An Amish Nightmare: The Shaken Baby Misdiagnosis

     On December 23, 1999 Liz Glick, the 4-month-old daughter of Samuel and Liz Glick, Amish dairy farmers in Dornsife, Pennsylvania, died in the hospital two days after her parents found her unconscious in her crib. The baby was ill with a fever and had been vomiting. At the Geisinger Medical Center in Danville, pediatricians experienced in treating Amish babies determined that the infant had died of vitamin K deficiency, a genetic and sometimes dietary condition associated with babies born at home and breastfed who were not given the vitamin through precautionary shots or formula. The symptoms of vitamin K deficiency include bleeding in the brain and eyes as well as the presence of bruises caused by normal handling and movement.

     Dr. Michael Kenny, a pathologist at Geisinger, performed the autopsy and, as Kate Rush later reported in "Genomics in Amish Country," concluded the baby died of a "closed-head injury" (as opposed to a "penetrating head injury" caused by a bullet, stabbing instrument or a blunt object.) Since Dr. Kenny was not the medical examiner and it was not his job to make an official manner of death ruling, that decision fell to the county coroner, an elected official without a medical degree. Instead of conferring with pediatricians familiar with Amish patients, the coroner took the unusual step of convening an inquest, a jury-enpannelled hearing to determine if the death was suspicious enough to warrant a full-scale criminal investigation. (The coroner's inquest, as a first step in the criminal justice process, while still available in most states is an antiquated way of determining manner of death.)

     Dr. Kenny's "closed-head injury" finding, combined with the bruises and the brain and eye bleeding led the coroner's jury to rule that Liz Glick may have been the victim of a shaken baby syndrome (SBS) homicide.

     The Glick case became national news when a child protection agency speculated that the other seven Glick children in the wake of the coroner's jury decision were in danger. For their own protection the children were placed in foster homes until the Pennsylvania State Police and perhaps a jury at a murder trial determined if the parents had committed criminal homicide. The Glick children were split up and sent to non-Amish (English) foster parents, an action that stunned and terrified the residents of this traditional central Pennsylvania community.

     The plight of the Glick family caught the attention of Dr. Holmes Morton, a Harvard trained pediatrician who in the 1980's treated Amish patients at Children's Hospital in Philadelphia. Dr. Morton moved to Strasburg, Pennsylvania, where in 1989, he founded a nonprofit clinic in the heart of Amish country called the Clinic for Special Children specializing in the treatment and study of illnesses and disorders affecting the Amish. Supported by donations and fund-raising events the clinic incorporated a state-of-the-art laboratory for the diagnosis and study of biochemical genetic disorders. Dr. Morton should have been one of the first experts consulted by the authorities in the Glick case. He was well-known, had expertise pertinent to the case and was local. No one, however, sought his opinion on the cause of the Glick baby's death.

     Without being asked, Dr. Morton conducted his own inquiry into the Glick baby's medical history. A few days later he announced that the infant had been born with a genetic liver condition that rendered her body incapable of breaking down vitamin K. The symptoms of vitamin K deficiency--the bleeding in the brain and eyes, and the severe bruising--could easily be mistaken for signs of SBS. In Dr. Morton's opinion the Glick child had not been killed by shaking. There had been a terrible mistake; this baby's death had been of a natural cause.

     But criminal investigations are like freight trains--once they get rolling they are hard to stop. Even though Dr. Morton had thrown his body across the tracks the train kept coming. Weeks passed. Finally, in February 2000 the case went before a state medical advisory board of physicians. The doctors heard testimony from several pediatricians who agreed with Dr. Morton's diagnosis. The panel of physicians voted to recommend that the manner of death in the Glick case be changed to natural.

     The local coroner, in light of the physicians' recommendation, changed his cause of death ruling and shortly thereafter the child protection agency gave the Glick children back to their parents. A month later the district attorney announced that Samuel and Liz Glick were no longer the targets of a homicide investigation. One can only guess how far down the criminal justice track the prosecution train would have rolled had it not been for Dr. Morton's intervention. One or both of these parents could have been sent to prison. 

