Title: Commonwealth v. Millien

State: massachusetts

Issuer: Massachusetts Supreme Court

Document:

NOTICE:  All slip opinions and orders are subject to formal 
revision and are superseded by the advance sheets and bound 
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error or other formal error, please notify the Reporter of 
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SJC-11928 
 
COMMONWEALTH  vs.  OSWELT MILLIEN. 
 
 
 
Middlesex.     December 7, 2015. - June 3, 2016. 
 
Present:  Gants, C.J., Spina, Cordy, Botsford, Duffly, Lenk, & 
Hines, JJ. 
 
 
Assault and Battery.  Child Abuse.  Evidence, Expert opinion.  
Constitutional Law, Assistance of counsel.  Due Process of 
Law, Assistance of counsel.  Practice, Criminal, New trial, 
Assistance of counsel. 
 
 
 
 
Indictments found and returned in the Superior Court 
Department on December 23, 2009. 
 
 
The cases were tried before S. Jane Haggerty, J., and a 
motion for a new trial, filed on June 24, 2013, was heard by 
her. 
 
 
The Supreme Judicial Court granted an application for 
direct appellate review. 
 
 
 
David Hirsch for the defendant. 
 
Kate Cimini, Assistant District Attorney, for the 
Commonwealth. 
 
The following submitted briefs for amici curiae: 
 
Seth Miller, of Florida, Katherine H. Judson, of Wisconsin, 
Adam W. Deitch & Lindsay A. Olson, of New York, & Mark W. Batton 
for The Innocence Network. 
 
Heather Kirkwood, of Washington, & David E. Meier for David 
Ayoub & others. 
2 
 
 
 
 
Matthew R. Segal, Dennis Shedd, & Chauncey B. Wood for 
Committee for Public Counsel Services & others. 
 
 
 
GANTS, C.J.  On the evening of October 20, 2009, the 
defendant's six month old daughter, Jahanna, was rushed to the 
emergency room, unconscious and unresponsive.  She was diagnosed 
with traumatic brain injury, and scans of her brain showed 
retinal hemorrhages, subdural hematoma, and brain swelling, the 
three symptoms known as "the triad" associated with shaken baby 
syndrome.  The defendant, who was the baby's sole caretaker when 
she became unconscious, claimed that Jahanna accidentally fell 
backwards from the couch where she was sitting and landed on the 
wooden floor.  After Jahanna's physicians concluded that her 
brain injuries could not have been caused by an accidental fall 
from the couch but were instead caused by a violent shaking, the 
defendant was charged and later convicted by a jury of assault 
and battery on a child causing substantial bodily injury (head 
injuries), in violation of G. L. c. 265, § 13J (b), and assault 
and battery on a child causing bodily injury (fractured 
vertebrae), in violation of G. L. c. 265, § 13J (a).1 
 
There is a heated debate in the medical community as to 
whether a violent shaking of a baby alone can generate enough 
                                                          
 
 
1 The defendant was found not guilty on two indictments 
alleging assault and battery on a child causing bodily injury 
(fractured tibia and fractured ribs), in violation of G. L. 
c. 265, § 13J (a). 
3 
 
 
 
force to cause the triad of symptoms of traumatic brain injury, 
and as to whether these symptoms can sometimes be caused by a 
short accidental fall.  At trial, the jury heard only one side 
of this debate, because the defense attorney did not retain a 
medical expert to offer opinion testimony or to assist him in 
cross-examining the Commonwealth's medical experts.  We conclude 
that, in these circumstances, where the prosecution's case 
rested almost entirely on medical expert testimony, the 
defendant was denied his constitutional right to the effective 
assistance of counsel because, by not providing the jury with 
the other side of this debate, his attorney's poor performance 
"likely deprived the defendant of an otherwise available, 
substantial ground of defence."  See Commonwealth v. Saferian, 
366 Mass. 89, 96 (1974).2 
 
Background.  1.  Evidence at trial.  We summarize the 
evidence presented at trial.  The defendant was in his early 
twenties when his girl friend, Amanda Leavitt, told him that she 
was pregnant.  He urged her to "keep" the baby, and accompanied 
her to medical appointments during the pregnancy.  Although he 
was disappointed when he learned that Leavitt was going to have 
                                                          
 
 
2 We acknowledge the amicus briefs submitted by The 
Innocence Network and "concerned physicians and scientists," and 
the amicus brief jointly submitted by the American Civil 
Liberties Union of Massachusetts, the Committee for Public 
Counsel Services, and the Massachusetts Association of Criminal 
Defense Lawyers. 
4 
 
 
 
twin girls, preferring a boy, he was happy when the girls, 
Jahanna and Taeja, were born on March 27, 2009, and was with 
Leavitt in the operating room when she had her cesarean section. 
 
Before the babies were born, Leavitt moved to the home of 
her mother, Dianna Gagnon, who lived with her boy friend and 
Leavitt's teenaged siblings in Woburn.  The defendant visited 
nearly every day and generally stayed overnight after the twins 
were born.  The defendant shared the responsibilities of child 
care with Leavitt; he fed, changed, and played with the twins 
daily.  When the twins were approximately five months old, 
Leavitt found a job at a restaurant, working several nights a 
week from between 4 and 5 P.M. to between 9 P.M. and midnight, 
and during that time the defendant, Leavitt's mother, or the 
defendant's mother or sister cared for the twins.  In September, 
2009, Leavitt and the twins moved to a townhouse apartment in 
Woburn, and the defendant lived there with them. 
 
The defendant was inexperienced in caring for babies, but 
he sought advice regarding child care from Leavitt and Gagnon.  
No witness ever saw him spank or abuse the twins, but at times, 
he patted the twins too roughly while trying to burp them and on 
a few occasions walked away from the changing table while he was 
changing them.  He was responsive to criticism, however, when 
other caretakers instructed him how better to care for the 
twins.  Jahanna was the fussier baby, and the defendant was more 
5 
 
 
 
comfortable caring for Taeja than he was caring for Jahanna.  
But when Jahanna was colicky, the defendant sometimes would pick 
her up and walk around and talk with her.  Gagnon described the 
defendant as a man of quiet demeanor whom she never saw angry 
and never heard shout, and whom she never saw hit or grab 
anyone. 
 
There were no complications regarding the twins' birth, but 
Jahanna soon developed various health problems.  She was 
"cranky," cried often, and was difficult to feed.  When Jahanna 
was approximately two months old, her primary care pediatrician, 
Dr. Elizabeth Burba, placed her on a more gentle formula.  Nine 
days later, Leavitt telephoned the doctor's office and reported 
that Jahanna had vomited blood.  She was referred to the 
emergency room at Winchester Hospital, where she was diagnosed 
with gastro-esophageal reflux and was prescribed antacid 
medication.  Dr. Burba noted at Jahanna's three-month "well 
visit" that she was "taking her feeds now" and gaining weight.  
Leavitt discontinued using the medication after "a couple of 
months" because Jahanna was doing well.  When Jahanna was 
approximately four months old, Leavitt noticed that one of her 
legs "would kind of be limp."  She testified, "I would hold her 
up and one leg would be touching the ground and one would be in 
the air, like a bend in the knee."  Leavitt took Jahanna to Dr. 
Burba's office, where she was diagnosed with a "hip click."  She 
6 
 
 
 
was given a hip ultrasound, which was normal.  On September 29, 
2009, Leavitt reported that Jahanna had again vomited blood, and 
returned to the Winchester Hospital emergency room, where she 
was given an abdominal x-ray, which was normal, and once again 
was prescribed the antacid medication.  At her six-month "well-
visit" on October 2, Jahanna was "no longer fussy or irritable," 
and her "gross motor development examination," which showed that 
she could roll over from side to side, move objects from one 
hand to another, and sit up with a bit of support, was normal 
for her age.  During her care of Jahanna, Dr. Burba saw no sign 
that Jahanna had been abused. 
 
