COMMONWEALTH OF MASSACHUSETTS BRISTOL SUPERIOR COURT
Docket No. 1996-00106
COMMONWEALTH OF MASSACHUSETTS
BRIAN J. PEIXOTO
AFFIDAVIT OF DR. WANEY SQUIER
I, Dr. Waney Squier,being duly sworn under oath, hereby state to the best of my knowledge and belief as follows:
1. I am Consultant Neuropathologist to the Oxford Radcliffe Hospitals and Honorary Clinical Lecturer in the University of Oxford. I have been a consultant neuropathologist since 1984, having trained at the Institute of Psychiatry and Great Ormond Street Hospital for Sick Children.
2. During my 28 years in Oxford, I have specialized in the pathology of the developing brain in the fetus and neonate. My other areas of interest are developmental causes of epilepsy and muscle pathology. I have been involved in research into the nature and timing of brain damage due to intrauterine and pre-natal insults, the effects of asphyxia on the immature brain, correlation of imaging and anatomic pathology in the pre-term human brain, and the neuropathology of cerebral palsy in children. I have published widely on these subjects in peer-reviewed journals and have edited a book “Acquired Damage to the Developing Brain: Timing and Causation”. I am a member of the British Neuropathological Society and the British Paediatric Neurology Association. I am a fellow of the Royal College of Physicians (by election following membership by examination in paediatrics), and a fellow of the Royal College of Pathologists. In the last ten to fifteen years, my experience with infant brain pathology has extended to many forensic cases and I have written reports and given evidence in court for both the prosecution and defense in many cases. A full description of my educational background, work history, and professional credentials is contained in my curriculum vitae annexed hereto.
3. I submit this Affidavit in support of the Motion for New Trial of Brian Peixoto, who was convicted of murder, in connection with the death of then three-year old Christopher Affonso, Jr., who died on January 22, 1996.
4. I have reviewed materials provided by the defendant, including, but not limited to, the autopsy report of Dr. James Weiner (forensic pathologist); a surgical pathology report signed by Thaddeus Dryja, M.D.; a state police report from the crime laboratory on hospital specimens; a toxicology report of Christopher Affonso, Jr. submitted by Dr. Weiner; and, a neuropathology diagnosis of a Dr. William Schone; Probable Cause testimony transcript of Dr. James Weiner; Trial testimony transcript of dr. James Weiner. I have also received a chronology of events from the Defendant and/or his counsel which I will describe and discuss in this Affidavit.
5. History: By the chronology provided, Christopher Affonso Jr. was three years old when he died. He was playing with his sister when she called out that the child was throwing up. Mr. Peixoto went to find Christopher having a seizure, convulsing, throwing up, with his eyes rolling back. He was unresponsive. He was rushed to the paramedic station and then to St. Anne’s Hospital where he was pronounced dead. It is also reported that on January 12, 1996, ten days prior to his death, Christopher had fallen down a flight of stairs while alone in the custody of his mother, Ami. He was diagnosed with a broken collarbone. After the fall, many people witnessed Christopher to be “acting funny” including appearing “wobbly”, drunk, quiet, wetting his pants and just not himself. Three days before his death, Ami called the paediatrician and was told that if this continued, she should take him to the paediatrician’s office and was given an appointment for the following Monday. On that day, Christopher was so symptomatic that he was not sent to daycare and Ami failed to take him for his paediatrician appointment. His seizure and death occurred in the early evening of that day.
Autopsy Report–-James Weiner. Dr. Weiner notes the history that the deceased was brought in from his residence, dead on arrival and with “obvious head trauma.” Dr. Weiner described multiple contusions, including some over the head, and an extensive subgaleal haemorrhage of the entire occipital region. He had a fracture of the skull, approximately 6” in length, extending from the left mid occipital region to the right occipital region. There was a fracture of the right clavicle. On opening the head, Dr. Weiner found 50mls of acute subdural haemorrhage in the left occipital region and preserved the brain and spinal cord for subsequent examination. He noted no blood in the meningeal space and clear CSF. The brain weighed 1280gms with no sign of increased intracranial pressure. Histology indicates that some of the skin contusions sampled showed early granulation tissue. There is no description of Perls stain to look for blood breakdown products in any of these sections. Dr. Weiner concluded that cause of death was multiple blunt force injuries to the head.
Neuropathology Report—Dr. Schoene. Dr. Schoene describes contusions of the inferior frontal lobes, and only slight brain swelling. He describes samples of dura and blood clot by naked eye but there is no evidence that any histology was done on them or indeed on the brain itself. There is no description of the spinal cord.
Eye Pathology-Dr. Dryda. Dr. Dryda describes a few subdural red blood cells in each optic nerve sheath but no evidence of retinal haemorrhage. There is no evidence that Perl’s statin was performed on the optic nerves.