The Shaken Baby Syndrome: The Shirley Ree Smith Case

     When a presumably healthy baby dies in his or her crib for no apparent reason, and there is no evidence of foul play, rather than classifying the cause of death as "unknown," or "undetermined," a coroner or medical examiner will usually call the fatality a "sudden infant death syndrome" (SIDS) case. Although this is the same as ruling the death as "undetermined," it sounds more scientific. At one time the parents of SIDS babies found themselves under clouds of suspicion. Today, as a result of scientific study of these cases, forensic pathologists are attributing natural death causes in infant deaths that earlier would have been classified as SIDS fatalities.

     The "shaken baby syndrome" (SBS) refers to signs of physical trauma found in children under six who have been violently shaken. When a baby or toddler is shaken too hard the victim's brain is jarred against the skull causing it to bleed and swell. Most pediatricians and forensic pathologists believe that to diagnose SBS they must find, at minimum, evidence of subdural hematoma (brain hemorrhaging), retinal bleeding (broken veins in the eyes) and cerebral edema (liquid on the brain that causes it to swell). The conventional wisdom was that a child with these injuries who had neither been in a car accident or fallen from a two-story window had been violently shaken. Supportive evidence of SBS might include trauma to the neck and spine, bruises on the arms and torso and broken ribs.

     In the late 1990s a handful of pediatric researchers began to question the science behind the standard SBS diagnosis.Could cerebral edema and blood in the eyes and brain have other causes such as vitamin deficiency, disease or reactions to vaccines and drugs? Diseases thought to cause symptoms of SBS included hypohosphatasia, a brittle bone disease; Alagilles's Syndrome, a liver ailment; Bylers Disease, a liver disorder common among the Amish; and glutaric acidura, acid buildup in infants that causes paralysis and retinal bleeding. Some experts believe that a relatively short fall to a hard surface, say from three feet, can cause damage to the brain similar to that found in SBS victims.

     Because there is no agreement among pediatricians and forensic pathologists what physical evidence of SBS consists of, homicide trials involving defendants accused of shaking infants to death often involve expert witnesses testifying against each other.

The Shirley Ree Smith Case

     In 1997 a jury in Van Nuys, California convicted Shirley Ree Smith of shaking her seven-week-old grandson to death. The prosecutor convinced the jury that Smith had shaken the baby to stop him from crying. The medical examiner, in explaining why there wasn't as much cerebral bleeding as one might expect in a SBS case, said the baby had been shaken so violently the blood vessels in the brain stem suffered "shearing," causing instantaneous death without bleeding due to the fact the baby's heart had stopped beating. The autopsy had failed to produce evidence of brain swelling or retinal bleeding.

     The Smith defense put two forensic pathologists on the stand who classified the death as a SIDS case, noting that the baby had jaundice, a heart murmer and low birth weight. The jury accepted the prosecution's version of the facts and found Shirley Ree Smith guilty. She received a sentence of fifteen years to life.

     A state court of appeals upheld the Smith conviction. The Ninth Circuit federal court of appeals, however, in 2006, reversed the conviction and ordered Shirley Ree Smith released from prison on the grounds the jury had misclassified the baby's death as a SBS fatality. The state prosecutor appealed the case reversal to the United States Supreme Court.

     On October 31, 2011 the Supreme Court, in a 6 to 3 decision, reinstated Shirley Ree Smith's homicide conviction. This meant she would have to return to prison. The six justices upheld a longstanding legal principle that an appeals court cannot substitute its judgment for a jury's. The high court, recognizing the jury in the Smith case may have relied on the wrong forensic pathologists, reminded the Ninth Circuit Court that judges in jury trials cannot decide the law and the facts. If Shirley Ree Smith had a remedy in law, it would have to be in the form of executive clemency.