On October 20, 2009, Leavitt was at work and the defendant 
was alone in her Woburn apartment caring for the twins.  At 
approximately 8:45 P.M., Robert Jeffrey, who lived next door 
with his wife, Eileen, knocked on the door to Leavitt's 
apartment, which was slightly ajar, and asked the defendant for 
a cigarette.  He saw the defendant sitting on the couch in the 
living room feeding Jahanna, with Taeja sitting in "a little 
bouncy thing" on the floor.  Their demeanor appeared "good"; 
Jahanna "was just whining like she was hungry."  The defendant 
said he did not have any cigarettes, so Robert3 drove to a nearby 
gasoline station, approximately four minutes away.  When Robert 
                                                          
 
 
3 We refer to Robert Jeffrey and Eileen Jeffrey by their 
first names because they share the same last name. 
7 
 
 
 
parked in front of his apartment, about ten minutes later, the 
defendant ran over, looking "[v]ery shooken up," and asked to 
use Robert's telephone to call his girl friend because something 
had happened to one of the babies.  Eileen, who was a certified 
nurse assistant, was walking towards Robert from the steps of 
the Jeffrey home when Robert returned.  She heard the defendant 
say that the baby fell, and when Eileen asked if she was okay, 
the defendant said he did not know.  She then immediately walked 
into the defendant's apartment and saw Jahanna on the couch.  
Jahanna was pale and unresponsive, and her eyes were closed.  
Robert then drove the defendant and Jahanna to the emergency 
room at Winchester Hospital. 
 
At trial, Eileen testified that she was sitting at her 
computer on the first floor of her apartment when Robert left to 
find cigarettes, and she went outside when she heard him 
returning.  Although the walls between her apartment and the 
Leavitt apartment were thin, and she could often hear noises 
coming from the Leavitt apartment, Eileen heard no banging or 
other noise during the time that Robert was gone. 
 
Jahanna arrived in the emergency room of Winchester 
Hospital at approximately 9:18 P.M.  Dr. Atima Delaney, the 
attending pediatric physician in the emergency room who treated 
Jahanna, obtained a medical history of Jahanna from the 
defendant that evening.  Dr. Delaney described the defendant as 
8 
 
 
 
"worried and quiet."  The defendant told Dr. Delaney that he had 
been sitting on the couch while Jahanna had been lying on the 
couch.  When he turned around to grab a bottle, Jahanna fell off 
the couch.  When he turned back, he saw the baby lying on her 
back on the hardwood floor.  She immediately vomited, and then 
became unconscious. 
 
A computerized tomography (CT) scan taken at Winchester 
Hospital revealed a large subdural hematoma (a collection of 
blood between the dura4 and the brain), brain swelling, and a 
comminuted skull fracture located in the left parietal skull.5  
The CT scan also showed a "midline shift," meaning that one side 
of the brain had started to push over to the other side because 
of the brain swelling.  Because of the severity of Jahanna's 
injuries, she was transferred to Children's Hospital, where a 
pediatric neurosurgeon, Dr. Mark Proctor, performed emergency 
brain surgery.  When he opened the dura inside the skull to 
relieve the brain swelling, the fluid, including clotted blood, 
was under such high pressure that it "squirted up about one and 
a half to two feet."  The presence of clotted blood revealed 
that the injury had happened "within hours."  Dr. Proctor did 
                                                          
 
 
4 The dura is the membrane between the skull and the brain. 
 
 
5 A fracture is characterized as comminuted where there is a 
series of fractures that cross or are parallel rather than a 
single fracture in one straight line, which is characterized as 
linear. 
9 
 
 
 
not see extensive injury to the brain itself, but saw that the 
brain was swelling to such an extent that he needed to remove 
more bone to relieve the pressure.  He located the torn blood 
vessel that was the cause of the hemorrhage, which was in the 
subdural space towards the top of the head, to the left of the 
midline. 
 
On the afternoon of October 21, Inspector Timothy Donovan 
of the Woburn police department interviewed the defendant at 
Children's Hospital.  The defendant recounted essentially what 
he had told Dr. Delaney, but with some additional details.  He 
said he was sitting in the middle of a two-seat loveseat, 
watching a baseball game on the television, and was preparing to 
feed Jahanna.  He placed her to his right on the loveseat, 
facing the back of the couch.  He reached back to grab a bottle 
and saw Jahanna fall off the couch.  When he picked her up from 
the floor, her eyelids were closed, she was not crying, and her 
head was "bobbling."  He saw that she was breathing, but 
unresponsive, so he took off her pajamas, brought her upstairs 
to the bathroom, placed her in her "bathinet," and sprinkled 
water on her face.  When he saw that she was still unresponsive, 
he put her pajamas back on, and ran next door to speak to the 
Jeffreys.  When the inspector told him that Jahanna's injuries 
were consistent with her having been shaken, the defendant 
replied that the only shaking he ever did was bouncing Jahanna 
10 
 
 
 
on his knee.  The inspector later measured the distance from the 
floor to the seat of the couch and determined that it was 
seventeen and one-half inches tall. 
 
The defendant spoke that same day with Donna Hughes, an 
investigator with the Department of Children and Families, and 
told her essentially what he had told Dr. Delaney and Inspector 
Donovan, but with one important additional detail:  he said 
that, when Jahanna fell, she fell backwards and her head hit the 
floor. 
 
An examination by a pediatric ophthalmologist, Dr. Iason 
Mantagos, on October 22 found no sign of direct trauma to the 
eyes.  But he found in both eyes extensive hemorrhages (blood 
spots) in all four quadrants of the retina (the multiple layers 
of cells that include the photo receptors that are stimulated by 
light and create impulses that are sent to the brain), from the 
center to the periphery of the retina, including on the optic 
nerve (which sends information from the retina to the brain) and 
in the macular (the area of the eye responsible for sharpest 
vision).  Dr. Mantagos testified that "[t]his finding is 
consistent with trauma and the force that's required to cause 
such bleeding is extensive."  In describing the different kinds 
of trauma that can produce retinal hemorrhages, he included the 
extreme shaking of an infant, which causes the contents of the 
eyeball to move rapidly back and forth at different speeds, 
11 
 
 
 
which in turn causes the vitrious (the jelly that fills the eye) 
to separate from the retina and put traction on the blood 
vessels.6  Claiming reliance on the medical literature in peer-
reviewed journals, he opined on redirect examination that the 
retinal hemorrhaging he found would be consistent with a fall 
only if it were from the highest point of a swing to a cement 
floor, a fall down a flight of stairs in a stroller, or a fall 
from a height of one or two stories and hitting the ground. 
 
Dr. Alice Newton was the medical director of the Child 
Protection Program at Children's Hospital, and has written 
extensively on shaken baby syndrome, which she testified was now 
called abusive head trauma.7  She examined Jahanna on October 21 
                                                          
 
 
6 Dr. Iason Mantagos also testified that the shaking of an 
infant can cause bleeding inside the skull, swelling of the 
brain, and fractures of the vertebrae where the skull meets the 
spinal cord. 
 
 
7 In 2009, the American Academy of Pediatrics (AAP) in a 
policy statement recommended that pediatricians "use the term 
'abusive head trauma' rather than a term that implies a single 
injury mechanism, such as shaken baby syndrome, in their 
diagnosis and medical communications."  Christian, Block, and 
the Committee on Child Abuse and Neglect, Abusive Head Trauma in 
Infants and Children, 123 Pediatrics 1409, 1411 (2009).  The AAP 
explained, "The goals of this policy statement is not to detract 
from shaking as a mechanism of [abusive head trauma] but to 
broaden the terminology to account for the multitude of primary 
and secondary injuries that result from [abusive head trauma], 
some of which contribute to the often-permanent and significant 
brain damage suffered by abused infants and children."  Id. at 
1410.  It noted that the term "shaken baby syndrome" is 
"sometimes used inaccurately to describe infants with impact 
injury alone or with multiple mechanisms of head and brain 
 
12 
 
 
 
to determine whether Jahanna's injuries were caused by child 
abuse.  Dr. Newton testified that, "when one refers to shaken 
baby syndrome, one refers to a combination of findings":  
bleeding around the brain (subdural hematoma), brain injury, and 
retinal hemorrhages.8  She testified that Jahanna displayed all 
three of these injuries, and she described how shaking can cause 
each of them.  She opined to a "reasonable degree of medical 
certainty" that the cause of Jahanna's subdural hematoma, brain 
injury, and retinal hemorrhages was that Jahanna was "violently 
shaken."  She stated as the basis of her opinion that the 
constellation of injuries sustained by Jahanna fit the 
definition of shaken baby syndrome and "do not have any other 
medical explanation."  She declared that Jahanna "did not have 
some type of massive accidental head injury" and that "the 
amount of force in a short household fall is not very 
significant."  Dr. Newton also offered a motive for violently 
shaking a baby, explaining that when a caretaker is unable to 
handle a crying infant, he or she sometimes shakes the infant as 
a mode of discipline or simply out of frustration. 
                                                                                                                                                                                           
injury and focuses on a specific mechanism of injury rather than 
the abusive event that was perpetrated against a helpless 
victim."  Id. 
 
