would have been caused by forceful impact to the right side of the head, with one impact perhaps causing both fractures. 1723 I have found that JR sustained a traumatic head injury. Injury caused by either BR or the dogs is, based on the evidence of both Dr Edwards and Assoc. Prof. Taranath, inherently implausible and I have excluded as a reasonable possibility that BR or the dogs were responsible for JR’s head injuries. TR 1724 The defence has also raised the possibility that TR caused JR’s head injuries. TR was not called by the prosecution and there was no explanation as to why that was so. There was no obligation on the defence to call her. 1725 Text messages between TR and the accused had been tendered by defence on the voir dire concerning the argument as to the adequacy of the police investigation and tendered by consent by the prosecution on the trial.894 1726 The text messages between TR and the accused show that TR was in very frequent contact with the accused regarding issues with their children. In his evidence the accused described having constantly reassured TR that she was doing a good job with the children and was a great mother. He said that while he had told police TR did not suffer post-natal depression, at the time that was not part of his contemplation. The accused said:895 …because you know, [KR] and I, we got along well and I don't think I realised how much I was always there for [KR] to - for her reassurance until I read the text messages, that it was quite obvious that I was always there, I was always reassuring [KR], telling her she's doing a good job, and maybe she - she was second-guessing her - her as a mother, and I was trying to reassure her that she was a great mother. 894 Exhibit P91. 895 T 1410. -- 340 of 345 -- [2026] SADC 67 339 1727 During argument regarding the inadequacy of the police investigation in this matter, the defence submitted that while KR was not present within the home when symptoms were noted, she was present within a relevant time frame and furthermore, she ‘displayed a relevant propensity within the text communications, not so the accused’. In final submissions, the defence argued that the text messages ‘reveal a profound instability on [KR’s] part’ and that she ‘displays a relevant propensity within the text communications’. 1728 There is no doubt that the text messages show the accused played a supportive role in responding to his wife’s many communications about their children. Insofar as the text messages demonstrate any instability on KR’s part, while minds may differ as to what they demonstrate, in my view, they are simply indicative of a mother of two young children, who were at times stressful and frustrating, keeping the father of their children informed as to what was happening. It might be thought that KR’s openness about the issues that arose at home were healthy in that she was prepared to acknowledge and communicate her frustrations to the father of her children. I had no sense that the messages were indicative of instability or a propensity to harm either child. The statement KR was said to have made to Ms Walls was, in my view, of no relevance. 1729 In any event, as discussed below, the timing of the injuries JR sustained on 5 January 2020, do not allow for a finding that it was a reasonable possibility that KR was responsible for those injuries. Findings 1730 I accept Dr Edwards’ opinion that neither BR or the family dogs caused JR’s skull fractures that were identified at the WCH on 5 January 2020 and I exclude their involvement as a reasonable possibility. I also exclude as a reasonable possibility, that the head injuries JR sustained were caused by KR. Timing of the head injuries 1731 As discussed, I have excluded as a reasonable possibility, that JR’s head injury was sustained from the head knock at the time of the sofa incident or during his resuscitation. 1732 The accused said that on 5 January 2020, when JR was put down that morning, there was nothing unusual about his presentation. When JR had started fussing, after putting JR’s dummy back once or twice the accused started talking to him, got him out of the bassinet, unzipped him from his swaddle and put him on a change pad on the floor. After returning from the kitchen with JR’s bottle the accused said he returned and noticed that JR was gasping for air and looked like he was not breathing. JR was quite limp, was not breathing and his lips were going blue. 1733 I accept Dr Edwards’ evidence that it is known from witnessed incidents where somebody has a pure head injury, cessation of breathing will happen within -- 341 of 345 -- [2026] SADC 67 340 minutes of the injury happening, and there is around a 10-minute critical head injury time that people talk about as the critical moment to intervene after a head injury. When the paramedics arrived, they described JR having agonal or gasping respirations which she said suggested that the head injury had occurred very recently prior to their arrival, around the time of the description of JR becoming unwell. Findings 1734 I am satisfied beyond reasonable doubt that JR exhibited a very sudden and obvious change in behaviour, and I accept Dr Edwards’ opinion that the time when the change in JR’s behaviour was observed is the time frame within which the head injury occurred. JR could not have generated sufficient force to move on his own and his head injury must have involved an externally applied force. 