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For the third time in two years, a state medical examiner has backed away from a finding that an infant died of "shaken baby syndrome,'' but this time prosecutors are refusing to drop homicide charges, Middlesex District Attorney Marian Ryan said Tuesday.

The latest case, likely to intensify questions about the handling of this type of child abuse prosecution, involves the death of a 6-month-old girl from Burlington who lapsed into unconsciousness while being cared for by a home day care operator on March 27, 2014, and later died at Boston Children's Hospital.

A medical examiner who performed the autopsy, Dr. Anna McDonald, reviewed the case for a year and declared that the girl, Ridhima Dhekane, had died of abusive head trauma and excessive shaking, citing spinal fractures, brain swelling, and retinal damage.

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The day-care operator, Pallavi Macharla, was charged with murder.

Prosecutors maintain that 6-month-old Ridhima Dhekane died in 2014 from injuries suffered at the hands of her day care provider.
Prosecutors maintain that 6-month-old Ridhima Dhekane died in 2014 from injuries suffered at the hands of her day care provider.Middlesex District Attorney’s office

But since then, McDonald has gradually adjusted her determination of the cause of death. In December, she said the child's retinal damage was not caused by traumatic shaking, but continued to call the death a homicide. Last month, after reviewing reports from the defense's experts, McDonald stepped back from a homicide ruling altogether, saying the child died of cardiac arrest.

In a March 22, 2016, letter, McDonald told prosecutors and her former boss in the medical examiner's office, Dr. Henry Nields, that she believed the baby died of "a cardiopulmonary arrest of unknown etiology." She said other injuries found in her brain and eyes were related to aggressive revival efforts by medical staff or other causes related to poor blood flow.

The Globe's efforts to reach McDonald on Tuesday were unsuccessful. She left the medical examiner's office in August 2014 to join the faculty at Wake Forest School of Medicine in North Carolina, and her major findings and the revisions in the case all came after she left.

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Ryan said her office will continue to press murder charges against Macharla, 41, who ran an unlicensed day-care center in Burlington, but she acknowledged that McDonald's revised opinion could present complications with the jury.

Ryan told the Globe that a key factor in her decision to move forward is the future testimony of the chief medical examiner, Nields, who in 2014 supervised McDonald and was present at the autopsy. Ryan said Nields "remains steadfast in his opinion that the cause of the baby's death as stated on the death certificate should remain unchanged," prosecutors said in a filing.

In a release, Ryan said, "The Commonwealth is proceeding with the prosecution of this case because the only plausible explanation for the death of this otherwise healthy six month old baby is the defendant's conduct on March 27, 2014. . . . She had no underlying medical conditions that would explain the fractures to her spine or the bleeding in her brain and eyes."

Ryan also said "any suggestion that there was a problem with [Ridhima's] heart is belied by the fact that her heart was successfully transplanted into a baby who is thriving. The Chief Medical Examiner of the Commonwealth remains firm that the baby's cause of death is 'blunt force trauma and shaking injuries.' "

Prosecutors also question why Macharla did not immediately call 911 when the child became unconscious around 2:30 p.m. Instead, after about 11 minutes, prosecutors say, she called the baby's mother, who rushed to the home day care. After finding the baby unresponsive, the mother called 911. By that time, more than 20 minutes had elapsed.

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This case marks the third time in the last two years that a shaken-baby prosecution in Middlesex County has run into complications. In the two other cases, Ryan's office ultimately decided not to prosecute when the medical examiner, after reviewing defense experts' reports, changed the finding from homicide to undetermined.

One case involved an MIT employee, Geoffrey Wilson, accused of killing his son, and the other involved an Irish nanny, Aisling Brady McCarthy, charged with murdering a Cambridge baby girl in her care. Both cases were ultimately dropped by Ryan's office.

J.W. Carney Jr., an attorney who represents Macharla, who was a medical doctor in India, issued a press release Tuesday, still holding out hope that prosecutors will drop the case.

"She has been consistent and unwavering in her denials of harming the child in any way," he wrote.

In his statement to the court, Carney said Macharla was feeding applesauce to the infant when she "choked and vomited, and then became unresponsive." Macharla began CPR and called the infant's mother. Carney, who had also represented Wilson, said he later hired Dr. Elizabeth Laposata, former chief medical examiner of Rhode Island, who found that cardiac arrest was the cause of death.

When McDonald initially declared the death a homicide, Macharla was indicted and held without bail. However, in December, when McDonald began revising her opinion, Macharla was released on $25,000 bail, provided she remained under house arrest. She was allowed to go out only for court appointments and lawyer visits. Under a ruling issued Tuesday, Macharla is no longer under house arrest, but must still wear a GPS monitor.

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Despite Ryan's statements about continuing the prosecution, Carney hopes she will drop the charges, as she did twice before. "Dr. Macharla prays that the same result will occur in her case, rather than having to go through a trial that will be agonizing for her and the victim's family."

J.W. Carney Jr., attorney for Macharla, said his client “has been consistent and unwavering in her denials of harming the child in any way.”
J.W. Carney Jr., attorney for Macharla, said his client “has been consistent and unwavering in her denials of harming the child in any way.”Dina Rudick/Globe Staff/File 2015/Boston Globe

Patricia Wen can be reached at patricia.wen@globe.com. Follow her on Twitter @globepatty.