"This child's death could have been prevented"

27 March 2013

Fifteen years ago, a young physician started thinking about how she could better help abused and mistreated children. Now that physician, Dr. Bianca Navarro-Crummenauer, is in charge of the Forensic Outpatient Clinic for Victims of Domestic Violence at the Institute of Legal Medicine at Johannes Gutenberg University Mainz (JGU). Some 500 cases a year keep her busy.

The little girl looks at the world with startled eyes as she leaves the consultation room. One cannot help but notice that one of them is bruised. She has hardly turned the corner when Dr. Bianca Navarro-Crummenauer appears from the room. "Sorry for the delay," says the forensic pathologist. "An appointment got in the way."

And there are appointments enough to get in the way at the Forensic Outpatient Clinic for Victims of Domestic Violence at the Institute of Legal Medicine at the University Medical Center of Johannes Gutenberg University Mainz. Navarro-Crummenauer examines some 500 children annually and evaluates the cases for evidence of mistreatment or abuse. There is always a stream of visitors because anyone can contact the clinic – the youth welfare authorities, pediatricians, and private individuals. The examination is free. Navarro-Crummenauer considers this to be particularly important.

She takes a seat at a table in the consultation room with her cell phone in front of her. She never lets it out of her sight. Colorful children's pictures hang on a bulletin board. Behind her there is a couch with technical devices, while a jolly pirate grins from the curtains in the background.

Volunteering to fight abuse

This room, with its adjacent waiting room, has been here since 2010. "Before that, the kids had to wait in the corridor in front of the elevator." Thanks to generous donations, the forensic pathologist has been able to make everything more child-friendly. The German children's charity Ein Herz für Kinder [A Heart for Kids] gave EUR 45,000, but she still had to be very resourceful. So Navarro-Crummenauer, who had just had her second child at the time, lent a hand herself.

The Forensic Outpatient Clinic in Mainz has been in existence since 2007. The Rhineland-Palatinate Ministry of the Interior provides support to the institution so that examinations can be conducted free for those who need them. "The money is intended for travel expenses, other outgoings, and the necessary materials." In addition to her job at the Institute of Legal Medicine, Navarro-Crummenauer also works as an unpaid volunteer for the call-out service and does night and weekend shifts.

In 2002, Professor Dr. Dr. Reinhard Urban, the director of the Institute of Legal Medicine, decided that he and his team should examine victims of suspected abuse and mistreatment free of charge. "That was something very special in the beginning and the Outpatient Clinic still had to be institutionalized. Many have since imitated us elsewhere." As to the numbers of children being examined, the Institute of Legal Medicine in Mainz is still in the lead – and this is primarily attributable to the efforts of Dr. Bianca Navarro-Crummenauer.

When a child dies

When Navarro-Crummenauer talks about her work, there are always specific cases that come up. There is, for example, the boy who is now in hospital with cerebral hemorrhaging. "He had been admitted once before with scald burns." Was this a case of child abuse? The doctors who treated him were unsure at the time, so they sent him home. And now he is fighting for his life.

Such cases worry Navarro-Crummenauer. And when it comes to the lives of children, she takes a no-holds-barred approach. In a similar case, she flew off the handle with one doctor who wanted to return a severely abused child to its family despite her serious misgivings: "Do whatever you think is right, but consider the consequences for you if this child dies." The child died.

In 2002, Navarro-Crummenauer became aware that actually only the Criminal Investigation Department and District Attorney's Office were referring cases of suspected child abuse and mistreatment to the JGU Institute of Legal Medicine. That was not enough for her. "One day, I asked myself: Who generally deals with problems like this in Rhineland-Palatinate, who has experience of cases like this? Who sees the children concerned?"

The youth welfare authority, of course. "So I wrote to them: 'We specialize in cases of violence, especially those involving children.'" She offered two-hour lectures free of charge to provide information on what injuries are typical of maltreatment and what behavioral patterns are indicative of sexual abuse.

Calls around the clock

"At the beginning, I had no idea what I was starting. I just wanted to reach as many people as possible. I distributed hundreds of business cards with the invitation to call me at any time." Which is indeed what happened. "My telephone simply never stopped ringing, and the number of examinations we were conducting increased massively."

But there is also the question of financing. Navarro-Crummenauer wishes the health insurance organizations would be prepared to put up some money, but they have so far declined to contribute. "They claim they have nothing to do with legal medicine because forensic pathologists only examine corpses."

The response to her efforts has not always been positive. She now works closely with many youth welfare authorities and pediatric hospitals, but others have turned their back on her. "And, unfortunately, practicing pediatricians only contact us rarely," says Navarro-Crummenauer.

Some are uneasy when they have to deal with her – such as the doctors who called to report a case. "It was about a five-month old baby with a broken leg. They made a point of telling me that the parents had private insurance and the family was friends with professor so-and-so. And they claimed the parents were very caring in the way they treated the child."

Difficult legal situation

Navarro-Crummenauer shakes her head. "Why were they telling me all this? What did they want me to say? Parents who abuse their children often treat them affectionately because they have a guilty conscience. And I couldn't give a damn about their insurance. There is only one thing that is important: There is a child with a specific injury. Is there a reasonable explanation for how that child got that injury? Yes or no?"

Children are scalded and beaten, cigarettes are put out on their bodies. Navarro-Crummenauer talks about parents who beat their child with a belt. "They rubbed chili powder into the bleeding injuries just to make sure they would burn." And even if a lot has changed in recent decades, now that doctors, authorities, the police, and the public have become more aware of the problem, Navarro-Crummenauer is still not satisfied. "There are instances where it is clear to me that the child would not have died if those responsible had acted appropriately."

She is also dissatisfied with the legal situation. "The German Child Protection Act is good, but it is far from perfect. At one point it specifies: 'Physicians who see significant indications that a child's well-being may be at risk are entitled to notify the youth welfare authority.'" Navarro-Crummenauer takes a deep breath. "'Entitled'? Oh no, doctors should be obligated to contact the authorities in such cases."

A soft spot for children

Although the forensic pathologist can be caustic in her dealings with the adult world, she certainly has a real soft spot for children. "It's a fundamental requirement of my job." There are teddy bears ready to be cuddled and a drawer with little sweet-tasting bribes. The devices operate as inconspicuously as possible.

Navarro-Crummenauer points to a colposcope, an important instrument when it comes to the examination of possible victims of sexual abuse. "I tell the girls: 'Look, I've got this really great telescope so that I can see everything in close-up.'" The colposcope stays at a distance – it takes pictures without the small patients noticing. "Abuse is often associated with the children being photographed by the perpetrators," the forensic pathologist explains. The examination procedure in the Outpatient Clinic is to remind them as little as possible of this kind of thing.

Her cell phone rings several times during the interview. Navarro-Crummenauer makes sure she's always available. "It's relatively quiet today. I have a little more time than usual," she remarks as we take our leave. Perhaps it will stay quiet for a little longer. She deserves a bit of a rest.