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Twenty medical professionals at two hospitals and a few Kupat Holim Maccabi Health Maintenance Organization (HMO) clinics examined S., a two-and-a-half year old boy. Nobody suspected that the contusions on his head, the severe swelling of his shoulders and his injured hands attested to abuse. The little boy was beaten by his mother's boyfriend, and nobody cried foul.

Nor did the couple's repeated pleas, the concocted excuses about how the boy had "fallen in the mall," make any of the doctors take pause. Nor did anybody say anything when the couple yanked the boy out of a hospital emergency room, ignoring orders that he should stay in the facility and be treated.

Finally, after 10 visits to two hospitals and several clinics, when the abused boy's condition became critical, physicians at Sheba Medical Center, Tel Hashomer, got the diagnosis right.

This happened on September 1, 1998. But the diagnosis was too late; the boy suffered irreparable damage. As a result of the abuse, the boy has incurable disabilities, including severely impaired motor skills. He also yells constantly. Since September 1998, the boy has grown up in hospital rehabilitation wards, and with a foster family.

Police investigated the case. The mother's boyfriend was indicted, and convicted on assault and abuse charges. In June 1999, he was sentenced to 13 years in prison. The judge ruled, "Society can neither tolerate nor forgive the loathsome acts which [the man] perpetrated on a defenseless" boy. The judge, Bracha Ophir-Tom, criticized institutions and medical teams for having treated the 30-month-old victim, without identifying the cause of his suffering, and also censured the boy's mother and grandmother for not blowing the whistle on the abuse. The boy's mother, a nurse by profession, worked at Assaf Harofeh Hospital at the time when her own son was abused.

About a week ago, Dr. Yitzhak Berlovitz, deputy director-general at the Health Ministry, called a meeting of the ministry committee that deals with family violence to discuss findings in the S. case. These findings were submitted by a special panel which Berlovitz himself headed.

Dr. Berlovitz's special panel pointed to grievous errors in the conduct of the medical teams which examined the boy. Berlovitz has vowed that the ministry will implement all of the recommendations submitted by his special panel.

The panel's report stated: "In a three week period, the two-and-a-half year old boy was examined at nine or 10 health care facilities, due to problems that reflect physical abuse; yet none of these facilities cross-checked results, and none suspected that the damage was caused by deliberate abuse." The panel added, "During the entire course of the treatment given to the boy, not one of the doctors or nurses wondered explicitly why the boy kept coming back, why his situation was deteriorating, and whether his parents' account of the problem was plausible. None of the doctors undressed the boy to give him a full medical examination."

The panel speculated that had such a thorough medical examination been given, or had a social worker been called by one of the physicians, "the sequence of events that unfolded would have been prevented." In other words, the panel implied that had the medical teams done their work diligently, the boy might not be permanently disabled today.

Yet the panel stopped short of concluding explicitly that the medical personnel were guilty of negligence. For one thing, the mother's work as a nurse misled and blinded some of the medical teams which treated her child, Berlovitz's committee found. In some cases, deference to her profession was the crucial factor in the mistaken diagnosis reached by medical teams, the panel stated.

Nobody asked questions

On August 17 1998, S. was taken to Assaf Harofeh Hospital by his mother, who presented herself as a staff member of the facility, and her boyfriend. The mother and her partner told emergency room staff that a week earlier the boy had fallen down stairs at a shopping mall. Nobody bothered to ask why it took them a week to get to the hospital room after such an dangerous accident. An orthopedist found that the boy had a fracture in his hand, and also contusions and swelling in parts of his body. He put a splint on the boy's arm, sent him home, and recommended that he get follow-up care at an HMO clinic.

Berlovitz's panel found that medical personnel never undressed the boy during this visit to Assaf Harofeh.

Two days after this trip to the hospital, S. was brought to night-time health services center run by Maccabi in Holon. The little boy was half unconscious and he had vomited after taking blows to the head. This time also, the mother claimed her son had fallen a week earlier. The Maccabi physician checked S. and referred him to the hospital, suspecting he had concussion. Berlovitz's panel found that though the Maccabi doctor's diagnosis was mistaken, she made the right call when she sent S. to the hospital.

