by Justine Joya
The jurors in the Stone case have heard their fair share of expert witness testimonies, and on the morning of May 9 they endured yet another trial day of dense advanced medical diagnosis.
The trial day began with the defense calling Christine Uribe to the stand. Ms. Uribe was appointed by law to supervise defendant Stone’s visits with his children. These visits began in August of 2013 and continued through February of this year. They were scheduled two to three times a month and lasted for two hours. From what she gathered from the children’s interactions with Mr. Stone, she believed he was indeed a good father to his sons. She stated that he never lost his patience or was upset when they were around and that the kids were “always learning,” reading, playing and enjoying their time with their dad.
The prosecution’s cross-examination was brief, highlighting the fact that Ms. Uribe never saw Mr. Stone’s interaction with the infant victim, Sam, and never will.
Next after Ms. Uribe’s testimony, the defense called their second witness, Dr. John J. Plunkett and the lecture began. Dr. Plunkett is a general medical doctor and forensic pathologist. He has performed roughly two-thousand autopsies in his career and, of these two-thousand, about two hundred were children. He reported that the majority of these infants’ cases were natural deaths, also referred to as “Sudden Infant Death Syndrome.” After proving the qualifications of their witness, the defense requested Dr. Plunkett to be an expert pathology and bio-mechanics witness, and their request was met by Judge Richardson.
Delving into her examination, Deputy Public Defender Brushia was soon caught in a whirlwind of power-point presentations that were created by the doctor. To fully explain his findings and the reasoning behind them, Dr. Plunkett offered a detailed slideshow presentation. The bulk of the presentation was to prove that the severe head trauma seen in the victim could have been a result of the alleged fall even if there were no exterior visible signs. Dr. Plunkett shattered all previous medical opinions that testified to child abuse, stating that if the baby had been shaken violently enough to cause death, the neck should have shown signs of injury or a break—which it did not. When asked about the rib fractures, he noted that “normal handling” with a child who has a Vitamin D deficiency, which Sam did have, could result in rib fractures.
When the defense finally finished their portion of Dr. Plunkett’s testimony and turned him over to the prosecution for cross-examination, Mr. Mount began with high momentum, but that momentum was soon met with resistance as the examination turned into a battle of technicalities. Whenever Mount would attempt to re-phrase the doctor’s statements, Dr. Plunkett would not claim those statements or ideas as his own, arguing and frequently stating, “That’s not what I said.” When asked about prior testimonial statements, or specific findings within the doctor’s field work, Dr. Plunkett referred to the copies of documents before complying with the prosecutor’s assertions.
Despite Mount’s struggle in his questioning of Dr. Plunkett, he raised key issues that suggested that the doctor’s professional opinion was irrelevant to this particular case. In the doctor’s study on the effects of low level falls on children, Mount pointed out that the subjects involved were all older than Sam. In regards to the crash-test dummy, which mimicked an infant’s fall and was referenced in Dr. Plunkett’s power-point slides, Mount emphasized the unreliability of the dummy’s performance due to plastic covering and inability to perfectly reenact a real-life situation.
All in all, Ms. Uribe’s and Dr. Plunkett’s testimonies served in favor of the defense, but, despite resistance, the deputy district attorney managed to raise some questions that demonstrated concern with both witnesses.
Further jury trial is scheduled to continue Monday, May 12.
Good reporting.
More and more “reasonable doubt” is piling up.
Good for Dr. Plunkett for not falling victim to the prosecutor’s tactic of trying to distort his testimony. Too many times prosecutors like DDA Mount twist what is being said on the stand into something the witness never meant. Hopefully, the jurors will listen to the testimony and won’t be fooled by the DDA’s theatrics in the courtroom.
Justice can only happen when prosecutors start caring about finding the truth and stop caring about “winning” in the courtroom.
Themis
“Justice can only happen when prosecutors start caring about finding the truth and stop caring about “winning” in the courtroom.”
I completely agree. And I believe that the same applies equally to defense attorneys.
CBC Canada’s The Fifth Estate did an excellent investigative report on SBS a couple of years ago called Diagnosis Murder in which Dr. Plunkett was interviewed. His research in this area is extremely important.
Interesting………he was against all the very few,”experts,” who are against the studies of SBS…I watched it.
Odd to think he would testify for the defense? In fact, he disagrees and calls the ones that go against the theory of SBS, or facts, as being very few…
Hmmm…are we still claiming “illness?”
