[Lessons of an unpunished child abuse].

Around 2000–2500, physically abused children get into the sight of child protective services in Hungary. However, the number of unrecognized cases can be a multiple of this number. Cases with physical injury or severe neglect are often first seen by healthcare providers or, rather, alone in many cases. The reporting willingness of healthcare workers is low, and they often fail to fulfill their obligation to report. Apart from the consequences of failing the reporting obligations, we want to draw attention to the preventive role of reporting. The one-and-a-half-year-old girl was taken to the local dentist by her foster mother in a state of unconsciousness, mentioning food aspiration. The child was hospitalized after her deteriorating condition required resuscitation. The child was in a state of brain death during her whole hospital treatment. Bilateral frontal and multiple chest hematomas were recorded on admission; the CT described brain edema and double skull fracture. The child died on the 6th day of treatment. The case was not reported to the authorities, not during her treatment, and not when she died. Pathological autopsy found subdural bleeding and two skull fractures with different timing. The case was reported to the authorities 9 years later. The investigation found that the child died due to a head injury caused by the underaged son of the foster parents, who could not be punished due to his age at the time of the crime. The criminal responsibility of the foster parent was excluded because of the statutory limitation. The case reveals that strengthening forensic medical knowledge would be needed, but the optimal solution would be introducing clinical forensic medicine into Hungarian clinical practice. Orv Hetil. 2024; 165(14): 553–559.