In re X.C.

1

IN THE INTEREST OF: X.C., A MINOR APPEAL OF: R.C., FATHER IN THE INTEREST OF: X.C., A MINOR APPEAL OF: S.G., MOTHER

Nos. 2963 EDA 2023, 2964 EDA 2023

J-A14033-24, J-A14034-24

Superior Court of Pennsylvania

September 5, 2024

NON-PRECEDENTIAL DECISION - SEE SUPERIOR COURT O.P. 65.37

Appeal from the Order Entered October 26, 2023 In the Court of Common Pleas of Philadelphia County Juvenile Division at No(s): CP-51-DP-0000394-2023

BEFORE: LAZARUS, P.J., STABILE, J., and LANE, J.

MEMORANDUM

LANE J.

We address together the appeals of R.C. ("Father") and S.G. ("Mother") (collectively, "the Parents") from the orders finding them to be perpetrators of child abuse against their daughter, X.C ("the Child"), born in November 2022, and adjudicating her dependent. We affirm.

We first summarize that in March 2023, the Philadelphia Department of Human Services ("DHS") agency received a Child Protective Services ("CPS") report which: averred the Child, then four months old, had unexplained injuries; and indicated the Parents were perpetrators of child abuse for causing bodily injury to the Child either by recent acts or a failure to act. Initially, the Child remained in the Parents' home under an in-home safety plan, where two family members "agreed to move in[ and] provide line[-]of sight[-]supervision in the home." N.T. Child Abuse Hearing, 10/26/23, at 222. However, after a follow-up examination showed the Child sustained new injuries, DHS implemented an out-of-home safety plan, placing the Child first with her godmother and then her paternal grandmother. A supplemental CPS report was indicated for child abuse. See id. at 231.

DHS filed a dependency petition, which alleged the Child was dependent and/or abused. The trial court conducted an evidentiary hearing on October 26, 2023. DHS presented: Maria Henry, M.D., who testified as a fact witness and expert witness in child abuse pediatrics; Ciara Latimer ("Caseworker Latimer"), the DHS social worker who worked on the family's case; and Shyeera Williams ("Ms. Williams"), the CUA case manager supervisor. Mother, represented by counsel, testified on her own behalf and presented Jack Levenbrown, M.D. ("Dr. Levenbrown"), as an expert in pediatrics, radiology, and pediatric radiology. Father was represented by separate counsel and did not testify or present any evidence. The Child, who was eleven months old at the time of the hearing, was represented by a child advocate. We review the evidence presented in detail.

Mother testified to the following: at a mid-March 2023 pediatrician appointment, there were no concerns with Child's well-being. See N.T., 10/26/23, at 276-77. The next day, however, Mother observed a red line on the Child's forearm and returned to the pediatrician, and the day after that, took the Child to the emergency department of the Children's Hospital of Philadelphia ("CHOP").

At the hospital, a physical examination revealed the Child had two "linear bruises," on her left forearm and right calf. Id. at 25. Additionally, a skeletal survey, which was reviewed by two attending pediatric radiologists, revealed Child had two healing rib fractures on her right side.^[1]

Dr. Henry, a CHOP attending pediatric physician and member of the hospital's child protection team, testified that she reviewed the reports of the Child's bruising and skeletal surveys, and examined the Child. Dr. Henry met with Mother, who "provided a history of several episodes that were concerning for bruising:" in early February, Mother "noticed a linear mark on" the Child's arm, and "more recently[,] a circular, purple mark on [the C]hild's chest." Id. at 43. Mother denied there were any accidental drops, falls, or other events that could have caused the Child's injuries. See id. at 44.

Caseworker Latimer also interviewed Mother and Father, who explained they were Child's primary caretakers, but cared for her on "alternate shifts due to work schedules." Id. at 217. Neither Parent could explain what caused the Child's injuries. At this time, DHS implemented an in-home safety plan, under which "two family members[,] identified by the family[,] agreed to move[ in and] provide line of sight supervision in the home." Id. at 222.

Twenty days later the initial CHOP visit, Mother brought the Child back to CHOP for a follow-up skeletal survey. This survey showed the Child had two additional rib fractures on her left side, as well as a classic metaphyseal fracture ("CML fracture") in her left tibia, or shin bone.^[2] See id. at 31-32. A cast was placed on the Child's left leg.^[3] CHOP staff also conducted genetics testing for possible predispositions for fractures, a bone test for vitamin D deficiencies, and a blood test for a predisposition for bleeding, but the results were normal. See id. at 26-27.

