DKing West DOICW

I:IWest Seattle 

DKing East [King Southwest
I:IKing Southeast DAdoptions/BRS

 

Superior Court of Washington
County of King Juvenile Court

 

 

N0: 18-7-01689-2 KNT

Dependency of: 18-7-01688-4 KNT
CARTER, ELLEN Order Dismissing Dependency Petition as to
dob: mother, Megan Carter
(OROD)
CARTER, SPENCER
dob: Agreed as to El mother father other
Minor Children. Contested as to mother father other

Default as to mother father other
IE Dismissed 4.1

Disposition Order (ORDD) Included
ACTION REQUIRED:
Paragraphs 4.1, 4.3, 4.6 (EDL), 4.15, and the
boxes below.

 

 

The court will hear diSposition initial progress review El interim review dependency
review permanency planning (type of hearing) on (date)

at at: King County Superior Court,
Room/Department: located at:
King County Courthouse, 516 Third Avenue, Rm. Seattle, Washington 98104
El Regional Justice Center, 401 Fourth Avenue North, Kent, Washington 98032

 

 

 

Order of Dependency (OROD, - Page 1 of 26
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Additional clerk?s action required: Enter the code(s) that apply.

About today ?5 hearing:

Was adequate and timely notice given to the children?s caregiver? Yes (CGATN) El No
(CGNATN) 

Did the court receive a caregiver report? Yes (CGRR) No El

TE caregiver appeared. Did the court give the caregiver an opportunity to be heard? Yes XI
lNo

 

 

 

1. Hearing

1.1 Petition: A petition was ?led by DSHS alleging that the above-named children are
dependent, and the court held a contested fact-?nding trial on April 15, 16, 1'8,13,14,15,16, 21, 28, and 29, 2019.

1.2 The following parties appeared - the Department of Children, Youth, and Families
(DCYF), represented by Assistant Attorney General Laura Baird', CASA GAL Virginia
Whalen represented by Cristopher Jones, the mother, Megan Carter, represented by Adam
Shapiro and the Father, Russell Andrew (Andy) Carter represented by Linda Lillevikz.

1.3 The court heard testimony from: the father, Russell ?Andy? Carter; the mother, Megan
Carter; Dr. Elizabeth Woods; Dr. Karen Nilsen; Dr. Carole Jenny; Dr. Richard Boles; Dr.
Meta Lee; Dr. James Bennet; Jodi Gragg; Detective William Muse; GAL Virginia Whalen;
paternal grandmother, Ruth Carter; Satina Nepsa; John Gese; Jamie Vanden Brink; Diane
Penoyer-Hanratty; and Deirdre Bagocki.

1.4 In addition to the testimony presented, the Court has reviewed the exhibits admitted at trial.
II. Findings

Except where otherwise indicated, the following facts have been established by a preponderance
of evidence:

2.2 Child?s Indian Status: On May 23, 2018, the Court asked each participant on the record
whether the participant knows or has reason to know the child is an Indian child. Father
and mother testi?ed at that time that the child is not an Indian child as de?ned in RCW
13.38.040 and 25 U.S.C. 1903(4). The petitioner has made a good faith effort to
determine whether the child is an Indian child.

 

DCYF worker Sara Miller appeared intermittently throughout the trial and was not called to testify.

2 Father and his counsel were initially present during the father?s testimony and were excused on 04/16/19 upon
conclusion of his testimony. Afterwards, on occasions, father was present in the courtroom.

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Megan Carter and Russell Carter are the biological parents of Spencer Carter (DOB

and Ellen Carter The parents are married. Paternity is not

an issue.

This dependency trial was as to the mother only. The father, Russell ?Andy? Carter entered
an agreed order of dependency on April 15, 2019. The order was amended and signed by
this court on May 29, 2019.

The State ?led a Petition for Dependency under these cause numbers on May 11, 2018.
The petition alleged that Megan Carter committed medical abuse against her children,
Spencer and Ellen Carter.

As to Spencer, the Dependency Petition alleges his dependency under prongs and 
of RCW 13.34.03 0(6) as follows: the child is abused or neglected as de?ned in chapter
26. 44. RC W, and the child has no parent, guardian or custodian capable of adequately
caring for the child, such that the child is in circumstances which constitute a danger of
substantial damage to the child?s or physical development. The petition
alleged that Spencer has been the subject of a dependency action between March and
November 2011 ?due to concerns of medical abuse by the mother; specifically, that the
mother was obtaining medical care, including procedures and surgeries, for the child who
was about 2 years old. The remaining factual allegations in the Petition are mainly based
on the reports made in March and May 2018 regarding Ellen Carter. Spencer Carter was 8
years-old when the Dependency Petition was ?led. He is currently 9 years old.

During the trial, evidence was presented and admitted by agreement of the parties that the
2011 Dependency case involving Spencer was dismissed by the Department of Social and
Health Services and that a ?nal administrative determination was also made that the
allegations of abuse were ?unfounded.? The dismissal order and unfounded determination
were entered in this case as Exhibit 323 by agreement of the parties.

At trial, allegations were raised by the mother that the DCYF had distributed medical and
other case records to its witnesses in violation of RCW 26.44.03 1 . DCYF, through counsel
acknowledged that the records regarding the 2011 case which was ?unfounded? and also
dismissed by the Court were in fact distributed by DCYF. This Court ?nds that DCYF
distributed the records pertaining to Spencer?s prior dependency case which was more than
7 years prior in violation of RCW 26.44.03 1.

At trial, there was little evidence presented regarding Spencer. The trial testimony from
Spencer?s pediatrician, Dr. Meta Lee, established that she had diagnosed Spencer with
ADHD, that Spencer also has a diagnosis of Autism Spectrum Disorder, which was
diagnosed by a specialist, and that he had allergies and was currently undergoing further
testing to determine whether his allergies still persist. Satina Nepsa, a Speech and Language
Pathologist, testi?ed about Spencer?s educational issues, and the development of his
Individual Educational Plan (IEP), as well as the educational support services that he
receives. Ms. Nepsa testi?ed that the IEP was the result of a team decision-making and

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based on objective evaluations from Spencer?s educators. Ms. Nepsa testi?ed that while
the mother participated in the IEP meetings, her participation and input was not the basis
for the determinations and the recommendations contained in Spencer?s IEP. Ms. Nepsa
testi?ed that the mother has always been cooperative and supportive of Spencer?s IEP and
educational support services recommended.

DCYF presented Exhibit 427 as evidence of medical abuse committed by the mother. This
exhibit contains Swedish Hospital medical records from February and April 2012. This
record indicates concerns were raised at the time between Dr. Uma Pisharody and Dr.
Bruce Oriel regarding mother?s reports about Spencer?s gastrointestinal issues.

Spencer?s additional medical records and lab tests in Exhibits 272 and 273 showed that
while Dr. Pisharody and Dr. Oriel were concerned about the mother?s representations to
them about Spencer?s claimed pancreatic insuf?ciency, the lab tests showed that Spencer
in fact had a "severe exocrine pancreatic insu?iciency The lab test results of February 4,
2012 and August 28, 2012 were contained in Exhibits 272 and 273.

The Court Appointed Special Advocate, Virginia Whalen, acknowledged in her
testimony that Spencer has an ADHD diagnosis but she testi?ed that she believed the
diagnosis of autism needed to be further investigated. The Court does not ?nd a basis for
Ms. Whalen?s recommendation. While Ms. Whalen is the appointed CASA on this case,
she did not testify as a mental health provider and was not introduced or quali?ed as a
mental health expert in order to opine as to the diagnosis made by a Specialist. There was
no other evidence submitted to support Ms. Whalen?s recommendation. While this matter
has been pending for one year, neither Ms. Whalen nor the previous appointed CASA
requested a re-testing of Spencer during the pendency of this matter.

This Court ?nds that there was virtually no credible evidence presented at trial regarding

allegations of current medical abuse, any other abuse or neglect committed by the mother
against Spencer Carter.

At trial DCYF acknowledged that it was not presenting evidence or arguing that Spencer
was a victim of any current abuse or neglect by the mother. However, position
was that based on the allegations related to his sister, Ellen, DCYF would argue that
Spencer should also be found dependent.

