People v. Jacobazzi (398 Ill. App. 3d 890, 2009)

JUSTICE O’MALLEY

delivered the opinion of the court:

Defendant, Pamela Jacobazzi, appeals from the order of the circuit court of Du Page County denying her postconviction petition following an evidentiary hearing. On appeal, defendant argues that the trial court’s determination was manifestly erroneous. We affirm but remand for a further evidentiary hearing.

BACKGROUND

This being the third appeal in this case, the background facts are well known by the parties and this court, and there is no need for a full recapitulation. Instead, we present a brief summary of the background and will include where appropriate other facts relevant to the disposition of this appeal.

In 1999, defendant was tried for the first-degree murder (720 ILCS 5/9 — 1(a)(2) (West 1994)) of the victim, Matthew C. The State’s evidence showed that the victim was essentially comatose when his mother picked him up on August 11, 1994, from the home of defendant, who was the victim’s day care provider. The victim was hospitalized and found to have injuries including a subdural hema-toma, subarachnoid bleeding, and retinal hemorrhages. He never regained consciousness and died several months later. The State’s theory was that the victim’s injuries were so severe that they could not have been inflicted accidentally. The State further argued that the injuries would have been immediately disabling and that since there was no evidence that the victim was acting abnormally before he was placed in defendant’s care on the morning of August 11, 1994, they must have been inflicted while the victim was in defendant’s charge that day. The State noted that in the medical literature subdural hematoma, subarachnoid bleeding, and retinal hemorrhages in infants are often collectively referred to as “shaken baby syndrome” because they are typically associated with a violent shaking of a child. The State presented the foregoing theory through 10 expert witnesses.

The defense challenged the strength of the State’s theory that the victim suffered a violent shaking by defendant on August 11, 1994. The defense suggested that the victim’s condition on August 11 was from an injury on a prior date. Defendant testified that, on August 8, the victim was sitting on the kitchen floor when he lost his balance and fell forward from a sitting position, striking his head on the tile and sustaining a bruise to which defendant applied ice. Dr. Kenneth Sullivan, the neuroradiologist who read the victim’s CT scans on the night he was hospitalized, and Dr. Jan Leestma, a neuropathologist and defendant’s sole retained expert, testified that the CT scans showed “old” blood, indicative of a hematoma that originated days before and rebled on August 11, mimicking the indicia of shaken baby syndrome. Dr. Leestma also found old blood in the pathology slide of the hematoma. Dr. Leestma opined that the oldest of the blood in the hematoma was 10 or 11 days old and that defendant’s accident three days before August 11 might have aggravated the hematoma.

Defendant was convicted and sentenced to 32 years of imprisonment. She filed a timely appeal raising 47 separate claims of ineffective assistance of trial counsel. See Strickland v. Washington, 466 U.S. 668, 80 L. Ed. 2d 674, 104 S. Ct. 2052 (1984). We rejected these contentions and affirmed the conviction. See People v. Jacobazzi, No. 2 — 00— 0523 (2001) (unpublished order under Supreme Court Rule 23) (Jacobazzi I). One of defendant’s arguments was that trial counsel was ineffective for choosing Dr. Leestma as an expert, because (1) his testimony “was not consistent with facts developed at trial”; and (2) he was extensively impeached with his past professional writings in which he warned against many of the angles that defense counsel themselves were using at trial to discredit shaken baby syndrome as a viable diagnosis both in general and in the case at hand. Our discussion of that issue spanned just these few sentences:

“Other allegations of error simply employ hindsight to question defense counsel’s performance, without considering the circumstances as known to defense counsel at the time. For example, defendant alleges that defense counsel ineffectively selected Leestma as an expert witness because he was impeached with his prior writings and his opinion was inconsistent with the facts developed at trial. Defendant fails to identify the expert witness, if one exists, who was available to testify on her behalf and would have provided more favorable testimony. Nor does defendant identify anything in the record to suggest that defense counsel knew of such a witness and failed to call her or him. We believe that this argument is little more than an attempt to construe the evidentiary weakness of defendant’s case as the ineffectiveness of defense counsel.” (Emphasis added.) Jacobazzi I, slip op. at 95-96.

We immediately followed with these comments:

“We find that the weaknesses we have identified above are common to many of the remaining allegations of error in defendant’s ineffective assistance argument. However, there is no need to inquire further into the individual allegations of error, because we may proceed directly to the second prong of the Strickland analysis. [Citation.] Therefore, the question before us is whether, in light of the evidence presented, the outcome of defendant’s trial would have been different absent the alleged errors.

