                       Illinois Official Reports

                               Appellate Court



                   In re Audrey B., 2015 IL App (1st) 142909



Appellate Court   In re AUDREY B., a Minor (The People of the State of Illinois,
Caption           Plaintiff-Appellee, v. Michael C., Respondent-Appellant).


District & No.    First District, Fourth Division
                  Docket No. 1-14-2909


Filed             April 30, 2015


Decision Under    Appeal from the Circuit Court of Cook County, No. 13-JA-701; the
Review            Hon. Nicholas Geanopoulos, Judge, presiding.



Judgment          Affirmed.



Counsel on        Abishi C. Cunningham, Jr., Public Defender, of Chicago (Trenis
Appeal            Jackson, Assistant Public Defender, of counsel), for appellant.

                  Anita M. Alvarez, State’s Attorney, of Chicago (Alan J. Spellberg,
                  Nancy Kisicki, and Nicole Lucero, Assistant State’s Attorneys, of
                  counsel), for the People.

                  Robert F. Harris, Public Guardian, of Chicago (Kass A. Plain and
                  Lynn Pavalon, of counsel), guardian ad litem.



Panel             JUSTICE HOWSE delivered the judgment of the court, with opinion.
                  Justices Ellis and Cobbs concurred in the judgment and opinion.
                                               OPINION

¶1       On August 1, 2014, the State filed a petition for adjudication of wardship of Audrey B.,
     born November 25, 2011, and a motion for temporary custody. The same day, the circuit court
     of Cook County entered an order granting temporary custody of Audrey to the Illinois
     Department of Children and Family Services (DCFS) guardianship administrator, and an order
     appointing the Cook County public guardian as attorney of record and guardian ad litem for
     Audrey. On August 19, 2014, following a hearing, the court entered an adjudication order
     finding that Audrey was abused and neglected as defined in section 2-3 of the Juvenile Court
     Act of 1987 (Act) (705 ILCS 405/2-3 (West 2012)). The court set the matter for a dispositional
     hearing.
¶2       On September 3, 2014, following the dispositional hearing, the trial court found
     respondent, Michael C., was unable and unwilling to care for, protect, train, or discipline the
     minor and adjudged Audrey a ward of the court. The court placed Audrey in the custody and
     guardianship of the DCFS guardianship administrator with the right to place the child and set
     the matter for a permanency planning hearing on March 4, 2015. On September 19, 2014,
     Michael C. filed a notice of appeal from the court’s September 3, 2014 judgment. For the
     following reasons, we affirm.

¶3                                           BACKGROUND
¶4        Michael is Audrey’s father and primary caretaker. Her mother, also named Audrey B., is
     not a party to this appeal. On June 12, 2013, DCFS received a hotline report regarding Audrey
     alleging bone fractures, medical neglect, and cuts, welts, and bruises. The same day, Carolyn
     Hudgins-Teil, a DCFS child protection investigator, responded to Roseland Hospital
     (Roseland). Hudgins-Teil spoke to Michael at Roseland. On the evening of June 12, 2013,
     Michael told Hudgins-Teil that on June 11, 2013, he had taken Audrey to a park and that
     Audrey had fallen three times while trying to walk and run. Michael told Hudgins-Teil that the
     first fall resulted in a bruise on her nose, the second time Audrey put her hands out to try to
     catch herself but she fell, and the third time she fell on her side and rolled over. Michael did not
     state to Hudgins-Teil that Audrey cried after any of the falls. Michael told Hudgins-Teil that he
     was with Audrey and, other than a bruise to her nose, he did not notice anything wrong with
     Audrey until 11 p.m. that night when he tried to get Audrey to lay down and she would not lay
     her arms out.
¶5        Michael reported that he lived with his parents. Hudgins-Teil and Michael agreed he would
     go with his sister and girlfriend to take Audrey to University of Chicago Medicine Comer
     Children’s Hospital (Comer) the next day for a second opinion as to what happened to Audrey.
     Hudgins-Teil had no further involvement in the case.
¶6        On June 14, 2013, DCFS assigned Lisa Maltbia to Audrey’s case. That day, Maltbia spoke
     to Dr. Ramaiah from Comer and met with Michael and his parents at his parents’ home.
     Michael told Maltbia that on June 11, 2013, he had taken Audrey to the park and she fell and
     scraped her nose. Michael told Maltbia that as they were approaching a set of stairs to leave the
     park, Audrey fell and braced herself. Then, as they approached their residence, he and Audrey
     were playing and she fell, braced herself, and flipped over into the grass. Michael told Maltbia
     that when Audrey fell the third time, Michael picked her up by both hands. Michael told
     Maltbia that when they returned home he gave Audrey to his sister and he left the residence.

