Dobrozsi hated to leave town on May 6, one month into her maternity leave, but she and her parents had been planning a trip to Washington, D.C., for months. They were taking the boys to an event hosted by the national Spina Bifida Association, to lobby Congress for improved health care funding. Dobrozsi said she had no concerns about leaving their newborn with her husband, a pediatric physician and experienced father.
On the evening of May 8, one of Coxs friends came over to watch the Milwaukee Bucks game. Cox held the baby the entire night, the friend recalled in an interview, doting on his new daughter. It was almost annoying, he said. Like, John, can you put her down so we can watch the game? You could tell he was genuinely in love.
The baby woke up in her bassinet at around 5 the next morning, as she did most days, Cox said. He picked up the baby and held her in bed until she fell back to sleep, he said. Then he made the mistake of getting himself more comfortable.
We were chest to chest, cuddling, Cox said. I distinctly remember thinking, This is nice. I havent gotten this yet with my daughter.
Cox said he was disoriented when he awoke about an hour later to the sound of the babys cry. His heart raced as he came to the realization that his body had shifted, Cox said, and that he was partially on top of her, his weight pressing the babys shoulders together.
At Dr. Al Pomeranzs office later that morning, Cox recounted the same sequence of events that hed described to his wife on the phone that morning, and he shared his concern that hed broken her clavicle. The baby appeared to be moving both arms normally at that point, Pomeranz noted in her medical records, and initial X-rays came back negative for signs of a collarbone injury. But while examining the girl, Pomeranz spotted two tiny marks on the insides of her arms, and another on the middle of her back, according to the records.
Cox hadnt noticed them before then, he said. The marks on her arms could have come from when he picked the baby up abruptly that morning, when he initially thought hed smothered her, Cox told the doctor, but he couldnt say for sure.
Pomeranz, who had helped train both Cox and Dobrozsi when they were medical residents, teared up, Cox recalled, and later, in a letter, he would describe what followed as the most difficult decision of his 38 years in medicine.
Doctors in Wisconsin, as in all states, are legally required to report to authorities when they have concerns that a child may have been abused. Pomeranz told Cox and later Dobrozsi that he didnt have that concern, but he wanted to make sure that he did the right thing, treating them no differently than he would anyone else. So he contacted the hospitals in-house child abuse specialists known as the child advocacy team at Childrens Wisconsin to make them aware of the situation.
Cox tried to stay calm as Pomeranz explained his reasoning. As an ER physician, Cox knew the importance of flagging suspicious injuries. During his fellowship training, hed worked on a research project that aimed to improve the early detection of child abuse in the emergency room. But over the years, hed also grown uneasy with what he described as an aggressive approach by his colleagues in child advocacy anytime a child arrived with difficult-to-explain injuries, especially bruises.
I knew in the back of my mind that this could spin out of control, Cox said. But I dont think I realized just how bad it could get.
Later that day, a child abuse pediatrician, Dr. Hillary Petska, examined the baby, and she, too, noted three small bruises, according to records. Dobrozsi had arrived back in Milwaukee by then and was in the room as Petska looked the baby over. As part of the standard child abuse workup, Petska ordered a slew of additional tests, including full body X-rays and labs to screen for bleeding disorders that could lead to easy bruising.
The baby screamed as a hospital staff member pricked the bottom of her foot and squeezed it to draw a blood sample that afternoon, Dobrozsi recalled. Finally Dobrozsi was cleared to take her home.
That night, after Cox and Dobrozsi had gotten the kids to bed, two investigators with Child Protective Services knocked on their front door. They asked to see the baby.
Cox hadnt expected the state to get involved so quickly, he told them, given that the hospital hadnt even completed its evaluation. Dobrozsi got the baby out of bed and undressed her. The child welfare workers examined her arms and back, looking for the reported bruises.
Well, Cox and Dobrozsi recalled one of the workers telling them before leaving that night, those are underwhelming.
A focus on sentinel injuries
Small bruises might seem insignificant, but to Dr. Lynn Sheets, they sometimes signal something more ominous. As the top child abuse pediatrician at Childrens Wisconsin and the medical director of its child advocacy team, Sheets has gained national acclaim for her work studying the ways small, seemingly trivial injuries can foreshadow serious abuse.
Sheets has preached the same message for years: If doctors can better recognize early warning signs of abuse, they might be able to save lives. Her 2013 research into these sentinel injuries a term she coined and popularized found that nearly a third of seriously abused children had previously suffered minor injuries, such as bruises.
Dr. Lynn Sheets.Scott Paulus / Milwaukee Business Journal
In 2019, the research became the inspiration for federal legislation now working its way through Congress. The bill would provide funding to perform exhaustive medical examinations, including full-body X-rays and CT scans, on infants who come to hospitals with bruises and other common injuries.
