An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 30^th and 31^st of July and the 1^st, 2^nd, 3^rd, 6^th and 23^rd of August 2001, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Bradley James Burton Bowers.

1. Introduction

1.1. At about 1:50pm on 16 December 1999, Theresa Bowers brought her 11-month old son, Bradley, into the surgery of Dr Samer Shahin on Port Road at Welland.

1.2. Dr Shahin quickly realised that Bradley was gravely ill – he diagnosed a brain injury. He also noted a number of bruises on Bradley’s face and chest. Having regard to the nature and extent of the injuries, Dr Shahin strongly suspected that Bradley’s injuries were not accidental (T59). Dr Shahin has a postgraduate diploma in child health, and has previously worked at the Women’s and Children’s Hospital (‘WCH’).

1.3. Dr Shahin quickly called an ambulance, and also telephoned the senior doctor on duty in the Accident and Emergency Department of WCH to warn them of Bradley’s impending arrival.

1.4. An ambulance arrived at the surgery at 2:06pm. Both ambulance officers noted the bruising to Bradley’s forehead. Paramedic Darren McInerney attended to Bradley while Paramedic David Lewis spoke to Theresa Bowers and her defacto husband Andrew McGann.

1.5. Mr McInerney found that he was unable to insert an airway, as Bradley’s jaw was locked (‘trismus’) so he gave him oxygen with a mask. He was also unable to find a vein to insert a cannula, either in his arms or legs, suggesting that Bradley was in shock and was beginning to ‘shut down’ (loss of peripheral blood circulation, a sign of organ failure).

1.6. Mr Lewis said that when he asked how long the bruise had been present, Andrew McGann said:

‘He likes to play rough with his toys and he’s got some hard toys in his cot. But we removed those and left the soft toys in the cot’.

(Exhibit C42, p2)

When he asked Theresa Bowers how long Bradley had been unresponsive, Andrew McGann said ‘since last night’, and Theresa Bowers said ‘since about 11pm’. She also mentioned that Bradley had vomited.

1.7. During this time, Andrew McGann became aggressive and threatening to the ambulance officers saying ‘you better not hurt him because he’s not my kid’, whatever that meant.

1.8. Mr Lewis said he was not satisfied with the explanations he received as to how Bradley had been injured and so he continued to question them. He said that Theresa Bowers ‘sort of laughed’ and said ‘ok, he likes to play rough’. He commented that her demeanour seemed ‘inappropriate’ in the circumstances (exhibit C42, p3), and that she did not seem to appreciate the seriousness of Bradley’s condition (T83).

1.9. The ambulance arrived at the WCH at 2:28pm where it was quickly appreciated that Bradley was gravely ill. He was admitted to the Intensive Care Unit (‘ICU’) where he was noted to be deeply unconscious. It was assessed that on the Glasgow Coma Scale, he had a score of 4, which is very near death. A CT scan confirmed that he was suffering from a severe intra-cranial injury. An operation was performed by Dr Ahmad Hanieh, neurosurgeon, that afternoon and an intra cranial pressure monitor was inserted.

1.10. Despite the best efforts of the attending doctors at WCH, Bradley’s condition failed to improve, and at 6:05am on 18 December 1999 Dr Neil Matthews, Medical Unit Head of the Paediatric ICU, diagnosed brain death. Life-support was discontinued at 9:50am and Bradley’s life was declared extinct.

1.11. Cause of Death
A post-mortem examination of Bradley’s body was performed by Professor Roger Byard, a specialist Paediatric Forensic Pathologist who is widely recognised as an authority on unexpected infant death. Professor Byard’s report is exhibit C40.

1.12. Professor Byard’s anatomical findings were as follows:

‘1) Recent brain trauma with:

(i) Diffuse hypoxic-ischaemic encephalopathy

(ii) Bilateral acute subdural haematomas

(iii) Subarachnoid haemorrhage

(iv) Diffuse axonal abnormalities

(v) Cerebral oedema with cerebellar herniation

(vi) Bilateral retinal and optic nerve haemorrhages

2) Injury to the spinal cord with:

(i) Spinal subdural haemorrhage

(ii) Spinal subarachnoid haemorrhage

(iii) Axonal abnormalities of upper cervical cord

3) Recent intracranial pressure monitor insertion in good order

4) Multiple bruises involving the:

(i) Head with scattered subgaleal bruises

(ii) Face and neck

(iii) Upper chest

(iv) Abdomen

5) Recent fracture of right tibia

6) Stress effect of thymus gland

7) Congestion and oedema of lungs

8) Evidence of recent attempts at medical resuscitation

9) Plagiocephaly

(Exhibit C40, p3-4)

1.13. In Professor Byard’s opinion, the cause of death was:

‘Blunt head trauma with intracranial haemorrhage and hypoxic brain damage’.

