Pathologist cleared over failure to spot signs of abuse
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《英国医生杂志》
A government pathologist has been cleared by the General Medical Council of serious professional misconduct over his failure to spot signs of abuse in the postmortem examination of a 14 month old boy (BMJ 2003;327:640).
Just two weeks after Dr Michael Curtis, assistant state pathologist for Northern Ireland, missed spotting multiple rib fractures in David Filipache, the infant抯 twin brother was admitted to hospital with a fractured skull.
The two baby boys were 11 months old when they were legally adopted in Romania by Geoffrey Briggs, a former missionary, and his wife in July 2000 and brought back to Northern Ireland. Four months later David Filipache was dead and Samuel Filipache was in hospital. Mr Briggs was sentenced to two years?imprisonment after he admitted punching Samuel. He has since been released but was recently questioned by police over the death of David, whose case is still open.
Dr Curtis carried out a postmortem examination on David抯 death in October 2000 but missed up to 16 healing rib fractures. When David抯 brother was injured 13 days later, Dr Curtis requested that David be exhumed for a second postmortem examination, and the fractures were discovered. No clear cause of death was established, however, since the fractures were already healing when David died.
Dr Curtis told the GMC hearing that even with hindsight, he stood by this finding. But he added that having carried out 7000 postmortems in his career, he was embarrassed to have missed the rib fractures.
Although Dr Curtis admitted failure to exercise reasonable skill and competence in the first postmortem, the GMC抯 professional conduct committee found "not proven" the charge that he had failed to protect David抯 brother.
He was found to have failed to properly interpret David抯 x ray films. The committee抯 chairman, Mr Ian Chisholm, summing up, said: "The errors made were significant but must be viewed against the background of inadequacies in the system and the standards applicable within the field of forensic pathology at the time of these events."
"Reliance was placed on information from a consultant radiologist which was relayed to you via a third party indicating that the x rays were 慜K,? said Mr Chisholm. The committee was "aware that these actions took place in the absence of any formal protocol or system for reporting on the results of x rays."
Dr Curtis抯 solicitor, Charles Atkins, said his client "deeply regrets his failure to note the fractures at the first postmortem and everything that flowed from that. He is reassured to think that valuable lessons will be learnt from his experience for the benefit of the public and the medical profession too."
It has become standard practice since the Filipache case for paediatric pathologists to attend postmortem examinations on babies.(London Owen Dyer)
Just two weeks after Dr Michael Curtis, assistant state pathologist for Northern Ireland, missed spotting multiple rib fractures in David Filipache, the infant抯 twin brother was admitted to hospital with a fractured skull.
The two baby boys were 11 months old when they were legally adopted in Romania by Geoffrey Briggs, a former missionary, and his wife in July 2000 and brought back to Northern Ireland. Four months later David Filipache was dead and Samuel Filipache was in hospital. Mr Briggs was sentenced to two years?imprisonment after he admitted punching Samuel. He has since been released but was recently questioned by police over the death of David, whose case is still open.
Dr Curtis carried out a postmortem examination on David抯 death in October 2000 but missed up to 16 healing rib fractures. When David抯 brother was injured 13 days later, Dr Curtis requested that David be exhumed for a second postmortem examination, and the fractures were discovered. No clear cause of death was established, however, since the fractures were already healing when David died.
Dr Curtis told the GMC hearing that even with hindsight, he stood by this finding. But he added that having carried out 7000 postmortems in his career, he was embarrassed to have missed the rib fractures.
Although Dr Curtis admitted failure to exercise reasonable skill and competence in the first postmortem, the GMC抯 professional conduct committee found "not proven" the charge that he had failed to protect David抯 brother.
He was found to have failed to properly interpret David抯 x ray films. The committee抯 chairman, Mr Ian Chisholm, summing up, said: "The errors made were significant but must be viewed against the background of inadequacies in the system and the standards applicable within the field of forensic pathology at the time of these events."
"Reliance was placed on information from a consultant radiologist which was relayed to you via a third party indicating that the x rays were 慜K,? said Mr Chisholm. The committee was "aware that these actions took place in the absence of any formal protocol or system for reporting on the results of x rays."
Dr Curtis抯 solicitor, Charles Atkins, said his client "deeply regrets his failure to note the fractures at the first postmortem and everything that flowed from that. He is reassured to think that valuable lessons will be learnt from his experience for the benefit of the public and the medical profession too."
It has become standard practice since the Filipache case for paediatric pathologists to attend postmortem examinations on babies.(London Owen Dyer)