     In April 2012 California Governor Jerry Brown commuted the 51-year-old's conviction. Shirley Ree Smith was immediately released from prison. 

The Li Hang Bin Shaken Baby Syndrome Case

     In 2007 Li Hang Bin and his common-law wife Li Yang, immigrants from the Fujian Providence in China, resided in the Flushing section of Queens, New York. Just after midnight on October 22, 2007 Mr. Li called 911 to report that his two-month-old daughter Annie had become unresponsive and had turned blue. The infant arrived at the emergency room thirty minutes later with a fractured skull, brain and eye injuries, two broken legs and a fractured rib.

     According to the baby's 23-year-old father the unhealthy infant had been ill with a fever. On the night in question Mr. Li said he found Annie pale and unconscious. In his attempt to revive his daughter he accidentally bumped her head against a table. It wasn't until after the baby had turned blue that Mr. Li called 911. Five days after the infant's hospitalization Annie died.

     The forensic pathologist with the New York City Medical Examiner's Office who performed the autopsy ruled the baby's death a homicide by violent shaking and blunt force trauma. According to the forensic pathologist, the victim had all the signs associated with a shaken baby syndrome (SBS) death. The indicators included bleeding between the brain and the skull, brain swelling and bleeding in the retina. Pathologists call this the triad of SBS symptoms.

     In March 2008, five months after the baby's death, a Queens prosecutor charged Li Hang Bin with second-degree murder, and as a backup charge second-degree manslaughter. The prosecutor also charged Li Yang with a lesser criminal offense related to the baby's death. Both suspects were incarcerated in the city jail on Riker's Island. Fearing that they might flee to China, the magistrate denied them bail.

     Mr. Li and his 22-year-old companion insisted that the infant had not been violently shaken and bludgeoned to death. The case dragged on for five years during which time prosecutors offered the defendants plea deals involving lesser crimes and immediate release from jail. Li Hang Bin and Li Yang rejected the plea offers on the grounds they were innocent of any wrongdoing in the baby's death. Mr. Li demanded the opportunity to be exonerated at his trial. He said he was not going to admit to something he didn't do just to get out of jail.

     In January 2013, prosecutor Leigh Bishop, after dropping the charges against Li Yang, made her opening statement to the jury at Mr. Li's Queens murder trial. Prosecutor Bishop told jurors that the defendant had "violently, repeatedly, and with depraved indifference," slammed the baby's head into a hard object causing "abusive head trauma."

     Cedric Ashley, Mr. Li's defense attorney, blamed the baby's death on poor health. The lawyer said he would produce medical evidence that would explain the infant's fractured skull, broken rib and broken legs. Mr. Ashley said these injuries had been caused by a rare disease called Osteogenesis Imperfecta, also known as brittle bone disease.

     Over the next two weeks jurors heard testimony from a battery of medical witnesses on both sides of the issue. As is often the case involving dueling experts, the confused jurors settled for a compromise verdict. In February 2013 the jury acquitted the defendant of second-degree murder, a crime that carried a sentence of 25 years to life. However, perhaps because of the severity of the victim's injuries, the jurors did not acquit the defendant of criminal homicide. They found Li Hang Bin guilty of second-degree manslaughter, the lessor offense.

     Mr. Li, who had been in jail almost five years, faced a maximum 15 year sentence. He expressed shock at his conviction and promised to fight to clear his name. 

     On March 4, 2013, Justice Richard L. Buchter of the State Superior Court in Queens sentenced the defendant to 5 to 15 years in prison. The Chinese immigrant continued to maintain his innocence.

     Infant death cases are problematic because of the difficulty of ruling out the possibility of nonviolent, natural sources of the SBS symptoms. There are several forensic pathologists around the country who regularly testify for the defense in SBS homicide trials. A forensic pathologist who commented publicly on the Li trial said he was between 80 and 90 percent certain that this case involved a SBS caused death.