Regarding Ellen Carter, the Dependency Petition alleged her dependency under prongs 
and of RCW 13.34.030(6) as follows: the child is abused or neglected as de?ned in
chapter 26. 44. RCW, and the child has no parent, guardian or custodian capable of
adequately caring for the child, such that the child is in circumstances which constitute a
danger of substantial damage to the child?s or physical development. The
factual allegations included that there were concerns for possible intentional harm to Ellen
by her mother, Megan Carter, and that the mother had committed medical abuse against
Ellen in May 2018 by withholding and wasting Lovenox, an anticoagulant medication,
while Ellie was receiving treatment at Mary Bridge Hospital in Tacoma, WA. The Petition

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alleged that Megan Carter?s acts of wasting the medication had been caught on video tape.
The petition also alleged that reports had been received from a relative alleging that Megan
Carter had been the victim of medical abuse as a child, had made factitious medical
complaints as an adult and bene?tted from secondary gain from Ellen?s medical condition.

The evidence established that Ellen Carter was born very premature at 24 weeks? gestation
with a birth weight of 15 ounces. She spent over 4 months in the Neonatal Intensive Care
Unit after her birth.

It is uncontested that Ellen suffered a number of signi?cant medical issues due to
prematurity, including necrotizing enterocolitis, chronic lung disease, two ventricular
hemorrhages, adrenal issues, and chronic kidney disease. Dr. Jenny acknowledged these
issues could affect Ellen?s development.

It was clear from the testimony of the mother?s witnesses, and the testimony of the
parents as well as medical professionals who know Ellen and Spencer that the children
are bonded with their mother. This was not contested by the GAL or DCYF.

The mother testi?ed that she provided almost all of Spencer?s and Ellen?s medical care
until they were removed from her care in May 2018.

The mother testified that she is a nurse by profession but that she stopped working after
the birth of Spencer and has not renewed her license.

The father testi?ed that the mother provided almost all of Spencer?s and Ellen?s medical
care prior to their removal from the mother?s care in May 2018 and that she took the
children to almost all of their medical appointments. He testi?ed that Ellen would
sometimes have 1-2 appointments a week. He testi?ed that he worked full time while the
mother stayed home with the children. He testi?ed that he attended some of the medical
appointments and the ones that he did not attend, mother would keep him updated.
Father did not have concern of abuse by the mother.

Other family members testi?ed regarding the mother?s care of the children. The father
has a bonded family with Sunday dinners at his parents and family vacations with
extended family members. Several family members testi?ed that they spent time with
Ellen and observed mother?s interactions with the children; none testi?ed as to any
concerns regarding the mother.

The medical records show that Ellen Carter was admitted to the Mary Bridge Hospital in
March 2018 due to an infection in her central line. She was diagnosed with sepsis and
had multi-organ failure.

This dependency investigation was initiated pursuant to an intake, during the March
hospitalization, called in by a hospital social worker at the request of a doctor other than
Dr. Elizabeth Woods. Exhibit 98.

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Dr. Woods received a request to review the medical records by a social worker ?due to
social concerns during recent admission for fever/possible line
in?etion/bacteremia/sepsis in chronic medically complex well known patient to Mb. Dr.
Woods notes dated 2/5/18 state: ?No evidence of concern on review of notes ?om
multiple consultants and hospitalist providing care. Exhibit 158.

Dr. Woods is employed at Mary Bridge Children?s Hospital as the Medical Director of
the Children?s Abuse Intervention Department (CAID). She testi?ed that she performed
a review of Ellen?s medical record and consulted with some of Ellen?s medical
subspecialists. She testi?ed that, based on her review of the record and consultations, she
formed the opinion that Ellen was the victim of medical child abuse.

Dr. Woods noted on April 3, 2018, referred to ?concerns?'om multiple entities that Ellie
has had multiple unexplained illnesses and that ?[tjhere has been heightened concern
over many months that Ellie known illnesses are providing secondary gain to mother of
child and concern that there may be some source of deception involved. Exhibit 91. Dr.
Woods in her testimony did not identify the ?multiple entities? and did not explain the
basis for these concerns ?over many months or what these ?heightened concerns were.
The record presented only indicated that one note was written to CPS on March 30, 2018
(see below). There are no other medical records (except the social worker requesting
review in February See ?2.25) showing concerns or notes to CPS. In her notes, Dr.
Woods noted that ?Mom asked for information regarding who made the CPS referral
when I was speaking with her. I told her that referrals are anonymous but I do know that
concern came across ?om multiple entities and it was not a specific individual. Dr.
Woods? testimony was as vague as her answer to the mother. Furthermore, Dr. Woods in
her testimony did not give the basis for the allegation of ?secondary gain against the
mother or the basis for the allegation that there was ?concern for some source of
deception by the mother The Court ?nds that most of Dr. Woods? testimony were
conclusory and without supporting factual basis. It is also concerning that Dr. Woods
testi?ed as to the protocol among doctors of not documenting concerns of medical abuse
in the patients? ?les. Dr. Woods testi?ed that the medical providers who suspect medical
abuse would in fact ?not document? their concerns in the patients? medical ?les because
such ?les were accessible to the patients. The medical records that CASA submitted in
Exhibit 427 from Swedish contradicted Dr. Woods? testimony on this same exact point.
Exhibit 427 shows that the doctors documented their suspicions and concerns regarding
medical abuse together with the basis for such concerns in Spencer?s ?le. How else
would medical providers be alerted to such concerns by their fellow colleagues regarding
a mutual patient? The records and testimony presented clearly show that the patients?
medical ?le is the shared document that all health-related information is kept; it is the
document that is updated by all medical providers who have contact with the patient. The
Court does not ?nd Dr. Woods? testimony regarding doctors? lack of recording
persuasive.

 

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There was a note admitted in the record as Exhibit 98 which docwnents a referral to CPS
made by Barbara Guerrero, a social worker who reported ?concerns of mother ?5 capacity
to care for this child This note was generated on March 30, 2018 only a few days after
Ellen?s admission to Mary Bridge Children?s Hospital for an infection later diagnosed as
sepsis. There is no explanation or details provided in this note about the nature of the
concerns raised about the mother. Barbara Guerrero did not testify at trial. It is assumed
the call was made due to Ellen?s serious condition at the time. However, no evidence was
submitted during the trial to explain the reason why Ellen suffered from sepsis. Dr. Jenny
testi?ed that she could not determine the cause of Ellen?s sepsis. There is insuf?cient
evidence for this Court to ?nd that the mother bore any responsibility for Ellen?s sepsis.
The note from Barbara Guerrero does not corroborate medical abuse by the mother.

Dr. Woods testi?ed that the maternal grandfather sent a letter to the Mary Bridge
Children?s Hospital expressing concern over the mother?s history of medical child abuse.
A cepy of this letter was not produced during the trial and the mother did not contest that
the letter was received by the hospital. Dr. Woods ?lrther testi?ed that upon review of the
letter, she concluded that the maternal grandfather had not had contact with the family for
many years and that the allegations in the letter were not credible. She testi?ed that she
had not given weight to the letter and had not spoken with the maternal grandfather. This
letter, however was brought up at the CAID meeting and Ellen?s medical providers at the
meeting were noti?ed of the allegations in the letter.

Testimony established that the hospital held two CAID conference meetings to discuss
Ellen?s medical case in 2018.

The initial CAID meeting in 2018 discussed concerns about the mother?s secondary gain
and involvement in Ellen?s medical care. At that meeting, it was decided to remove the
mother from Ellen?s medical care.

Mary Bridge Children?s Hospital physicians decided to place Ellen and the mother in a
videotaped room with :1 room-monitors. The purpose of the room-monitors was to
monitor mother?s behavior towards Ellen and mother?s manipulation of Ellen?s lines,
drains and medical care. Exhibit 61.

Subsequently, the medical staff asked permission from Dr. Nilsen to ask the mother to
administer Ellen?s anticoagulant medication. Dr. Nilsen authorized it as the injections
were uncomfortable for Ellen to receive. The mother testi?ed that she was also allowed
to provide wound care for Ellen.

After the mother was removed from Ellen?s care, the mother did not approach the
hospital staff to ask permission to administer the anticoagulation medication or to be
actively and directly involved with Ellen?s care. She did not seek permission, it was the
hospital sta? who asked the mother to help them with the injections.

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At the time that Dr. Nilsen granted the request from the hospital staff and authorized the
mother to administer the anticoagulation medication by injections, she was aware of the
allegations against the mother.

On May 6, 2019, the child developed a blood clot and the diagnosis was con?rmed by
test results on the morning of May Exhibits 211, 212.

Jodi Gragg was the In-patient Nurse Director at Mary Bridge Hospital during Ellen?s
admission to the hospital in March through May 2018. Nurse Gragg testi?ed that when
on the morning of May 7, 2018, she came to Ellen?s hospital room and told the mother
that the test results showed that Ellen had developed blood clots and that she would be
moved to PICU, the mother?s reaction appeared ?jovial? to her. Based on her previous
interactions with the mother, Nurse Gragg found this to be a strange reaction.

