Shortage of paediatric radiologists acting as an expert witness: position statement from the British Society of Paediatric Radiology (BSPR) National Working Group on Imaging in Suspected Physical Abuse (SPA)

One of the most challenging areas of radiological imaging in children is the diagnosis of physical abuse. There is a dearth of paediatric radiologists willing to act as expert witnesses, particularly in the family courts. There are a number of reasons why radiologists may not be interested or willing to put themselves forward to work as expert witnesses in this field. A group of imaging experts recently formed the “British Society of Paediatric Radiology (BSPR) Working Group on Imaging in Suspected Physical Abuse (SPA)”. The group comprises radiologists and neuroradiologists with current or previous experience of providing expert witness reports to the court in cases of SPA. The group met in January 2019 to explore pragmatic solutions to the chronic inefficiencies in both medical and legal practices and the challenges that arise from working in a legal arena with different structures, goals, and assessment criteria. Key issues concerned organisational inefficiencies, variable support from National Health Service Trusts and the Royal College of Radiologists to conduct this work, and the risk/benefit of involvement. This work is important for the patient, parents, and society in general, and highly rewarding for clinical practitioners who are involved, but there are several issues with current practices that discourage active participation. With several members of the group either retired or close to retirement, the shortage of experts is becoming a pressing issue within the UK, which requires an engaged multidisciplinary group to come up with creative solutions. Here, the group provide a consensus opinion highlighting the current barriers and potential facilitators to increasing the number of radiologists willing to provide opinions to the court.

Introduction

Radiological imaging in children who have undergone suspected physical abuse (SPA) is fraught with difficulties. SPA can manifest as a range of abnormalities from fatal or near-fatal catastrophic traumatic brain injury, multiple fractures of the axial and appendicular skeleton, to the identification of occult healing fractures indicative of previous trauma.¹ This work is important for the patient, parents, and society in general, and highly rewarding for clinical practitioners who are involved, but there are several issues with current practices that discourage active participation.

Like all clinicians, paediatric radiologists and neuroradiologists are aware of the safeguarding and child protection role they play in their daily clinical practice. Similarly, they recognise that their clinical findings in this context may result in their involvement with and possible court attendance in both family and criminal proceedings. For these reasons and others, the Royal College of Radiologists (RCR) and Society and College of Radiographers (SoCR) have produced comprehensive joint guidelines, endorsed by the Royal College of Paediatrics & Child Health (RCPCH), on the careful handling and documentation required when assessing and imaging a child suspected of having undergone physical abuse.² This includes the establishment of radiological imaging protocols to ensure nationwide standardisation of high-quality imaging. The role of the expert witness in court has also been clearly defined, as described in Part 25 of The Family Procedure Rules 2010 “The Duties of an Expert”.³

In clinical practice, radiologists work as an integral and essential part of the multidisciplinary team, including social workers, police, paediatricians, ophthalmologists, neurosurgeons, and neurologists (amongst others), whose expertise within their respective disciplines is eventually presented to the court to facilitate the optimal decision-making process on behalf of the child. Often, these are cases in which the cause of the injuries may not be immediately apparent, and the clinical history is often incongruous with the clinical and radiological findings.

There is a national shortage of radiologists in all subspecialties including paediatric radiology. The RCR 2017 census indicated 8% unfilled consultant paediatric radiology posts.² As a consequence, much of this specialist work is frequently conducted by non-specialists, in district general hospitals (DGHs), who may not see a sufficient volume of cases or may not have undergone rigorous training in the imaging of children in this particular, forensic, context. If the case subsequently becomes the subject of court proceedings, it is not uncommon for a neuroradiologist or paediatric radiologist to be instructed to provide an expert opinion within their particular specialism.

This “expert witness” in most family cases is a single joint appointed expert whose role is to help the court interpret, understand, and integrate often complex imaging findings with the clinical findings from other disciplines in what are usually complex and difficult cases. The number of experienced personnel available and willing to give such an opinion is small and currently decreasing. The shortage of medical experts has been recognised by the legal profession, with the Rt Hon. Sir Andrew McFarlane, the President of the Family Division of the High Court of Justice, noting in a recent key note address,

“…I have been struck by accounts from courts all over the country as to the greater difficulty that now exists in finding experts who are prepared to take on instruction in a family case. This is apparently a particularly acute problem in the field of paediatric radiology, which, as you will imagine, is a core discipline in many child abuse cases, and (even more worryingly) in the field of paediatrics itself.⁴”

Following from this, a working party was established by the Rt Hon. Sir Andrew McFarlane to identify and attempt to seek solutions to the shortage of medical experts willing to provide input into the family courts, including radiologists.