(Exhibit C40, p4)

1.14. Professor Byard commented:

‘1). Death is attributed to deprivation of oxygen from the brain (diffuse hypoxic- ischaemic encephalopathy) resulting from severe brain swelling (cerebral oedema) and compromise of the blood supply, secondary to blunt head injury.

2). It is difficult to determine the precise mechanism of injury, however, bruising to the scalp and bruising under the scalp (subgaleal haemorrhage) are evidence of direct trauma to the head - either due to the head being struck by an object such as a fist, or to the infant's head impacting on an object. The non-specific pattern of the bruises to the head and scalp does not help to clarify the type of trauma.

Bleeding beneath the fibrous tissue coverings of the brain (subdural and subarachnoid) and haemorrhage around the optic nerves and within the retinas may occur from direct trauma or from severe shaking. Unfortunately the time delay between injury and death (~ 2 days) has resulted in the superimposition of hypoxic and ischaemic damage to the brain substance. Thus, the findings of diffuse nerve damage (axonal abnormalities) throughout the brain merely indicate severe injury and do not help to separate direct impact injury from shaking injury from subsequent hypoxic-ischaemic damage.

The intracranial pressure monitor site was intact. Although the monitor and associated surgery may have caused a small amount of localised haemorrhage, it could not have caused any of the significant intracranial injuries noted above.

The subdural and subarachnoid haemorrhage around the spinal cord may have tracked from the cranial cavity, however, the amount was in excess of that usually seen from this passive phenomenon. In addition, the finding of a very localised area of axonal damage in the upper cervical cord is significant. The focal nature of the injury is not that which is seen with diffuse hypoxic-ischaemic damage and suggests a local injury. The absence of soft tissue bruising around the spine at that level is against direct trauma and thus the lesion is more suggestive of a shaking injury.

3). No lethal injuries were identified outside the cranial vault.

4). Assessment of the time frame of the lethal injuries from the autopsy findings is complicated by survival for a little over 2 days in the Intensive Care Unit at the WCH. However, the absence of reactive changes within the areas of intracranial bleeding would be in keeping with a recent injury; i.e. within several days of death.

Given the nature of the cerebral damage, Bradley would not have appeared normal after the injury had occurred. He would have had an altered conscious state and have at least been drowsy and listless with possible vomiting, and most likely loss of consciousness.

5). Multiple bruises were present which were not in themselves lethal, but which indicated multiple sites of trauma involving the head, face, chest, abdomen, buttocks, and legs. The number and distribution of bruises was not that which occurs with normal 'wear and tear', particularly in an infant who has not yet begun to walk. Bruises of this type are commonly seen in infants who have suffered physical abuse. Again, given the survival time, it is difficult to precisely date the bruises, other than to say that they appeared to be of different ages; i.e. yellow-brown bruises being older than red-blue bruises. This suggests that there was more than one episode of trauma.

6). Review of radiographs, bone scans and histologic findings has revealed only one definite fracture - that of the right tibia (lower leg bone). The lack of tissue reaction indicates an age of under one week. In the absence of a plausible history this type of fracture in an infant of Bradley's age must be considered due to inflicted trauma such as bending or striking the leg. There was no evidence of underlying bone disease.

7). Blood coagulation studies performed during Bradley's hospital stay did not reveal any clotting defects. The intracranial haemorrhages, spinal haemorrhages and bruises were not, therefore, due to an undiagnosed bleeding disorder.

8). Microbiological studies did not reveal any infections.

9). Toxicological screening did not reveal any drugs other than those which were known to have been administered in hospital.

10). The changes in the thymus gland were non-specific indicators of stress. Congestion and oedema of the lungs were also reactive phenomena. Enlargement of the right thigh may have been due to fluid leak from intravascular infusion as the only trauma noted were several relatively minor bruises. The abnormal shape of the skull (plagiocephaly) was an incidental finding and not related to death. There were no pre-existing organic illnesses which could have caused or contributed to death.

11). SUMMARY: Death in this 11-month-old boy was caused by severe brain injury, most likely due to direct impact, although there is some evidence that shaking may have also been involved. The neuropathological findings are in keeping with an injury occurring on the night before hospital admission. The other injuries (bruises and fracture) could have occurred at the same time or in the week preceding death.’

(Exhibit C40, p4-9)

1.15. Professor Byard offered the opinion that, in the absence of a history of severe trauma (eg. a motor vehicle accident or a fall from a height), the injuries were indicative of having been inflicted (ie. not-accidentally). He said that the trauma could either have been direct, (ie. from a blow) or the result of Bradley having been shaken violently while being held by the shoulders or arms (‘shaken baby syndrome’) or both (T32). He said that a combination of the clinical picture, the history given and his findings excluded accident as a mechanism of death (T39).