One of the things we realized is, if you just call it a bruise, everyone has bruises,” Sheets told The Milwaukee Journal Sentinel last year, after the bill was introduced. Everyone thinks about it as a minor injury, including the doctors, including child welfare. So we needed to change the way people are thinking about these minor injuries in young infants.
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But some doctors, defense lawyers and parental rights advocates have criticized the effort to redefine minor injuries as beacons of future danger. They warn that it opens the door for increased prosecutions of innocent families, especially people of color, who are more likely to be flagged as abuse suspects, and parents of children with rare disorders that predispose them to bruising.
In interviews, several emergency room doctors at Children’s Wisconsin said theyve seen firsthand the unintended consequences of the philosophy.
I agree that children are abused and that we need to protect them, one physician said. But it seems theres a total disregard for the harm done to the child and family when theres a complete medical workup done and charges brought when its not really abuse.
Several Childrens Wisconsin physicians said they had concerns about the work of child advocacy specialists prior to Coxs ordeal, but after watching the handling of his case, they are seeing many of the teams practices in a new light.
For example, several staff members told a reporter that child abuse pediatricians at the hospital routinely review medical records of children whove been admitted to the ER even when no doctor has asked for their opinion and then weigh in on whether Child Protective Services should be called. Sometimes child abuse specialists send notes scolding ER physicians for failing to flag children, even though those physicians did not believe the child had been abused, several doctors said.
In at least three instances, according to interviews and two sets of internal messages reviewed by a reporter, some child abuse pediatricians have gone so far as to ask treating physicians to edit a childs medical records, deleting or amending passages in which they had initially noted little concern for abuse.
In one such case, Sheets suggested amending a medical record because she was concerned that, without language noting a concern for abuse from the initial treating physician, Child Protective Services would stop investigating, according to messages between doctors.
Sheets did not respond to an email from a reporter, and hospital officials did not respond to detailed written questions about internal concerns raised by members of the medical staff.
Diane Redleaf, a family law attorney in Illinois who wrote a paper on the ethics of expert physician testimony in child abuse cases, said the practice of editing medical records to assist with state child welfare investigations is unethical and shocking.
Doctors are not supposed to be advocates for a result, especially a legal result; doctors are supposed to be providing medical information, Redleaf said.
Keith Findley, a professor at the University of Wisconsin Law School who co-founded the Wisconsin Innocence Project, said that when physicians work in concert to shape the message sent to investigators, it undermines the legal systems access to full truth.
What theyre really doing is shaping the evidentiary record, and in fact deliberately hiding from the legal system inconsistent opinions that might be useful to the legal fact finders who are working to determine what actually happened, Findley said. Its deeply problematic.
Sheets and her team have shaped more than just hospital practices; her vigilance for seemingly minor injuries has also permeated the child welfare and criminal justice systems in Milwaukee.
After Child Protective Services workers initially visited Cox and Dobrozsi at their home, one of them noted in her written report that the babys bruises were very small and unremarkable, according to a motion filed by Coxs lawyer in Milwaukee County Circuit Court arguing that the state lacked enough evidence to bring charges. But, due to a concern about sentinel injuries, Cox and Dobrozsi later learned, the workers Child Protective Services supervisors determined that additional action needed to be taken.
The next morning, Cox received a call from a different case worker, Jessica Barber, who explained that higher-ups at Child Protective Services and the hospital had decided that the baby needed to immediately undergo an additional evaluation with another child abuse specialist, Cox said. And this time, she told Cox, neither he nor his wife could attend. Cox was at work and relayed the message to his wife.
An agency spokesman declined a reporters request to interview Child Protective Services staffers who worked on Coxs case.
Barber showed up at their home 20 minutes later. Dobrozsi pleaded with her: Why cant I come? I dont understand why this is happening.
Barber told her that it was normal procedure for parents to be blocked from attending appointments with child abuse specialists, Dobrozsi recalled. Later, she said Barber gave a different explanation: They werent allowed to attend, because as doctors, they would be in a position to ask hard questions and challenge the assessment.
As a pediatric oncologist, that didnt sound right to Dobrozsi. One of the most important steps in making an accurate diagnosis is talking to patients or their parents. How could someone assess the credibility of Coxs story if they didnt bother to hear it?
Barber asked Dobrozsi if she had her consent to take the baby.
It sounds like I dont have a choice, Dobrozsi remembered saying.
She cried as Barber loaded the girl into her car and drove away.
Youre taking my child
Nearly two hours later, Barber called Dobrozsi and told her she could come meet her at the hospital. As she sat with the caseworker that afternoon, awaiting additional test results, a police officer entered the room and explained that someone at the hospital had reported a baby with unexplained injuries.
Dobrozsi was stunned. She said she turned to Barber and demanded to know what had happened during the medical examination that morning.