 
8 Dr. Alice Newton noted that it is not always true that the 
violent shaking of an infant results in all three of the 
constellation of injuries. 
13 
 
 
 
 
She further testified that in addition to the brain 
bleeding, brain injuries, and retinal hemorrhages, Jahanna was 
diagnosed with fractures of multiple ribs and of the tibia of 
her right leg, both of which were in an advanced state of 
healing and were "probably at least a month old."  Dr. Newton 
also noted that Jahanna had compression fractures of thoracic 
vertebrae eleven and twelve.  She said she could not opine when 
the vertebral fractures occurred, because they do not heal with 
new bone formation like ribs and the tibia, but she did offer 
the opinion that these fractures were caused by "some type of 
crushing force," which could include the extreme flexion caused 
by violent shaking. 
 
Dr. Newton opined to a reasonable degree of medical 
certainty that, of all the injuries suffered by Jahanna, "the 
only injury . . . that could possibly be related" to a short 
fall was the skull fracture, but that this was "very unlikely," 
because short falls are more likely to result in linear, rather 
than comminuted, fractures.  She testified that the skull 
fracture required "some type of blow," such as "slamming the 
child against something."9  She stated that one could not 
determine when a skull fracture occurred simply by looking at 
                                                          
 
 
9 Dr. Newton noted that it is "common" that the violent 
shaking of an infant is followed by the angry caretaker throwing 
the infant on the floor, resulting in swelling of the scalp or 
some type of fracture. 
14 
 
 
 
the CT scan because it heals in the same way that vertebrae 
heal, but she felt strongly that the skull fracture was "acute, 
although that's a little bit harder to be definitive about." 
 
The defendant called three witnesses in his defense:  his 
sister, his mother, and himself.  His sister testified that she 
never saw the defendant shake, spank, or throw Jahanna, and 
never saw him compress Jahanna's ribs.  His mother said little 
regarding the defendant's care of the twins because, when the 
twins were at her house, she or the defendant's sister would 
feed and change them, not the defendant.  The defendant's 
testimony was essentially consistent with what he had already 
told Dr. Delaney and the investigators.  The defendant offered 
no expert witness to rebut the medical opinion evidence 
regarding shaken baby syndrome. 
 
The prosecutor in closing argument argued that the 
defendant "shook [Jahanna] with such violence it caused the 
blood vessels in her brain to hemorrhage.  It caused the [blood 
vessels in her] retinas in the back of her eyes . . . to 
hemorrhage in an attempt to get her to stop crying so he could 
focus on the game that he so wanted to watch. . . .  He collided 
her head against a blunt object or surface to cause that 
multiple fracture in her skull, and shook her with such force 
that T11 and T12 vertebrae were fractured in a compressive 
manner consistent with her shaking back and forth with her spine 
15 
 
 
 
moving back and forth in a rapid acceleration and deceleration 
fashion."  The prosecutor also argued that "[i]t does not make 
sense" that Jahanna's fall from the couch could have caused her 
extensive brain bleeding and swelling, or her comminuted skull 
fractures.  He claimed that "[c]hildren fall all the time" and 
"[t]heir heads collide with hard objects or floors," but "[t]hey 
do not go unresponsive" or sustain the injuries found here. 
 
The defense attorney in closing argument focused almost 
entirely on the multiple persons who cared for Jahanna before 
October 20, and invited the jury to consider that any one of 
them could have been responsible for the fractures to her ribs 
and tibia that occurred before that date.  As to the head 
injuries suffered on October 20, he said that it was an 
"accident that can happen with any one of us who may be taking 
care of children." 
 
The defendant's strategy of focusing the jury on the number 
of Jahanna's caretakers was successful in obtaining acquittals 
on the two indictments charging the defendant with causing 
Jahanna's fractured tibia and fractured ribs, both of which 
showed signs of healing before October 20 and therefore occurred 
before that date.  But the jury found the defendant guilty on 
the indictments alleging that the defendant caused Jahanna's 
16 
 
 
 
head and vertebral injuries on the theory of intentional assault 
and battery.10 
 
2.  Motion for new trial.  The defendant filed a motion for 
a new trial under Mass. R. Crim. P. 30 (b), as appearing in 435 
Mass. 1501 (2001), on grounds of ineffective assistance of 
counsel.  The defendant claimed that trial counsel was 
ineffective for failing to consult or call an expert on the 
science of shaken baby syndrome, and that his counsel's failure 
to do so denied him a substantial ground of defense.  The trial 
judge held an evidentiary hearing on the motion. 
 
At the hearing, where the defendant was represented by new 
counsel, the defendant presented an affidavit from his trial 
attorney.11  Trial counsel attested that the defendant was 
indigent but he was retained privately by the defendant's 
father.  He sought funds from the defendant's father to retain 
an expert, but the father refused to pay, so he did not consult 
with any medical expert or present any expert testimony.  
                                                          
 
 
10 The defendant was sentenced to not less than four and not 
more than five years in State prison on the indictment charging 
assault and battery on a child causing substantial bodily injury 
(head injuries), followed by a five-year term of probation on 
the indictment charging assault and battery on a child causing 
bodily injury (fractured vertebrae). 
 
 
11 Although the affidavit was not formally admitted in 
evidence, it was informally admitted in that the defendant 
submitted the affidavit at the hearing, the judge suggested that 
she would consider it, and the Commonwealth did not object. 
17 
 
 
 
Instead, he reviewed the studies Dr. Newton cited in her 
testimony and the medical literature on shaken baby syndrome. 
 
At the hearing, the defense offered the judge a glimpse of 
the scientific evidence that could have been presented at trial 
through the testimony of Dr. Ronald Uscinski, a board-certified 
clinical neurosurgeon.  Dr. Uscinski testified to opinions that 
challenged the opinions of the Commonwealth's experts who 
testified at trial and offered an alternative scientific 
explanation for Jahanna's injuries consistent with an accidental 
fall. 
 
First, Dr. Uscinski called into question whether shaken 
baby syndrome is a valid and scientifically supported medical 
diagnosis.  He testified to the weaknesses of the methodologies 
employed by many of the foundational shaken baby syndrome 
studies, and stated that numerous studies have shown that humans 
cannot shake babies hard enough to cause bleeding in the 
subdural space.  He explained that no one knows the minimum 
force required to cause subdural bleeding in a baby, but it is 
known that "[t]here's a range, and we don't come anywhere near 
that range by shaking."  He pointed to research showing that if 
an infant were shaken so violently to produce the level of force 
needed to cause the triad of symptoms of shaken baby syndrome, 
the infant's neck would not be able to withstand the force and 
would suffer some sort of injury.  He concluded that shaken baby 
18 
 
 
 
syndrome is a hypothesis that has "never been proved" and is 
"scientifically . . . not plausible."  He also opined to a 
reasonable degree of medical certainty that shaking an infant 
cannot cause the "triad of injuries" associated with shaken baby 
syndrome (subdural hematoma, brain swelling, and retinal 
hemorrhages). 
 
Second, Dr. Uscinski put forth an alternative theory of the 
cause of Jahanna's injuries.  Dr. Uscinski opined to a 
reasonable degree of medical certainty that a skull fracture of 
the type Jahanna sustained can be caused by a fall of seventeen 
and one-half inches onto a hard surface.  He explained that a 
fracture can result from an impact in another area of the head, 
caused by one part of the bone being pushed in and other parts 
of the bone being pushed outward.  He explained that the 
parietal bone is "quite thin in [the area of compression] and 
will be susceptible to being cracked if bent that way, and that 
resulted in that parietal fracture."  He also stated that the 
impact from the fall could have caused the tearing of the blood 
vessels and the development of subdural bleeding.  The subdural 
bleeding could then have caused elevated intracranial pressure, 
the presence of which was evident from the increased retinal 
venous pressure shown on Jahanna's CT scan.  In his opinion, 
this elevated intracranial pressure in turn caused the retinal 
hemorrhages.  Based on this scientific theory, Dr. Uscinski 
19 
 
 
 
testified that a short fall of seventeen and one-half inches 
onto a hard surface could account for the head injuries that 
Jahanna sustained. 
 