2. Background

2.1. Theresa Bowers was the mother of (name suppressed) (born in 1992) and (name suppressed) (born in 1994) before Bradley. Each of the children had different fathers.

2.2. The evidence before me indicates that none of the children received good and attentive parenting from Theresa Bowers. A friend of Theresa Bowers’, (name suppressed), told police about Theresa Bowers’ neglect of (name suppressed), to the extent that (name suppressed) became her permanent foster-mother (see exhibit C9a). There is also some evidence that Theresa Bowers ill-treated (name suppressed) physically (see exhibits C20a, the statement of William Argent and C22a, the statement of Colleen Wanganeen).

2.3. (Name suppressed’s) father, (name suppressed), described how he found large bruises on her buttocks and legs and a large dark red hand print on her back when she was only 5 months old. When he confronted Theresa Bowers with this, she admitted that she had hit her and ‘she just kept saying she could not stop’ (exhibit C23a, p5).

2.4. In an earlier incident, (name suppressed’s) father, (name suppressed), also witnessed Theresa Bowers physically abusing (name suppressed). He described the incident as follows:

‘The door was open and I hear (name suppressed) screaming and a smacking noise. I walked straight into the house and into the bedroom. (name suppressed) was in her cot and Terri was standing over her smacking her with both hands. I am not sure how many times she hit her but she had both hands going and was smacking (name suppressed) very forcefully. As I walked in Terri looked up at me and said, ‘Dad, I can’t stop’. I went over to Terri and took hold of her arm and took her out into the lounge. When we got to the lounge Terri started apologising. She said, ‘I don’t know what happened, I don’t know what made me do it but I couldn’t stop’. Terri was not crying but she was trembling and her teeth were clenched. After a while Terri calmed down and said that she was sorry and that it would never happen again.

I then went into the bedroom and checked on (name suppressed). She was still crying and sobbing and I could see red hand marks on her legs. It was very red and looked like bad sunburn. I stayed with them for a while and Terri calmed down and gave (name suppressed) a bottle. After every thing seemed all right I left them and went home.’

(Exhibit C24a, p3)

2.5. (name suppressed) told Theresa Bowers to leave after the later incident, and he has retained custody of (name suppressed) since that time.

2.6. In subsequent conversation with Monica Ryan, Theresa Bowers denied hitting (name suppressed) (exhibit C9a, p6).

2.7. Ms Ryan did not notice any sign of bruising or injury on Bradley on the several occasions she saw him in 1999 (exhibit C9a, p9).

2.8. Another friend of Theresa Bowers’, (name suppressed), told me that she had seen marks on Bradley’s arms in May or June 1999 when she was bathing him. She had also noted a mark on Bradley’s nose which she thought might have been a cigarette burn, but Theresa Bowers said he must have scratched himself. (T149).

2.9. (name suppressed) said she saw Theresa Bowers smack Bradley forcefully in late November 1999, causing red marks on his arm. She said this was the only time she had actually seen Theresa Bowers hit Bradley. (T153).

2.10. On 13 December 1999, (name suppressed) saw a number of round bruises on Bradley’s cheeks which looked like finger marks. She said that Theresa Bowers said:

‘Oh, you can see those too’

On the other hand, Andrew McGann said:

‘Nup, I don’t know what yous two are on about, I can’t see them.’

(Exhibit C44, p5)

2.11. There is no other evidence to support (name suppressed’s) allegations, since they were not reported to the appropriate authorities at the time. The description of a number of the bruises (name suppressed) saw on Bradley’s face on 13 December 1999 corresponds with the description given by the doctors at WCH at the time of his admission on 16 December 1999.

2.12. Theresa Bowers began attending Dr Shahin’s clinic in 1998 when she was first pregnant with Bradley. Dr Shahin first saw Bradley on 30 July 1999 with a cold. He saw Theresa Bowers for the first time on 6 August 1999 when he diagnosed that she was 5 weeks pregnant with another child.

2.13. Dr Shahin continued to see Theresa Bowers and Bradley throughout the second half of 1999. He said that Bradley appeared appropriately cared for, treatment was sought for minor ailments and he had no concerns for Bradley’s welfare. He said he would have examined Bradley’s body, particularly the head and chest area on a number of these occasions, and did not note any sign of bruising or injury. (T54).

2.14. Theresa Bowers had a termination of pregnancy in August 1999 at The Queen Elizabeth Hospital. Dr Shahin did not note any signs of depression or distress following that procedure. (T71).

2.15. On 8 December 1999 Theresa Bowers brought Bradley to Dr Shahin, saying that he had injured his mouth when he fell onto the crossbar of his pusher. Dr Shahin examined him, noted a slight injury and prescribed ice for the swelling and Panadol for the pain. He told me that he did not suspect that the injury was other than accidental. (T56).