It turns out, a nurse practitioner on the hospitals child abuse team, Rita Ventura, had examined the baby and concluded that her body was covered in more than a half dozen bruises, including along the backs of her arms.
Those are birthmarks! Dobrozsi remembers telling Barber. Plus, she said, none of the doctors whod examined the baby a day earlier had noticed any other bruises.
Det. James Donovan spent hours questioning both Dobrozsi and Cox separately at the hospital that Friday afternoon, they recalled in an interview. He also reviewed the medical findings and examined the baby. Afterward, he asked to speak privately with one of the Child Protective Services caseworkers.
Donovan told the worker he wasnt sure why they were even out there as he did not see anything criminal, the worker wrote in her notes, according to a motion filed as part of the criminal case.
A spokesman for the Wauwatosa Police Department declined a request to interview Donovan, citing a department policy of not commenting on pending criminal matters.
Despite the officers initial reservations, Cox and Dobrozsi entered into a safety agreement with Child Protective Services that evening. While child welfare workers and police continued their investigations, Dobrozsis parents would move in with them and supervise them at all times when they were with their children.
If they just followed the rules and continued to tell the truth, Cox and Dobrozsi told themselves, everything would be OK.
Two days later, at the urging of Pomeranz, their pediatrician, they took the baby to see a pediatric dermatologist at Children’s Wisconsin, Dr. Yvonne Chiu, for a second opinion.
Chiu examined the girl and reviewed photos taken during her initial doctors visit with Pomeranz on the morning of the incident. Chiu, who as a dermatologist is an expert in differentiating bruises from other skin marks, concluded that the baby had suffered only the three small bruises Pomeranz had originally noticed, which had mostly resolved over the weekend. The other marks on her body were birthmarks or other benign lesions that are common in newborns, Chiu wrote.
Chiu believed that the two arm bruises could have been the result of the way Cox picked the baby up when he was panicked. And the bruise on the babys back appeared to match Coxs wedding band and was located in the spot where he normally patted her back while burping her, according to Chius report.
Like Pomeranz, Chiu had no concerns that the girl had been abused. She shared her findings with Child Protective Services and police. Later, six other dermatologists reviewed the medical records and agreed that Ventura had been mistaken when she reported widespread contusions.
But when Cox and Dobrozsi later filed a grievance with Childrens Wisconsin administrators over Venturas finding, child advocacy team leaders responded that they were better equipped than dermatologists in these matters: Differentiating accidental from inflicted injuries is the primary focus of child abuse medical professionals and is not usually a primary focus of dermatologists, they wrote.
Kate Judson, a lawyer in Madison and executive director of the Center for Integrity in Forensic Sciences, reviewed the case at NBC News request and said it follows a familiar pattern that shes observed over the years. Child abuse specialists, she said, sometimes overstate their expertise while minimizing the expertise of other subspecialists.
Whats striking to me is that you have these leaps in logic that are unsupported, Judson said. So you have a nurse practitioner here saying, Well, I can determine with accuracy and certainty that this bruise was intentionally inflicted. And then you have a dermatologist, who is unquestionably an expert in the examination of skin lesions, whos saying, Well, this isnt even a bruise.
Authorities in Milwaukee took Venturas word for it.
On May 24, two weeks after the initial incident, Child Protective Services workers returned to Cox and Dobrozsis home. They had come to take the baby, and this time they wouldnt be bringing her back.
Cox and Dobrozsi said they pleaded with the caseworker, Amy Scherbarth, the same one who they said weeks earlier had described the babies injuries as underwhelming. What about the dermatologists report? Shouldnt her opinion carry more weight than a nurse practitioner who never heard Coxs account of what happened or talked to anyone whod cared for the baby?
Why couldnt Dobrozsis parents continue to supervise them? What had changed?
Scherbarth said she understood the dispute over whether some of the babys birthmarks had been confused for bruises, Dobrozsi recalled, but the worker said nobody could explain the bruise on the bottom of the babys foot.
What bruise? Dobrozsi demanded. There was never a bruise on her foot.
Youre taking my child from me and you cant answer any of my questions, Dobrozsi remembered saying.
And then she looked me in the eye and said, Youre not her mother.
Dobrozsis parents and Cox were all present and attested to her description of the exchange.
Afterward, Dobrozsi asked her mom to shove some diapers and formula into a bag. Dobrozsi grabbed the babys stuffed unicorn and a pacifier. Then she and Cox sat on the floor with her and took turns holding her as they sobbed.
We told her that we loved her, Dobrozsi said, and that we would do everything we could for the rest of our lives to try to get her to come home.
A few minutes later, she was gone.
A series of mistakes
Night after night, for weeks afterward, Dobrozsi would wake up in a panic, terrified that her children were in danger. She would get out of bed to check on each of the boys, placing her hand on them as they slept.