The Commonwealth again called Drs. Mantagos and Newton to 
testify at the hearing.  Dr. Mantagos testified that retinal 
hemorrhages can result from elevated intracranial pressure, but 
such hemorrhages "tend to be isolated in number[]."  In 
contrast, where caused by abusive head trauma, the retinal 
hemorrhaging tends to be more extensive, to involve more layers 
of the retina, and to be present in all four quadrants of the 
retina.  He testified that the retinal hemorrhaging in Jahanna's 
right eye was extensive, was in at least two layers of the 
retina, and was in all four quadrants, and that the retinal 
hemorrhaging in her left eye was "less extensive . . . but still 
a significant number."  He opined that he "would not expect" 
intracranial pressure to be the cause of the retinal 
hemorrhaging in both eyes. 
 
Dr. Mantagos admitted that retinal hemorrhages can occur 
even with short falls, but stated that they "tend to be" rare, 
associated with bleeding in the brain, and isolated in one eye.  
Dr. Mantagos stated that "the hemorrhages that we see here 
involve both eyes and they're more in number than you would 
expect to see from falls."  He opined that he "would not expect" 
20 
 
 
 
a short fall of seventeen and one-half inches to be the cause of 
the retinal hemorrhages. 
 
Dr. Newton reiterated the opinion she gave at trial that 
the only cause consistent with Jahanna's injuries was the 
intentional infliction of injury by her caretaker.  But her 
testimony at the motion hearing differed from her trial 
testimony in that, at trial, Dr. Newton had opined that 
Jahanna's brain injuries and retinal hemorrhaging were caused by 
shaking alone, but she testified at the motion hearing that the 
cause of these injuries was shaking combined with a slamming 
against a hard surface.  She opined that it is "very, very 
unlikely" that Jahanna's comminuted skull fracture, which was 
located on the left side of her skull, could have resulted from 
a fall onto the back of her head.  Rather, she testified that 
the amount of swelling and the collection of blood around the 
fracture signify that Jahanna had a blow to the left side of her 
head.  She rejected Dr. Uscinski's opinion that Jahanna's head 
injuries were consistent with an accidental fall as described by 
the defendant. 
 
The judge concluded that trial counsel's failure to consult 
with an expert to attempt to counter the opinions of the 
Commonwealth's experts, explore an alternative theory of 
causation, and assist him in cross-examination fell below the 
minimum level of performance expected from an ordinary, fallible 
21 
 
 
 
criminal defense attorney, because it ceded the "pivotal issue" 
of causation and left the defendant "without an opportunity for 
a viable defense."  She determined that trial counsel "should 
have sought the necessary funds to hire an expert to examine the 
medical records in order to explore whether Jahanna could have 
sustained her injuries from falling from . . . a couch."  But 
the judge denied the defendant's motion for a new trial because 
she concluded that, "due to the powerful medical evidence that 
was before the jury, it is unlikely that an expert's assistance 
or opinion would have 'accomplished something material for the 
defense'" (citation omitted).  In short, the judge determined 
that the Commonwealth's experts had so overwhelmingly 
established that Jahanna's injuries were intentionally inflicted 
that "it cannot be reasonably asserted that Jahanna sustained 
[the injuries] by merely falling off of a couch onto the back of 
her head," so neither better cross-examination nor an expert's 
opinion would have "added anything substantial to the defense." 
 
The defendant appealed from his convictions and from the 
denial of his motion for a new trial, and we granted the 
defendant's motion for direct appellate review.  The defendant 
presents two claims on appeal.  First, he contends that the 
judge erred in denying his motion for a new trial.  Second, he 
contends that the evidence was insufficient as a matter of law 
to support his conviction on the indictment charging assault and 
22 
 
 
 
battery of a child causing bodily injury (fractured vertebrae) 
because no reasonable jury could ascertain when these fractures 
occurred and that he had caused them. 
 
Discussion.  1.  Motion for new trial.  As we consider 
"whether there has been a significant error of law or other 
abuse of discretion" in the denial of the motion for a new 
trial, Commonwealth v. Grace, 397 Mass. 303, 307 (1986), it is 
important to recognize that the Commonwealth's case rested 
almost entirely on inferences regarding the defendant's conduct 
based on the medical evidence.  There was no evidence that the 
defendant had ever before shaken, spanked, or struck Jahanna; at 
worst, he was inexperienced in caring for an infant and, at 
times, burped her a bit too hard and left her without adequate 
vigilance when she was being changed.  On October 20, within ten 
minutes of when Jahanna was found unconscious and unresponsive, 
Robert Jeffrey saw the defendant feeding her on the living room 
sofa.  During those ten minutes, despite the thin walls that 
separated their neighboring apartments, Eileen Jeffrey heard 
nothing unusual.  The Commonwealth's theory of the case at trial 
was that, at some moment within those ten minutes, the defendant 
became so enraged at Jahanna that he shook her so violently that 
he caused her to suffer the triad of symptoms of shaken baby 
syndrome. 
23 
 
 
 
 
Essentially, the Commonwealth's prosecution rested on two 
related claims:  first, that the only medically reasonable 
explanation for the nature and severity of Jahanna's injuries 
was that she was violently shaken by the defendant; and second, 
that injuries of the nature and severity she suffered could not 
possibly have been caused by an accidental fall from a sofa, so 
the defendant was lying when he offered that explanation, 
demonstrating his consciousness of guilt.  A competent defense 
attorney would have recognized that, if the jury were to find 
that the defendant's report of an accidental fall was credible 
and that medically it was reasonably possible that Jahanna's 
injuries were caused by that fall, the jury might have a 
reasonable doubt whether the defendant violently shook Jahanna. 
Therefore, it was critically important to the defendant to 
elicit evidence, whether through cross-examination of the 
prosecution's expert, the testimony of a defense expert, or 
both, that may cause the jury to have a reasonable doubt whether 
Jahanna's injuries could have been caused by the accidental fall 
described by the defendant. 
 
To prevail on a motion for a new trial claiming ineffective 
assistance of counsel, a defendant must show that there has been 
a "serious incompetency, inefficiency, or inattention of counsel 
-- behavior of counsel falling measurably below that which might 
be expected from an ordinary fallible lawyer," and that 
24 
 
 
 
counsel's poor performance "likely deprived the defendant of an 
otherwise available, substantial ground of defence."  
Commonwealth v. Saferian, 366 Mass. 89, 96 (1974).  We agree 
with the judge that the first prong of the Saferian test was met 
in this case. 
 
The defendant's trial counsel here was ineffective, not 
because he failed to understand that he needed an expert witness 
to advise him regarding the medical evidence and to offer 
opinion testimony, but because he failed to seek funds from the 
court to retain an expert witness for his indigent client.  A 
defendant who is indigent is entitled to funds for an expert 
witness where the retention of such a witness is necessary to 
the defense even where the defendant's family member is paying 
the defendant's legal fees.  See G. L. c. 261, § 27C 
(Commonwealth shall provide funds to cover "extra fees and 
costs" for indigent defendant if "the document, service or 
object is reasonably necessary to assure the applicant as 
effective a . . . defense . . . as he would have if he were 
financially able to pay").  Where, as here, the defendant was 
indigent and the family member who was otherwise furnishing 
funds for the defense refused to pay for an expert witness, it 
was manifestly unreasonable for defense counsel not to apply to 
the judge for the funds needed to retain an expert witness.  See 
Hinton v. Alabama, 134 S. Ct. 1081, 1088 (2014) ("The trial 
25 
 
 
 
attorney's failure to request additional funding in order to 
replace an expert he knew to be inadequate because he mistakenly 
believed that he had received all he could get under Alabama law 
constituted deficient performance"); Commonwealth v. Kolenovic, 
471 Mass. 664, 674 (2015), quoting Commonwealth v. Acevedo, 446 
Mass. 435, 442 (2006) (where defendant's ineffective assistance 
of counsel claim "is based on a tactical or strategic decision, 
the test is whether the decision was '"manifestly unreasonable" 
when made'").  See also Commonwealth v. Haggerty, 400 Mass. 437, 
442 (1987) ("Failure to investigate the only defense a defendant 
has, if facts known to or with minimal diligence accessible to 
counsel support that defense, falls beneath the level of 
competency expected"). 
 