2.16. However, Dr Shahin noted that the pusher was filthy, with ‘thick black grime’ on the handles and crossbar, which he cleaned off. He said he gave Theresa Bowers a ‘brief lecture’ about cleanliness, and asked her to bring Bradley back in a month for review. He said:

‘If there was any evidence to be found with regards to neglect my plan was to refer the case to Family and Community Services.’

(Exhibit C41, p2)

Dr Shahin made a note at the time ‘? FACS’. I accept that Dr Shahin had not formed a suspicion that Bradley was being neglected at that stage, which would have called for a report pursuant to Section 11 of the Children’s Protection Act 1993. He regarded the state of the pusher as a sign which put him on alert, in case grounds became apparent which would require such a report. I think that this was entirely appropriate, and there is no cause for criticism of Dr Shahin in that regard.

2.17. In summary, there is some evidence that Theresa Bowers had neglected and abused her other children, that she was an inattentive, careless and insensitive mother, who was prone to lose control and physically abuse them on occasions. There is also some evidence that Bradley had been physically abused, either by Theresa Bowers or Andrew McGann, particularly on 13 December 1999, only two days before he was fatally injured.

3. Who inflicted the injuries?

3.1. I have already outlined how Theresa Bowers and Andrew McGann gave Mr Lewis, the Ambulance Officer, an explanation for Bradley’s injuries. They both implicitly admitted that they had been present with Bradley the previous evening, and had noticed the bruise on his forehead which had ‘got worse’ during the evening. They also admitted that Bradley had been ‘floppy’ and unresponsive at 11pm. When asked why they had left it so long before seeking medical attention, they both said that they thought he was asleep.

3.2. I heard evidence from Dr Roger Byard, as I have said, and from Dr Diana Lawrence, a Consultant Paediatrician in the Child Protection Unit at the WCH who also has wide experience in cases of suspected child abuse. I also received a written report from Dr Jane Edwards, a Senior Paediatric Registrar who treated Bradley on the evening of 16 December 1999 before the surgery. The report is exhibit C43.

3.3. On the basis of this evidence, which is unanimous, I unhesitatingly reject the explanation given by Theresa Bowers and Andrew McGann as to how Bradley suffered those horrific injuries, namely that he had crawled over hard toys in his cot. This ludicrous story was repeated to Dr Edwards at the WCH. She reported:

‘Once Bradley was stabilised I held a brief interview with Teresa and Andrew for the purpose of obtaining a relevant medical history. They were both very upset and agitated. They reported that Bradley had been quite well the previous day, (15^th December 1999) and that he had been put to bed as usual at approximately 7.30PM. Teresa had then fallen asleep in the loungeroom at approximately 10 PM. She sleeps in the loungeroom normally, as Bradley sleeps in her bedroom. At approximately 11 PM Andrew, who was still awake watching television, stated that he heard a noise which he initially thought was coming from the television. He stated that he then realised it was coming from Bradley’s room and so he went to check on him. Andrew reported finding Bradley vomiting and making choking/gagging noises.

Andrew then allegedly woke Teresa and she went into Bradley and cleaned him up. She noted him to feel ‘floppy’ at that time with some breathing difficulties. After a period of time he settled and they put him back to bed. The next morning when Bradley had not roused, Teresa went to check on him and found that he was ‘floppy’ and drowsy but opened his eyes briefly. When he had not roused by early afternoon, Teresa and Andrew took him to their GP.

When asked about the bruising evident to Bradley’s face, neck and chest Teresa stated that these had resulted from Bradley ‘crawling over hard toys’. She did not state specifically when she noticed these events. She stated that Bradley was not yet walking or climbing. Teresa denied the possibility that Bradley could have been injured by herself or Andrew.

Teresa stated that she and Andrew have been together for the previous two – three months and that he was not the father of Bradley. Teresa reported that Bradley had been well in the past apart from a febrile illness in May for which he was admitted to hospital overnight. She did state that Bradley often had may bruises in the past which she again attributed to him crawling over hard toys.

(Exhibit C43, p2)

3.4. Later in the evening, a further interview was conducted with Theresa Bowers. Dr Edwards reported:

‘Bradley was identified to the detectives and a further interview was held with Teresa Bowers. Additional historical details obtained were as follows. When Teresa went to sleep the previous evening at 10:30 PM she stated that Andrew was awake sitting on the bed watching Bradley sleeping in his cot. Teresa reported that Andrew had been outside the house smoking when he told her he heard Bradley vomiting. When she saw Bradley he was covered in vomit and had ‘gurgly’ breathing. After she cleaned him up she gave him to Andrew who sat with him on his lap, propped up patting his back. Teresa gave him approximately 0.7 mls of infant Panadol.

After approximately two hours Teresa believed Bradley’s breathing had returned to normal and she put him back in his porta-cot. Teresa said she went back to sleep and awoke again at approximately 5.30 – 6 AM to check on him. She reported that when she touched his cheek he opened an eye and moaned. Andrew was still awake at this time.