                                                  -2-
       Michael told Maltbia that he did not have any contact with his family between the time he left
       the residence and 7 a.m. the next morning. Michael’s sister had called him at 6 a.m. but he
       missed her call. Michael’s mother called him at approximately 7 a.m. and told him that Audrey
       needed to go to the hospital. Michael told Maltbia that Audrey fell frequently but other than a
       fall about two weeks earlier, when she fell on her stomach running from the family dog, he did
       not give specific dates or provide details.
¶7          On July 13, 2013, Maltbia spoke to Michael again. Michael told Maltbia that he was
       Audrey’s primary caretaker and that he was the person who always bathed, clothed, and fed
       her. By this time, Maltbia had learned that Audrey had a fracture to her collarbone that
       predated their first interview. When Maltbia asked Michael about the collarbone injury
       Michael said he had no knowledge of that injury and he did not observe anything in Audrey’s
       demeanor that indicated she had any type of injury or pain.
¶8          The trial court qualified Dr. Veena Ramaiah as an expert in pediatric medicine, pediatric
       emergency medicine, and child abuse pediatrics. Dr. Ramaiah is an attending physician in the
       pediatric emergency room and is an attending physician on the child protective services team
       (CPS). Dr. Ramaiah consulted as a member of CPS when Audrey went to the emergency room
       at Comer. Dr. Ramaiah was not able to speak to Michael that day because he was not present.
       Pursuant to their protocol, the team at Comer requested a skeletal survey to look for additional
       injuries. The skeletal survey and other imaging surveys of Audrey revealed four bone fractures
       in Audrey’s arms. Audrey had fractures on two forearm bones (the radius and ulna) in both her
       left and right arm.
¶9          Dr. Ramaiah testified that the arm fractures were less than 7 to 10 days old. She testified
       these fractures were unusual in that they were bilateral fractures–meaning fractures on both
       arms. Dr. Ramaiah testified that usually when children fall they fall on one arm. She also
       testified that a ground-level fall on an outstretched hand can cause the type of fracture Audrey
       had in a child her age, but that it is unusual to have fractures in both arms. A radius-ulna
       fracture is common in children Audrey’s age but a bilateral radius-ulna fracture occurs very
       rarely. Dr. Ramaiah testified that she has seen a bilateral injury in the context of an automobile
       accident. Dr. Ramaiah described Audrey’s injuries as mirror-image, which she testified meant
       the injuries were fairly symmetric and looked almost the same on both arms. Audrey’s
       fractures occurred at approximately the same distance from her wrist in both arms. Dr.
       Ramaiah testified that bilateral fractures are often asymmetric. Dr. Ramaiah testified she had
       only seen mirror image bilateral fractures in the context of a “much more significant impact.”
       Dr. Ramaiah testified that in her experience in the emergency room, pediatric emergency
       room, and on the CPS she has never seen bilateral mirror-image radius and ulna fractures
       caused by just a ground-level fall. She testified that most of the mechanisms of bilateral
       fractures are high velocity. She did not come across case reports of bilateral forearm fractures
       in children resulting from ground-level falls.
¶ 10        Dr. Ramaiah testified that if someone were to inflict injuries of the type Audrey had in her
       arms it would require a direct impact across both arms at the same level or taking the bones and
       bending them back the wrong way. Dr. Ramaiah opined to a reasonable degree of medical
       certainty that simply lifting the child by the wrists in a reasonable manner would not cause
       these types of injuries. An adult could generate enough force while bending the child’s arms
       back to account for Audrey’s injuries. (Although it was not Dr. Ramaiah’s opinion to a
       reasonable degree of medical certainty that was what occurred in this case.) She testified that