The Court heard the testimony of the mother that by the time that Nurse Gragg came to
the room, Ellen had been in the hospital for a number of weeks and that she had been
hoping that Ellen would be released from the hospital soon. Mother testi?ed that she had

expressed her desire for Ellen to be discharged as soon as possible to Dr. Nilsen. Exhibit
218.

Mother further testi?ed that she had been the one who had noticed the swelling and the
redness in Ellen?s chest area on May 6?h and had brought it to the attention of the medical
staff. Although at that time, there were room-monitors in Ellen?s room and there were
nurses checking on Ellen, none of them had noticed the swelling.

Mother testi?ed that during the night Ellen went through a number of diagnostic
procedures and that she had been up all night with her. Mother testi?ed that by the time
Nurse Gragg came to the room, she was exhausted, frustrated, and upset. She testi?ed
that she was relieved that they had ?nally found out what had caused the swelling and the
redness but that at the same time she was having a dif?cult time with the fact that Ellen
was being returned to the PICU. She testi?ed that she was not happy about Ellen?s
condition and in fact was quite upset.

Nurse Gragg testi?ed that she began to question why Ellen would develop a clot while on
anticoagulant medication, and she testi?ed that she realized that it was the only medical
care that the mother was allowed to provide.

This court ?nds that Ms. Graag?s perception or reading of the mother?s reaction did not
establish that the mother was happy about Ellen?s condition on the morning of May 7,
2018. The record established that the night of May 6?h to the morning of May 7?'1 was a
dif?cult time for Ellen and her mother. Ellen was going through a number of diagnostic
tests and their sleep was interrupted throughout the night. After a long night, mother, for
the ?rst time, heard from Nurse Gragg that Ellen had in fact developed blood clots and
was being moved to PICU. It is plausible that by the time Nurse Gragg came to the room,
mother was tired and experiencing a ntunber of different emotions. Nurse Gragg did not

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testify that the mother said anything to show that she was ?pleased? or ?delighted? at the
news of the blood clot. In fact, Nurse Gragg only based her perception of the mother?s
emotion on a passing reaction that she believed she saw and nothing else. There is no
evidence to support that Nurse Gragg?s perception of what she believed mother?s reaction
was on the morning of May 7?h is in fact accurate. Nurse Gragg?s perception of a passing
reaction does not corroborate the allegations of medical abuse nor that the mother was
receiving secondary gain from Ellen?s illness.

Dr. Nilsen testi?ed that at the request of Nurse Gragg, she identi?ed in the medical record
times that the mother could have been administering anticoagulant medication to Ellen.
Based on that review, she identi?ed 5-10 frames of security footage.

Nurse Gragg testi?ed that she ?rst looked at the videos in the security of?ce and
identi?ed two periods of time where it appeared to her that the full dose of anticoagulant
medication was not given to Ellen.

Dr. Woods testi?ed that the police were called after staff reviewed the surveillance
footage. Detective Muse testi?ed that a responding of?cer placed Ellen in protective
custody. Mary Bridge Children?s Hospital issued a no-trespass order against the mother
ordering her removed from the premises, and that no-trespass order was still in effect at
the time of the fact-?nding trial in these matters.

The Court heard testimony that Ellen was on varying doses of anticoagulant medication
while in the mother?s care, and this is re?ected in the medical records. Exhibit 161.

At trial DCYF presented the testimony of Detective Muse, Dr. Woods, Dr. Nilsen and Jodi
Gragg pertaining to the allegations of the mother wasting Lovenox in the hospital. The
videos of the alleged incidents were viewed during the testimony of Detective Muse, Dr.
Nilsen and the mother. DCYF alleged that the mother disposed/wasted Lovenox when she
pointed the syringe downward after appearing to administer the medication to Ellen,
pushing down on the syringe plunger, and expelling the medication into the hospital bed
sheets. The videos were admitted as exhibits 162, 163 and 283.

Nurse Gragg testi?ed that Mary Bridge Hospital uses two type of syringes: Vanish Point
syringes and BD Safety Glide syringes. She testi?ed that the syringe used to administer
Lovenox to Ellen was a BD Safety Glide, which has a distinct solid grey cap and white
safety apparatus on the side. Ms. Gragg testi?ed that Vanish Point syringes have a
retractable needle but that to her knowledge, as a rule, these syringes were not provided to
the mother to administer Lovenox to Ellie. Both syringes were demonstrated as to how they
each worked. Dr. Woods, Dr. Jenny, Dr. Nilsen and Virginia Whalen all testi?ed that they
did not know which syringe was used by Megan Carter to administer Lovenox to Ellen.

The evidence established that the Lovenox syringes were pre-loaded with the medication
at the hospital pharmacy and that a nurse would hand deliver the syringe to the mother
while another staff observed and entered the information in the patient?s medical ?le.

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2.50 The evidence and the videos of May 4th and May 6?h established that neither Nurse Gragg,
Dr. Nilsen, Dr. Woods nor Dr. Jenny were present in the hospital room at the time the
nurses handed the syringes to the mother to administer the Lovenox to Ellen. On both
occasions, there were other nurses and room-monitors present. DCYF did not present any
testimony from the nurses who handed the syringe to the mother or the nurses and room-
monitors who were present at the time.

2.51 Mother testi?ed that she was given and used the Vanish Point syringe to administer the
Lovenox on both occasions. Mother demonstrated how she used the Vanish Point syringe.
She also testi?ed that she administered the Lovenox to Ellen?s port slowly as it would
cause a burning sensation. She testi?ed that each time after the administration of the
Lovenox, she would take the syringe out of the port and push down on the syringe to retract
the needle before capping it for safety purposes and handing the syringe to the nurse.
Mother testi?ed that she administered the full dose of medication to Ellen and that she did
not push down on the plunger to expel, dispose or waste any medication, but simply to
retract the needle. The Court has viewed the videos for both occasions and ?nds the
mother?s explanation to be consistent with the images on the videos.

2.52 This Court watched the videos in exhibits 162, 163 and 283 carefully. BD Safety Glide and
Vanish Point Syringes were both di3played and admitted as evidence. The syringes are
quite distinct in appearance. The BD Safety Glide syringe has a solid, grey cap and a white
safety device on its side. The Vanish Point syringe has a clear cap and no safety device on
its side. The video images do not show the BD Safety Glide syringe being used by the
mother in administering the Lovenox to Ellen. The images are consistent with the
appearance of the Vanish Point syringe being used by the mother. The Vanish Point syringe
requires a push down on the syringe plunger after administering the medication in order to
retract the needle before capping the syringe. This is consistent with the mother?s testimony
on how she administered the medication to Ellen.

2.53 DCYS admitted exhibits 3, 4, 6, 8,12, 29, 33, 38, 42, 45 which document medical abuse as
a concern or problem list for Ellen. These records were generated after May 9, 2018 and
subsequent to Dr. Woods, Dr. Nilsen and Nurse Gragg suspecting that the mother had
diSposed/wasted Ellen?s Lovenox instead of administering it to her. Dr. Nilsen testi?ed that
after reviewing the videos, she contacted Ellen?s care providers to disclose the abuse that
she believed she had observed on the videos and to discuss and re-think Ellen?s medical
care. This Court ?nds that the mention of medical abuse in these exhibits were generated
under the mistaken suspicion that the mother had diSposed/wasted Ellen?s medication on
May 4th and May 6th and does not corroborate actual medical abuse by the mother.

2.54 It is clear from the videos that at least two hospital staff were present in the room with the
mother and Ellen at the time the mother administered the Lovenox, including nurses and a
room-monitor speci?cally tasked to watch the mother?s behavior towards Ellen. These
people were in close proximity to the mother and Ellen at the time the Lovenox was

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administered. DCYF did not present any evidence that any of the nurses or the room-
monitors had any concern that the mother had not administered the Lovenox as she was
supposed to.

Most importantly for the Court is Dr. Nilsen?s testimony during her direct examination by
Ms. Baird regarding the videos. Dr. Nilsen viewed videos of the mother administering the
Lovenox to Ellen on both dates in Exhibits 162 and 163. Dr. Nilsen testi?ed that she did
not see anything of concern as to how the mother administered the Lovenox to Ellen. The
Court gives great weight to Dr. Nilsen?s testimony on this point. Dr. Nilsen had spent hours
on reviewing the videotapes in this case. She has been the doctor overseeing Ellen?s care,
knows the family and is also fully aware of the allegations against the mother. She is the
one who authorized the mother to administer the Lovenox. She testi?ed that the mother did
not do anything wrong in either occasion when administering the Lovenox.

