Editor’s note: This story contains graphic testimony and descriptions of injuries to an infant that some readers may find disturbing.
ASHEVILLE, N.C. (828newsNOW) — A pediatrician who specializes in child abuse told jurors Monday that her diagnosis in the death of a Buncombe County infant was “child torture.”
Nickolas Shane Stephenson, 37, is on trial for first-degree murder and intentional child abuse causing serious bodily injury in the June 2022 death of his 12-week-old daughter, Riley Leshae Hannah Stephenson.
The child’s mother, 32-year-old Diandra Haleigh Fuhr-Farlow, pleaded guilty to intentional child abuse causing serious bodily injury in the case.
Dr. Sarah Monahan-Estes, who leads the Child Abuse Pediatrics team at Mission Hospital, briefly took the stand Friday before court recessed for the weekend. She resumed her testimony Monday morning.
Monahan-Estes explained that her role is to evaluate children when physicians or emergency staff suspect possible abuse or trauma. She said she is often consulted by doctors in the emergency department, intensive care unit or inpatient hospital.
She told the court she was called to consult after Riley was brought to Mission Hospital’s emergency department in June 2022. The infant had suffered cardiac arrest, was unresponsive and showed abnormalities in her skin exam that raised immediate concerns of neglect and abuse, Monahan-Estes testified.
In her review of the case, she said she examined Riley’s medical records from her birth and her final emergency room visit, the autopsy report and photographs and videos provided by investigators and the district attorney’s office.
Monahan-Estes said the findings led her to conclude Riley was the victim of “child torture.”
The hospital
Monahan-Estes said the infant showed signs of severe neglect and multiple healing fractures at the time of her death.
She explained the medical term “cachectic,” which she used to describe Riley’s appearance. The word refers to wasting syndrome often seen in patients with advanced cancer or other serious illness, she said, meaning the child appeared extremely thin and malnourished.
Developmentally, a 12-week-old can cry, eat and go to the bathroom, Monahan-Estes told jurors.
“They can’t roll over, they can’t sit up. They are completely dependent on their caregivers to provide all basic necessities for life,” she said.
Monahan-Estes said by the time she arrived, the baby had been pronounced dead. No family members were present, and she said she gathered information from medical staff and hospital records.
Her examination, combined with CT scans ordered by the emergency department, revealed multiple healing injuries, including a broken arm and fractures in several ribs and the collarbone.
“These fractures were in the process of healing,” Monahan-Estes said, explaining that infants’ bodies begin repairing bone almost immediately after an injury.
She also identified a metaphyseal fracture in the baby’s arm, which she described as a type of injury typically caused by a strong shearing or jerking force.
“These are not the kind of injuries you expect to see in a healthy infant,” Monahan-Estes testified.
Gathering information
Monahan-Estes told jurors she based her report on Riley Stephenson’s death on medical records, photographs, videos, the baby’s autopsy and her own examination.
Riley was born April 4, 2022, the first child for her mother, via cesarean section after the mother’s cervix stopped dilating. Monahan-Estes said she did not review the mother’s medical records because they were not available, but Riley’s chart documented limited prenatal care and a history of anxiety treated with medication.
At birth, Riley weighed 7 pounds, 10 ounces, placing her in the 70th percentile. She scored 7 and 8 on Apgar tests — considered normal — and there were no complications.
“It takes significant force to fracture an infant’s ribs,” Monahan-Estes said, adding that a C-section delivery would not cause such injuries.
Routine newborn screenings for hearing and congenital heart defects were negative. Riley was discharged April 6 weighing 7 pounds, 4 ounces, which Monahan-Estes described as normal newborn weight loss. Parents were given feeding instructions, safe-sleep guidance, information about sudden infant death syndrome and were required to watch a video on the dangers of shaking an infant.
