Concern is mounting about dangerously low levels of vitamin D in pregnant women and two hospitals' failure to identify rickets after the death of Jayden Wray, a baby who suffered from the disease.
Chana al-Alas, who was just 16 when she fell pregnant, and her partner Rohan Wray, then 19, were acquitted at the Old Bailey last December of killing Jayden. Multiple fractures found after his death in 2009 were caused by congenital rickets, which was undetected in his 18 weeks of life, and not by abuse, the court found.
The couple, now 19 and 22, had their second child returned to them by the family court this week. Jayda, now 18 months old, was taken into care at birth for her own safety because of the allegations against her parents.
Questions are being asked about the levels of specialist expertise of the radiology departments at two London hospitals, University College London and Great Ormond Street hospital (GOSH), which failed to identify rickets in baby Jayden while he was alive.
At the family court, Mrs Justice Theis said there had been only one other case in the last 30 years of such severe rickets in so young a baby. "This case has demonstrated the difficulties in identifying rickets just by images. In this case it was queried by the radiologist at UCLH, missed by the radiologists at GOSH and picked up by the paediatric pathologist," she said in her written judgment, but she added that the baby received "sub-optimal care" from the two hospitals.
Great Ormond Street said that Jayden had a full skeletal survey on 23 July 2009 that found multiple fractures but said it would not have been obvious to hospital radiologists that these were caused by weak bones. "It is clear to us from the judgment that this was an atypical case where abnormalities were much less visible on the radiology, than were shown by the postmortem," GOSH said in a statement.
It had subsequently commissioned an independent review of radiology issues arising from the case by Dr Stephen Chapman, of Birmingham Children's hospital. This said: "It would have been best practice to raise the possibility of an underlying bone disease in the report (eg. vitamin D deficiency/rickets) ..." but concluded that it was "not an obvious case of rickets".
But a former GOSH paediatric radiologist, Karen Rosendahl, disputed that, in general, cases of rickets were necessarily hard to detect on a survey. She saidtold the Guardian: "It's very often not particularly difficult to see but you need experience. It's complex. You need five to 10 years of experience to get the diagnosis correct."
Rosendahl, who specialises in multi-skeletal (MSK) radiology, claimed in a BBC London documentary this week that GOSH had not replaced experienced MSK radiologists who had left in recent years, and this had led to misdiagnosis in cases of suspected child abuse.
Dr Rosendahl, who is now a consultant paediatric radiologist at Haukeland University hospital in Bergen, Norway, having left GOSH in April 2010, told the BBC: "I have concerns about children's safety. One particular case was misdiagnosed and had the wrong sort of treatment. Another case was misdiagnosed as abuse when it wasn't abuse."
The hospital said it accepted that it had lost MSK specialists but strongly rejected the claim and said that child protection work was a core part of the work of all its paediatric radiologists. GOSH said the decision to prosecute Jayden's parents for causing his death was taken by the Crown Prosecution Service after rickets had been diagnosed at a postmortem examination. "It is therefore fair to say that GOSH's radiological opinion was not the determining factor in that decision. Neither would a diagnosis of rickets at GOSH altered the sad clinical outcome."
The Jayden case is the latest in a line of high-profile controversies to hit Great Ormond Street. In May 2009 it was criticised by the NHS regulator over a catalogue of errors and failures,which meant serious injuries inflicted on Peter Connelly, the toddler known as Baby P, were not spotted. Peter had died in 2008 at the hands of his mother and her lodgers, shortly after being examined by a GOSH doctor in Haringey, north London.
A year later MPs called for an investigation after 50 GOSH consultants signed a letter of no-confidence in the chief executive, Jane Collins amid allegations of "fear and intimidation" at the trust. This week a BBC London documentary alleged GOSH had bullied staff and tried to cover up clinical failures, charges the hospital rejected.
Alas breast-fed Jayden, but this made his condition worse because her own vitamin D levels were so low. There is growing concern about deficiencies in mothers and their babies. Last year, Andrew Walker, coroner for north London, wrote to the health secretary, Andrew Lansley, asking him to ensure "greater public awareness" of the issue after a three-month old boy died of an infection to which low levels of vitamin D contributed. In February, the UK's four chief medical officers issued an important reminder to GPs of the need for pregnant and breastfeeding women to take supplements. Breast-fed babies and those whose mothers did not take supplements should also be given vitamin D.
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