Ellen developed a blood clot on May 6?h with a con?rmed diagnosis on May 7, 2018. This
was not the ?rst or the only time that Ellen had developed blood clots. DCYF presented
evidence about ?uctuating Lovenox levels in Exhibits 10 and 11. DCYF argues that the
blood clot establishes that the mother did not administer the Lovenox to Ellen as alleged.

DCYF admitted evidence to show that the levels of Lovenox had ?uctuated while Ellen
was in hospital in March - . May 2018. However, the evidence established that Ellen had
suffered three prior blood clots earlier during the hospitalization when Ellen was in the
Pediatric Intensive Care Unit (PICU). Mother was not administering any of Ellen?s
medication in PICU. All of Ellen?s care was done by the nursing staff. Exhibit 3 17. Mother
testi?ed that Ellen had a prior blood clot in August 2017.

The Court also heard the testimony from Dr. Nilsen that there are ?many things? which
can impact Lovenox levels in the blood, including the nature of the child?s illness at the
time, diet, child?s in?ammatory state, and other medications that the child is taking at the
time. Dr. Nilsen further testi?ed that the reason for differing Lovenox levels cannot be
determined.

Dr. Richard Boles testi?ed that Ellen?s blood clots did not establish medical child abuse
against the mother. He testi?ed that there were a large number of factors involved in
?clotting? which varies among people and also varies within any one person at any given
time. Dr. Boles testi?ed that clotting is very common in patients who have a constellation
of conditions and such as Ellen. Dr. Boles testi?ed that the fact that Ellen has
not had blood clots since the mother was removed from Ellen?s medical care is due to the
fact that Ellen?s central line was removed as well as to the varied causes for clotting.

Dr. Boles and Dr. Nilsen both testi?ed that Ellen?s central line created a heightened risk
factor for infection and clotting. The Court ?nds that there are many con?icting facts that
may have caused the ?uctuations in Lovenox levels in Ellen?s blood or the blood clot of
May 7th. The Court notes that while DCYF presented evidence of the ?uctuating levels of
Lovenox in Ellen?s blood, it did not establish that this was the cause of Ellen?s blood clot

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diagnosed on May 7, 2018 nor that the mother was responsible for the ?uctuating levels.
The Court ?nds that there are independent and plausible reasons for Ellen?s ?uctuations in
the Lovenox levels or the blood clot diagnosed on May The exhibits presented by
DCYF do not demonstrate what the levels were on May 4th or May 6th when DCYF alleges
that the mother did not administer the medication or on May 7?11 when the Ellen?s blood
clot was diagnosed. The Court does not ?nd that the ?uctuations in Ellen?s Lovenox levels
or the blood clot diagnosed on May establish the allegation that the mother disposed of
or wasted Lovenox instead of administering it to Ellen. The evidence presented by DCYF
about Lovenox levels or the blood clot of May 7?1 do not corroborate nor establish medical
child abuse by the mother.

Testimony was presented from Dr. Woods and Dr. Jenny that the mother had been the
victim of medical child abuse, which they stated was a risk factor for perpetrating abuse.
Neither Dr. Woods, Dr. Jenny or any of the witnesses presented at trial investigated this
allegation and no evidence was presented about what abuse the mother suffered. An
expert?s opinion must be supported by credible evidence. The Court did not hear what
evidence the doctors had used to opine that the mother ?was a victim of medical child
abuse herself?. No evidence was presented to show what. when or how the mother had
been a victim. There was no evidence presented at trial to establish that the mother was a
victim of medical abuse. Without any factual basis to support the Opinion of Dr. Woods
and Dr. Jenny on this point, the Court is not convinced that the opinion is in fact accurate.

The Dependency Petition alleges that the mother made factitious medical complaints as an
adult, neither DCYF nor CASA presented any evidence to corroborate this allegation. As
to the mother?s medical issues, the Court heard testimony from Dr. Boles who testi?ed that
he reviewed some of the mother?s medical records and found that she suffered from
medical conditions including hypersensitivity to pain, lupus, chronic fatigue and decreased
bladder sensitivity. Exhibit 203 There were no evidence submitted at trial to show that the
mother had made any factitious medical complaints as an adult.

The Dependency Petition alleges that the mother bene?tted from secondary gain associated
with Ellen?s illness. The evidence presented at trial established that Ellen lost her
?Shermie? doll while in the hospital and that the mother placed a message on her Facebook
page asking for people to keep an out for the doll. Exhibit 206 demonstrates that the
hospital staff initiated the tweet to Richard Sherman, and not the mother. When Richard
Sherman answered the hospital?s tweet and subsequently came to the hospital, it was a
major event for the hospital. Many of the hospital staff were present for the Richard
Sherman?s visit together with Ellen and her family. There was no evidence presented that
the mother had initiated Sherman?s visit to the hOSpital or that the mother received special
attention. Richard Sherman?s visit to the hospital was a major event for the hOSpital and
arranged by the hospital.

There was evidence presented that Ellen?s image was used by the hospital for the publicity
of the Mary Bridge Hospital?s charity event and for the hospital?s internal staff publication.
There was no evidence that the mother initiated the use of Ellen?s image for either of these

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uses. Mother testi?ed that the hospital asked permission to use Ellen?s image for the charity
event?s brochure and that the hOSpital requested that the family provide them with a few
family photos. Mother testi?ed that she gave permission for the use of Ellen?s photo on the
brochure and also provided the family photos. Mother testi?ed that she was not aware that
the hospital had used Ellen?s image on an internal staff publication. Dr. Woods testi?ed
that a ?secondary gain bene?t could be the ?attention that one tries to get for the child?s
illness or condition. However, apart from the Richard Sherman visit and Ellen?s images
appearing at the hospital?s publication, there were no other credible evidence showing that
the mother ?gained secondary benefit? from Ellen?s illness. As to those two instances, the
evidence established that it was the hospital staff and not the mother who initiated contact
with Richard Sherman and approached the mother with the request to use Ellen?s image on
the hospital?s charity brochure and publication. If there were any bene?t gained ?om
Ellen?s status as a patient or from her image, the bene?t was gained by the hospital and not
by the mother. There was no evidence presented that the mother gained any bene?t from
Ellen?s illness.

This Court ?nds that the evidence presented at trial by DCYF and the CASA failed to
corroborate or prove by a preponderance of the evidence that Megan Carter committed
medical abuse against Ellen Carter as alleged in the Dependency Petition.

In addition to the allegations in the Petition, DCYF made a number of additional claims
that the mother committed acts of medical abuse against Ellen which were not alleged in
the Dependency Petition. DCYF alleged that the mother exaggerated Ellen?s health
condition to medical care providers which resulted in Ellen receiving unnecessary medical
care including oxygen, medication, tests, and surgeries. However, this Court ?nds that
DCYF and the CASA did not provide suf?cient evidence to corroborate such claims and
did not prove them by a preponderance of the evidence.

Dr. Meta Lee has been Ellen?s pediatrician since her release from the neonatal intensive
care unit. Dr. Lee is the Medical Director at Valley Medical Center and Chief of Pediatrics.
She testi?ed that she was aware of the prior allegation of medical abuse against the mother
regarding Spencer and was vigilant about that concern. On one occasion, Dr. Lee called
Child Protective Services (CPS) when she learned that Spencer had injected some water

into Ellen?s feeding tube when the mother was ?ushing the tube. CPS investigated the
incident and resolved it.

Dr. Lee testi?ed that Ellen had legitimate medical issues from the time she began seeing
her. These medical issues included dif?culty feeding, intestinal dysmotility issues, she
could not take-in enough calories to grow and failed to gain weight. In fact, a Feeding
Evaluation was performed when Ellen was approximately 5 months old (soon after her
release from the hospital) which corroborated her eating dif?culties. The Feeding
Evaluation was admitted as Exhibit 285. The Feeding Evaluation was not based only on
the mother?s reports, but on the testing and observation of the Feeding therapist.

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Dr. Lee testi?ed that she had over 80 appointments with Ellen and 35 with Spencer. Mother
accompanied the children to most, if not all the visits. Dr. Lee testi?ed that she examined
the children regularly and opined that based on her experience and expertise, Ellen suffered
from legitimate medical issues. She refuted that Ellen?s medical conditions were based on
exaggerated, false or misleading reports of the mother.