                                                   -3-
       bilateral fractures could occur from a fall, although she had never seen a case where that
       happened. Audrey would experience pain if someone was to pick her up by her arms or hands
       if her arms were broken. She would be able to do something with her hands but she would not
       be able to pull herself up or grab things while playing if her arms were broken.
¶ 11       Audrey’s skeletal survey also revealed a healing clavicle fracture on her left side. The two
       pieces of bone were completely separated. Dr. Ramaiah testified that clavicle injuries are
       common in children and can occur from a fall. She testified Audrey’s clavicle injury was at
       least 7 to 10 days old at the time of the skeletal survey because callous had begun to form. She
       consulted with an orthopedist who estimated that Audrey’s injury was two to six weeks old.
       Dr. Ramaiah learned that, about a week or two earlier, Audrey had been playing with the
       family dog and fell.
¶ 12       Dr. Ramaiah testified that with a collarbone injury movement of the shoulder and lifting of
       the arm would create pain. Dr. Ramaiah testified:
                “I would imagine that anybody who was changing her shirt, where you would have to
                lift her arm up or if you’re bathing her, since she’s completely dependent on you, I
                would hope would have noticed pain.”
¶ 13       Dr. Ramaiah found it hard to believe that a child as young as Audrey would go for as long
       as her injury existed with no one noticing that Audrey was having some pain with her arm
       movement. Dr. Ramaiah testified that her opinion to a reasonable degree of medical certainty
       was that the lack of knowledge of the clavicle fracture was medical neglect because “to not
       notice that the child can’t lift up her arm or that she cries when you do your activities of daily
       living, to me that seems odd.” She also found it concerning that a toddler would have three
       fractures in such a short period of time.
¶ 14       Dr. Ramaiah testified that she did not have an opinion as to the manner of injury to a
       reasonable degree of medical certainty. However, she did testify, to a reasonable degree of
       medical certainty, that it was more likely than not that Audrey’s injuries were inflicted rather
       than not inflicted. Dr. Ramaiah wrote a report in which she stated that Audrey’s injuries were
       “highly suspicious for inflicted injury and at minimum medical neglect.” The report stated that
       the manner of the injury was “indeterminate due to incomplete assessment.” On
       cross-examination, Dr. Ramaiah explained:
                     “So when my reports end up sounding open ended a bit, in the way this one did,
                where I couldn’t say definitively that this was abuse and I left it at highly suspicious, it
                is because, honestly and ethically, I can’t say definitively one way or the other. I can’t
                say that, oh, no, this was definitely an accident, which I have done, or this was
                definitely abuse, which I have done.
                     And so it ends up being in the middle. Because with the information provided and
                with the investigation that was done that *** there was no one to corroborate the
                injuries, there was nobody else at the park. I don’t know who else the detectives talked
                to except the family members.
                     Sometimes the reports do end up a little open-ended because we do have to be
                honest about what we know and what we don’t know.”
¶ 15       Dr. Ramaiah also stated that the multiple ground-level falls that were described in the
       reports by DCFS investigators could account for Audrey’s injuries if you look at them



                                                     -4-
       individually. When she was asked whether, in her medical opinion, those explanations were
       plausible, Dr. Ramaiah responded in part as follows:
                 “So when you take each individual injury and all those different things that are
                 described, then those injuries are possible in the grand scheme of possibility. But three
                 fractures in a toddler in a short period of time–I mean, not to be facetious, but she’s a
                 really unlucky kid. That’s what makes it highly suspicious in the symmetrical nature.”
¶ 16        Dr. Ramaiah also noted that no specific mechanism of injury was ever identified. She
       specified that, for example, it was not stated that “Oh, yeah, I saw the child fall and *** she
       started crying. And I thought something was wrong with her arm and I had her shake it off.
       There really wasn’t any of that. It was just a very nonspecific, ‘Oh, she just fell while she was
       running at the park.’ ” Dr. Ramaiah concluded that it was her opinion to a reasonable degree of
       medical certainty that Audrey’s injuries were highly suspicious for inflicted injury and it was
       her medical opinion that it is more likely than not that the falls that were described did not
       cause Audrey’s injuries.
¶ 17        Dr. Christopher Sullivan testified for Michael as an expert in the field of orthopedics and
       pediatric orthopedics. Dr. Sullivan testified that the fractures in Audrey’s left and right
       forearms were minimally displaced and very similar. He stated that these fractures “are almost
       always produced by a person falling on an outstretched hand.” Dr. Sullivan testified he sees
       three or four new injuries of that type each week but those are unilateral fractures. He testified
       that it is “unusual to have both arms broken at the same time. It’s unusual to have them exactly
       symmetric.” He could not recall when he saw bilateral fractures of the radius and ulna that
       were symmetric, but he had seen that type of injury. Dr. Sullivan testified that “her falling and
       landing with both hands in a protective position” could have accounted for Audrey’s injuries.
¶ 18        Dr. Sullivan testified on cross-examination that there was no way to know whether or not
       Audrey’s injuries to her forearms occurred from two separate incidents. He also testified that
       falling from a standing height is adequate to produce her fractures, and that a greater force
       would have resulted in greater displacement of the fractures. Audrey’s fractures were
       minimally displaced. Also, if an external force like a rod had hit her “you would expect to see
       bruising at the area of the fracture site, whereas if the patient is falling on their hands, you
       wouldn’t expect to see bruising at the fracture site.” Dr. Sullivan opined that it would be
       difficult for a person to intentionally produce the exact same injury on both sides. He stated
       that Audrey’s injury was unusual, and that “the most obvious reason to have it is you had the
       same thing happen to you which means you fell and your hands were out when you fell.”
¶ 19        Audrey’s clavicle injury was also fairly common and Dr. Sullivan testified that he saw that
       type of injury approximately twice per month. The outward signs of the clavicle injury would
       have been that Audrey “would have guarded using the arm initially. So she wouldn’t have
       wanted to do activity that required strength and movement of the arm until it started to get a
       little bit more stable.” Initially, after the fracture, it would have hurt if Audrey were to raise her
       arm up to or above her shoulder and it would have hurt to touch the area of the fracture. He
       opined that a reasonable parent taking care of a child with a clavicle fracture could have missed
       that injury. The patient with the clavicle injury would have only been symptomatic for a couple
       of days, then she would start using the arm normally and “it would be really difficult to tell that
       there was anything going on.” Dr. Sullivan testified that he has seen multiple clavicle fractures
       that were not identified until weeks later. His opinion was that missing a clavicle injury for any
       length of time would not rise to the level of medical neglect.