At approximately 7 AM she heard Andrew join her on the mattress in the loungeroom. Teresa woke again at 9.30 AM, checked on Bradley who was still asleep, but roused slightly. Teresa then went out to pay some bills and returned home at around midday. She reported that both Andrew and Bradley were still asleep on her return.

Teresa decided that she should wake Bradley and get him up. When she did so she noted that Bradley’s arms and legs were ‘very stiff’ and she had trouble dressing him. She noted that he had a wet nappy. Teresa became more concerned at this point and went to the phone box to make an appointment with her GP. The Receptionist allegedly told her that the doctor was not yet in so to bring Bradley in, in half an hour. When Teresa returned home she received a phone call (home phone is for incoming calls only) saying that the doctor had arrived and that they should attend immediately.

When asked about the bruising Teresa said that most of the ‘small round bruises’ were a result of Bradley crawling over hard toys. She knew this because he had had similar bruises in the past and as a result had taken all the hard toys from his cot. Teresa said that he had not had any hard toys in his cot the previous evening. Teresa said she had seen the bruising to his forehead the previous day and was unsure as to how that had occurred.

Teresa indicated that she had first seen the remainder of the bruises the previous evening after Bradley vomited or that morning when she changed him again.’

(Exhibit C43, p3-4)

3.5. Dr Edwards expressed the following opinion:

‘The presence of multiple areas of soft tissue injury in the form of bruising as described above along with the acute fracture of the right tibia indicate that Bradley had suffered direct trauma to multiple areas of his body.

The distribution and nature of these injuries and the absence of any adequate accidental explanation indicate that they are the result of physical assault. It is difficult to accurately age any of the bruises present, and the absence of any periosteal reaction to the fractured right tibia indicate that this fracture was recent, ie had occurred less than 7 – 10 days prior to his presentation to the Women’s & Children’s Hospital on the 16^th December 1999.

In relation to the fatal intracranial injury, the time frame of Bradley’s presentation and deterioration would suggest it was sustained on the evening of the 15^th December 1999. If the history given regarding his vomiting, floppiness and difficulty breathing at this time is accurate then this would imply that the injury occurred shortly prior to 11 PM that evening. This is because the widespread intracerebral and intracranial damage indicates he has suffered acute injury to the brain substance. The nature of the damage, gleaned from clinical examination and imaging studies makes acceleration/deceleration the mechanism of injury. Such injury would have caused an immediate alteration in his conscious state. Such an alteration in conscious state is often evident by vomiting and difficulty in protecting one’s airway (ie noisy or gurgly breathing).’

(Exhibit C43, p4-5)

3.6. Dr Lawrence agreed with Dr Edwards. She had seen Bradley with Dr Edwards on the morning of 17 December 1999, and noted the injuries documented by Dr Edwards the previous evening, which she described as ‘very extensive’. Dr Lawrence described the CT scans which she produced, describing not only subdural and subarachnoid bleeding, as well as deep cerebral contusion indicating that Bradley had suffered injury to the brain substance deep within the brain (T94).

3.7. Dr Lawrence outlined from the CT scan how Bradley had suffered injury to both the front and back of his head, a so-called ‘contra-coup’, injury where the soft tissue inside the cranial cavity first impacts on the front of the skull, then rebounds in a sort of whiplash and impacts on the rear of the skull as well (T95).

3.8. Dr Lawrence said that blood coagulation tests demonstrated that Bradley did not have a blood disorder which might have caused or exacerbated these various haemorrhages (T96).

3.9. Dr Lawrence participated in the assessment after Bradley died on Saturday, 18 December 1999. In particular, she took a number of photographs of his injuries, arranged for a full skeletal radiological survey which demonstrated his fractured tibia, and generally participated in the post death assessment.

3.10. When asked to express an opinion about the causation of Bradley’s head injuries, Dr Lawrence said:

‘As you mentioned it's really what we call a high velocity head injury so we only see it in high velocity, like motor vehicle accidents or falls from great heights or in infants where it's inflicted head injury the usual causes are sometimes a shake, shake, throw impact onto a surface but alternatively it could have been just a severe impact without the shake before it. I don't think you can really say just looking at the examination findings and the CTs but certainly he's had, looking at the CTs and his frontal region, I'd say he's had an impact, a severe acceleration, deceleration impact head injury.’ (T104)

Dr Lawrence added that the severity of the bleeding in the brain suggested to her that there was strong evidence of an impact injury, either instead of, or additional to, the shaking (T126).