Dr. Lee reported that she made the referrals to the specialists that Ellen saw, that the
specialists were competent physicians and that she was very picky about whom she referred
her patients. Dr. Lee testi?ed that she communicated regularly with these specialists, and
reviewed all their reports. Dr. Lee testi?ed that she had no concerns about the reasons for
her referrals. Dr. Lee testi?ed that she was in regular communications with the specialists,
followed Ellen?s medical conditions closely and never heard any concerns from Ellen?s
health care providers about concerns of abuse.

Dr. Lee testi?ed that she participated in Care Conference in September 2017 where all
providers attended. Dr. Lee questioned whether any of the providers had concerns of abuse,
and none were raised. Dr. Woods did not attend that conference and no records or
statements ?om any of the providers who attended that conference were offered into
evidence to demonstrate that medical abuse as a concern was raised at that meeting. Dr.
Woods? testimony that concerns were raised about medical abuse at that Care Conference

is uncorroborated and not supported by the records in this case.

Dr. Lee testi?ed that medical decisions were not made based on the mother?s reports alone.
Decisions were correlated with medical tests and physical examinations. Dr. Lee testi?ed
that doctors don?t make decisions based on a parent?s report alone. Dr. Lee testi?ed that
she did not ?nd the mother to exaggerate or fabricate Ellen?s conditions and found her to
be appropriately concerned and following through with the recommendations as instructed
by her and the specialists.

Dr. Woods and Dr. Jenny testi?ed that the mother was responsible for Ellen having
oxygen prescribed unnecessarily. The Court has reviewed the exhibits admitted in this
case. Exhibit 266 demonstrate that Dr. Murphy, Pediatric Pulmonologist, prescribed the
oxygen based on a number of factors including a physical examination of Ellen and an
oxygen saturation test. argument that Dr. Murphy prescribed oxygen for Ellen
solely based on the mother?s reports are not supported by the records. Dr. Murphy did not
testify at trial; however, his reports and chart notes were admitted into evidence. In a
letter dated 6/29/2018 (after mother was removed from the children?s care) from Dr.
Murphy, he noted the following about Ellen: ?There is no clear etiology for her lung
disease other than the GERD and microaspiration. [am concerned that this is a basic
metabolic issue like a mitochondrial process that is not working well enough. The
medical records admitted into evidence do not establish that Dr. Murphy or any other
doctor recommended that Ellen be removed from the use of oxygen at any time prior to
her hospitalization in March 2018, or that the mother exaggerated Ellen?s to
Dr. Murphy or that the mother did anything other than follow Dr. Murphy?s
recommendations. No evidence was presented at trial to demonstrate that at the time Dr.

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Murphy prescribed oxygen for Ellen it was not medically necessary or helpful for Ellen.
The medical records in Exhibits 267-268 and 270 demonstrate that Dr. Murphy examined
Ellen and re-a?irmed his prescription for oxygen and did not recommend terminating
Ellen?s use of oxygen - even at the visit a few days before Ellen was admitted into the
hospital in March 2018. There is no evidence presented that Dr. Murphy?s medical
decisions were medically inappropriate at the time or that he had not exercised his
medical judgment in treating his patient, Ellen.

The Court ?nds that the prescription of oxygen for Ellen was not the result of medical
abuse perpetrated by Megan Carter.

DCYF position also infers that Dr. Murphy did not exercise his independent medical
expertise and judgment in making his prescription, which is also unsubstantiated.

In May 2018, Ellen was removed from oxygen in the hospital. The coincidence that the
removal of oxygen was after the mother was removed from Ellen?s care does not without
more- corroborate medical abuse. There was no evidence produced at trial that Ellen did
not need oxygen at the time it was prescribed; there was no evidence submitted that the
mother?s reports to Dr. Murphy were exaggerated or misleading, there was no evidence
admitted to establish that Dr. Murphy did not consider information other than the mother?
reports in deciding to prescribe oxygen and no evidence was admitted that Dr. Murphy did
not exercise his own medical expertise and judgment in prescribing oxygen. There was no
evidence admitted that the removal of oxygen was not simply because Ellen?s health had
improved. Also, there is no evidence that Dr. Murphy ever rescinded his prescription,
doubted his diagnosis, or that another medical provider opined that the child should not
have been prescribed oxygen. Dr. Murphy in his letter of 6/29/2018 noted and cautioned:
?Maintenance and good health with less therapy is evidence of improvement to me. The
primary pulmonary issues we faced previously were oagzgen dependency and no obvious
explanation for that. .. However, given her history of extreme prematurity, it is likely that it
will be of value to have on hand the tools we commonly do use for those problems such as
A trovent and Albuterol. In his note, Dr. Murphy still recommends having Atrovent and
Albuterol on hand for Ellen. The only logical inference from Dr. Murphy?s note is that
Ellen?s proper breathing is still an issue to be dealt with caution and that she may yet need
pulmonary help and medication for proper breathing.

The mother testi?ed that Ellen was on oxygen until May 2018 per Dr. Murphy. DCYF did
not produce testimony or credible evidence that Dr. Murphy?s medical decision was in fact
wrong. Dr. Lee who regularly saw Ellen did not testify that in her opinion Ellen did not
need oxygen. There is no credible evidence on the basis of which the Court would second
guess the medical decision of Dr. Murphy in prescribing oxygen to Ellen. Dr. Woods or
Dr. Jenny?s speculation that at some point in the past the child would not have bene?tted
from oxygen is a speculation at best. Ellen was born with many different medical
complications and required many complicated procedures. She has grown to be an active
child and as Dr. Lee testi?ed, Ellen may have overcome many of her medical conditions

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simply by growing out of them. Ellen is now 6 years old and in a much different situation
health wise than when she was as a new born or a toddler. The Court does not ?nd that
there is credible evidence to believe that medical abuse was the cause of Ellen being
prescribed oxygen or its continued use. The medical record established that Ellen had a
medical need for the use of oxygen. The record also established that Ellen?s health
improved in the hospital to the point that she was able to keep her oxygen level at the proper
level without the use of additional oxygen. Ellen?s improvement after a prolonged illness
does not establish medical abuse by the mother.

Dr. Woods and Dr. Jenny testi?ed Ellen did not suffer from legitimate dysmotility in her
gastrointestinal tract. They opined that Ellen?s dysmotility issues and the resulting medical
interventions were caused by false and exaggerated reports to the doctors by the mother.
However, the Court ?nds that Ellen?s dysmotility issues were in fact well documented in
the medical records admitted in Exhibits 214, 216, 312, 313 and 318. Moreover, Dr. Lee
and Dr. Nilsen both testi?ed about Ellen?s dysmotility and gastrointestinal issues. Dr. Lee
testi?ed that Ellen has suffered from dysmotility and gastrointestinal issues since birth.

No evidence was presented to corroborate the claims of DCYF and CASA that the mother
exaggerated Ellen?s feeding and gastrointestinal issues. Dr. Lee, Megan Carter, Andy
Carter, Ruth Carter, Diedre Bagocki and Dianne Hanratty Penoyer all testi?ed about
Ellen?s issues with oral feeding. Even after Ellen was removed from the mother?s care, the
weight chart presented by Dr. Jenny established that Ellen lost weight. Dr. Lee testi?ed
that in the last year Ellen has gained less than a pound.

The allegation that the mother starved Ellen was uncorroborated and not supported by the
weight of the evidence and the testimony of witnesses at trial. Dr. Lee never had a concern
that Ellen was being starved or intentionally malnourished. Testimony was presented by
Megan Carter, Andy Carter, Ruth Carter, Deidre Bagocki, Diane Hanratty Penoyer, and
John Gese that Megan would regularly offer food to Ellen, that Ellen had a seat at the
family dinner table and food would be offered and placed in front of her. There was also
testimony that Ellen would not often eat food orally, or eat very little. None of the witnesses
who observed the mother and Ellen outside of the hOSpital or in the doctor?s of?ce ever
witnessed the mother restrict Ellen from eating food. The Court heard testimony that
mother always had snacks available for the children and that Ellen was offered food at
meals and whenever she wanted it. Exhibit 276 showed photos of Ellen eating orally on a
number of different occasions.

Dr. Woods? testimony that Ellen ?wolfed down? a Happy Meal after the mother was
removed ?om the hOSpital was not corroborated by the evidence. In light of the history of
Ellen?s eating habits, and testimony of other witnesses, Dr. Woods? testimony on this point,
is not plausible. Dr. Nilsen testi?ed that she did not witness Ellen consume a Happy Meal
and had such an event occurred, she would have heard about it because it would have been
a signi?cant event. Ellen?s alleged consumption of a Happy Meal was not corroborated by
the medical records admitted at trial nor by the testimony of any other witness.

