A mother whose children were placed in foster care because of a misdiagnosis of shattered bones in her infant boy stated that she cannot move on from the painful event.
In October 2020, the boys, ages eight months and four years, were placed in foster care for ten days.
She stated that motherhood, her “primary identity,” suddenly felt “tainted.”
Betsi Cadwaladr’s health board issued an apology and stated that it always acted “in the best interests of the kid.
Mother-of-two Liz, a fictitious name, stated that she still struggled with anxiety, nightmares, and mentally repeating the incident.
The parents brought their infant son George, also not his real name, to Wrexham Maelor Hospital on October 24, 2020, because he appeared to be in discomfort following a fall.
“I ran out of the room to get a vest and diaper liner,” Liz recalled, recounting the incident.
It literally must have been less than ten seconds before he rolled, since he could roll, and fell off the side of the bed.
They hurried to the hospital that night, but personnel only performed an X-ray on his collarbone, advising his parents that this was the most likely site of injury.
Where the failures occurred
This X-ray was negative, therefore he was discharged that evening and his parents were instructed to administer pain medication.
The next Monday, his parents took him to a general practitioner, who referred him to Glan Clwyd Hospital in Denbighshire for another X-ray.
He was hospitalized for the night, X-rays were obtained, and radiologists identified five fractures: one in each leg and three down his right arm.
Radiologists are medical specialists who interpret diagnostic imaging, including X-rays.
“This is the crucial part, where the failures occurred,” Liz added.
“The physician informed me that two radiologists discovered these fractures. Two separate radiologists independently inspected these radiographs and independently discovered these fractures.”
The existence of the fractures was “communicated as if it were certain” to Liz.
“We had complete faith in the doctors’ ability to make an accurate diagnosis,” Liz explained.
“Consequently, we were stunned and devastated. It never occurred to me that there would be a mistake.”
She was informed that two radiologists examined the X-rays, per Royal College of Radiologists’ norms.
After reviewing the X-rays and the radiologists’ remarks, the orthopedic physician expressed safety concerns.
The police and social workers conducted a child protection check on Tuesday. Both Liz and her husband were arrested two days later.
‘Horrific‘
Liz said: “The police officer then arrived, and it was the last time I saw George [before his return]. Due to my arrest, I was unable to say farewell to him.”
Even at that moment, I couldn’t believe it, I was brought to jail.
Just before the police interview, a social worker informed Liz and her husband that she had “severe concerns” for the well-being of their two sons and requested that they voluntarily place them in foster care.
That was the worst thing that could have happened, Liz said.
It’s one thing for this to happen to us as adults, but the removal of the children from their safe home was horrifying.
“Because George was breastfed, he had never been separated from me, so we knew it would be horrifying.”
On the same day, the boys were placed in foster care.
“We were then in shock for several days, didn’t sleep, didn’t get dressed. We traveled to my parent’s home because we were unable to manage on our own “said Liz.
Vindication
Alder Hey Children’s Hospital in Liverpool viewed the X-rays three days after the couple’s detention.
The evaluated X-rays were considered at a two-day-later safeguarding meeting.
George’s parents believed he had injured his right leg by falling awkwardly, which was confirmed by the pediatric radiologist at Alder Hey Children’s Hospital, who stated that only one fracture had been discovered in George’s right leg.
On the X-ray, one on the right arm appeared as a visual blur. The growths on his left leg and right arm were the results of natural bone development.
Liz remarked, “We understood immediately that they had made a mistake because they lack pediatric training and are not pediatric specialists.”
However, the parents had to wait an additional ten days before their children were handed to them, as a second skeleton exam was required as part of the process to ensure the children’s safety.
After this, their bail restrictions were lifted, and their attorney withdrew their consent for their children to be placed in foster care, threatening to sue the government.
Therefore, their boys were returned to their grandparents, and after 15 days they were permitted to see their children again.
The guilt felt by Liz and her husband is unbearable.
‘Distressed’
She remarked, “I feel so awful that I’ve missed so much of the boys’ lives because I’ve been psychologically preoccupied.”
“I cannot view a photograph of the boys from that year without remembering this.
“It’s not about me, I know the guys are fine, but I’m concerned about the trauma they’ve through.”
It has impacted Liz’s professional life as well.
She had to take six months of sick leave and switch jobs within her organization to manage her stress as a key worker in north Wales.
Liz acknowledged the “very tough” tasks of professionals in pediatric care but stated that her case revealed “a lack of competency, aptitude, and skill set to treat children with fractures” at Maelor and Glan Clwyd hospitals.
A year later, in October 2022, the health board gave them a letter detailing what had transpired.
Despite being informed by phone that the hospital had made an error, no admission of error was made.
They filed a complaint with the Welsh Public Services Ombudsman.
At a meeting in December 2021, twelve radiologists examined the X-rays and identified a fracture in the patient’s right leg.
Liz stated that they had yet to receive an explanation for the identical four errors committed by two different radiologists at Glan Clwyd hospital.
She now desires that the Welsh National Health Service expedite its referral process and enhance its radiography offerings.
“Children should not be placed in care without first consulting a professional in this field. That is the crucial point, “added Liz.
“They must be fully honest about the difficulty of interpreting X-rays. They should not provide agencies with conclusive reports when there are potential ramifications involved.”
She was informed that one of the radiologists would enhance his report writing and that pediatricians would henceforth assess the understanding of medical jargon by agencies.
What has said the health board?
Gill Harris, the deputy chief executive and executive director of integrated clinical services at Betsi Cadwaladr University Health Board, stated, “I would want to take this opportunity to apologize to the family involved in this complex and heartbreaking case for what they have been through.”
“I cannot even begin to understand what they went through. I express my deepest condolences to them.
“However, as healthcare providers, it is always our responsibility to prioritize the health of children in such situations. This is accomplished in collaboration with other agencies, which must then determine their course of action.
“We have reviewed our instructions on how to frame reports to other authorities so that it is clear when more clinical investigations are required.
“However, we apologize once more for our original failure to detect a fracture and for the agony and grief this must have caused the kid.
“This unusual incident caused us to revise our policy for all instances of non-accidental and suspected non-accidental skeletal injuries and to strengthen our procedures.
“The public services ombudsman for Wales is satisfied with the steps implemented and the remedies provided to this family. He has determined that this matter does not merit a thorough examination.
Every member of the health board staff involved in this case has great compassion for the tragedy this family has through, but we always act in the child’s best interests.