                                                     -5-
¶ 20        Dr. Sullivan agreed that each of Audrey’s injuries would have caused her to cry when it
       occurred and that he was aware that Michael did not report that Audrey cried while they were
       at the park. Dr. Sullivan agreed that no history of any incident that may have caused the radius
       and ulna fractures was given by a caregiver except what occurred at the park, but he stated that
       fractures in this age range occur where parents do not observe the episode. Dr. Sullivan
       testified that Audrey could have been injured in an unobserved fall that was not one of the three
       Michael described as occurring at the park and that fact would not change his opinion. He
       opined that this “could have been something pretty minor where the child just fell over and
       produced these injuries. It doesn’t take that much force to produce them.”
¶ 21        Dr. Sullivan testified that his opinion to a reasonable degree of medical certainty was that
       the likelihood that Audrey’s forearm injuries were produced by nonaccidental trauma was 1%
       or 2%. Dr. Sullivan testified that in this case it “probably meets the level of suspicion [for
       nonaccidental trauma] which is basically greater than random chance.” But he added that
       “having bilateral distal radius fractures would put you in the 2 or 3 percent chance of abuse
       rather than anything higher.” On cross-examination Dr. Sullivan maintained his position,
       despite being unable to recall the last time he had seen a bilateral radius and ulna fracture. He
       agreed that multiple injuries in various stages of healing increases the risk for nonaccidental
       trauma. He also opined that “it’s very low likelihood that the clavicle fracture would have been
       from abuse” because such fractures are “almost always produced by accidental forces rather
       than nonaccidentally. This is not a fracture that is suspicious for abuse.” Dr. Sullivan noted that
       at least four different adults had been around the child for two to six weeks before the skeletal
       survey and no one noticed anything going on with her arm. He stated that he must base his
       opinion as to whether an injury was inflicted or accidental on outside circumstances, including
       whether someone injured the child or if there is something suspicious about the child. He
       testified that in this case, “there’s barely more suspicion than random chance.”
¶ 22        Following arguments by the parties, the trial court announced its ruling. The trial court
       stated that it would explain the bases for its decisions. The court began by reviewing the
       pertinent testimony, although the court made clear that failure to mention any piece of
       evidence in particular should not be construed to mean that the court did not consider that
       evidence.
¶ 23        The trial court found that it was not incredible that Dr. Ramaiah did not have an opinion
       about the manner of injury to the clavicle because she was not given a history to explain that
       injury. The trial court held that there was not sufficient evidence as to the injury to the clavicle
       to make a finding that it resulted from physical abuse. The court held regarding the injury to the
       clavicle that it is commonplace enough that there is a plausible explanation and it could have
       resulted from an accident.
¶ 24        The trial court noted the great difference of opinion between Dr. Ramaiah and Dr. Sullivan
       with regard to the bilateral symmetrical radius and ulna injuries. The court noted Dr.
       Ramaiah’s testimony that when a person falls, you fall to one side. The court found that “the
       fact that you would brace yourself identically and hit something just perfectly to cause the
       exact breaks doesn’t seem to make much sense to me.” The court stated that it had considered
       Dr. Sullivan’s testimony and found that regarding the bilateral symmetrical radius and ulna
       injuries it is more likely that they were the result of physical abuse and not an accident.
¶ 25        The trial court found aspects of Dr. Sullivan’s testimony troubling. The court found that
       Dr. Sullivan did not feel that the history given by the father made any difference to his opinion.