Turning to the second prong of the Saferian test, we 
consider whether counsel's failure to seek funds to retain an 
expert witness prejudiced the defendant.  Prejudice in this 
context means that the defendant has likely been deprived of an 
"available, substantial ground of defence," Saferian, supra at 
96; the challenge is to articulate when a defense is substantial 
such that its deprivation requires a new trial. 
 
Ten years after we established the Saferian test to 
determine when a defendant is entitled to a new trial because of 
the ineffectiveness of counsel, the United States Supreme Court 
established its own test under Federal constitutional law. 
26 
 
 
 
Strickland v. Washington, 466 U.S. 668, 693-694 (1984).  The 
Court held that, where counsel has been ineffective, the 
defendant must "affirmatively prove prejudice."  Id. at 693.  In 
order to prove prejudice, 
"[t]he defendant must show that there is a reasonable 
probability that, but for counsel's unprofessional errors, 
the result of the proceeding would have been different.  A 
reasonable probability is a probability sufficient to 
undermine confidence in the outcome." 
 
Id. at 694.  We have not adopted this precise formulation but 
have recognized that the prejudice standard under the 
Massachusetts Constitution "is at least as favorable to a 
defendant as is the Federal standard."  Commonwealth v. Curtis, 
417 Mass. 619, 624 n.4 (1994). 
 
In reviewing convictions in noncapital cases such as this, 
we have sometimes said that, for a new trial to be ordered 
because of counsel's inadequate performance, "there ought to be 
some showing that better work might have accomplished something 
material for the defense."  Commonwealth v. Satterfield, 373 
Mass. 109, 115 (1977).  This phrase from Satterfield has often 
been cited as the prejudice standard where counsel failed to 
investigate or present a ground of defense.  See, e.g., 
Commonwealth v. Valentin, 470 Mass. 186, 190 (2014) (citing 
Satterfield and explaining that its statement that "better work 
might have accomplished something material for the defence" is 
standard for Saferian requirement that counsel's ineffectiveness 
27 
 
 
 
must have deprived defendant of "available, substantial ground 
of defence" [citations omitted]); Commonwealth v. Marinho, 464 
Mass. 115, 129 (2013) (same); Commonwealth v. Dargon, 457 Mass. 
387, 403 (2010) (same); Commonwealth v. Urena, 417 Mass. 692, 
701 (1994) (same).  But, when viewed in the context of the 
opinion in Satterfield, the words that have subsequently been 
described as a prejudice standard appear to be simply a minimum 
threshold for a showing of prejudice, which in that case the 
defendant failed to meet.  See Satterfield, supra.12 
 
In other cases, we have drawn parallels between the second 
prong of the Saferian test and the standard that applies where a 
claimed error that defense counsel failed adequately to 
                                                          
 
 
12 In reviewing convictions of murder in the first degree, 
where we determine pursuant to G. L. c. 278, § 33E, whether 
there has been a substantial likelihood of a miscarriage of 
justice, we have declared that "a new trial is called for unless 
we are substantially confident that, if the error had not been 
made, the jury verdict would have been the same."  Commonwealth 
v. Alcide, 472 Mass. 150, 157 (2015), quoting Commonwealth v. 
Spray, 467 Mass. 456, 472 (2014).  We have also said that a new 
trial is required where the error "was likely to have influenced 
the jury's conclusion."  Commonwealth v. Gonzalez, 473 Mass. 
415, 421 (2015), quoting Commonwealth v. Wright, 411 Mass. 678, 
682 (1992), S.C., 469 Mass. 447 (2014).  If we were to apply the 
language in Commonwealth v. Satterfield, 373 Mass. 109, 115 
(1977) -- "better work might have accomplished something 
material for the defense" -- as a prejudice standard, it would 
appear to be more favorable to defendants than the Alcide or 
Gonzalez standard under § 33E, which would be inconsistent with 
our view that the substantial likelihood of a miscarriage of 
justice standard applied to § 33E cases is more favorable to a 
defendant than the substantial risk of a miscarriage of justice 
standard applied to noncapital cases.  See Wright, supra at 681. 
28 
 
 
 
challenge at trial is raised for the first time on appeal or in 
a postappeal motion for a new trial.  See Commonwealth v. Azar, 
435 Mass. 675, 685 (2002), S.C., 444 Mass. 72 (2005); 
Commonwealth v. LeFave, 430 Mass. 169, 173-174 (1999).  In those 
cases, we have said that the defendant is entitled to a new 
trial if there is a substantial risk of a miscarriage of justice 
arising from counsel's failure. See Azar, supra; LeFave, supra.  
See also Commonwealth v. Robideau, 464 Mass. 699, 705 (2013).  
Under that standard, a defendant is entitled to a new trial "if 
we have a serious doubt whether the result of the trial might 
have been different had the error not been made."  Azar, supra, 
quoting LeFave, supra at 174.  We now declare that this standard 
is effectively the same as the prejudice standard under the 
second prong of Saferian:  where counsel was ineffective for 
failing to present an available ground of defense, that defense 
is "substantial" for Saferian purposes where we have a serious 
doubt whether the jury verdict would have been the same had the 
defense been presented.13  The defendant need not prove that he 
                                                          
 
 
13 We recognize that the language we adopt for the prejudice 
standard under the second prong of the test in Commonwealth v. 
Saferian, 366 Mass. 89, 96 (1974) -- "we have a serious doubt 
whether the jury verdict would have been the same had the 
defense been presented" -- differs slightly from the language of 
the substantial risk of a miscarriage of justice standard that 
we used in Commonwealth v. Azar, 435 Mass. 675, 685 (2002), 
quoting Commonwealth v. LeFave, 430 Mass. 169, 174 (1999) ("we 
have a serious doubt whether the result of the trial might have 
 
29 
 
 
 
or she would have been found not guilty if defense counsel had 
presented the jury with this ground of defense. See Strickland, 
466 U.S. at 693 ("a defendant need not show that counsel's 
deficient conduct more likely than not altered the outcome in 
the case"). 
 
We conclude that the judge erred in finding that counsel's 
ineffectiveness did not prejudice the defendant.  The judge 
recognized that Dr. Uscinski challenged the proposition that the 
force produced by shaking a baby alone could have caused 
Jahanna's head injuries, but determined that this opinion did 
not relate to this case because "there was evidence that Jahanna 
was not only shaken but suffered some sort of impact trauma as 
well."  At trial, however, as earlier noted, Dr. Newton offered 
the opinion that the cause of Jahanna's triad of head injuries 
was that she was "violently shaken."  She did not claim the 
skull fracture to be a contributing cause of these injuries 
until she testified at the hearing on the motion for a new 
trial.  Therefore, had Dr. Uscinski's expert testimony been 
                                                                                                                                                                                           
been different had the error not been made").  We believe the 
standards are identical in their application; we have revised 
the language only because we think it more clear. 
 
30 
 
 
 
offered at trial, the defendant could have challenged Dr. 
Newton's opinion as to the cause of Jahanna's head injuries.14 
 
Nor can we say with confidence that such a challenge to Dr. 
Newton's opinion that violent shaking caused Jahanna's head 
injuries would not have been persuasive.  An expert witness 
testifying at trial in October, 2010, once his or her opinion 
was challenged on cross-examination, on redirect examination 
could have cited to numerous scientific studies supporting the 
view that shaking alone cannot produce injuries of the type and 
severity suffered by Jahanna.15  Indeed, Dr. Newton herself 
                                                          
 
 
14 Dr. Mantagos was a treating physician and did not offer 
an opinion as to the cause of Jahanna's retinal hemorrhaging, 
but the reasonable takeaway from his testimony was that it was 
caused by extreme shaking.  Dr. Uscinski's expert testimony 
would also have challenged this apparent conclusion. 
 