The State presented overwhelming evidence of defendant’s guilt. *** [T]he State presented one medical expert after another who testified that the victim’s injuries were the result of shaken baby syndrome and could not have resulted from dancing, tumbling, or other accidental causes, except an automobile accident or a fall from a height of two or more stories. The experts also substantially agreed that the injuries occurred on August 11, 1994, during the time period while the victim was in defendant’s care. Other witnesses testified regarding the victim’s condition, narrowing the possible time frame for the victim’s injuries to a small period on the afternoon of August 11. The only medical expert who testified that the victim’s injuries could have occurred outside this time frame, [Dr. Leestma,] was thoroughly impeached with prior inconsistent statements that supported the State’s theory of the case. *** We do not find that absent the errors defendant identifies, that [sic] a substantial probability exists that the jury would have evaluate [sic] the expert medical testimony or [the victim’s mother’s] credibility differently.” (Emphasis added.) Jacobazzi I, slip op. at 96-97.

On May 17, 2002, defendant filed a petition for relief pursuant to the Post-Conviction Hearing Act (the Act) (725 ILCS 5/122 — 1 et seq. (West 2002)), raising two new claims of ineffective assistance of trial counsel. First, defendant argued that counsel was ineffective for failing to call certain witnesses on her behalf and to cross-examine the victim’s mother regarding the victim’s medical history. Second, defendant contended that counsel was ineffective for failing to review, and have Dr. Leestma review, the records of Dr. David Nadelman concerning his treatment of the victim in the years before the injury. Defendant argued that counsel was ineffective for failing to present evidence at trial that the victim’s injuries may have resulted from one or more of the following preexisting medical conditions that were either expressly diagnosed in the Nadelman records or inferable from them: sickle cell trait, external hydrocephalus (enlarged head), hemophilia, fever, dehydration, and anemia. To support her claim that counsel could have presented a meritorious defense based on the Nadelman records, defendant attached affidavits from Dr. Claus Speth and Dr. Urna Subramanian. Both challenged the conclusiveness of the State’s claim that the various pathologies found in the victim on August 11, 1994, were the result of a violent shaking that day.

Dr. Speth averred that he is board-certified in anatomic, clinical, and forensic pathology and is a former state medical examiner. Dr. Speth noted that the victim’s subdural hematoma was “unilateral” and that “in shaken baby syndrome, subdural hematoma in the majority of cases is just a thin layer of blood that does not compress the brain and is more often bilateral.” Dr. Speth also noted: “[S]ubarach-noid hemorrhage is not a general finding characteristic of shaken baby, although it is frequently present, but then in just small amounts and not necessarily in relationship with subdural hematoma.” Dr. Speth further remarked that the victim also suffered “cerebral infarction,” which is “not generally a characteristic of shaken baby.”

Dr. Speth also opined that, assuming the conditions found in the victim have some general association with shaken baby syndrome, in this particular case those conditions are more likely attributable to a preexisting pathology known as sickle cell trait. Dr. Speth described sickle cell trait and distinguished it from sickle cell disease:

“Hemoglobin molecules found within the round red blood cells of the circulating blood[ ] take up oxygen in the lungs and release the oxygen out at the ends of the blood stream to the cells. Hemoglobin molecules are made up of four protein molecules called globins that chemically lend the characteristics of hemoglobin-F in the newborn, gradually changing over to adult hemoglobin-A by 4 to 6 months of age. Sickle cell disease involves the inheritance of mutated globins in the hemoglobin molecules (designated hemoglobin-S). If a child inherits hemoglobin-S from both parents (called homozygous), the child has sickle cell disease; if from only one parent (called heterozygous), the child has sickle cell trait. The hemoglobin-S tends to polymerize (form chains that lend it a viscous gelatin-like character), damaging the red blood cell membranes, causing the red blood cells to adhere to vessel walls and to eventually take on a sickle shape. In those with homozygous sickle cell disease, these abnormal red blood cells clog small vessels with multiorgan damage and infections, and resulting in vast destruction of the sickled red blood cells in the spleen resulting in anemia. In the child with only the trait, there is enough adult hemoglobin-A in the red blood cells to compensate and these complications occur only under severe hypoxia (lack of oxygen), severe exertion or dehydration. The abnormal hemoglobin can be identified by a laboratory process called hemoglobin electrophoresis. However, in some persons with apparent sickle cell trait there can be what is called co-dominance (as if they were homozygous) and there are also other variants of hemoglobin-S, and then these persons will have variable degrees of complications like those with the full sickle-cell disease. These abnormal forms of hemoglobin-S require special testing methods including DNA analysis.” (Emphases in original.)

