Diagnosis in Translation

Shaken-baby syndrome is being reconsidered across the globe, including in Sweden where the courts and government are weighing in

U.S. doctors travel to the Scandinavian country in a clash of case consultants, expert witnesses and visiting educators

Holding signs that read “witch hunt” and “legal scandal” in Swedish, demonstrators in 2009 protest a case of a man convicted of shaking his daughter. Högsta domstolen, the Swedish Supreme Court, granted him a retrial in 2013, and prosecutors later dropped the charges. (Photo courtesy: Mats Hellberg)

By Mark Olalde
The Medill Justice Project

Ezbjörn Hahne still has trouble sleeping. The 33-year-old lies awake at home in Stockholm, his heart thumping, his bed drenched in sweat. Memories drag him back to the more than two years he spent in prison—most in solitary confinement—after being convicted of shaking his one-month-old daughter Nadine to death. When placed in the general prison population, Hahne said he was beaten by inmates who meant to teach him a lesson for his grievous offense.

Except he didn’t commit the crime.

Convicted in 2005, Hahne had received a five-year prison sentence and fled to Spain, only to be caught and sent back to Sweden. The Swedish Supreme Court—Högsta domstolens—heard his case in 2013 and granted him a retrial after it determined new medical research no longer supported the conclusion his daughter’s injuries could have come only from shaking or other abuse. Prosecutors continued to probe his case until he received official notification in February they dropped the investigation.

Hahne used to own a construction company, but in an interview for this story he said he cannot work while he tries to rebuild his life. “It feels like your heart will explode in your breast or run away,” he said of the stress from the trauma of what happened. “It’s terrible, so my goal is take it step by step and get back to a normal life.”

For years, shaken-baby syndrome was a largely uncontested diagnosis in the United States and United Kingdom, but around the turn of the century, doctors in those countries began questioning the validity of the science behind the diagnosis. Now, questions about the science behind shaken-baby syndrome are increasingly being asked across the globe, and courts in Canada, New Zealand and elsewhere recently acquitted defendants accused of shaking children. With a population of only 9.5 million and a medical community averse to disagreement among its doctors, the discussion in Sweden is progressing in fast forward, according to lawyers following the international debate.

Heather Kirkwood, a Seattle-based attorney who dedicated her career several years ago to fighting the diagnosis in the United States and has since consulted on cases in Sweden, said questions raised in Sweden’s medical community can influence doctors around the world. “The medical community is international, so it’s all interwoven,” she said. “They [doctors] read the same journals. They read the same material.”

For years, prosecutors in the United States and Sweden relied largely on a triad of symptoms—bleeding and swelling in the brain and bleeding in the eyes—to earn convictions of caregivers accused of shaken-baby syndrome. But recently, research linked those symptoms to other causes such as preexisting medical conditions and cast doubt on the shaken-baby syndrome diagnosis, which also has come to be known as abusive head trauma. In Sweden—where the sun shines sparingly for half the year and foods are not often fortified with vitamin D—children are at risk of developing rickets, which causes brittle bones that can lead to fractures. These can be misidentified as abuse, doctors said.

Recently, courts in the United States have begun challenging the shaken-baby syndrome science as well, and in some cases, set prisoners free. Last year, U. S. District Court Judge Matthew F. Kennelly ordered the release of Illinois day care worker Jennifer Del Prete after he issued a 97-page opinion declaring “no reasonable jury” would find Del Prete guilty of murder based on the evidence, including revelatory findings by The Medill Justice Project. In December, a county judge in New York state overturned a day care operator’s murder conviction in part due to new medical science.

In the last five years, similar questions surrounding skakvåld—shaken baby syndrome—have arisen in Sweden, and at the invitation of Swedes involved in the debate, American and British doctors arrived in the Scandinavian country to review medical evidence, testify in cases and lecture about the diagnosis. In its first decisions rejecting the diagnosis, the Swedish Supreme Court recently granted a retrial in two cases and overturned a conviction in a third, citing evolving medical thinking in all of its rulings. A government-sponsored review of all international literature about shaken-baby syndrome and abusive head trauma is also underway in the country.

The network

The shaken-baby syndrome diagnosis originated in the United Kingdom from a paper written by British pediatric neurosurgeon Dr. Norman Guthkelch in the early 1970s and was later adopted in the United States. A number of Swedish doctors credit the diagnosis’ arrival in Sweden in the late 1990s to the homecoming of Dr. Olof Flodmark—a radiologist who studied in Vancouver—and his part in creating a child-abuse unit in Stockholm that identifies and treats potential abuse cases.

As in the United States, men in Sweden are accused more often than women of violently shaking infants, and cases frequently hinge on doctors’ expert testimony since eyewitnesses are rarely at the scene of the alleged crime. To be sure, oftentimes the diagnosis is correct. But also similar to the United States, the diagnosis began losing its standing in Sweden when influential doctors questioned the triad of symptoms and other medical evidence.

The Medill Justice Project created a database and map of shaken-baby syndrome cases in Sweden. To access the database, click the image of the map.