When asked if the injuries could have been caused in the normal course of life, Dr Lawrence said:

‘No. You don't see that pattern of bruising in children that have accidental bruising and in fact in my experience, but it is also very well documented in the medical literature, that children before they are actually walking or cruising or running virtually have no bruising, or if they do have bruising it is usually maybe a bruise on a bony prominence of the forehead, or children that are walking around furniture for example sometimes fall and get bruising to bony prominences, but in children before they are cruising and before they are walking it is very very rare to see any bruising whatsoever, and if you do see bruising it is almost always in this pattern of inflicted injury. So trauma from a physical assault for example, and that is certainly my experience in the past eight years doing child protection work, and as I said there has been quite good large studies in the medical literature looking at bruising in normal children, infants leading up to young children, and the pattern of bruising that you see from accidents.’ (T105)

3.11. In relation to the fractured right tibia, Dr Lawrence said that the absence of periosteal bone formation suggested that the injury was less than seven days old. She described the fracture as ‘not really severe’ (T106). However, in a child who was not yet walking:

‘You obviously have to be very concerned that the most likely cause of that fracture was an inflicted injury as well.’ (T110)

She suggested that the fracture could have been caused by Bradley being thrust down on his feet, or a direct blow to his posterior part of the leg, or even by being lifted by the leg, a grip with a twist or a pull to it (T128).

3.12. In relation to the timing of the injury, Dr Lawrence said that the description given by Theresa Bowers and Andrew McGann, namely that the child vomited, appeared ‘floppy’ and unresponsive, indicated that the injury occurred around that time. She said:

‘A It almost certainly occurred around that time where he was first noticed to have gurgly breathing and vomiting and being floppy because most children when they have a significant head injury appear like that, and then depending on the severity of the injury many of them will then retain conscious state, or proceed to further decreased conscious state, so it's a very, quite a common finding in significant head injury to be unconscious and therefore have difficulty with your airway and have gurgly breathing and vomiting is really common in head injury and even minor concussion, many children will vomit, and the younger you are the more likely it is that you will vomit with head injury. So in the infants it's a very common response to head injury, they often vomit.

 

Q A contemporaneous response with the trauma occurring or shortly after the trauma occurring.

 

A Yes, and in fact our routine protocol for children that suffer fairly minor head injury or concussion in the emergency department is to watch them for four hours because if they're going to vomit they'll vomit within four hours and if they haven't vomited by four hours we then send them home. So it's something that happens routinely within the first few hours following head injury.’ (T111, 112)

3.13. As I have said, Dr Lawrence categorically rejected the explanation that Bradley’s injuries were due to crawling over his toys (T120).

4. Police investigation

4.1. Senior Constables Dietman and Beck attended at WCH at about 5:15pm on 16 December 1999. After speaking to the doctors, they interviewed Theresa Bowers at 6:09pm. She gave basically the same story she had given Dr Edwards earlier (exhibit C45, p4-8). Her initial comment to the police officers was:

‘You better not be from fucken welfare’.

(Exhibit C33a, p1)

4.2. Senior Constable Dietman made notes, which he read back to Theresa Bowers and she acknowledged they were correct. As to what happened during the evening of 15 December 1999, she said this:

‘Put Bradley to bed at about between 7.30 and 8.30 last night. You saw no bruises on his stomach. He was dressed in a singlet and nappy. He went to sleep within about 30 minutes. I went outside and had a cigarette. I went to sleep on the lounge watching television, watching TV with Andrew. Andrew was in the bedroom sitting on the bed watching Bradley. About 10.30 I dozed off. At about 11, 11.30 Andrew woke me up. Andrew said ‘Go and check on Bradley, he doesn’t look too good.’ Andrew stayed out and was pacing around the house. I found Bradley was floppy like a rag doll.

I changed him, I changed his nappy. He’d vomited. I went into the lounge and then Andrew was holding Bradley. I saw bruises on his belly for the first time. He already had baby bruises on his cheek and legs. Maybe one or two bruises on his tum. When he went to bed he had a stuffed frog, a teething ring, a bottle, but he had no hard toys.

Andrew was pacing around, then came into the lounge. Bradley looked like he was drugged out.

Bradley was having trouble breathing. He was on his back and he had his head to the side. Andrew was patting him on the back. Bradley would not wake up. I thought some, I thought it was seriously wrong and I thought he might die.’

(Exhibit C45, p4)

4.3. Theresa Bowers said that she checked Bradley a number of times during the night and he remained asleep. He was still ‘asleep’ when she went out the next morning to pay some bills. When she returned, she said:

‘I thought it was too long and I was worried. I went in, I changed his nappy. He had stiff arms, his head was floppy, he had a wet nappy. His eyes were half open. He would stir and he had a little murmur and he’d move his legs and arms.

I started to get panicky. Andrew was saying ‘Not good, get to the doctor’. I rang the Hindmarsh Clinic. I spoke to the receptionist, Camilla, and I rang from a phone box.

The receptionist told me to wait about half an hour and then bring him in and when I got home the clinic rang back and said to bring him in straight away.’