6. Comment. From the history given, it is clear that Christopher had a fall ten days before his death which was serious enough to cause a fracture of his right clavicle. There is also evidence that he was behaving abnormally and had symptoms and multiple further falls or tumbles in the period between the fall downstairs and his death. It is clear that the timing of the head injury was not fully considered at the autopsy or at brain examinations. More detailed histological examination of the samples taken was necessary to look for altered blood products and tissue reactions which would allow aging of the bruises and fractures. My own expertise is in examination of the brain and I am surprised that no histological study appears to have been undertaken. Dural samples should have been examined by histology paying particular attention to evidence of older injury and tissue reactive changes.
7. Stairway falls are recognized to have the potential to cause severe or fatal injuries. Lantz (see Reference List attached hereto as Ex. “B”) has described a fatal stairway fall in an infant and made a detailed review of the literature describing the outcome of short falls in children and infants. Most of the papers he reviews have been published since 1996. Hall studied falls in children under 15 years of age and found that 41% of deaths occurred from minor falls such as falls from furniture or while playing. While this study includes older babies and children, it does point to the fact that minor falls can cause lethal head injury. More commonly, short falls lead to nonfatal injuries. Since Hall’s study, however, there have been further case reports of short falls leading to fatal injury (Hall, Reyes, et al. 1989; Gardner 2007; Lantz and Couture 2011). See attached Reference List, Ex. “B”.
8. Importantly, a baby or young child may suffer a serious head injury–like here–and experience extended lucid periods afterwards. There are many examples of this in the literature.
9. Patients attending emergency departments with a history of a head injury will be handed a card with information about the symptoms and signs that may appear at any time in the days following injury, even if there are none at the time of presentation.
10. Several studies of children have addressed the early signs of brain injury in children. Simon (Simon, Letourneau et al. 2001, Ref. List, Ex. “B”) studied children less than 16 years old who had experienced some form of minor head injury. 16% of the patients who were well initially had intra-cranial injury, including subdural hematoma, epidural haematoma, subarachnoid haemorrhage or brain contusion. Three went on to require surgery.
11. Adams (Adams, Graham et al, 1982, Ref. List, Ex. “B”) studying adults, noted that immediate loss of consciousness was the hallmark of diffuse axonal injury (DAI), while a lucid interval typically followed hypoxicischaemic brain injury, which is the typical finding in infant head injury, DAI is rare in this group.
12. Snoek (Snoek, Minderhoud et al. 1984, Ref. List, Ex. “B”)) studied 967 consecutive patients under 17 years of age following head injury. 42 children developed neurological signs after a seemingly minor head injury. 13 patients had seizures, 29 did not. Patients under the age of 5 were twice as likely to have seizures. Only 1 of the 42 patients had an intra-cranial bleed, but the majority showed a mild transient syndrome and 3 children died. These 3 deaths were considered due to unilateral or diffuse brain swelling. Howard et al. (Ref. List, Ex. “B”) studied 28 infants with subdural haemorrhage. Of these patients, 40% immediately lost consciousness and 10 had a delayed deterioration in their level of consciousness more than one hour after the time of injury. The patients presented for neurological evaluation between 2.5 hours and 4 weeks after injury, 15 within 24 hours, 4 between 24 and 72 hours, and 9 more than 72 hours after a head injury was reported or symptoms were first noted. In the series of Vinchon 2002, only 8 of 18 children with head injury presented within one day of trauma. Another 8 presented up to 23 days after injury. These were all babies under 21.4 months and all had subdural haemorrhage. This series indicates that traumatic head injury associated with subdural haemorrhage does not necessarily produce immediate symptoms.
13. Arbogast studied children less than 48 months of age who sustained fatal head injury. She concluded that young victims of fatal head trauma may present as lucid before death. Infants less that 24 months old, thought to have inflicted injury, were ten times more likely to present with mild or moderate signs than those who had been involved in motor vehicle accidents. (Abrogats, Margulies et al. 2005, Ref. List, Ex. “B”).
14. Indeed, one of the problems with interpreting the literature is that “lucid interval” may not be uniformly defined in the studies quoted and most depend on the reports of caregivers or parents who are not trained paediatricians. Subtle signs may be missed by parents. It is possible that they may also be missed by hospital doctors, even in the course of examination. It was noted by Simon (2001) that, in the paediatric population, a normal neurological examination and maintenance of consciousness do not preclude significant intracranial injury.
15. Opinion. Based upon my professional background and experience, my review of the medical records and related case documentation, and my review of the available medical and scientific literature, it is my opinion that Christopher was clearly not well prior to his collapse on January 22, 1996, and that it is likely, to a reasonable degree of medical and scientific certainty, that Christopher died as a result of his fall down stairs ten (10) days earlier. It is further my opinion that ensuing falls by Christopher in the days after his fall down the stairs, including his reportedly stumbling and once again falling up and down stairs, may also have likely contributed to his sudden collapse and death on January 22, 1996.
Signed under the pains and penalties of perjury this
_______ DAY OF December, 2012.
DR. WANEY SQUIER
MBCHB FRCP FRCPath