Dr. Speth then summarized the portions of the Nadelman records that mention sickle cell trait, fever, and anemia:

“The [victim] was found to have what was characterized as being ‘consistent with sickle cell trait’ (001096) by a method called iso-electric focusing on 10/7/93, to be repeated (001113). On 11/29/93 (001079) and on 12/6/93 (001080 & 001081) it is reported that blood drawn on 10/12/93 showed sickle cell trait (SAS trait). Because of continuing anemia, and possibly also because of recurrent upper respiratory infections, even though on 12/6/93 it stated ‘no further specimen needed’ (001081), another one was drawn on 12/7/93 and reported on 12/15/93 reported [sic] as: ‘Possible abnormal hemoglobin present. Please retest at 2 years of age’ (001101)[.] On 3/16/94 the [victim] was with ‘mom’s boyfriend’s sisters’ while the mother works, had an upper respiratory infection, was not sleeping and not eating (001083). On 3/21/94 the [victim] was better (incidentally the [victim] was found to have bilateral metatarsal adductens, an orthopedic deformity) (001084). On 5/9/94 it was determined again that the [victim] was still anemic (001084), indicating yet again the need to test for sickle cell hemoglobin. This anemia was again apparent on 5/31/94 (001085) and again with recurrent infections and fever. On 6/2/94 hemoglobin electrophoresis was again ordered (001085) — the results were reported as 40% hemoglobin-S, as well as continuing anemia (001086). On 7/18/94 the [victim] again had a febrile illness and dehydration, with continuing anemia (001086). Finally on 8/09 to 8/10/94 the [victim] had a febrile illness (temperature 102), one day before the incident (000001).”

Dr. Speth opined that the victim had “a variant of sickle cell trait that was causing continuing anemia and recurrent infections, and threatening to also cause the various unpredictable complications normally seen in persons with the homozygous sickle cell disease.” (Emphases in original.) Dr. Speth noted that “[t]esting to identify the exact mutation of [sickle cell trait] was never conducted.” Dr. Speth opined that sickle cell trait could have caused the conditions seen in the victim on August 11, 1994, including “a unilateral subdural hematoma compressing the brain, significant subarachnoid hemorrhage beneath the area of subdural hematoma!,] and infarction of the brain in the same region.” He explained:

“The complications that might arise under these circumstances (especially under the effects of dehydration associated with a just remitting febrile illness) include: [i] unilateral subdural hematoma (a collection of blood creating a space within the inner-most cell layers of the thick lining dura) compressing the brain, [ii] subarachnoid hemorrhage (blood spreading out through the cerebrospinal fluid over a surface of the brain under that portion of the arachnoid membrane) causing chemical irritation and spasms of the adjacent blood vessels, [iii] ischemic and hemorrhagic cerebral infarctions (destruction of brain tissue usually due to lack of blood supply and or hemorrhage into the brain tissue from vessels) and [iv] a high incidence of cerebral aneurysms (outpouching of an artery supplying blood to the brain) which can rupture into the subarachnoid and subdural spaces.”

Dr. Speth noted that he possessed “a collection of peer-reviewed articles dealing with these complications of sickle cell anemia from recognized medical journals.”

Dr. Speth explained that a subdural hematoma or subdural hemorrhage caused by sickle cell trait may be mistakenly attributed to shaken baby syndrome:

“It is vitally important to note that, in the context of shaken baby, an important differential diagnosis is the rupture of a cerebral aneurysm (an outpouching of an artery supplying blood to the brain) or a ruptured arteriovenous [AV] malformation (a congenital knot of arteries joined directly with veins on or in the brain). These do produce unilateral subdural hematoma and/or subarachnoid hemorrhage in the area of rupture, will cause sudden severe rise in intracranial pressure and can also cause secondary infarction of brain tissue — all found in [the victim]. It should be recalled! ] that ruptured aneurysms have been found in association with sickle cell anemia. Of note, though, is that the CT scans, performed on [the victim], are not designed to visualize aneurysms or AV malformations, and the blood flow scans that followed could not visualize the left side of the brain because of the severe swelling, where an aneurysm or malformation would have been located. The surgeon did not visualize the brain and, finally, the autopsy report of the brain does not mention examination of the arteries in the area of subdural hematoma/subarachnoid hemorrhage and brain infarction.”