(Exhibit C45, p6)

4.4. Theresa Bowers’ ‘panicky’ state seems inconsistent with the rather breezy note she left on the door for her friend (name suppressed). According to (name suppressed), it read:

‘Kaz, have gone to the doc’s, will be back ASAP luv ya Terri.’

(Exhibit C44, p8)

4.5. At about 7:30pm, Theresa Bowers and Senior Constable Beck inspected Bradley in the ICU and noted his injuries. She again failed to properly explain how they had occurred.

4.6. At about 8:30pm the unit at Allenby Gardens was searched by police and a number of exhibits were seized, including toys which were found in Bradley’s cot (exhibits C40b, C40c). After examining them in court, Professor Byard repeated his opinion that these toys would not have caused the injuries Bradley had suffered (T26).

4.7. At about the same time, Senior Constable Dietman interviewed Andrew McGann at Adelaide Police Station. He had been arrested earlier in the evening for disorderly behaviour, having kicked over a number of chairs in the waiting room, and pushed Dr Hanieh, the eminent neurosurgeon, while he was attempting to explain the treatment Bradley required.

4.8. During the Record of Interview (exhibit C45b) McGann admitted he had been feeding Bradley when he was injured on 8 December 1999, when his mouth area hit the crossbar on the pram. He described the incident as Bradley ‘headbutting’ the pram because he didn’t like the toast McGann was feeding him (exhibit C45b, p12).

4.9. Andrew McGann asserted during the interview that he ‘took off’ at about 10:00 – 10:30pm to a mate’s place, and didn’t get back until after midnight (exhibit C45b, p23). He said that Bradley was alright when he got home (exhibit C45b, p31).

4.10. Later, McGann said he had not gone out the previous evening. He said he heard Bradley wake up while he was sitting out the front of the unit. He said:

‘Well, like I said, I was virtually out the front. I heard a noise. I thought it was actually the TV ‘cos the TV was a little bit up and a little bit too loud and I thought it was the TV. I heard this, you know, huh, huh, and I though well, shit, you know, I better go and have a , have a bit of a sticky nose. I actually turned the TV down. I went in the room. I turned the light on. I looked down. Bradley’s there. I didn’t move him. I didn’t touch him. He was being sick. He was still asleep. Um I went in to Terry’s room, like into the lounge room. I woke Terry up. Um Terry grabbed him. We cleaned him up. Um put him on the mattress for a, maybe two hours, I could be wrong. Um I said to Terry, ‘Well he seems to be alright. We’ll put him back in the, in the er, in the cot’ so we put him back in the cot. Um let him sleep. Terry woke up in the morning. Um I said I’d wake up. She said she was going shopping. I said ‘Not a problem’. I said ‘where’s the little man?’ She said ‘Well, virtually still asleep.’ I said ‘Oh right, cool.’ Um he was still asleep. Terry come home, I think it would have been about 11 o’clock, asked me where Bradley was. I said ‘He’s still asleep. He didn’t wake up.’ I said ‘He’s been stirring.’ Um she went in. Well actually we both, we both went in. Um Terry didn’t like the way he was sleeping and all those shits for so long. I said to Terry ‘Well, let’s take him to the doctor’s.’ Um the secretary said ‘Oh no, leave it for half an hour’ or some bullshit like that. I told Terry ‘Fuck off. No way in the world. We’re going straight down there.’ We get a phone call from the secretary saying that the doctor’s on his way. We went there um, doctor checked him out, ra, ra- said ‘Look, he’s gonna go to the hospital.’ I said ‘Fuckin why?’ Um he just said he was a crook baby and I said ‘Well fuckin’ how can he be?’ I said ‘You know, from last night, tonight.’ I said ‘That’s bullshit.’ Um ambulance come in. They were doing what they had to do and that was it.’

(Exhibit C45b, p34-35)

Later on the interview Dietman said:

‘Dietman: The injury to Bradley’s head has been done with some force. It’s nothing that’s accidental.

Andrew McGann Nuh, well I- I don’t know nothing about that, mate, and I’m telling you here right now, mate, I don’t know nothing about that at all.’

(Exhibit C45b, p37)

McGann agreed with Bowers that Bradley looked ‘drugged out’ and floppy, like a rag doll, when they looked at him at about 11pm. He said he thought Bradley’s condition was due to the Panadol Theresa Bowers had given him. He admitted that she was crying at that stage, saying that she didn’t want the Welfare on her back, she didn’t was to lose Bradley (exhibit C45b, p40).

4.11. McGann said the only mark he saw on Bradley that night was a brown mark the size of his fingernail on Bradley’s forehead (exhibit C45b, p42).

4.12. Following the interview, Andrew McGann was arrested and charged with Bradley’s attempted murder (exhibit C45b, p52).