Then she would go to the babys room and stand over her empty crib, before curling up on the nursery floor and crying herself to sleep.
Because the adoption had not yet been finalized, Cox and Dobrozsi were not granted the same legal rights as other parents. They could not visit the baby, and the state did not allow her to stay with family members.
During the day, between their busy work schedules and taking care of their boys, Cox and Dobrozsi tried to fight the allegations. They hired a lawyer and began digging through medical records.
Dobrozsi said she soon identified a series of mistakes and misstatements by Ventura, the nurse practitioner whod reported numerous bruises to authorities, and Petska, the child abuse pediatrician whod initially seen the baby a day earlier.
Neither Ventura or Petska responded to messages seeking comment.
They both inaccurately described Coxs account of what happened not surprising, Dobrozsi said, considering that neither of them ever spoke with him in person.
They both also wrongly reported that the baby had suffered an earlier bruise on her face, twisting an account provided by Dobrozsi, who at one point mentioned noticing a mark on the girls face weeks earlier that lasted just a few hours, after shed slept on a pacifier clip. Dobrozsi said she never described the earlier mark as a bruise, but highlighted it as evidence that the babys skin was sensitive.
And most notably, both Petska and Ventura had incorrectly reported that the results of the babys initial lab tests were negative for a bleeding disorder that could cause easy bruising. Dobrozsi, who as a pediatric hematologist oncologist is an expert in assessing children for bleeding disorders, was outraged when she read the test results.
The labs indicated a delay in how quickly the babys blood formed clots, which suggested a possible bleeding disorder and should have resulted in a referral for more extensive testing, according to four hematologists, including the medical director of the Comprehensive Center for Bleeding Disorders at Childrens Wisconsin, who have since reviewed the records.
Instead, Petska reported to authorities that the blood tests were normal. And Ventura wrote, Results available at this time indicate no concern for a clinically significant bleeding disorder.
Cox and Dobrozsi have shared the expert hematology reports with Child Protective Services, the county prosecutor and hospital administrators, but as far as they know, no follow up testing has been completed.
The girl did undergo additional X-rays in the weeks after Child Protective Services took her, and one of the scans seemed to bolster Coxs case. It showed a healing collarbone fracture, not only confirming the initial concern that prompted Cox to take the baby to the doctor, but according to four orthopedic surgeons who have since reviewed the medical records, validating the account he gave to authorities.
But child abuse specialists and state authorities saw it differently, according to documents filed as part of the criminal case. They concluded that the broken collarbone was further evidence of abuse, seeming to contradict medical literature on the subject. Numerous publishedstudies say collarbone fractures are common in infants and are not particularly concerning for abuse.
Honestly, wrote Dr. Matthew Wichman, one of the orthopedic surgeons who reviewed the medical records, this all seems quite preposterous.
In response to complaints filed last year by Cox and Dobrozsi over the hospitals handling of their case, Dr. Michael Gutzeit, chief medical officer at Childrens Wisconsin, defended the work of the hospitals child abuse specialists.
In this rapidly unfolding situation, a good faith effort was made to protect the child, individuals involved in the process and the rights of those involved, Gutzeit said in the Aug. 1 letter. It is my opinion that all involved in the case have attempted to provide compassionate, competent care focussing on the best interests of [the child].
The most unsettling error wasnt revealed until November, five months after the state had taken the baby. Thats when Child Protective Services finally provided Cox and Dobrozsi with photos that Ventura took during her examination, which inexplicably had been stored outside of the childs medical records and shared only with investigators.
Dobrozsi and their lawyer scrolled through the images on his computer. Her heart sank when they reached the picture of the bottom of the babys foot.
The child welfare worker had been right; there was a bruise on the babys heel. And once Dobrozsi saw it, she knew immediately how it had gotten there.
Ventura initially had a hunch, telling Child Protective Services that the bruise could have been the result of a heel prick, according to a motion filed by Coxs lawyer in his criminal case. But Ventura said that was an unlikely explanation since it had been a month since the baby had blood drawn for her newborn screening, according to the motion.
If Dobrozsi had been allowed to attend the appointment, she could have helped Ventura solve the mystery. Shed been in the room, just a day earlier, when a hospital worker pricked the babys foot to collect a blood sample ordered by Petska the same lab work that pointed to a potential bleeding disorder, but that doctors failed to read correctly.
Dobrozsi cried, angry at herself for not making the connection sooner.
The injury that a Child Protective Services worker cited as the primary basis for taking her baby had been inflicted, not by Cox, but by staff at Childrens Wisconsin.
It has to end
In mid-January, Cox was notified that despite the outside medical opinions, despite the repeated mistakes by medical staff, despite the fact that investigators never even interviewed the friend whod been with him just hours before the incident the county was preparing to file criminal charges.
Cox was booked at the county jail on Thursday and released.