Dr. Speth went on:

“Subdural hematomas in shaking do not compress the brain in the absence of beatings and therefore do not cause serious injury or death. They are simply indicators of some type of to-and-fro acceleration/deceleration, but in which all other possible causes (such as ruptured aneurysms, AV malformations, sickle cell disease and a myriad of other causes) have been fully explored and ruled out. The subdural hematomas in shaking do not in any way infer or lend information about the degree of force applied! And, as stated above, generally are not massive and unilateral.”

Dr. Speth observed that retinal hemorrhages, too, may result from sickle cell trait:

“Sickle cell disease, already beginning in infants, and progressing in early childhood, causes very significant changes in the eyes. Sickle cell disease characteristically causes retinal neovascularization (growth of new small vessels in the retina) and vitreous hemorrhages (hemorrhages in the glass body of the eye itself). But it also afflicts these infants with retinal hemorrhages and retinal detachment, albeit somewhat different in character and distribution than that which was identified in [the victim]. But the infants afflicted with sickle cell disease would obviously be vulnerable and susceptible to the rapid development of the type of findings described in [the victim’s] retina on August 12, 1994, when such a predisposed infant is subjected to very sudden increases in intracra-nial pressure (as occurred in [the victim]) or even minor trauma or relatively minor accelerations/decelerations. For example, it is known that the rupture of aneurysms (a high incidence of which is found in association with sickle cell disease) — with their attendant sudden increased intracranial pressure and massive subarachnoid hemorrhage, not infrequently also breaching the arachnoid causing associated subdural hematoma — can cause retinal folds and vitreous hemorrhage in non-predisposed persons. It is no great step to realize and predict that this could then be found in an infant under the circumstances when that infant is predisposed by sickle cell disease and its attendant retinal changes. Finally, oft-quoted peer-reviewed literature emphasizes that in the majority of cases, the type of unilateral retinal findings in [the victim] (but in the absence of the prediposing sickle cell disease) would generally be found in infants subjected to, not only severe shaking, but severe beating— [and] there was virtually no external evidence of a severe beating on [the victim].” (Emphases in original.)

Dr. Speth noted that for these claims as well he had “a collection of peer-reviewed articles *** from recognized medical journals.”

Dr. Speth also averred that the Nadelman records show that the victim had a “disproportionately enlarging head during his infancy,” which might indicate external hydrocephalus. Dr. Speth quoted at length from a 1999 article by Dr. Joseph H. Platt noting that, in infants with external hydrocephalus, subdural hematomas have been found “ ‘to be secondary to minor trauma or have even been described as spontaneous.’ ” (Emphasis in original.) Dr. Platt also noted that “ ‘although retinal hemorrhages in infancy has been considered virtually pathognomonic of child abuse, in the setting of external hydrocephalus a more cautious interpretation may be appropriate.’ ” Dr. Platt elaborated:

“ ‘External hydrocephalus is a common condition characterized by diffuse enlargement of the subarachnoid spaces. ***

*** Whereas enlargement of the subarachnoid spaces persists during infancy, the brain does not fill the space available within the cranial cavity, and a state of “craniocerebral disproportion” exists. The presence of craniocerebral disproportion that develops from any case — external hydrocephalus, internal hydrocephalus, arachnoid cyst, or chronic subdural hematoma — makes the patient exceptionally susceptible to subdural hematoma after what would otherwise be inconsequential trauma. In particular, the prevalence of subdural hematoma in case series of patients with external hydrocephalus seems significant. In a study reported by Azais and Echenne, “spontaneous” subdural hemorrhage was demonstrated in five of 41 patients with “benign enlargement of the subarachnoid spaces” on ultrasonography and computerized tomography scanning. Laubacher, et al., have described a “non-battered” infant among their 22 patients with pericerebral subarachnoid space enlargement, in whom a “spontaneous” sub-dural “hygroma” developed that the authors attributed to the vulnerability of the bridging subarachnoid veins. Mori, et al., have reported three infants with subdural hemorrhage [out] of 20 patients with infantile subarachnoid fluid collection. Although they fell within the shadow of publication bias, these series suggest that the prevalence of subdural hematoma in infants with external hydrocephalus may be as high as 11%.