@Themis……agree with Tia, it goes both ways. No theatrics coming from DDA’s in this case so far…
Somebody needs to be a voice for baby Samuel…….I pray the little guy gets justice.
If you are referring to CBC’s investigative report Diagnosis Murder, then you have Dr. Plunkett confused with someone else.
Goodness……again, the bogus,” vitamin D” deficiency!! Talk about beating a dead horse til it bleeds!!
How many times do we have to make it clear, HE did not have a low enough rin fact, it was within normal range according to the latest standards.
Hmmmm….seems as though every doctor.for the defense wants to dance around the DA, or get nasty….interesting….
What a blind eye we turn to all the other facts in this case..clinging to a ridiculous notion of an invisible cause….whether from an alleged fall or ruled out illness…
Agree there is “reasonable doubt,” raised….but on what? Who? And by what means? Fall? Illness?
You are the one beating a dead horse. The experts on both sides unanimously have agreed that the Vitamin D level was low.
” The experts on both sides unanimously have agreed that the Vitamin D level was low.”
The difficulty is with the word “low”. 20 ng/mo is the lower level of normal.
Not a treatable level.
Not a level of clinical concern. Not a level that one would associate with rickets.
The testimony by the prosecution expert was “low”, not “normal” and not “lower end of normal”. “Low” is what he told the jury. It was clearly below the reference range and therefore not within the normal range for that lab.
And a level of 20 certainly can be associated with bone disease, as this very case has demonstrated per the abnormal bone findings of Dr. Barnes. And for many, many physicians, myself included, it is a level of clinical concern that would be treated.
Nope……I am not….watched the same show……did not get what you got, obviously..
You have confused Dr. Plunkett with the president of the American Academy of Pediatrics who was also interviewed in the documentary. Dr Plunkett was one of the many experts who spoke against the SBS theory.
@Tia….I think I may have stumbled upon the missing piece of the puzzle….this can prove innocence or guilt. But I have to confirm something first……it may be that defense has found it too….
Four doctors agree, and confirm and two were opposing the SBS.
It may be too late, but it sure will up a more purposeful, logical reasonable doubt.
With all due respect and gratitude for the coverage, is the author of the article reporting without bias, or has this become a commentary ?
It shouldnt be? What would the bias be?
Most commentaries are written by David.
some of us have observed that these articles have crossed lines at time from news to commentary, you in particular have taken a very prosecution stance in your writing and comments. you are missing key flaws in the construction of the prosecutor’s case.
No….Elizabeth…….low but not low enough for defiency, not enough for Rickets….
But feel free to cling to that, if thats all you have….
Correct, I had wrong Dr.
Those two cases in that story were believable….but completely different circumstances. True, doctors and authorities may throw the SBS theory out there way too much. But ……have to wait to hear rebuttle of Dr. Omalu tomorrow.
I dont believe he performed a certain test, didnt find it in my notes…
you are wrong, Dr Coulter testified that the level was low as have all the experts. The disagreement among the experts has been the effect that this low level had on the baby. You are distorting the evidence as presented by
the experts to support your theory.
Elizabeth
I have no theory at all to put forth. And no personal stake in the outcome. And I have no prejudgement to withhold by spinning information presented to bolster my predetermined conclusion.
So why do you suppose that I keep posting that 20 ng/ml is low normal and not of clinical significance ?
I honestly have no idea why you continue to insist on that Tia as the level of 20 in this case was below the reference range for the lab that performed the test and was reported as “low” by all the experts, not “low normal” or “normal”. The experts in this case have no disagreement on this point, you seem to be the only one who disagrees.
Elizabeth
Here is the question I would pose to you as a doctor.
If the lab range for normal for a Hgb is 11.5 or above, would you diagnose anemia at a level of 11.5 ? Would you prescribe supplements at a level of
11.5 ? If there were a question of cause of death of a patient, would you say that a level of 11.5 could have been a contributory factor to a heart attack, or renal failure or any other cause of death which could be attributed to a “low Hgb” level ?
If not, please explain to me how this situation is different in your mind.
fair question, Tia
Here is the difference. I do not routinely treat anemia in my practice because it simply does not have the same clinical significance in my specialty as does a low Vitamin D level. So I do not have the experience in treating anemia that I have treating D deficiency. B
hmmm, I am having difficulty with this post, it posted prematurely for some reason.