 
15 See, e.g., Bandak, Shaken Baby Syndrome:  A Biomechanics 
Analysis of Injury Mechanisms, 151 Forensic Sci. Int'l 71, 78 
(2005) (infant shaking cannot cause serious injuries without 
also resulting in neck injury); Ommaya, Goldsmith, & Thibault, 
Biomechanics and Neuropathology of Adult and Pediatric Head 
Injury, 16(3) Brit. J. of Neurosurgery 220, 233 (2002) (based on 
standard biomechanical principles, shaken baby syndrome 
hypothesis requires forces that are biomechanically improbable 
and increased intracranial pressure is more likely to cause 
retinal bleeding than shaking); Duhaime, Gennarelli, Thibault, 
Bruce, Margulies, & Wiser, The Shaken Baby Syndrome:  A 
Clinical, Pathological, and Biomechanical Study, 66 J. 
Neurosurgery 409, 413-414 (1987) (subjecting biomechanical model 
to repetitive violent shaking demonstrated that shaking fell 
below established injury thresholds).  See also Cavazos v. 
Smith, 132 S. Ct. 2, 10 (2011) (Ginsburg, J., dissenting), 
quoting State v. Edmunds, 308 Wis. 2d 374, 386 (2008), and 
sources cited ("Doubt has increased in the medical community 
 
31 
 
 
 
appears to have changed her opinion that shaking alone caused 
Jahanna's triad of head injuries. 
 
If a defense expert had caused the jury to doubt whether 
violent shaking alone could have caused Jahanna's severe 
injuries, they may have asked whether there was any 
corroborative evidence that Jahanna was slammed against the wall 
or thrown to the floor.  But Eileen Jeffrey heard nothing 
unusual during the ten minutes her husband was gone, even though 
the walls between the apartment were thin and sounds could often 
be heard from next door.  And if the jury had determined that 
Jahanna's injuries could not have happened without impact 
trauma, they might have considered more carefully whether the 
impact trauma described by the defendant -- Jahanna's head-first 
fall from the sofa onto the wooden floor -- could have sufficed 
to cause her head injuries. 
 
If they had done so, it is likely that the opinion 
testimony of such a defense expert would have influenced the 
jury's evaluation of whether the Commonwealth had eliminated the 
                                                                                                                                                                                           
'over whether infants can be fatally injured through shaking 
alone'"). 
 
 
A more recent study would also support this proposition.  
See generally Jones, Martin, Williams, Kemp, & Theobald, 
Development of a Computational Biomechanical Infant Model for 
the Investigation of Infant Head Injury by Shaking, 55 Med., 
Sci., & Law 291 (2015) (biomechanical study using computational 
model suggests shaking cannot generate levels of force necessary 
to produce injuries associated with abusive head trauma). 
32 
 
 
 
possibility that Jahanna's injuries were caused by the 
accidental fall described by the defendant beyond a reasonable 
doubt, such that we have a serious doubt whether the jury's 
verdict would have been the same.  See Commonwealth v. LaBrie, 
473 Mass. 754, 772-774 (2016) (counsel's failure to consult with 
independent oncologist likely deprived defendant of substantial 
ground of defense on key issue in case -- whether defendant 
intended to kill her child by failing to give him prescribed 
medication).  The judge erred in finding that Dr. Uscinski 
"failed to address the severity of Jahanna's injuries."  The 
judge determined that, although Dr. Uscinski testified that it 
was possible to sustain head injuries from an accidental short 
fall, he "did not mention whether a fall from such a short 
distance could cause the extent of the skull fractures and brain 
hemorrhaging that Jahanna suffered."  Dr. Uscinski, however, 
stated unequivocally in his testimony that a short fall from 
seventeen and one-half inches "could account for" the head 
injuries that Jahanna sustained.  Dr. Uscinski also explained in 
detail why Jahanna's comminuted skull fracture could have been 
caused by a fall of only seventeen and one-half inches.  
Specifically, he stated that "a fracture of this nature can be 
sustained from a fall of that distance." 
 
Moreover, an expert witness testifying at trial in October, 
2010, could have cited to numerous scientific studies in support 
33 
 
 
 
of an opinion that accidental short falls can produce injuries 
of the nature and severity suffered by Jahanna.16  Such opinion 
                                                          
 
 
16 See, e.g., Roth, Raul, Ludes, & Willinger, Finite Element 
Analysis of Impact and Shaking Inflicted to a Child, 121 Int'l 
J. Legal Med. 223, 225 (2007) (based on computer simulation, 
eighteen inch fall as likely to cause subdural hemorrhage as 
shaking); Prange, Coats, Duhaime, & Margulies, Anthropomorphic 
Simulations of Falls, Shakes, and Inflicted Impacts in Infants, 
99 J. Neurosurgery 143 (2003) (shaking and minor falls produce 
similar rotational responses, with falls of only twelve inches 
with head impact producing accelerations in excess of those 
produced during shaking); Hymel, Jenny, & Block, Intracranial 
Hemorrhage and Rebleeding in Suspected Victims of Abusive Head 
Trauma:  Addressing the Forensic Controversies, 7 Child 
Maltreatment 329 (2002)(describing two cases of serious head 
trauma from accidental short falls); Jenny, Shams, Rangarajan, & 
Fukuda, Development of a Biofidelic 2.5 kg Infant Dummy and Its 
Application to Assessing Infant Head Trauma During Violent 
Shaking, Injury Biomechanics Research, Proceedings of the 
Thirtieth International Workshop, at 138 (Nov. 10, 2002) (based 
on biomechanical experiment, maximum head center of gravity 
acceleration produced by shaking less than one-third of that 
produced by rolling off sofa); Plunkett, Fatal Pediatric Head 
Injuries Caused by Short-Distance Falls, 22 Am. J. Forensic Med. 
& Pathology 1, 7-9 (2001) (symptoms attributed to shaken baby 
syndrome also found in fatal short falls); Christian, Taylor, 
Hertle, & Duhaime, Retinal Hemorrhages Caused by Accidental 
Household Trauma, 135 J. Pediatrics 125, 127 (1999) (reporting 
three cases of infants between seven months and thirteen months 
of age who had retinal hemorrhages after short falls); Hall, 
Reyes, Horvat, Meller, & Stein, The Mortality of Childhood 
Falls, 29 J. Trauma 1273-74 (1989) (of fatal falls by children 
in Cook County, Illinois, during four-year period, forty-one per 
cent were minor falls from less than three feet). 
 
 
More scientific support for this proposition will be 
available at a new trial.  See Barnes, Imaging of Nonaccidental 
Injury and the Mimics:  Issues and Controversies in the Era of 
Evidence-Based Medicine, 49 Radiologic Clinics of N. Am. 205, 
217 (2011) (based on clinical, biomechanical, neuropathological, 
and neuro-radiological evidence, significant head injury, 
including subdural and retinal hemorrhages, may result from low 
level falls); Squier, The "Shaken Baby" Syndrome:  Pathology and 
 
34 
 
 
 
testimony would likely have caused a reasonable jury carefully 
to consider whether they were certain beyond a reasonable doubt 
that Jahanna's head injuries were not caused by the accidental 
fall described by the defendant.  At the hearing on the motion 
for a new trial, Dr. Mantagos said that he "would not expect" 
that Jahanna's retinal hemorrhages could have been caused by a 
fall of seventeen and one-half inches, and Dr. Newton testified 
that it was "very, very unlikely" that the fall could have 
caused Jahanna's comminuted skull fracture.  But, in the 
circumstances of this case, the jury would need to determine 
more than whether such injuries were unexpected or very 
unlikely; they would need to determine whether they were certain 
beyond a reasonable doubt that these injuries were not caused by 
an accidental fall from the sofa onto the hardwood floor. 
 