Riley’s first pediatric visit at MAHEC was April 20, when she was 16 days old — later than the recommended 1-2 days after discharge. At that appointment, she weighed 3.41 kilograms, still below her birth weight. Doctors provided reassurance about bowel habits but noted no medical condition causing concern. Follow-up visits were scheduled but either canceled or missed.
By June 28, 2022, emergency responders found Riley pale and gray with loose skin, signs of malnutrition and dehydration. Her blood sugar was critically low at 36. EMS documented she was pulseless and in ventricular fibrillation. They administered CPR, epinephrine and glucose, but she was pronounced dead at Mission Hospital.
A CT scan revealed healing rib fractures, a clavicle fracture, and a fracture in her right arm. Monahan-Estes said the injuries showed evidence of healing and could not have resulted from CPR. She also observed burns and bruising on multiple areas of Riley’s face and scalp.
Based on her review, Monahan-Estes testified she diagnosed medical neglect and child physical abuse.
“A 12-week-old infant cannot cause these injuries herself,” she told the jury. “The fractures, the bruising, the burns — combined with malnutrition — indicate repeated trauma and neglect.”
Looking at the photos
Monahan-Estes testified Monday that photographs and videos taken from the mother’s phone documented a series of injuries to Riley in the weeks before her death.
Monahan-Estes said an image dated May 6, 2022, showed blood in the infant’s nose and a cut along her jawline. “It was the first photograph where I could clearly see visible injuries,” she said.
Other photos taken over the next several weeks showed additional wounds, including bruises on Riley’s hard palate, cuts on her face and abrasions around her nose and mouth. Monahan-Estes told jurors Riley was not developmentally capable of causing such injuries on her own.
“A baby that age cannot intentionally shove something into her mouth with enough force to bruise the upper palate,” she said.
Several images also raised concerns about unsafe sleep conditions. In photos from early and mid-May, Riley was pictured with a pacifier lodged in her mouth and her hat pulled down over her nose and mouth, which Monahan-Estes said could increase the risk of suffocation or aspiration if the baby vomited. Loose blankets and dark stains, possibly blood, were also visible.
Later images from late May showed circular bruises across Riley’s forehead, as well as lacerations to her face and nose. By the end of the month, Monahan-Estes said, Riley appeared noticeably thinner, with blood in her nostrils and injuries on multiple planes of her face.
Videos reviewed by the doctor also raised red flags. In one, she said, Riley’s toe showed an unexplained lesion. In another, the baby was handled in a way that failed to support her head and neck, leaving her disoriented and at risk of neck or brain injury.
By June, Monahan-Estes said, the images showed Riley visibly wasting away. A video from June 23 depicted the infant lying on her side with a pacifier in her mouth, a large bruise on her head and facial lesions similar to those later documented in the emergency room on the day she died.
“These photographs and videos consistently demonstrated injuries and unsafe conditions,” Monahan-Estes testified. “They are not injuries that a 12-week-old infant could have caused herself.”
Riley’s injuries
Monahan-Estes said Riley suffered repeated injuries consistent with child abuse, including bruising, fractures, burns and oral trauma.
She said she reviewed photographs, medical records and the autopsy report prepared by Dr. William Harrison, the pathologist who examined Riley after her death in June 2022.
Monahan-Estes told jurors Riley’s injuries were consistent with a diagnosis of repeated physical abuse.
She cited several findings:
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Oral injuries: Photographs showed bruising inside the infant’s mouth and a torn frenulum, the thin piece of tissue that connects the gums to the lips or tongue. Such injuries, she said, are common in toddlers who fall with objects in their mouths but are highly concerning in infants, who lack the developmental ability to cause them on their own.
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Bruising: Monahan-Estes said Riley had bruises on her face, torso, arms, legs and both ears. “Any bruising in an infant is concerning,” she testified. “Ear bruising at any age requires significant force. Seeing it on both ears indicates multiple impacts.”
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Burns: She described injuries consistent with second-degree burns across the baby’s face, which she said would have been extremely painful and required medical treatment to control pain and prevent infection. By the time she examined Riley, the burns were healing, but she testified that the child likely suffered greatly when they first occurred.