As I was saying, I have far more experience with D deficiency than anemia even going back to my days in dietetics prior to med school. I routinely treat my patients for low Vit D and like to see them at 50 or above. I tend to follow the recommendations of the Vitamin D Council as Dr John Cannell is one of the most knowledgeable physicians I know in this area. Like many physicians, I am extremely uncomfortable with a level of 20, especially in children and pregnant women, given the known cases of bone disease at that level (an average level of 21 in a case series of infantile rickets) to which we can now add this case due to the bone disease as described by Dr. Barnes.
Elizabeth
I totally respect your response regarding your experience with anemia. As for the significance of what I perceive ( based on the norm cited by all of the colleges I stated) as a normal value of vitamin D, I think that we will simply have to agree to disagree on this topic.
One thing that you said early on in the discussion did resonate with me. You made the statement that when you tested women in your practice, 95% of them were deficient in Vitamin D. Please correct me if I paraphrased you incorrectly.
I am wondering if you are referencing a general population, or only patient’s who come to you for specific problems. What is your sample size ? Assuming that your population is living in California and has what we would consider at least a reasonable nutritional status ( for instance are not anorexic or do not have a major malabsorption problem) then I would say that the standard that you are using is not reflective of a true deficiency. Norms for an entire population are established such that if 95% of a reasonably healthy population is “deficient”, then the line for “deficiency” is being drawn in the wrong place.
I am referring to my own practice which is largely female and a majority over 50. Nutritional status can vary from excellent to terrible (high sugar, processed foods etc) I have been routinely testing Vitamin D for several years and have been shocked by how low everyone is with probably 90-95% being below 30 (which is the lowest recommended level that I will consider, I abandoned 20 a few years ago) and probably about one third are below 20 and a significant number of those are in single digits. Since I would like all of my patients to be in the 50-75 range, almost everyone ends up being supplemented. When I first started testing everyone, one of our nurses was so shocked at the numbers that we were seeing, that she wanted to be tested as well, and her level came back at 6 – this is a 30 something busy, healthy, working mom who had no idea that something that ominous was going on. Nothing surprises me anymore when it comes to Vitamin D levels except I am surprised when I see a 35 or 40 as it happens so rarely.
Elizabeth
Is this case study of rickets among the articles that you have already cited ? If so, I missed the reference.
Would you mind re posting it ?
There are 2 recent studies of rickets cases in the US and I will post when I retrieve them. Meantime, I can refer you to a very important Vitamin D study done in the UK of pregnant women with varying degrees of Vitamin D status with only 5.9% being defined as deficient. Yet fully one quarter of these cases showed evidence of infantile rickets in utero via 3D ultrasound. The Mahon study has highlighted the urgent need for ensuring adequate Vitamin D status in pregnancy. It is studies like this that causes Dr. Barnes and others to refer to a level of 20 as “very low”.
http://www.ncbi.nlm.nih.gov/pubmed/19580464
There is also an important Scandinavian study showing 71% of pregnant women and 15% of newborns were Vitamin D deficient, which are astonishing numbers.
http://www.ncbi.nlm.nih.gov/pubmed/20139235
Unfortunately I only had time to review the first abstract you referenced.
“Three groups of women were identified with 25-hydroxyvitamin vitamin D concentrations that were sufficient/borderline (> 50 nmol/L, 63.4%), insufficient (25 to 50 nmol/L, 30.7%), and deficient (50 nmol/L ( > 20 ng/ml) l as in their
“sufficient range” which is the same as I have posted previously as the lower limit of normal accepted by the colleges of Ob/Gyn, Pediatrics, IM and FP.
As you know, this is an area of current controversy with some experts preferring using the
20 ng/ml as the lower limit of normal while others prefer using 30 ng/ml. As of yet, I have found no reference to 50 ng/ml as the lower limit of normal.
Again where one draws the line on
“deficiency” is key to how one decides what percentage of the population is “deficient” and there is not agreement on this point.
With reference to the Stone case, I believe that the lack of certainty over the science is likely to provide reasonable doubt. I do not think that there is sufficient certainty to make the claim that this tragedy was caused by Vitamin deficiency.
Fortunately, our legal standard is based on reasonable doubt, not certainty of medical evidence of which there is none in this case.
I know there has been much interest in Vit D levels, and their impact on health and disease in the last few years. I am more familiar with the claims in geriatrics….could the controversy over levels and their ‘labels’ that you and Elizabeth are discussing come from the evolving interest in Vit D and how important it might be, therefore what might be a low level or not? Not semantics exactly but citations at different times when the science of Vit D is seen as more or less important role in disease?