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Even after the removal of the mother from Ellen?s medical care, the evidence established
that Ellen continues to have feeding issues. Ellen still has a G?tube installed a year after
the mother?s removal as her caretaker. Ellen continues to have feeding issues. Father and
Ruth Carter (paternal grandmother) testi?ed about the challenges of Ellen?s oral intake.
Father has been taking Ellen to a feeding therapist who is helping Ellen overcome her
feeding issues. Dr. Lee testi?ed that weight gain continues to be a signi?cant challenge
for Ellen.

The evidence did not establish that the installation of Ellen?s G-tube was the result of false
or exaggerated reports by the mother about Ellen?s feeding or gastrointestinal 
The medical records in Exhibits 265 and 267 establish that the decision to install the G-
tube was made by Dr. Abdullah and supported by Dr. Murphy. There is no reason to believe
that this recommendation was based on anything other than the doctors? expertise and
sound medical judgement.

Dr. Pickens did not testify at trial. However, his records and those of Dr. Murphy establish
that there were legitimate medical issues to support their recommendations to install a G-
tube. The recommendation came from the doctors, not the mother. No credible evidence
was presented to demonstrate that the information provided to the doctors by the mother
about Ellen?s were false or exaggerated. No credible evidence was presented
that Ellen did not need the G-tube at the time it was recommended and installed. There is
no plausible reason to believe that the recommendation for the G-tube was made based on
anything other than the expertise and sound medical judgment of Dr. Pickens and Dr.
Murphy. In fact, Ellen continues to have a G-tube over a year after the mother was removed
from Ellen?s medical care. The evidence presented at trial does not support the claim that
medical abuse perpetrated by the mother was the reason for doctors? decision to install or
maintain Ellen?s G-tube.

Dr. Woods testi?ed that the mother misrepresented information to doctors which resulted
in Ellen going through an unnecessary split surgery. Dr. Woods testi?ed that Dr.
Pickens sent Ellen for a motility study at the Seattle Children?s Hospital prior to the
decision to proceed with the G-J Split surgery and that the mother miSpresented to the
motility specialist that Dr. Pickens had decided not to proceed with the motility study. Dr.
Jenny joined in the Opinion that the G-J split surgery was unnecessary and performed based
on the mother?s false reports. The medical records submitted at trial do not support these
doctors? opinions or the conclusion that the 6-1 split surgery was the result of medical
abuse by the mother. Exhibits 239, 241, 242 demonstrate that Ellen was having ongoing
problems with her J-tube coiling in her stomach which caused her pain and required
ongoing procedures and medical intervention to correct the problems. The GI Split surgery
was considered by the doctors as a way to address this problem. Exhibit 229.

Exhibit 231 is a medical record drafted by Dr. Pickens which states that he referred Ellen
to the Children?s Hospital ?to discuss an antiduodenal manomerry and motility study.?
Mother testi?ed that her understanding was that they were referred to ?discuss? the options
and not to have a study done. Dr. Ambartsumyan?s medical records does not suggest that

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Ellen was scheduled for a ?study?. Dr. Picken?s medical records admitted as Exhibit 232
state that he would await recommendations from Dr. Ambartsumyan at Children?s HOSpital
and would speak with Dr. Lao and the family about ?options.?

Dr. Ambansumyan?s medical note in Exhibit 229 states that she not only obtained Ellen?s
medical history from the mother, but she also reviewed Ellen?s ?radiographs, labs and
chart notes great detail. Dr. Ambartsumyan?s note does not state anywhere that the
mother reported that Dr. Pickens or any other doctor had already decided to proceed with
the OJ split surgery and/or that the motility study was unnecessary.

Dr. Ambartsumyan?s note does not speci?cally recommend a motility study. Instead she
states that ?if she fails primary ?zeds and continues to be TPN dependent, then we would
recommend antiduodenal study to assess the neuromuscular integrity of the intestine for
consideration of a diverting ostomy. Dr. Ambartsumyan did not oppose a split surgery
for Ellen.

Dr. Picken?s medical note in Exhibit 233 demonstrates that he communicated with Dr. Lao
and received phone messages from Dr. Ambartsumyan before the decision to proceed with
the G-J split surgery. Dr. Lao?s note in Exhibit 234 demonstrates that he conferred
?extensiver with Dr. Pickens and they both agreed to the procedure.

There is no indication in any of the records ?'om Dr. Pickens, Dr. Ambartsumyan or Dr.
Lao that the decision to proceed with the G-J split surgery was the result of false or
misleading information provided by the mother. To the contrary the medical records
establish that the doctors had signi?cant communications with each other prior to the
surgery, that the surgery was recommended by the doctors according to their expertise and
sound medical judgment, and that Megan and Andy Carter?s decision to proceed with the
surgery was made in order to follow the recommendations of the doctors. Ellen Carter had
the G- tube split for approximately one and a half years. There were no medical records
or other evidence submitted to show that the medical care providers who recommended the
surgery ever changed their minds or believed that their recommendations were due to false
or exaggerated information provided by the mother.

Dr. Pickens was the treating doctor for the Carter children for the majority of the time. The
records from Dr. Pickens show that he was closely involved with Ellen?s digestive issues
and provided treatment for her. The record also shows that the mother followed Dr. Pickens
and other medical providers? recommendations. Dr. Woods? opinion that somehow the
mother by false reports tricked Dr. Pickens into proceeding with the J-G Split surgery is
not plausible. If needed, Dr. Pickens could ask Dr. Ambartsumyan for a written report,
could consult with Dr. again or send Ellen back for more tests. There was
no evidence submitted to claim that the mother would not have followed the
recommendation of taking Ellen for more tests. In fact, the record clearly shows that the
mother followed through with all of Ellen?s medical providers? recommendations. There is
no credible evidence submitted to show that the doctors who are specialists in their ?elds
made the decision to go forward with a procedure on Ellen only based on the mother?s

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reports and without medically sound reasons. Dr. Pickens and Dr. Lao jointly decided to
go forward with the procedure. There is no evidence to establish that the G-J Split surgery
was the result of medical abuse perpetrated by the mother.

The decision to begin TPN nutrition through a central line was likewise not based on false
or misleading reports of Ellen?s condition by the mother. The medical record in Exhibit
313 demonstrates that the decision to begin TPN was made by Dr. Desai because of
concerns about Ellen?s feeding intolerance; motility and issues with Ileus (food not moving
through her GI tract property).

Dr. Woods and Dr. Jenny testi?ed that Ellen did not suffer from a seizure disorder. They
testi?ed that the mother provided false or exaggerated reports of seizures which resulted in
unnecessary care. The evidence presented established that Ellen had legitimate seizures
and medical conditions causing seizures and that others beside the mother had observed
her seizures.

Dr. Nilsen testi?ed that she witnessed a seizure in the hOSpital and witnessed another
seizure-like event. Dr. Nilsen con?rmed on the stand that what she observed was certainly
a seizure. Nurses and other doctors reported their observations in Exhibits 213, 308, and
315 of Ellen suffering from seizures or seizure-like The mother presented
videos in Exhibit 319 during her testimony of Ellen suffering from a seizures or seizure-
like at home and at the hospital. Ruth Carter testi?ed that since returning from
the hospital, there have been times that Ellen becomes unresponsive for short periods.
Records were also presented from Ellen?s neurologist, Dr. Al Mateen, in Exhibit 5 that he
had diagnosed Ellen with epilepsy in September 2015 and decided to prescribe Keppra for
Ellen to control her Dr. Al Mateen noted in his notes that ?3 days ago,
grandmother noted blank stare for about 20 seconds. She then rested for the next few
hours. He also notes that: normal EEG does not exclude epilepsy.? Even after the
removal of the mother from Ellen?s care, the diagnosis of epilepsy remains present in
Ellen?s medical records. There was testimony that one of the seizure medications has been
discontinued, but Dr. Mateen has continued Ellen on anti-seizure medication.

Dr. Woods testi?ed that Ellen did not suffer from aspiration. The medical records presented
in Exhibits 228 and 237 demonstrate otherwise.

Dr. Woods testi?ed that Ellen did not suffer from legitimate adrenal issues, but Exhibit 316
which is a report from Mary Bridge Pediatric Endocrinology Clinic dated 6/11/2018 states
that Ellen has Cortisol de?ciency and the report explains that: ?This means that her body
is unable to process enough of the hormone needed to support her body functions in times
of severe physical stress. 