Caffey, who first described the shaken infant syndrome, recognized that infants with hydrocephalus were prone to the development of subdural hematomas, but neither he nor any subsequent author has arrived at the following logical conclusion: the development of a subdural hematoma after minor trauma in an infant with craniocerebral disproportion might be the occasion for unjustified accusations of child abuse. The concomitant presence of retinal hemorrhages in such an instance would reinforce that the diagnosis of inflicted injury is incorrect in such cases.’ ” (Emphases in original.)

Dr. Speth noted that no imaging studies were performed on the victim’s head prior to August 11, 1994, and that subsequent imaging would not have detected external hydrocephalus, if any, because of the severe brain swelling.

Dr. Speth concluded:

“With regard to this case, based on all of the above, there is no compelling evidence that [the victim] was shaken on August 11, 1994, and no evidence that he was beaten or subjected to blunt injury. Whether or not there may have been [an] old injury is not at issue in this [affidavit] and was examined by the experts at trial. What was not explored by [the] Defense in Direct Examination were the more likely causes of [the victim’s] malady. High on the list would be a ruptured aneurysm (particularly in association with sickle cell anemia), a ruptured AV malformation, a so-called ‘spontaneous’ subdural hematoma due to a minor trivia energy-loading event in the presence of external hydrocephalus, dehydration[,] and sickle cell anemia, or subarachnoid infarction in conjunction with sickle cell anemia.”

In her affidavit, Dr. Subramanian averred that she is a medical professor at the University of Chicago and is board-certified in pediatrics and pediatric hematology and oncology. She opined that the victim’s conditions could have been caused by hemophilia, a stroke or infarction induced by sickle cell trait, or a ruptured aneurysm. Dr. Subramanian elaborated:

“Hemophilia

*** [T]he cause of [the victim’s] August 11, 1994 trauma[ ] could have been *** an undiagnosed bleeding disorder — hemophilia. Hemophilia is an X-linked bleeding disorder (mother is carrier of gene and male offspring manifests the disease). Hemophilia is due to decreased clotting factors VIII or IX. When the hemophilia is mild (level of clotting factor is between 5% and 40%), bleeding can be brought about by minor trauma. [The victim] had a history of at least one fall, hitting his head, three days prior to onset of signs and symptoms. With hemophilia the onset of bleeding can be delayed. There have been reported cases in which parents/ caregivers have been accused of child abuse and later[ ] the infant is found to be afflicted with a bleeding disorder. The absence of bleeding history in the family or absence of a carrier gene in the mother cannot rule out the diagnosis of hemophilia because gene mutation can occur. In light of the history that [the victim] fell and hit his head, on at least one occasion, within a few days prior to August 11, 1994, it can not [sic] be ruled out that the cause of the subdural bleeding that presented on August 11, 1994, could have been hemophilia.

Sickle Cell Trait

Though Sickle Cell trait per se should not cause neurological problems; however, there have been reported and documented cases in literature in which strokes as well as infarction has [sic] been known to occur as a result of Sickle Cell trait. (Handler & Perkin 1982; Reyes 1989; Greenberg T, Massey E.W 1985; and Radhakris-han K. et al. 1990).

Ruptured Aneurysm or A-V Malformation

Ruptured aneurysm or A-V malformation causing a spontaneous bleed and sudden deterioration. Since the CT Scan showed the combination of old and new blood, the possibility of an intracranial bleed due to organic causes existed. Especially[ ] with the presence of hemophilia, severe, (factor VIII or IX level is less than 1%) spontaneous intracranial bleed[ing] can occur and can be repetitive. Children less than 1 year of age can be at risk for such a bleed.

Based on my review of [the victim’s] records received from Dr. Nadelman, the existence of at least one of the above three organic conditions in [the victim] on August 11, 1994, is a strong possibility. It is impossible to rule out that the bleeding was not due to some underlying organic cause[ ] as opposed to Shaken Baby Syndrome because the above and other bleeding disorders were never ruled out by [the victim’s] treating physicians subsequent to August 11, 1994. Furthermore, the presence of one of the organic causes would also explain the continued bleeding suffered by [the victim] *** during his initial stay at Lutheran General Hospital subsequent to his initial surgery on August 11, 1994; and provide a contrary medical explanation to Shaken Baby Syndrome for the cause of the affliction suffered by [the victim] on August 11, 1994.”