I do not mean to suggest that 50 is the lower end of “normal” but rather that is what I consider to be “optimal” level as opposed to “normal”. I do not want my patients to be at the lowest end of “normal” when it comes to Vitamin D, the same goes for some other hormones for that matter.
I do not think that the 30-100 range is controversial, in fact it seems to be what is generally used these days. I see that both major labs in the country, LabCorp and Quest, use 30-100 for the reference range. I don’t know where the 20-100 range is still in use, if anywhere, but I suspect that eventually all labs will be using the higher range.
As an aside, I was looking over the lab values of my patients today and noticed that none of the 12 I saw had a baseline (pre-supplementation) D level of 30 or more. The baselines ranged from 4 to 28 with 3 in single digits, 3 above 20 and the majority between 10 and 19. That is typically what I see in my patient population, as I said before, everyone is extremely deficient.
SODA, I think you are exactly right. The science in this area is exploding and we are learning more about the harmful effects of deficiency and the importance of maintaining adequate levels.
this is a good example – it’s very clear you have made up your mind on this case.
Davis Progressive…I did not write this one…but didnt think it sounded like it was a commentary…believe David would have caught it?
I apologize for sounding bias in articles though, if it comes out that way.However, we all write our personal opinions in comments…trying to only state some points.
I also never said DDA is absent of flaws….your words not mine.
I guess I am just waiting for the,”smoking gun,”…..way too much speculation on maybe both sides. But hopeful Dr. Omalu will answer a question, not yet asked of anyone yet.
I am anxious to hear…Never said I am right…..just my own analysis of testimony heard thus far.
Elizabeth…..the normal range is just above 20mg. Are you saying I did not hear this? Wefe you present when he testified?
If doctors agreed, yes, it was low…but still not low enough….Rickets were ruled outIf that standard is different among docs, so be it….even still….there are other things to look at.
But not going to argue anymore….lets let it finish and let jurors decide.
@Davis Progressive….so if I believe what you or anyone else wants or thinks, that isnt bias?
You dont make sense…….every single one of us have our own beliefs, understandings….and however we lean towards…is the desciption of bias..correct?
But I will let you win…….losing the prospective…
And…nope, have not made up my mind at all…..be patient…some things we dont know yet.
Dear readers,
Thanks for keeping up with our reports and contributing your own interesting thoughts. It’s difficult to remain totally objective in emotional cases like People v. Stone (guilty!), but we should try our best to leave personal, unprofessional opinions aside. The reminder is appreciated.
Next Stone article coming soon!
Disagree, Jane.
As long as we are not setting out to purposely offend or use unbecoming language, or posts that may subject themselves for trouble, it is perfectly fine to voice your thoughts.
Or we would not have a comment section?
A few of us may, on occasion, get a bit over zealous, but I think the open forum stays pretty decent.
We do have freedom.of SPEECH….and press.
Personally, I appreciate the critisism at times and the expression of anothers thoughts. I do not feel anyone has the right to say someone elses opinion is not valid…..its discounting..
I dont straddle any fences…only point out the obvious for those interested in discussing.
And much rather a person be frank, honest with me, to my face, rather I turn and take a knife in the back….just saying…kid.
SODA
I think that your observation is accurate. In the adult population, vitamin D levels tend to decline with aging.
This becomes a concern in terms of bone fragility in the elderly with regard to fracture prevention. There are of course other confounding factors such as obesity, changes in hormones especially affecting the female population.
So yes, I think one important point is the age based requirements. Elizabeth has noted that her population of patients is composed of the largely over 50 population which will certainly effect how she looks at the importance of Vitamin D. We could also see the importance of panel composition in the example that I chose to ask her about how anemia should be handled. My population tends to be younger and so this is frequently a more pressing issue in my practice.
I would argue that as a group, pregnant women are hands down the most important patient population for Vitamin D screening because of the fetal effects.
Growing up as a kid I had very lo levels of vitamin D, and my doctor was concerned and put me on a high dose of Vitamin D, and then gradually lowered my level as the numbers increased. I find it interesting that though when I visited a GI doctor for other problems he said that everyone seems to have a Vitamin D deficiency. It’s more common now is what he told me. This whole trial is difficult, so many doctors, with so many different practices.