Fatal abusive head trauma cases: consequence of medical staff missing milder forms of physical abuse.

OBJECTIVES: Missed diagnosis of child abuse may lead to chronic abuse with potential for death. This paper reports 3 such cases.
METHODS: This is a retrospective chart review of 38 cases diagnosed as abusive head trauma between January 1, 2004 and December 31, 2006 at a university hospital. We sought to identify fatal cases with a past medical history of physical abuse that was missed by the medical staff.
RESULTS: Three cases (7.9%) had a past medical history of physical abuse that was missed by the medical staff. Infants were 2 males and 1 female. Their ages were 2.5, 3.5, and 6 months, respectively. Missed abuse episodes involved rib fractures, a metaphyseal tibial fracture, and a shaking episode, respectively. The intervals that had elapsed between the missed and the fatal abuse episodes were 24 hours, 12 days, and 6 weeks, respectively. Perpetrators of fatal head trauma were all biological fathers. One plead guilty, and 2 were convicted of involuntary manslaughter. The infants were in the care of the perpetrators of the fatal abuse episodes at the time the missed abuse episodes occurred.
CONCLUSIONS: Physicians assessing children, especially infants, should be alert to indicators of abusive trauma to recognize abuse early on. Including abusive trauma in the differential diagnostic list and taking appropriate steps to rule out or confirm the diagnosis are of paramount importance in establishing child protective services and preventing further abuse and neglect that may at times be fatal.