1735 I accept that JR’s head injuries and cardiorespiratory arrest were caused by a deliberate act. 1736 I accept that JR was not injured prior to the time KR left the home and that JR sustained the head injury at a time just prior to the accused’s 000 call. 1737 I have rejected as a reasonable possibility that BR, the dogs, KR or the paramedics were responsible for the injuries that JR sustained on 5 January 2020. Furthermore, I have rejected as a reasonable possibility that the injury JR sustained from the sofa incident was the cause of the head injuries he sustained on 5 January 2020, or that they were caused by CPR or a re-bleed of the sofa incident injury, or that his presentation was a result of pneumonia. Was the accused responsible for the injuries JR sustained on 5 January 2020? 1738 I must consider whether I am satisfied beyond reasonable doubt that the accused was responsible for JR’s head injuries. My findings must not be based on speculation or assumption and there is of course, no onus on the accused to prove his innocence. Unless I am satisfied beyond reasonable doubt, I must find the accused not guilty. Findings 1739 As outlined earlier, the prosecution case against the accused is wholly circumstantial and to find the accused guilty I must be satisfied that the accused inflicting the injuries is the only rational inference open on the evidence. I must consider the whole of the circumstantial evidence relied on by the prosecution and return a verdict of not guilty if there is a reasonable hypothesis inconsistent with the accused’s guilt. The accused’s guilt must therefore be the only rational inference the proven facts enable me to draw. 1740 As observed by the High Court in R v Baden-Clay:896 896 R v Baden-Clay (2016) 258 CLR 308, [46]-[47]. -- 342 of 345 -- [2026] SADC 67 341 The principles concerning cases that turn upon circumstantial evidence are well settled. In Barca v The Queen [(1975) 133 CLR 82 at 104], Gibbs, Stephen and Mason JJ said: When the case against an accused person rests substantially upon circumstantial evidence the jury cannot return a verdict of guilty unless the circumstances are ‘such as to be inconsistent with any reasonable hypothesis other than the guilt of the accused’. To enable a jury to be satisfied beyond reasonable doubt of the guilt of the accused it is necessary not only that his guilt should be a rational inference but that it should be ‘the only rational inference that the circumstances would enable them to draw’[.] For an inference to be reasonable, it ‘must rest upon something more than mere conjecture. The bare possibility of innocence should not prevent a jury from finding the prisoner guilty, if the inference of guilt is the only inference open to reasonable men upon a consideration of all the facts in evidence’. Further, ‘in considering a circumstantial case, all of the circumstances established by the evidence are to be considered and weighed in deciding whether there is an inference consistent with innocence reasonably open on the evidence’. The evidence is not to be looked at in a piecemeal fashion, at trial or on appeal. (some citations omitted) 1741 The prosecution must exclude as a reasonable possibility that what the accused said to police on 5 January 2020 and in the evidence before me, denying the offence was untrue. 1742 The combined force of the inferences in this case lead me to reject the evidence given by the accused that nothing had occurred before JR’s cardiorespiratory arrest to cause his head injuries. I am satisfied beyond reasonable doubt that the accused had the opportunity to inflict the head injury to JR after KR left the home. I am satisfied beyond reasonable doubt that the accused inflicted JR’s head injury at around the time of his collapse and at a time when JR was in the accused’s sole care. 1743 In arriving at that finding, I have regard to the accused’s good character and his consistent denials. The accused has no convictions that are in any way relevant to the charge he faces before me. Clearly, the accused is a hardworking man from a close family who is held in high regard by those who know him. The evidence of his family and that of Ms Zimmer and Mr Kutcher, as defence counsel submitted, was that he is known to be of even temperament and good character and there was no suggestion of domestic violence or anger management issues. Family members had not perceived any marital issues or that the accused was struggling around the