4.13. A number of Andrew McGann’s friends supported his first story that he went out that evening (see Doof [exhibit C13a], Janet McGann [exhibit C14a], Bell [exhibit C15a], Winter [exhibit C16a] and Evans [exhibit C17a]).

4.14. However, the credibility of this evidence was doubtful in light of the statements of Julie Lambert and her son Tyrone, who live near Doof’s house and had been unhappy about the light show he put on at his house every Christmas. On Tuesday, 14 December 1999 she noted in her diary that a man fitting Andrew McGann’s description threatened to kill Tyrone with an iron bar (exhibits C18a and C19a).

4.15. When this became apparent, most of the above witnesses recanted, saying that after they had given the matter ‘further thought’, Andrew McGann’s visit had indeed been on 14 and not 15 December 1999 (see exhibits C13b, C14b and C15b).

4.16. On Friday, 17 December 1999 at 4:50pm, Theresa Bowers was also arrested for attempted murder. She replied ‘I haven’t done anything’ (exhibit C45, p10). At 7:30pm that evening she was interviewed in the presence of her father and, on legal advice, declined to answer questions (exhibit C45, p14).

4.17. At 5:11am on Saturday, 18 December 1999, Theresa Bowers was being transported to WCH as Bradley was dying. On the way, and after she had been warned about self-incrimination, she told Senior Constable Dietman that she had been having ‘doubts’ about Andrew McGann, but declined to elaborate (exhibit C45, p20).

4.18. At the inquest, both Theresa Bowers and Andrew McGann declined to answer any questions about these events, as they were entitled to do pursuant to Section 16(2) of the Coroner's Act, 1975.

5. Conclusion

5.1. The conclusion is inescapable that Bradley Bowers suffered fatal head injuries at some time around 10:30pm – 11:00pm on 15 December 1999. Dr Lawrence’s evidence is that the unresponsiveness and vomiting at that time suggests that a severe head injury had been inflicted just before then.

5.2. The head injuries referred to were the result of either severe blunt trauma to the forehead, and/or severe shaking. This abuse occurred in the context that Bradley had suffered a number of other episodes of trauma, severe enough to cause bruising, in the two weeks or so before his death.

5.3. Both Theresa Bowers and Andrew McGann were present in the house at 1/30 Barham Street, Allenby Gardens at all relevant times when Bradley suffered these fatal injuries. It is not possible to determine which (or both) of them inflicted the fatal injuries. However, it is clear to me that they both know who did. Their explanations, that the injuries were caused accidentally, are completely untenable. I am satisfied that both of them are deliberately concealing the truth about what occurred.

5.4. Both Theresa Bowers and Andrew McGann were in loco parentis at the time Bradley suffered fatal injuries. McGann told police that he ‘tripped out’ when he saw Bradley at about 11pm, and Bowers told him that she thought Bradley might die. McGann said Bowers was worried about the Welfare, and that she might lose Bradley. Yet neither of them sought medical attention for him then, or at any time until about 1:30pm the next day when they attended upon Dr Shahin. In failing to act earlier, they deprived Bradley of whatever slim chance he had of surviving these terrible injuries (see the evidence of Dr Lawrence at T113).

6. Recommendations

6.1. Section 25(2) of the Coroner's Act 1975 empowers me to make recommendations following an inquest if, in my opinion, such a recommendation may ‘prevent, or reduce the likelihood of, a recurrence of an event similar to the event that was the subject of the inquest’.

6.2. Mrs Atkins, Counsel assisting me, submitted that I should recommend that the Attorney-General should review the relevant provision of the criminal law in this area, since an effective prosecution of such serious behaviour should act as a deterrent and prevent similar deaths.

6.3. I do not think that it is appropriate to do so, however, since before making such a recommendation it would be necessary to examine whether the present criminal law is inadequate for the purpose. To do so would put me at risk of offending against Section 26(3) of the Coroner's Act 1975.

6.4. In order to avoid such offence, I will not discuss the issue further, except to comment that it does seem to be a matter which is clearly deserving of further analysis.

6.5. Mr Bonig, Counsel for WCH, submitted that public awareness of the fact that help is available for people who may see themselves as being at risk of losing control and hurting their children should be greater. Of course that is incontrovertible, and I would recommend that any public awareness campaign which has been conducted or is planned (I am aware that there have been several such campaigns) should be encouraged and supported to the greatest extent possible.

6.6. The difficulty, however, lies in the fact that, in many such incidents, as here, the people in loco parentis place self-interest before the welfare of the child. I am unable to see that education campaigns can overcome such an obstacle, but I would encourage the attempt.

6.7. I therefore recommend that the Attorney-General and the Minister for Human Services examine the issue in order to determine if more can be done in this area.

 

Key Words: Infant death; homicide allegations

 

 

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Inq.No. 17/01 (3151/1999)