                                                    -6-
       The court said that specific aspect of Dr. Sullivan’s testimony was troubling because “unless
       you have an eyewitness who actually observed the injury, then obviously the things you have
       to take into consideration” are “what are people saying happened to the child beforehand that
       might account for indicating that it is actually an accident or child abuse.” The court found that
       “[j]ust telling me it’s an accident because I say it’s an accident is not plausible.” The court
       found that Dr. Sullivan had no basis for his opinion that the likelihood that Audrey’s forearm
       injuries were produced from nonaccidental trauma was 1% or 2% because forearm injuries are
       almost always produced accidentally in a standing child or a child who is able to stand. The
       court found that Dr. Sullivan gave no opinion other than he thinks it was an accident and the
       court did not know how Dr. Sullivan could come up with such an exacting percentage other
       than “because I say it’s an accident.”
¶ 26       The trial court also discounted Dr. Sullivan’s testimony that the fact Audrey suffered
       mirror-image bilateral symmetrical fractures was not significant, in part because Dr. Sullivan
       could not state any time he had seen that same injury. The court stated: “On the one hand to
       give an opinion that this is something that it’s rudimentary and happens all the time, and then
       not be able to give a time frame when he’s even seen something like that, I just find to be less
       credible than Dr. Ramaiah’s testimony regarding that point.”
¶ 27       The trial court ruled that the State had proved physical abuse with regard to the forearm
       injuries by a preponderance of the evidence but stated that it could not name a perpetrator. The
       court also found that the State proved an injurious environment and substantial risk of injury by
       a preponderance of the evidence. Specifically, the adjudication order found that Audrey was
       neglected due to lack of care and an injurious environment (705 ILCS 405/2-3(1)(a), (b) (West
       2012)) and abused due to physical injury and a substantial risk of physical injury (705 ILCS
       405/2-3(2)(i), (ii) (West 2012)). The court set the matter for a dispositional hearing.
¶ 28       Michael failed to appear at the dispositional hearing. Following testimony by the DCFS
       employee assigned to Audrey’s case and argument by the parties, the trial court ruled that it
       was in the best interests and welfare of Audrey and the public that she be adjudged a ward of
       the court. The trial court stated that it would give the parents additional time to engage in
       services aimed toward reunification. The court placed Audrey in the custody and guardianship
       of the DCFS guardianship administrator with the right to place the child.
¶ 29       This appeal followed.

¶ 30                                             ANALYSIS
¶ 31       The Act creates a two-step process for deciding whether a minor should be removed from
       his or her parents’ custody and made a ward of the court. In re Yohan K., 2013 IL App (1st)
       123472, ¶ 108 (citing 705 ILCS 405/1-1 et seq. (West 2010)). The court’s primary concern in
       child custody proceedings under the Act is the best interests and welfare of the child. In re
       Gustavo H., 362 Ill. App. 3d 802, 812 (2005).
               “[T]he first step is an adjudicatory hearing on the petition for adjudication of wardship.
               [Citation.] At the adjudicatory hearing, the trial court is to determine whether the child
               was neglected or abused, not whether the parents were neglectful or abusive.
               [Citations.] Following the adjudicatory hearing, if the trial court has determined the
               minor is abused, neglected, or dependent, the trial court moves to the second step of the
               process, the dispositional hearing. [Citation.] At the dispositional hearing, the trial
               court is charged with determining whether it is consistent with the health, safety and