The judge accurately found that, although "Dr. Uscinski 
. . . testified that retinal hemorrhaging can be caused by an 
increase in intracranial pressure and noted that such increase 
was present in [this] case . . . , he did not opine specifically 
                                                                                                                                                                                           
Mechanisms, 122 Acta Neuropathologica 519 (2011) (same); 
Cummings, Trelka, & Springer, Atlas of Forensic Histopathology, 
Cambridge Univ. Press (2011) (skull fractures, subdural 
hematomas, and retinal hemorrhages have all been found after 
short falls); Lantz & Couture, Fatal Acute Intracranial Injury, 
Subdural Hematoma, and Retinal Hemorrhages Caused by Stairway 
Fall, 56(6) J. Forensic Sciences 1648 (2011) (case study of 
infant who fell from short height and had subdural hemorrhage, 
midline shift, mild edema, and severe retinal hemorrhages). 
35 
 
 
 
as to whether Jahanna's retinal hemorrhages were caused by this 
increased intracranial pressure."17  But the judge erred in 
concluding that this meant that the defendant was not deprived 
of a substantial ground of defense by the failure to retain a 
defense expert.  The defendant bears the burden of proving the 
second prong of the Saferian test, but he may meet this burden 
by showing that the poor performance of his attorney deprived 
him of expert evidence that would likely have influenced the 
jury's conclusion as to whether the prosecution had eliminated 
reasonable doubt regarding the cause of Jahanna's retinal 
hemorrhages; the defendant is not required conclusively to prove 
that the intracranial pressure arising from the accidental fall 
was the cause of the retinal hemorrhages.  See, e.g., 
Commonwealth v. Polk, 462 Mass. 23, 34 (2012) (evidence 
regarding alleged victim in sexual assault case that is 
consistent with diagnosis of disorder is "sufficient to permit a 
reasonable inference that the alleged victim may have the 
disorder"); Commonwealth v. Alvarez, 433 Mass. 93, 103-104 
(2000) (new trial ordered for ineffective assistance of counsel 
                                                          
 
 
17 Dr. Uscinski testified that a short fall of seventeen and 
one-half inches may account for a subdural hematoma (which he 
called an "intradural hematoma") like the one sustained by 
Jahanna, and that a subdural hematoma, in turn, can cause an 
increase in intracranial pressure, which can result in retinal 
hemorrhages.  Dr. Uscinski noted that the computerized 
tomography scans of Jahanna's brain showed an increase in 
intracranial pressure. 
36 
 
 
 
because "the jury may have ruled differently" if medical 
evidence of defendant's brain damage had been properly 
investigated, reviewed with the defense expert, and presented at 
trial).  See also Strickland, 466 U.S. at 693. 
 
We recognize that the testimony of Drs. Newton and Mantagos 
regarding the cause of Jahanna's injuries finds support in 
scientific research, and that numerous scientific studies were 
cited in support of their opinions.18  But a defense expert could 
have assisted a competent defense attorney in mounting a 
significant challenge to their opinions at trial on cross-
examination by identifying the methodological shortcomings of 
                                                          
 
 
18 See, e.g., Trenchs, Curcoy, Morales, Serra, Navarro, & 
Pou, Retinal Haemorrhages in Head Trauma Resulting from Falls:  
Differential Diagnosis with Non-Accidental Trauma in Patients 
Younger Than 2 Years of Age, 24 Child's Nervous System 815, 818-
819 (2008) (study of infants who sustained accidental falls 
showed that accidental falls provoked only small, isolated, and 
unilateral retinal hemorrhages, whereas inflicted injury caused 
bilateral and diffuse retinal hemorrhages); Newton & Vandeven, 
Update on Child Maltreatment with a Special Focus on Shaken Baby 
Syndrome, 17 Current Opinion in Pediatrics 246, 249 (2005) 
(based on review of studies on shaken baby syndrome, retinal 
hemorrhage found to be much more common in inflicted than non-
inflicted injuries); Schloff, Mullaney, Armstrong, 
Simantirakais, Humphreys, Myseros, Buncie, & Levin, Retinal 
Findings in Children with Intracranial Hemorrhage, 109 
Ophthalmology 1472, 1475 (2002) ("Our study suggests that 
intraretinal hemorrhages in children with intracranial 
hemorrhage from causes other than shaken baby syndrome would be 
expected in less than [eight per cent] of cases"). 
 
37 
 
 
 
the studies they cited.19  A defense expert could also have 
assisted a competent defense attorney in highlighting in cross-
examination the studies that recognize the difficulties faced by 
physicians in accurately diagnosing the cause of injuries that 
                                                          
 
 
19 See, e.g., Vinchon, Defoort-Dhellemmes, Desurmont, & 
Dhellemmes, Accidental and Nonaccidental Head Injuries in 
Infants:  A Prospective Study, 102 J. Neurosurgery:  Pediatrics 
380, 383 (2005) ("[T]he evaluation of the incidence of [retinal 
hemorrhages] in child abuse remains a self-fulfilling prophecy" 
because children are diagnosed as being abused "in great part 
based on the presence of [retinal hemorrhage]"); Donohoe, 
Evidence-Based Medicine and Shaken Baby Syndrome, 24 Am. J. 
Forensic Med. & Pathology 239, 240-241 (2003) (performing review 
of shaken baby syndrome literature from 1966 through 1998 and 
concluding that "there existed serious data gaps, flaws of 
logic, inconsistency of case definition, and a serious lack of 
tests capable of discriminating [non-accidental injury] cases 
from natural injuries. . . .  [By 1999] the commonly held 
opinion that the finding of [subdural hematoma] and [retinal 
hemorrhages] in an infant was strong evidence of [shaken baby 
syndrome] was unsustainable").  For example, in one study 
seeking to determine whether short falls of children cause 
death, after finding an unexpectedly large number of deaths 
after reported short falls, the author excluded those deaths 
because they assumed those reports to be false.  See Chadwick, 
Chin, Salerno, Landsverk, & Kitchen, Deaths from Falls in 
Children:  How Far Is Fatal?, 31 J. Trauma 1353, 1355 (1991). 
 
 
The challenges to this research have not subsided.  See, 
e.g., Gabaeff, Exploring the Controversy in Child Abuse 
Pediatrics & False Accusations of Abuse, 18 Legal Med. 90, 93 
(2016) (documenting unreliability of confessions used in shaken 
baby syndrome research); Guthkelch, Problems of Infant Retino-
Dural Hemorrhage with Minimal External Injury, 12 Houst. J. 
Health L. & Pol'y 201, 207 (2012) ("[Shaken baby syndrome] and 
[abusive head trauma] are hypotheses that have been advanced to 
explain findings that are not yet fully understood. . . .  [They 
are] not proven medical or scientific facts"). 
38 
 
 
 
allegedly result from child abuse.20  See Commonwealth v. Baran, 
74 Mass. App. Ct. 256, 277 (2009) (expert could have 
strengthened cross-examination and provided material for 
rebuttal).  See also Dugas v. Coplan, 428 F.3d 317, 340 (1st 
Cir. 2005) (had defense counsel been advised by expert in arson 
case, "his cross-examination of the fire investigators could 
have been far more pointed"). 
 
Considering together the opinion testimony regarding the 
cause of Jahanna's head and vertebral injuries that reasonably 
could have been offered by a defense expert and the assistance 
such an expert could have offered to defense counsel's cross-
examination of the Commonwealth's medical experts, we conclude 
                                                          
 
 
20 See, e.g., Christian, Taylor, Hertle, & Duhaime, Retinal 
Hemorrhages Caused by Accidental Household Trauma, 135 J. 
Pediatrics 125, 127 (1999) (recognizing overlap between 
accidental and abusive head injury and cautioning against 
presumption of abuse when infants under one year present with 
traumatic retinal hemorrhages); Sirotnak, Medical Disorders that 
Mimic Abusive Head Trauma, in Abusive Head Trauma in Infants and 
Children 191 (2006) (many conditions mimic abusive head trauma); 
Barnes, Ethical Issues in Imaging Nonaccidental Injury:  Child 
Abuse, 13(2) Topics in Magnetic Resonance Imaging 85, 86-87, 91 
(2002) (applying standard of evidence-based medicine to shaking 
mechanism and concluding that no scientific basis exists 
indicating force required to produce traumatic brain injury and 
that many conditions mimic child abuse); Case, Graham, Handy, 
Jentzen, & Monteleone, Position Paper on Fatal Abusive Head 
Injuries in Infants and Young Children, 22 Am. J. Forensic Med. 
& Pathology 112, 116-117 (2001) (acknowledging that retinal 
hemorrhages have many nontraumatic causes, including increased 
intracranial pressure, bleeding disorders, sepsis, meningitis, 
and vasculopathies, and that pathogenesis of retinal hemorrhages 
is not precisely understood). 
39 
 
 
 
that defense counsel's manifestly unreasonable failure to seek 
public funds to retain such an expert likely deprived the 
defendant of an available, substantial ground of defense.  
Because the defendant was deprived of his constitutional right 
to effective counsel, we vacate the defendant's convictions and 
order a new trial. 
 