At this juncture, we note that following this second skeletal survey, DHS implemented an out-of-home safety plan due to the fact that the Child now had two additional rib fractures and a CML fracture. The Child was removed to her godmother's home, and later to the Child's paternal grandmother's home. See id. at 223.

With respect to the possible cause of the injuries, Dr. Henry opined the following. A rib fracture is typically caused by compression of the chest, and a four-month-old infant could not have inflicted this injury on herself. See N.T., 10/26/23, at 34, 41, 49. A CML fracture is typically caused by "a twisting or a yanking, or sometimes from an extreme[] flailing, as in shaking." Id. at 33. These fractures "have high specificity . . . for abuse, meaning that . . . they are most commonly caused by nonaccidental trauma." Id. Both rib fractures and CML fractures are uncommon injuries for a four-month-old infant. See id. at 51. Meanwhile, bruises, like the ones the Child had, can be caused by blunt trauma or squeezing, and are "incredibly rare in preambulatory infants." See id. at 34, 50. All three types of injuries -a CML fracture, bruising, and particularly a rib fracture - would likely be painful to a four-month-old child. See id. at 55-56. Although an infant does not "have a lot of ways to indicate pain, [she] can cry and be fussy." Id. at 39. With respect to a rib fracture, "sometimes[,] in particular with astute caregivers, they'll notice . . . paradoxical fussiness, where, in general, [if] you pick up a baby . . . by the chest, you can [cause] irritation of those rib fractures." Id.

Finally, Dr. Henry explained that when reviewing for possible child abuse, she considers injuries separately, but also reviews "the overall clinical picture," or "the constellation of injuries." Id. at 34. "The plausibility of accidental trauma goes down [when there are] multiple injuries with high specificity for abuse." Id. Here, the Child sustained several injuries, at different times, to "two different organ systems." Id. at 35-36. Dr. Henry concluded, within a reasonable degree of medical certainty, that the Child's injuries were not caused accidentally, but instead were "highly concerning for child abuse." Id. at 51.

Mother testified to the following. The day after the Child's regular pediatrician appointment, she observed the Child had a red line on her arm. Previously, Mother had observed the same type of mark on the Child's arm following a visit with the Child's godmother, as well as a "dry patch" on the Child's chest. See id. at 280. When Mother was informed, at CHOP, that the Child had rib fractures, she was upset and started crying. Sed id. at 284. At that time, Mother had not slept for more than twenty-four hours, as she had worked an overnight shift. See id. at 284-85. Neither the doctor nor social workers comforted her or "tr[ied] to jog [her] memory" as to how the Child could have sustained the injuries. Id. at 286. Afterward, Mother called Father, her mother, the Child's godmother, and "everybody that [the Child has] been around, asking [if] anything ever happened to the [Child] while they watched her." Id.

Mother further testified to the following. Two DHS social workers also interviewed her and similarly asked, inter alia, about the Child's medical history, whether Mother believed anyone hurt her, and where the Child slept. Subsequently, Mother remembered, and informed Caseworker Latimer by phone, that in February, she tried to carry the Child down the stairs in order to get a bottle. See id. at 203. The family's cat walked between Mother's legs, and Mother fell or slid down the entire flight of steps while she "squeezed [the Child] very tightly." Id. at 295. The Child did not touch the ground at any time, but Mother hurt her knee and had rug burns on her back. Afterward, as the Child was crying, Mother got her a bottle, then removed her clothing and inspected her. The Child stopped crying, and Mother believed the Child was not injured, and did not notice any fussiness or issues with the Child's movements. See id. at 296-97. Furthermore, Mother explained, the cat previously caused similar issues, and thus the family attached LED strip lights along the banister. See id. at 293. Mother also stated that when Caseworker Latimer visited their home, "the cat ran down beside her leg," causing Caseworker Latimer to grab the banister and wall. Id. at 297.

Finally Mother also testified to the following. At the first CHOP visit, a nurse made "a lot" of attempts to insert an intravenous line ("IV") into the Child's leg. See id. at 298-99. The nurse "started bending and twisting" the Child's leg while the Child cried. Id. at 298. Mother asked "her was that necessary," but the nurse did not stop. Id. at 298-99. One nurse then "pinn[ed] down" the Child's arms while a second nurse did "[p]retty much the same thing" before inserting the IV. Id. at 299-301. Mother "kept asking them was it...