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Fractures: CT scans and the autopsy revealed healing rib fractures, a broken clavicle and a fracture in the infant’s arm. She told jurors no bone disease was detected and the child was too young to cause the fractures herself.
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CPR: Asked whether resuscitation efforts could have caused the fractures, Monahan-Estes said CPR-related breaks are rare and would have been classified as acute injuries. “Riley’s fractures were all healing,” she said. “They were not the result of CPR.”
Monahan-Estes concluded that Riley’s constellation of injuries — affecting multiple parts of her body over a period of time — could not be explained by accident or medical condition.
“These are not injuries a 12-week-old could have inflicted on herself,” she testified.
The findings
Monahan-Estes said Riley suffered severe physical abuse and prolonged neglect, leading her to diagnose the infant’s case as “child torture.”
She told told jurors that Riley showed signs of medical neglect, nutritional neglect and repeated physical trauma.
She said medical neglect was evident because the infant’s facial burns were never treated by a doctor, despite an appointment being scheduled and later canceled.
“She would have been in significant pain, with open wounds at risk for infection,” Monahan-Estes said.
Riley’s autopsy also revealed untreated pneumonia, which she said would have produced symptoms — fever, cough or difficulty breathing — that should have prompted medical care.
Nutritionally, Riley weighed 7 pounds, 10 ounces at birth but only 6 pounds, 6 ounces when she died 12 weeks later.
“On the day she was born, she was in the 70th percentile,” Monahan-Estes testified. “On the day she died, she was below the first percentile.”
She said no medical condition was found to explain the weight loss. Instead, she concluded Riley was severely malnourished and had not received the interventions typically provided for infants diagnosed with “failure to thrive.”
Monahan-Estes said Riley’s numerous fractures also would have impaired her ability to breathe deeply, contributing to her pneumonia and overall decline.
“Every one of her 17 fractures would have caused her significant pain,” she said.
Based on the combination of repeated injuries, untreated medical conditions and severe malnutrition, Monahan-Estes told jurors Riley’s case met the accepted medical criteria for child torture. Those standards, she said, require evidence of at least two assaults causing prolonged pain, psychological abuse through neglect or isolation, and resulting injury, disfigurement or death.
“My conclusion was that Riley experienced numerous episodes of both abuse and neglect throughout her life,” Monahan-Estes testified. “Her injuries and presentation are consistent with the medical diagnosis of child torture.”
Cros examination
The defense pressed Monahan-Estes about whether some of Riley’s injuries could have been caused at birth or went unnoticed during early medical visits.
Monahan-Estes, a pediatrician specializing in child abuse cases, acknowledged it was possible for infants to sustain fractures not visible on routine skin exams. But she testified that Riley’s 17 fractures, bruises and burns were inconsistent with birth trauma.
“The totality of her injuries cannot be explained by anything other than abuse and neglect,” she said.
The defense also questioned her reliance on information provided by Riley’s mother, Diandra Fuhr-Farlow, who has pleaded guilty to intentional child abuse causing serious bodily injury. Monahan-Estes said while she considered the mother’s statements, her medical conclusions were based on records, imaging and physical evidence.
The defense also raised Riley’s mother’s mental health history and whether inadequate prenatal care may have played a role in Riley’s death. Monahan-Estes confirmed medical records noted anxiety treated with Celexa and documented “insufficient prenatal care,” but said those issues did not explain Riley’s extensive injuries.
Monahan-Estes told jurors she could not determine which factor — fractures, burns, pneumonia or malnutrition — contributed most to the infant’s death. “That determination belongs to the pathologist,” she said. But she maintained that, taken together, the findings were consistent with what she called “the medical diagnosis of child torture.”
Prior coverage
‘She would cry’: Mother recounts abuse before baby’s death
Body cam, crime scene evidence shown in Asheville murder trial
Emergency responders testify in death of 12-week-old