We are not the first State Supreme Court to vacate a 
conviction because defense counsel was ineffective in failing to 
consult with an appropriate medical expert where the theory of 
the prosecution's case was that the defendant injured an infant 
through violent shaking or blunt force trauma.  See, e.g., 
People v. Ackley, 497 Mich. 381, 388-398 (2015); State v. Hales, 
152 P.3d 321, 337-344 (Utah 2007).  Although each case alleging 
abusive head trauma is different and must be evaluated on its 
own facts, the legal analysis used by these two courts that 
yielded the conclusion that a new trial is in the interests of 
justice is similar to our own. 
 
In Ackley, 497 Mich. at 385, defense counsel contacted only 
one expert in preparing for trial, who advised counsel that 
there was a wide divide within the medical community between 
those who believe that an infant's injuries can be caused by a 
short distance fall and those who believe that such injuries are 
the result of shaking or striking the infant, and that the 
divide is so deeply held that it is "like a religion."  The 
40 
 
 
 
expert told counsel that "he [the expert] was on the wrong side 
of this debate to be able to assist the defendant," but 
recommended a forensic pathologist who had expertise in short 
falls.  Id.  Defense counsel never contacted this forensic 
pathologist or any other expert in short falls, and instead 
relied only on the first expert's advice in cross-examining the 
prosecution's experts.  Id. at 386-387.  The Supreme Court of 
Michigan concluded that "counsel performed deficiently by 
failing to investigate and attempt to secure an expert witness 
who could both testify in support of the defendant's theory that 
the child's injuries were caused by an accidental fall and 
prepare counsel to counter the prosecution's expert medical 
testimony."  Id. at 389.  As to the issue of prejudice, the 
court noted that "[t]here was no explanation for the child's 
injuries beyond the theories presented by the experts, and the 
prosecution produced no witnesses who testified that the 
defendant was ever abusive."  Id. at 395.  The court concluded, 
"Had an impartial, scientifically trained expert corroborated 
the defendant's theory, the defendant's account of the child's 
death would not have existed in a vacuum of his own self-
interest.  While we cannot say that a battle of the experts 
would have ensured the defendant's acquittal, counsel's failure 
to prepare or show up for the battle sufficiently 'undermine[s 
our] confidence in the outcome" of this case to entitle the 
41 
 
 
 
defendant to relief."  Id. at 397, quoting Strickland, 466 U.S. 
at 694. 
 
In Hales, 152 P.3d at 328-329, a murder case based on a 
theory of shaken baby syndrome, the prosecution at trial relied 
primarily on the testimony of experts that CT scans of the 
infant showed brain injury consistent with violent shaking.  The 
theory of the defense was that the infant's injuries were caused 
by a "near-miss car accident" hours earlier.  Id. at 329.  In 
support of this theory, defense counsel called an expert witness 
who testified that shaking can cause neck injury, but not brain 
injury, and that the most likely cause of the child's injuries 
was a "near-miss car accident that caused the bruising followed 
by a lengthy 'lucid interval.'"  Id.  Defense counsel, however, 
never retained a qualified expert to provide an independent 
interpretation of the CT scans and did not put forth any 
evidence contradicting the prosecution expert's interpretation 
of them.  Id. at 329, 340-341.  Nor did defense counsel offer 
any evidence that his theory of defense comported with the CT 
scan evidence.  Id. at 340-341.  In vacating the conviction, the 
Supreme Court of Utah reasoned that "the defense's theory that 
the injuries were caused by the near-miss car accident depended 
upon convincing the jury that the brain injury shown in the CT 
scans could have been caused by an impact injury and would not 
have caused immediate unconsciousness as [the State's expert] 
42 
 
 
 
had testified."  Id. at 340.  The court concluded that the 
defendant was prejudiced by his counsel's failure because, "had 
his trial attorneys sought out an expert analysis of the CT 
scans, there was a reasonable probability that they would have 
obtained and the jury would have credited [the defense's 
competing] expert testimony regarding the timing, nature, and 
violence of the injury," which was consistent with the injuries 
being caused by the near-miss automobile accident.  Id. at 344. 
 
In a policy statement issued in May, 2009, the American 
Academy of Pediatrics declared: 
 
"Few pediatric diagnoses engender as much debate as 
[abusive head trauma] . . . Controversy is fueled because 
the mechanisms and resultant injuries of accidental and 
abusive head injury overlap, the abuse is rarely 
witnessed, an accurate history of trauma is rarely 
offered by the perpetrator, there is no single or simple 
test to determine the accuracy of the diagnosis, and the 
legal consequences of the diagnosis can be so 
significant." 
 
Christian, Block, & Committee on Child Abuse and Neglect of 
American Academy of Pediatrics, Abusive Head Trauma in Infants 
and Children, Pediatrics, Vol. 123, No. 5, 1409, 1410 (2009).  
By vacating the defendant's convictions in this case and 
ordering a new trial, we do not claim to have resolved the 
ongoing medical controversy as to how often the triad of 
symptoms of abusive head trauma are caused by accidental short 
falls or other medical causes.  We are simply recognizing that 
there is a vigorous debate on this subject, that arguments are 
43 
 
 
 
being made on both sides with support in the scientific and 
medical literature, that this debate is evolving, and that, in 
the circumstances of this case, we do not have confidence in the 
justice of these convictions where defense counsel did not 
retain an expert to evaluate the medical evidence and, as a 
result, the jury heard only one side of this debate.  See 
Hinton, 134 S. Ct. at 1090 (risk of mistakes by prosecution 
experts "is minimized when the defense retains a competent 
expert to counter the testimony of the prosecution's expert 
witnesses").  See generally Melendez-Diaz v. Massachusetts, 557 
U.S. 305, 319 (2009) ("One study of cases in which exonerating 
evidence resulted in the overturning of criminal convictions 
concluded that invalid forensic testimony contributed to the 
convictions in [sixty per cent] of the cases"). 
 
2.  Sufficiency of evidence of assault and battery of child 
causing bodily injury (vertebral fractures).  The defendant 
claims that his conviction of assault and battery of a child 
causing bodily injury (fractured vertebrae) must be reversed and 
dismissed because the evidence was insufficient as a matter of 
law.  In essence, the defendant claims that, because there was 
uncertainty in the evidence as to when the vertebral fractures 
occurred and what caused them, no reasonable jury could find 
beyond a reasonable doubt that these injuries were caused by the 
44 
 
 
 
intentional infliction of force by the defendant on the evening 
of October 20 when he was Jahanna's sole caretaker. 
 
In determining whether a defendant is entitled to a 
required finding of not guilty, we consider whether, viewing the 
evidence in the light most favorable to the Commonwealth, a 
reasonable jury could have found the essential elements of the 
crime beyond a reasonable doubt.  Commonwealth v. Latimore, 378 
Mass. 671, 676-677 (1979).  At trial, Dr. Newton offered the 
opinion that the fractured vertebrae were caused by "some type 
of crushing force," which could include the extreme flexion 
caused by violent shaking, and that they could not be caused by 
the force involved in a short household fall.  Although Dr. 
Newton admitted that the age of the fractured vertebrae could 
not be discerned from the CT scan, a reasonable jury, viewing 
the totality of the evidence in the light most favorable to the 
prosecution, could have concluded beyond a reasonable doubt that 
Jahanna's head injuries were caused by a violent shaking on the 
evening of October 20, when the defendant was her sole 
caretaker, and that the same shaking that caused these injuries 
produced the extreme flexion that fractured her vertebrae.  
Therefore, the judge did not err in denying the defendant's 
motion for a required finding of not guilty on this indictment. 
 
Conclusion.  For the reasons stated above, the judge's 
order denying the motion for a new trial is reversed, and the 
45 
 
 
 
judgments of conviction are vacated.  The case is remanded to 
the Superior Court for a new trial on these two indictments. 
 
 
 
 
 
 
 
So ordered.