Dr. Jenny testi?ed that Ellen suffered from a high number of line infections, beyond the
number she found common in a study of children with central lines. Dr. Jenny also testi?ed
that she did not determine the causes of Ellen?s line infections and could not testify that
they were caused by medical abuse. Dr. Boles testi?ed that infections and blood clots are

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extremely common in patients with similar to Ellen?s and that Ellen has had less
infections than most of the patients he has cared for with similar medical issues. Dr.
Shwartz, Ellen?s infectious disease doctor, indicated in an email to CPS investigator,
Narissa Shirley, on May 3, 2018 that he had been treating Ellen for infections and had ?no
concerns. Exhibit 31 1.

Dr. Woods and Dr. Jenny testi?ed that the mother severely restricted Ellen?s activity level.
Dr. Woods testi?ed that the mother kept Ellen bedridden. Dr. Jenny testi?ed that Ellen?s
activity was restricted to the point that she had to use a wheelchair or walker. The Court
does not ?nd the doctors? testimony on this point accurate as the records and testimony of
other witnesses contradicts their opinion. There was no evidence submitted that Ellen was
ever in a wheel chair. Dr. Nilsen and Nurse Graag testi?ed that Ellen was quite active in
the hOSpital in April and May 2018 after her health began to improve. The Court notes that
when Ellen was admitted into the hospital, she was critically ill, hooked up to machines
and monitors and as such, she would not have been active. But the record is clear that after
her health improved she was active and would mostly be in the activity! play room or
playing on the ?oor in her room. Mother testi?ed that they put down a pad for her to play.
Megan Carter, Diedre Bagocki, Dianne Hanratty Penoyer, John Gese and Ruth Carter all
testi?ed that Ellen was quite an active child who participated in ballet and liked to play
with her brother and friends in the neighborhood. None of these witnesses ever saw the
mother restrict Ellen?s activity level in any inappropriate way. Videos of Ellen were also
admitted in Exhibit 277 showing Ellen to be a quite active and happy child.

Ellen Carter was cared for by many doctors over a ?ve-year period before the Dependency
Petition in this case was ?led, including Dr. Al Mateen, neurologist; Dr. Pickens,
gastroenterologist; Dr. Murphy, pulmonologist; Dr. Schwartz, infection disease; Dr.
Chang, hematologist; Dr. Nilsen, hospitalist; Dr. McCabe, hospitalist; Dr. Lee,
pediatrician; and Dr. Kett, complex care physician. None of the medical records admitted
at trial from any of these doctors raised the concern of medical abuse by Megan Carter
prior to Ellen?s May 2018. In fact, the medical records establish that Megan Carter
cooperated with Ellen?s medical care and followed doctors? recommendations. Dr. Nilsen
and Nurse Gragg testi?ed that they had signi?cant contacts with Ellen and Megan Carter
prior to May 2018 and that they never had any concern that the mother was engaging in
medical abuse. Dr. McCabe in his notes commented that the mother was very cooperative

and helpful in providing care for Ellen and that the mother did not have any agenda of her
own. Exhibit 315.

Until May 2018 when Nurse Gragg, Dr. Nilsen, Dr. Woods and Detective Muse watched
the videos admitted as Exhibits 162 and 163 and erroneously concluded that Megan Carter
had disposed of Lovenox instead of administering it to Ellen, there were no medical records
from providers with any concerns of medical abuse by the mother (see Findings regarding
social worker report, supra). Medical abuse is only mentioned after the videos were
viewed and misinterpreted. Dr. Woods? claims that doctors or other health care providers
raised concerns about medical abuse by the mother during a meeting which was held in

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May 2018 is uncorroborated by any medical records or statements from those doctors or
providers themselves.

Since the one referral made by Dr. Lee in 2014, it is signi?cant that Ellen?s many medical
care providers did not make any mandatory referrals to law enforcement or CPS regarding
concerns of abuse or neglect about the mother?s Care of Ellen (see Findings regarding
social worker report, supra). According to the policy and protocols of MultiCare and Mary
Bridge Children?s Hospital in Exhibit 325, any Mary Bridge Children?s Hospital staff
member who has ?reasonable cause to believe a child su?ered abuse or 
immediately report the abuse or neglect as required by law. The report must be made at
the ?rst opportunity, but in no case longer than 48 hours. While the policy and protocols
also require staff to report concerns of abuse or neglect to the CAID of which Dr. Woods
is a member, the policy does not provide that reporting concerns of abuse or neglect to
CAID is a substitute for or satis?es the requirement of reporting to law enforcement and
CPS. The policy requires staff members to report concerns of abuse or neglect to law
enforcement or CPS and to CAID, not one or the other. The policy also requires staff to
document concerns of abuse or neglect themselves.

The CASA testi?ed that she reviewed the medical records provided in discovery in this
case and saw ?inconsistencies? between the records and the reports of the mother. In the
over 10,000 pages of discovery which were discussed at trial, the only evidence in the
medical records which raised a concern about the mother?s reports appears in Exhibit 427.
See Findings 2.9 and 2.10 above. No evidence of other concerns about Megan Carter?s
care of Spencer or Ellen were raised by these or other doctors until May 2018.

DCYF also submitted Exhibits 13, 168 and 169 into evidence to document an incident
which it and the CASA claimed was evidence of false or exaggerated reports by the mother
about Ellen?s medical condition and to show mother?s inability to provide adequate care
for Ellen. Dr. Jenny supported these claims about these exhibits. These exhibits
demonstrate that on October 4, 2013, mother observed Ellen ?have a blood?tinged
regurgitation/spit?up associated with cough. She contacted Dr. Lee about the incident
and agreed to take Ellen to the Swedish Hospital Emergency Room after which she was
admitted to the hospital. In the hospital it was determined that the mother was mixing

Ellen?s formula incorrectly and the nursing staff were able to get Ellen to feed without
trouble.

2.78 The Court does not ?nd Exhibits 13, 168 or 169 are evidence of medical abuse. First, there

is no evidence that the mother provided a false or exaggerated report about Ellen?s
At the time, Ellen was 5 months old and most of her life had been in the hOSpital.
There is no dispute that Ellen was born extremely pre-mature and that she had complicated
and medically complex issues. There is a long, documented history in evidence about
Ellen?s feeding and gastrointestinal issues for which she continues to receive treatment.
While the nursing staff did not observe the regurgitation or spitting up which the mother
had reported happened earlier, that does not mean that it had not happened as mother
described. It is plausible that the mother would get worried when her medically and

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physically fragile baby who was recently released from the hospital, spits up and there is a
tinge of blood. Doing nothing in this situation and not having the baby checked by the
medical personnel would in such case be irresponsible parenting. The mother appropriately
reported the issue to Ellen?s doctor and followed the doctor?s instructions. While the
mother admitted that she had been mixing the formula incorrectly because she was either
mistaken about it or given the wrong instructions, she also testi?ed that when she was
informed of the mistake, she corrected it. Considering that at that time Ellen had recently
been released from the hospital, that mother was new to feeding Ellen outside of the
hospital setting, that Ellen had feeding issues and many other health concerns, it is plausible
that the mother got the mixture ratio wrong. There is no evidence that the mother did not
feed the baby only that the ratio was wrong. At any event, it is reasonable for the mother
of such fragile new born to become worried after seeing a tinge of blood when the baby
spit-up. There is no reason to believe that the mother was intentionally mixing Ellen?s
formula incorrectly. The Feeding Evaluation in Exhibit 285 was performed three weeks
before the hospital admission discussed in Exhibits 168 and 169 and documented legitimate
feeding issues. This Court ?nds that Exhibits 13, 168 and 169 do not corroborate medical
abuse by the mother.

DCYF and CASA argue that medical abuse is further established by Ellen?s improved
medical condition since the mother was removed as her caretaker. This conclusion was
supported by the testimony of Dr. Jenny and Dr. Woods. The Court is not persuaded by
these arguments and the doctors? testimony.

This Court ?nds that while Ellen suffered from a number of signi?cant medical conditions
and had a number of hospitalizations prior to the removal of the mother as her caretaker,
her condition was not as described by Dr. Jenny or Dr. Woods. Ellen was not starved or
intentionally malnourished by the mother. The evidence established that Ellen had
signi?cant feeding and gastrointestinal issues since birth which affected her oral intake of
food and ability to absorb calories and grow. The Court heard testimony ?om the family
members that that food was always available to Ellen, but that she did not often eat much.
Ellen?s physical activity was also not inappropriately restricted by the mother. Dr. Nilsen,
Nurse Gragg and the mother testi?ed that when Ellen felt well enough, she was often seen
in the playroom and had a lot of energy. Outside of the hospital, the mother arranged for
Ellen to participate in ballet and was often active playing with friends. Some of Ellen?s
activities were captured in the videos presented in Exhibit 277. The portrayal of Ellen as
constantly sick or sickly is not accurate.