The Medill Justice Project created a database and map of shaken-baby syndrome cases in Sweden. To access the database, click the image of the map.

Dr. Lina Davidsson, a kidney specialist and general practitioner in Stockholm, began challenging the diagnosis in Sweden six years ago after she consulted on a case she believed to be wrongly labeled as child abuse.

She slowly built a network of citizens who questioned the diagnosis and formed Riksförbundet för Familjers Rättigheter, the National Association for Families’ Rights, an organization that provides access to expert witnesses and other legal support to parents who believe they have been wrongly accused of abusing their children.

“The focus was from the beginning to work on this specific issue of small children where their parents had been accused of shaken-baby syndrome,” Jonas Segersam, the association’s president, said. “We are trying in many different ways to change the situation, but we are doing this on a volunteer basis.”

The government also stepped in, and the Swedish Council on Health Technology Assessment, an advisory body that examines issues affecting health care in Sweden, began in September a review of all the world’s research on shaken-baby syndrome and abusive head trauma. Swedish doctors say the country’s medical community respects the council’s findings, so the final report could reaffirm or tear down the science behind the shaken-baby syndrome and abusive head trauma diagnosis. The council is expected to disseminate the review to prosecutors, nongovernmental organizations and the medical community next year in the fall, and the report will help the Swedish government determine funding for research.

Kirkwood, the American attorney, said the Swedish Council on Health Technology Assessment’s study could prompt other countries to conduct their own research. Activists challenging the diagnosis in the United States are calling for a comparable review by the National Academy of Sciences, a government organization similar to Sweden’s council.

Segersam, the National Association for Families’ Rights president, said he believes the review’s international focus on the diagnosis’ science might cut through polarized opinions everywhere.

“This will be important also for the American debate,” he said of the review.

The courts

The National Association for Families’ Rights now has nearly 200 members and is assisting about 20 families, while searching for ways to appeal more cases. Davidsson, the doctor who helped found the association, said her initiative gained momentum when doctors from the United States and the United Kingdom came to Sweden to share their knowledge about the diagnosis.

A stigma existed around shaken-baby syndrome cases, and Swedish doctors did not want to testify for the defense, she said.

In a 2009 appeals case, American radiologists Drs. Patrick Barnes and Kathy Keller testified on behalf of a Swedish man convicted of shaking his daughter.

The Svea hovrätt, a Swedish appeals court in Stockholm where judges hear cases from district courts, has been the scene of confrontations over shaken-baby syndrome cases. (Photo courtesy: Mats Hellberg)

The Svea hovrätt, a Swedish appeals court in Stockholm where judges hear cases from district courts, has been the scene of confrontations over shaken-baby syndrome cases. (Photo courtesy: Mats Hellberg)

The Supreme Court granted him a retrial in 2013, and the prosecution declined to prosecute the case again.

In a statement to MJP on behalf of the national prosecutor’s office, Jenny Silfverberg, a Swedish prosecutor, said the country would continue to aggressively prosecute child abuse cases.

“Prosecutors have an absolute prosecution duty. Crimes against children are an important judicial issue,” Silfverberg said.

In recent years, an American pediatrician working in Sweden has stepped forward as the shaken-baby syndrome diagnosis’ champion: Dr. Gabriel Otterman. After working for a child-abuse unit started by Flodmark, the radiologist who is credited with introducing the diagnosis in Sweden, Otterman launched his own unit in 2012 at Uppsala University Children’s Hospital, about 40 miles north of Stockholm. Flodmark declined to comment, and Otterman did not respond to multiple interview requests.

Dr. Ingemar Thiblin, a Swedish professor of forensic medicine who is at the forefront of those questioning the diagnosis, also works at Uppsala University where he organized a conference on infant head trauma in September. Thiblin invited American radiologist Dr. Julie Mack to speak after he met her at another conference in Texas in 2013.

Dr. Anders Eriksson, the head of the forensic medicine unit at Umeå University in central Sweden, attended the conference Thiblin helped plan. A month after the conference, the Swedish Supreme Court released a groundbreaking ruling that acquitted a father convicted of shaking his three-month-old son, relying heavily on Dr. Eriksson reversing his position on the diagnosis after learning more about alternative causes of injuries from Swedish, British and American doctors. Dr. Eriksson told the court he could no longer say with confidence the triad of symptoms—which the infant displayed—must be a result of violent shaking.

The 11-page ruling written by five justices bypassed lengthy legal arguments in favor of a clear decision, explaining the science behind the shaken-baby syndrome and abusive head trauma is not enough evidence to secure a conviction.

“It can be concluded that, in general terms, the scientific evidence for the diagnosis of violent shaking has turned out to be uncertain,” the Supreme Court ruled.

Thiblin did not respond to requests for an interview, and Dr. Eriksson declined to comment.

In June, Uppsala will host a conference, with Otterman and other pediatricians—including Americans such as Drs. Cindy Christian and Howard Dubowitz—lecturing on the validity of shaken-baby syndrome and abusive head trauma. Christian and Dubowitz declined to comment.

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