The mother and her male friend returned to the emergency room at Assaf Harofeh. This time the examining physician, Dr. Eli Haiman, knew the boy had been examined at the hospital a few days earlier. Basic test results showed S. had no neurological damage but the doctor "didn't feel comfortable," and sent him for a CT scan (which turned out to be normal), and also for treatment in the children's surgery ward. The surgeon on duty, Dr. Sergei Kedar, complied with the mother's request that the boy be released. After Kedar received authorization from superiors, the boy was on his way home again.

The special panel of the Health Ministry wrote that, "The [mother's] request to take the boy home, in contradiction to the doctor's [Haiman's] orders, is an indication that the boy was being deliberately abused."

A few days after this second visit to Assaf Harofeh, S. was examined by an orthopedist, Dr. Eran Tamir, and a pediatrician, Dr. Daniel Shneiderman, at a Maccabi clinic in Holon.

According to the investigating panel, neither doctor tried to find out when the bruises and fracture had first appeared on the child's body.

On August 27, 1998, the boy was examined a second time by Dr. Tamir. This time, the Maccabi orthopedist ordered that S. be "taken quickly to a hospital." Hours later, the mother turned up with her son at the emergency room at Wolfson Medical Center in Holon. After examination, emergency room physicians at Wolfson apparently ordered that the boy be admitted for treatment, but the mother and boyfriend seem to have taken the boy away on their own initiative, grabbing his medical records to boot. Medical personnel at Wolfson, the special investigation panel concluded, apparently made no effort to track down the boy, "despite the fact that such a disappearance can be a sign of deliberate abuse." A Wolfson spokesman denies there are grounds to blame the hospital in the S. case.

Two days after the flight from Wolfson, the nurse and her son turned up yet again, for a third time, at Assaf Harofeh. This time the hospital's chief orthopedist, Dr. Yaron Bar-Ziv, checked S. He sent him home, with a recommendation for follow-up care at Maccabi.

Two days later, in early September 1998, the boy was taken to the emergency room at Sheba Medical Center, unconscious and with serious head injuries, contusions on his back, and fractures on his arms and legs. Evidence of abuse was finally detected when S. was treated in Sheba's intensive care unit.

An instructive case

The investigation panel pointed a long list of flawed examinations, yet concluded that there was no instance of negligence in S's case. "It is difficult to determine whether the [results] could have been avoided," wrote the panel. Due to the "web of deceit and fraud spun by the mother and her boyfriend, there is no cause to expect that one of the attending professionals could have seen the whole picture."

As the panel viewed it, this case does not attest to failed treatment at one specific medical facility. Instead, the panel concluded, the case points to follow-up and coordination problems between facilities in the health system as a whole.

In addition, the panel was highly critical of examination procedures followed by orthopedists. When it comes to detecting abuse, such procedures are highly lacking, the panel argued. Orthopedists do not routinely undress children who might be abuse victims and they tend to overlook evidence or deliberate abuse, wrote the panel.

The panel recommended that the Health Ministry ensure social workers are present in emergency rooms. When treating children, doctors should be forced to investigate the possibility of abuse, the panel wrote. It suggested that S's ordeal be used as an "instructive lesson," and that findings in the case be disseminated throughout the health system. Interns training in areas such as surgery, orthopedics, and trauma ought to be taught to identify signs of child abuse, the panel emphasized.

A spokesman for Assaf Harofeh Hospital relayed that lessons have been learned from this "sorrowful" case of the abused two and a half year old. Among other measures, hospital staff are being instructed to call social workers in suspicious cases, and to undress child patients who have bruises and various other injuries which could possibly result from abuse.

Maccabi says that as a result of this "tragic" case, the HMO is instituting a series of measures to raise staff awareness about violence toward minors.