Since release from the hospital Ellen continues to suffer from gastrointestinal issues,

seizure-like adrenal issues, developmental delays and has chronic kidney
disease. She continues to receive the majority of her nutrition through a G-Tube which

chart admitted in exhibit 172 con?rms this. The Court ?nds that Ellen?s physical condition

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has improved since May 2018 when she was released from the hospital, but that signi?cant
medical conditions and challenges remain. Dr. Lee testi?ed also that as Ellen grows, she
may out-grow many of her medical conditions.

The Court ?nds that the improvement in Ellen?s medical condition, since her release from
the hospital in May 2018, was not due to the removal of the mother as her caretaker. The
evidence submitted in trial and the testimony of the witnesses show that Ellen had been
critically ill and spent two months (March May) in the hospital including a few weeks in
the PICU. When she moved out of the PICU, the feeding directive from the doctors was
that she was to receive food through her J-tube and was only allowed to eat ice orally.
Exhibit 218. The fact that Ellen gained weight after her release from the hOSpital was due,
in part, to her poor condition after being seriously ill and hOSpitaIized for two months as
well as the restrictions placed on her oral feeding by the hospital staff.

Before discharge, Ellen?s central line was also removed. The Court heard Dr. Boles?
testimony that the primary reason for the improvement in Ellen?s general health condition
after her release from the hOSpital was the removal of her central line which was the cause
of a number of infections and hospitalizations. Dr. Boles testi?ed that Ellen?s illnesses
from infections due to her central line impacted Ellen?s ability to eat and grow. Dr. Lee
testi?ed that children like Ellen can age-out of some of their medical conditions. Also, a
number of changes to Ellen?s feeding protocols were made at the time of her release from
the hospital, including working with a feeding therapist, which has had a positive impact.
Both Dr. Lee and Dr. Boles testi?ed that Ellen?s progress is not evidence of medical abuse
committed by the mother. This Court ?nds that the progress Ellen has made since her
release from the hospital in May 2018 was due to a number of independent factors and not
due to the removal of the mother from caring for Ellen.

Dr. Boles, Dr. Woods and Dr. Jenny were all in agreement that Ellen was
?overmedicalized? at the time she was admitted to the hospital in March 2018. The Court
?nds that the overmedicalization was not the fault of Megan Carter or the result of medical
abuse. Likewise, this Court ?nds that the successful removal of some of Ellen?s
medications and medical interventions since mother?s removal from Ellen?s care is not
proof of medical abuse. No evidence was submitted at trial that the mother ever requested
particular interventions for Ellen or tried to substitute her judgment or opinions for those
of Ellen?s doctors. There was no proof submitted at trial that the doctors who ordered
Ellen?s medications and medical interventions acted negligently, committed malpractice,
or were improperly in?uenced by the mother. This Court ?nds that the doctors who made
their decisions about how to treat Ellen did so based on their expertise and sound medical
judgment. No evidence was presented to believe otherwise. These medical experts did not
make medical decision on a critically ill child with medical complications based on what
Megan Carter wanted. In fact, Megan Carter never suggested a speci?c course of treatment,
she just followed the recommended course. The evidence established that the medical
interventions were recommended by the doctors and that Megan and Andy Carter agreed
to them because they were recommended. The evidence established that the mother
followed the recommendation of the doctors.

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There was a plan for Ellen to have a ?well-admission? to evaluate her condition when she
was not sick; to which the mother agreed, but this plan was interrupted by Ellen?s admission
to the hospital in March 2018. There was also a plan for Ellen to be evaluated by the
Undiagnosed Disease Network, but that plan was also not followed through due to Ellen?s
hospital admission. In May 2018, after the mother was removed from Ellen?s care, the
medical providers recommended to de-escalate Ellen?s medications or interventions. The
Court does not ?nd that the medical abuse by the mother was the reason for Ellen?s
medicines and interventions at the time of her admission to the hospital in March 2018.
This Court ?nds that Megan Carter merely followed the recommendations of Ellen?s
doctors. Likewise, the failure to de-escalate Ellen?s medical care prior to her admission to
the hospital in March 2018 was because no such recommendations were made by the
doctors.

2.86 The Court ?nds Megan Carter?s testimony to be credible. She answered all questions asked

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of her and had a strong memory of events. She testi?ed that she did not provide false or
exaggerated information to doctors about Ellen?s and did not have any agenda in
seeking medical care for Ellen over the years. She testi?ed that she was not a victim of
medical child abuse herself and did not receive any pleasure from Ellen?s medical
conditions. She testi?ed that she followed the recommendations of the doctors and did
nothing to harm Ellen.

Dr. Woods? theory that the mother has falsely caused all the medical providers to act, that
she has wasted medicine, that she has bene?tted from secondary gain, that she has abused
the children are the core of the allegations against the mother. As attractive as it
may be, there needs to be more than just a theory to prove these allegations by the
preponderance of the evidence. There were none in this case. Dr. Woods in her testimony
was more defensive about her opinion than providing factual basis to support her
accusations against the mother. The record did not support Dr. Woods claims that there
were multiple providers with concerns, not only she did not document these independent
concerns, she did not name the multiple providers who she claimed had concerns
independent of and previous to her accusations. She did not tell the mother about ?multiple
entities with concerns and did not testify about them. The only conclusion that the Court
can reach is that there were none (with the exception of the social worker?s report), that
after receiving the maternal grandfather?s letter and seeing a child with multiple and
complex medical issues, Dr. Woods became suspicious of the mother and her suspicion
caused the removal of the mother from the lives of two medically and physically fragile
children. Ellen and Spencer are lucky that they have the support of their paternal
grandparents and their father.

Dr. Jenny who has extensive experience, was factually mistaken at times and at other times
did not support her opinion with the underlying facts. Her testimony showed that in her
review of the record, she basically rubber-stamped Dr. Woods? ?ndings without a critical
review of her ?ndings. For example, both doctors claimed that the mother was a victim of

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child medical abuse. Neither one ever investigated this claim. There was no evidence to
prove this claim, but they used it as a factor against the mother.

Ellen and Spencer are children who were both born pre-mature and with complex medical
issues. While Spencer?s medical issues are somewhat less complicated than his sister?s,
Ellen?s medical issues continue to be numerous. The children have loving parents and
grandparents. They have a close extended family and as such they are lucky children. As a
parent of a medically fragile child, Megan Carter has done an excellent job, she has been
thoughtful, caring, attentive to their needs and vigilant with their health issues. She has
kept consistency in their medical providers, she has followed every medical advice and
recommendation and has put many hours in providing, at times complex medical care that
her children needed. She has made the children her priority. She has made activities
available to Ellen such as ballet that would not normally be available to a child in her
condition. The family have gone through hardship because of the allegations brought

against them and at the same time they have stayed true to their commitment to their
children.

This Court ?nds that the facts presented at trial do not establish by a preponderance of the
evidence that Megan Carter committed medical abuse or any other abuse or neglect
against Ellen Carter or Spencer Carter.

This Court ?nds that Megan Carter is able to provide adequate care for Spencer Carter and
Ellen Carter and that neither of the children are dependent children.

111. Conclusions of Law

This court has jurisdiction over the mother and these children.

3.1

3.2

3.3

3.4

3.5

The mother was given timely and proper notice of these proceedings and attended every
day of the dependency fact ?nding trial.

After reviewing the testimony and exhibits admitted at trial, this Court ?nds that DCYF
has not proven by a preponderance of the evidence that Megan Carter abused or
neglected either of her children, Spencer Carter and Ellen Carter.

DCYF did not prove by a preponderance of the evidence that Megan Carter committed
medical abuse or neglect against Spencer or Ellen Carter as alleged in the petition and as
otherwise alleged by its medical experts, Dr. Woods and Dr. Jenny.

DCYF did not prove by a preponderance of the evidence at trial that Megan Carter is
unable to provide adequate care for her children, Spencer and Ellen Carter.

Spencer and Ellen Carter are not dependent children according to RCW 
or 

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IV. Order

4.1 The children, Spencer Carter and Ellen Carter, are not dependent pursuant to RCW

and because Megan Carter is available and can provide adequate care
for them.

4.2 The Dependency Petition alleging that Megan Carter is unable to provide adequate care
for Spencer and Ellen Carter is hereby dismissed.



Judge Susan Amini

DA TED: 06/21/201 9 I 

 

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