                                                   -7-
               best interests of the minor and the public that he [or she] be made a ward of the court.
               [Citation.]” (Internal quotation marks omitted.) Yohan K., 2013 IL App (1st) 123472,
               ¶ 108.
¶ 32       Before a court may adjudicate a minor a ward of the court the State has the burden to prove
       by a preponderance of the evidence that the child was abused or neglected. In re Malik B.-N.,
       2012 IL App (1st) 121706, ¶ 35. The preponderance of the evidence of abuse or neglect is “that
       amount of evidence that leads the trier of fact to find abuse or neglect is more probable that
       not.” Id. The trial court has broad discretion when making the determination of whether a child
       has been abused or neglected. Id. This court will not disturb the trial court’s findings unless
       they are against the manifest weight of the evidence or the findings are manifestly unjust. Id. A
       finding is against the manifest weight of the evidence if a review of the record makes it clearly
       evident that the opposite result would be the proper result. In re M.W., 386 Ill. App. 3d 186,
       196 (2008); Yohan K., 2013 IL App (1st) 123472, ¶ 110. This deference to the trial court is
       warranted by its superior ability to observe the witnesses for purposes of assessing credibility
       to weigh the evidence. M.W., 386 Ill. App. 3d at 196.
¶ 33       Michael argues that the trial court’s findings of abuse and neglect are against the manifest
       weight of the evidence because the court relied upon Dr. Ramaiah’s testimony and her opinion
       was based on a “constellation of injuries.” Michael also argues that the court adopted this
       “constellation of injuries” theory in its ruling and ignored Dr. Sullivan’s testimony. Michael
       argues that although the court denied it relied on a “constellation of injuries” in making its
       findings, the court merely substituted a “difficult-to-explain” analysis to support its findings,
       which were nonetheless based on Audrey’s multiple injuries. Michael also argues that the
       court minimized Dr. Sullivan’s testimony with regard to Audrey’s broken clavicle. Michael
       argues that because the trial court relied on a constellation of injuries in the absence of
       evidence of abusive causation of the injuries individually, the court’s judgment must be
       reversed as against the manifest weight of the evidence.
¶ 34       In Yohan K., this court held that “relying on a ‘constellation’ theory when there is no
       preponderance of evidence proving abusive causation as to each separate injury is akin to
       relieving the State of its burden of proof.” Yohan K., 2013 IL App (1st) 123472, ¶ 113. In
       Yohan K., several medical experts testified and offered conflicting explanations for the variety
       of medical conditions the child endured. In its ruling at the adjudicatory hearing the trial court
       in Yohan K. found that it could be persuaded that the individual conditions could be explained
       by something other than abuse or neglect but the individual explanations were only possible in
       the absence of other medical findings. Id. ¶ 101. That is, the trial court dismissed a nonabusive
       explanation for two conditions (intracranial bleeding and retinal hemorrhaging) because that
       explanation (a congenital abnormality called benign external hydrocephalus or BEH) did not
       explain a third condition (a possible fracture of the child’s left knee). Id. ¶ 117. “The [trial]
       court held that to conclude that all three of these infrequent to rare conditions came together at
       the same time to explain the minor’s condition was not reasonable.” (Internal quotation marks
       omitted.) Id. ¶ 101.
¶ 35       On appeal, this court found that the existence of the fracture was essential to the finding the
       minor was abused because “without a fracture, the ‘constellation’ theory of abuse falls apart.”
       Id. ¶¶ 117-18 (State’s expert testified that “if there was no fracture or if there was a diagnosis
       of rickets [(which would have explained the fracture)], he would have to reevaluate his opinion
       of ‘inflicted trauma’ ”). This court found that the manifest weight of the evidence did not

                                                    -8-
       support a conclusion that the minor had a fracture. Id. ¶ 119. Moreover, this court found that
       “not one of [the minor’s] individual injuries within the constellation had been proven to be by
       abuse.” Id. ¶ 146. The Yohan K. court found that the trial court had erred in failing to evaluate
       and weigh the evidence and expert testimony as to each alleged injury and instead allowed the
       State to elude its burden of proof by claiming that the “constellation” of the minor’s injuries
       created a preponderance of evidence that he was abused. Id.
¶ 36       In this case, the trial court addressed this court’s decision in Yohan K. when it made its oral
       ruling following the adjudicatory hearing. The court stated “to be clear, the basis of my
       decision here today has nothing to do with there being any constellation of injuries. In fact, I’m
       going to separate the injuries, the clavicle injury and the later bilateral symmetric radius and
       ulna fractures in making my decision.” Later, when discussing the relevance of Audrey’s
       multiple injuries, the court stated that “I want to make it very clear for the record that I’m not
       relying on a constellation of injuries, but even Dr. Sullivan says if you have multiple injuries,
       that’s something that he would consider.” The trial court found that this case was much
       different from Yohan K. and stated its reasons for that finding. The court noted the factual
       differences and that in this case the medical experts did not dispute the existence of the injuries,
       only whether it was more likely than not they were accidental. The court found that Dr.
       Ramaiah had not based her opinion on a constellation of injuries in her testimony and stated
       that the court did not consider any constellation of injuries. The court stated it would not have
       accepted Dr. Ramaiah’s opinions if a constellation of injuries was the whole basis of her
       opinions.
¶ 37       We find that Dr. Ramaiah did not base her expert medical opinion on a “constellation of
       injuries” theory. But rather it was the symmetrical nature of Audrey’s injuries combined with
       the absence of an identifiable incident where the minor displayed the effects of the injuries that
       made them highly suspicious. When asked, “Do you have an opinion to a reasonable degree of
       medical certainty as to the manner of injury?” Dr. Ramaiah responded forthrightly “I actually
       don’t.” Dr. Ramaiah continued: “In isolation, each of these can be caused by low level falls.
       But when you take them all together and the fact that the history was fairly nebulous in the
       beginning, I actually don’t know exactly what happened to this child.” The foregoing
       statement, upon which Michael based his argument as to Dr. Ramaiah, does not establish that
       Dr. Ramaiah based her expert medical opinion–that Audrey’s forearm injuries were more
       likely inflicted rather than not inflicted–entirely on the existence of multiple fractures in both
       forearms or the two forearm fractures combined with the fractured clavicle. Dr. Ramaiah
       testified that she reached her initial conclusion that Audrey’s forearm injuries were highly
       suspicious for inflicted injury based “on the fact that they were symmetric and bilateral, which
       is very unusual.” Thus, it was not simply the multiplicity of fractures but the fact that the
       fractures occurred in both forearms at the same distance from the wrist, and that an injury of
       that type is highly unusual, which raised Dr. Ramaiah’s suspicion. Dr. Ramaiah also relied on
       the absence of a reported incident to which Audrey’s injuries could be attributed. The
       explanation for Audrey’s injuries by both Michael and Dr. Sullivan were vague assertions that
       Audrey fell with her arms outstretched.
¶ 38       There is nothing in Dr. Ramaiah’s testimony to suggest that she used the improper
       reasoning applied in Yohan K. to reach her expert medical opinion. Dr. Ramaiah did not
       conclude that Audrey’s forearm injuries resulted from abuse because her falls in the park could
       not explain all of her injuries; nor did she ignore a nonabuse explanation for one injury because