relevant time. 1744 The evidence of the accused’s good character is before me for two purposes. That is first, being relevant to the probability that the accused committed the charged offence. The defence argues that the accused is a person of good character, and so is less likely to have committed the offence, as it is not in his nature. The second relevance is the use that I can make of it when assessing the accused’s evidence both in court and in his police interviews. -- 343 of 345 -- [2026] SADC 67 342 1745 That I find the accused to be someone of good character does not mean that I must find him not guilty. I may nevertheless accept other evidence that leads me to conclude beyond reasonable doubt that he is guilty and that sometimes, a person who was previously of good character is found to have committed a crime for the first time. 1746 While the prosecution referred to an occasion when the accused was frustrated and threw his helmet to the ground, it was apparently an isolated incident and occurred when the accused was 11 or 12 years old. It is of no relevance, and I have made no use of that evidence. 1747 I am mindful of the defence submissions as to the surrounding circumstances which they have submitted lend considerable support to the contention that the accused would not have deliberately assaulted his infant son. These included the use of listening devices in the family home and vehicle which revealed no evidence to assist the prosecution; the standard of the accused’s care for both JR and BR as observed by family and medical practitioners; evidence of the accused’s love of family and his placid nature; his immediate attempt to secure medical assistance; and the transparency with which he dealt with the medical authorities on 5 January 2020. 1748 While I put little weight on the prosecution submissions as regards the accused’s isolation and lack of opportunity to ‘de-stress’ in the wake of JR’s birth, I do accept that JR was a challenging baby by virtue of his colic and reflux; and because of the pain that I accept he would no doubt have experienced in association with his rib fractures, and, consistent with the reports to Dr Murphy, that JR was ‘always in pain’. While I do not doubt that the accused loved JR, these issues, together with the care of a 2-year-old child who was described as active and inquisitive and who threw tantrums if she did not get her own way, would bring a level of stress and frustration to any caregiver even where their natural instincts are to care and protect the child. 1749 I reject the accused’s evidence that on 5 January 2020 he took JR from his bassinet and placed him on the floor, at which time JR was in good health, or that it was only when he returned from the kitchen that JR was observed to be limp with difficulty breathing, ‘as reasonably possibly true’. 897 I reject any reasonable hypothesis consistent with the accused’s innocence. His guilt is the only rational inference the evidence permits. 1750 Having rejected the accused’s denials as not reasonably possibly true, to find the accused guilty of the offence I must also be satisfied beyond reasonable doubt that the elements of the offence have been proved by the prosecution. 1751 I find the following matters proved beyond a reasonable doubt: 897 Douglass v The Queen [2012] HCA 34, [13]. -- 344 of 345 -- [2026] SADC 67 343 • The head injuries JR sustained on 5 January 2020 occurred as a result of an injury inflicted by the accused, of a rotational nature onto a solid surface, in accordance with the evidence of Dr Edwards. • The accused’s act in doing so was voluntary and deliberate, that is, not accidental. • It is not in dispute that JR would not have survived had it not been for the very timely attention of the paramedics. I am satisfied JR suffered serious harm as a result of the accused’s act. • With respect to the accused’s recklessness as to causing that serious harm, the prosecution must show that the accused was aware of a substantial risk that his conduct could result in serious harm to JR and that he engaged in the conduct despite the risk. The accused was aware of the risk of harm that could be caused to an infant’s head in acting as he did. This is especially so given his experience arising from the accidental injury which was incurred from the sofa incident. • I am satisfied that the accused was aware of a substantial risk that his action could result in serious harm to JR and went ahead and acted as he did despite that substantial risk. • There is no question here of lawfulness. • It is not in dispute that the accused was in a relationship with JR or that he knew JR was under the age of 12 years at the relevant time. I am satisfied that the accused committed the offence knowing that JR was a person with whom he was, or was formerly, in a relationship and knowing that JR was under the age of 12 years at the time of the offence. Verdict 1752 I find the accused guilty. -- 345 of 345 --