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       that explanation could not explain another. Compare Yohan K., 2013 IL App (1st) 123472,
       ¶ 147 (“the trial court erred in disregarding the parents’ medical experts’ diagnoses because a
       single, uniform medical condition could not explain every medical finding Yohan presented”).
       Dr. Ramaiah did not disregard the fact a fall on an outstretched arm could have caused
       Audrey’s injuries. Dr. Ramaiah acknowledged that “all these multiple different ground-level
       falls *** could account for the multitude of injuries that she had if you took each of them
       individually.” But Dr. Ramaiah explained why the existence of bilateral fractures was
       informative when she testified that “[m]ost of the time when kids fall they usually fall on one
       arm.” We do not find that Dr. Ramaiah based her opinions on a constellation of injuries.
¶ 39       We also do not find that the trial court adopted a constellation of injuries theory when it
       found Dr. Ramaiah’s opinions more credible than Dr. Sullivan’s opinions. The trial court did
       not find abusive causation as to the clavicle fracture in this case and it found abusive causation
       as to the forearm injuries separately from the clavicle injury. The trial court also did not rely on
       a “constellation” of the multiple forearm fractures. The trial court’s oral ruling illustrates that
       the trial court recognized, but rejected, Dr. Sullivan’s conclusory testimony that the injuries
       could have occurred at different times. It is evident the trial court treated the forearm fractures
       as a single injury and, based on Dr. Ramaiah’s testimony, which the court found more credible,
       that finding is not against the manifest weight of the evidence. Thus, the trial court did not
       relieve the State of its burden of proof under Yohan K. See Yohan K., 2013 IL App (1st)
       123472, ¶ 113 (“relying on a ‘constellation’ theory when there is no preponderance of
       evidence proving abusive causation as to each separate injury is akin to relieving the State of
       its burden of proof”). The trial court relied on the symmetry of the bilateral injuries to find
       abusive causation as to Audrey’s forearm injuries, stating that “the fact that you would brace
       yourself identically and hit something just perfectly to cause the exact breaks doesn’t seem to
       make much sense to me.”
¶ 40       Michael argues the trial court used a “constellation of injuries” theory by another name
       when it based its decision on the fact Audrey’s symmetrical bilateral forearm injuries were
       difficult to explain. We disagree. That the trial court relied on the symmetry of the injuries is
       not the same as relying on the existence of multiple injuries. Dr. Ramaiah testified that she had
       seen bilateral radius and ulna fractures very rarely and that in her personal experience she had
       only seen that type of injury in the context of an automobile accident. She also testified that she
       had only seen mirror-image fractures in the context of a “much more significant impact.” She
       described how symmetric fractures could be inflicted on a child by bending the bones in the
       wrong direction. The trial court credited Dr. Ramaiah’s testimony that, in sum, “you would
       need some force that would hit both arms perhaps at the same time that could cause that kind of
       [symmetrical] injury.” The trial court found not credible the testimony that the symmetrical
       bilateral injury was not a significant fact because Dr. Sullivan was not able to recall a prior
       instance of its occurrence. Thus, we find that the trial court based its decision on the testimony
       and the relative credibility of the expert witnesses.
¶ 41       We also reject Michael’s argument the trial court simply ignored Dr. Sullivan’s opinions.
       “Though the trier of fact bears the responsibility of assessing the credibility of expert witnesses
       when they offer different opinions, there is an expectation that the conflict will be resolved by
       evaluating the relative merits of the experts and their opinions. [Citation.]” Yohan K., 2013 IL
       App (1st) 123472, ¶ 111. Here, the trial court conscientiously evaluated the relative merits of
       the experts’ opinions and clearly articulated its reasons for discounting Dr. Sullivan’s


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       opinions. The court did not ignore Dr. Sullivan’s testimony by stating “you don’t see
       [symmetrical bilateral radius and ulna fractures] in a child of Audrey’s age, *** it’s unusual
       because a toddler 18 or 19 months old doesn’t generate the type of force that you would need to
       cause that type of injury.” The court was actually stating Dr. Ramaiah’s reason for her opinion
       that Audrey’s injuries were highly suspicious for an inflicted injury, which the trial court
       credited over Dr. Sullivan’s contrary testimony.
¶ 42       Michael’s reliance on Dr. Sullivan’s testimony that he sees new radius fractures three to
       four times a week is misleading. Dr. Sullivan testified that he was referring to unilateral
       fractures when he made that statement. The trial court did not ignore Dr. Sullivan’s testimony
       that forearm breaks in young children are produced accidentally in a standing child or in a child
       who is able to stand. Dr. Sullivan testified that the likelihood Audrey’s injury was produced
       from nonaccidental trauma was only 1% or 2% “[b]ecause it’s almost always produced
       accidentally in a standing child or in a child who is able to stand.” The trial court did not find
       that testimony credible because Dr. Sullivan’s only reason for that opinion was, in the court’s
       words, “because I say it’s an accident.” On the contrary, Dr. Ramaiah testified how people
       usually fall (on one arm) and as to her experience that bilateral fractures are rare and typically
       seen only in high velocity impacts unless the injury was inflicted; whereas, Dr. Sullivan was
       unable to recall a single instance of an accidental mirror-image bilateral fracture of the radius
       and ulna in a child of Audrey’s age. The court did not ignore Dr. Sullivan’s opinions.
¶ 43       The trial court also concluded that the fact Audrey’s fractured clavicle went untreated for a
       period of from two to six weeks constituted neglect. Dr. Sullivan testified clavicle injuries
       often go undetected by parents. Conversely, Dr. Ramaiah testified that Audrey’s pain from the
       displaced clavicle fracture would have been readily noticeable to her caretakers, and the failure
       to notice the clavicle injury was medical neglect. The trial court explained its reasons for
       rejecting Dr. Sullivan’s testimony based on common experience of taking care of the needs of
       a child of Audrey’s age. The court noted that with an 18-month-old toddler, “in order to dress
       the child and bathe the child, obviously, you would have to help her move her arm.” The court
       concluded that it was not believable that the primary caregiver doing those things could go for
       two weeks and not notice that there was something wrong with the arm. The court stated that it
       considered the fact that Drs. Sullivan and Ramaiah gave conflicting opinions but concluded
       that Dr. Ramaiah’s testimony regarding that issue was more credible. The court found Dr.
       Sullivan’s testimony that a reasonable caregiver could have missed that injury was not
       plausible based on Dr. Ramaiah’s testimony. The court noted that Audrey’s clavicle was
       displaced and stated that it was not believable that an injury of that nature would not be
       noticed. The court found that despite the evidence that Audrey was fussy it was not plausible
       that her caregiver would not notice, for the length of time at issue, that there was something
       awry with her arm. The court found that Dr. Sullivan’s opinion was not credible and that Dr.
       Ramaiah was more plausible given that “at 18 months, you have to help the child get dressed.
       You have to help the child bathe.”
¶ 44       The trial court did not rely on a constellation of injuries theory. The record contains
       evidence to prove abusive causation as to Audrey’s bilateral radius and ulna fractures
       independently of her clavicle injury. We will not disturb a trial court’s findings of physical
       abuse and medical neglect unless the findings are against the manifest weight of the evidence.
       A finding is against the manifest weight of the evidence when a contrary conclusion is clearly
       evident. In this case, a contrary conclusion to the court’s judgment that Audrey was abused and


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       neglected is not clearly evident from our review of the record. Accordingly, the trial court’s
       judgment is affirmed.

¶ 45                                        CONCLUSION
¶ 46      For the foregoing reasons, the circuit court of Cook County is affirmed.

¶ 47      Affirmed.




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