Defendant also attached a May 16, 2002, letter from Dr. Leestma to Dr. Speth. In the letter, Dr. Leestma stated that none of the materials he was provided for his preparation in the case showed that the victim had sickle cell trait. Dr. Leestma had no memory of being told that the victim had that condition. Had he known of the victim’s sickle cell trait, he would have “incorporated [it] into [his] analysis and the formulation of [his opinion] in the case with respect to the range of medical conditions that might have or could have caused, or contributed to[,] the child’s intracranial pathology that ultimately brought about his death.”

After a preliminary review, the trial court found that defendant’s petition alleged facts sufficient to state the gist of a constitutional claim. The State later filed a motion to dismiss. Following a hearing, the trial court dismissed the petition. The court found that defendant’s arguments were waived due to her failure to raise them on direct appeal and, moreover, were not sufficient under Strickland.

Defendant filed a timely appeal challenging the dismissal of her postconviction petition. On November 24, 2003, this court affirmed in part, reversed in part, and remanded for additional proceedings. See Jacobazzi II, No. 2 — 02—1292. Specifically, this court determined that defendant’s first claim, that trial counsel was ineffective for failing to cross-examine the victim’s mother and call certain witnesses to testify regarding the victim’s medical history prior to the date of the victim’s fatal injuries, was barred by res judicata because it had been considered in defendant’s direct appeal. Jacobazzi II, slip op. at 6.

As for defendant’s second claim, that trial counsel was ineffective for failing to review the Nadelman records and provide them to Dr. Leestma, this court held that, although defendant failed to raise the contention in her direct appeal, the fundamental fairness exception to the waiver doctrine was applicable. Jacobazzi II, slip op. at 6. Thus, we went on to determine whether the claim warranted an evidentiary hearing. See People v. Edwards, 197 Ill. 2d 239, 246 (2001) (petition advances to third-stage evidentiary hearing if, together with any supporting affidavits, it makes a substantial showing of a constitutional violation). We defined the issue strictly as whether trial counsel and Dr. Leestma had reviewed the Nadelman records and, if not, whether Dr. Leestma would have testified differently had he known of the victim’s preexisting medical conditions as described in the records. We found that the affidavits of Drs. Subramanian and Speth cast no light on either aspect of this issue:

“[The affidavits] do not satisfy the first prong of the Strickland test, that the defendant’s trial counsel’s performance fell below an objective standard of reasonableness. [The affidavits] do not show that the defendant’s attorney did anything wrong. They certainly do not show that the defendant’s attorney failed to review and forward the victim’s medical records. They simply establish that there are other experts out there who would have testified more favorably to the defendant than Dr. Leestma. Dr. Leestma’s alleged deficient performance does not render the defendant’s attorney’s performance deficient. The fact that the [defendant] has now found two new experts who will testify differently and more favorably than Dr. Leestma also does not render the defendant’s attorney’s performance deficient.

Furthermore, [the affidavits] do not satisfy the prejudice prong of the Strickland test, that but for trial counsel’s alleged error, the result of the trial would have been different. It is important not to loose [sic] sight of the fact that Dr. Leestma was the defendant’s trial expert. The fact that Dr. Subramanian and Dr. Speth would have testified a certain way had they been given Dr. Nadelman’s records does not necessarily mean that Dr. Leestma would have testified that same way had he been given Dr. Nadelman’s records. Indeed, the question at hand is whether Dr. Leestma would have rendered a more favorable expert opinion had he been given Dr. Nadelman’s records. In other words, what is relevant in the present case is whether Dr. Leestma would have opined that the victim’s preexisting maladies were the cause of the victim’s fatal injury. Drs. Subramanian and Speth do not provide the answer to this issue.” (Emphases added.) Jacobazzi II, slip op. at 9-10.

We went on to find the insufficiency of the affidavits “inconsequential because sufficient fact questions [were] raised by the record itself.” Jacobazzi II, slip op. at 10. We found that the record disclosed that: (1) “defendant’s trial attorney may not have reviewed Dr. Nadelman’s records concerning the victim”; and (2) “defendant’s trial attorney may not have forwarded Dr. Nadelman’s records to Dr. Leestma.” Jacobazzi II, slip op. at 10. Accordingly, we concluded that “the portion of the defendant’s petition alleging that her trial attorney was ineffective for failing to review and forward the victim’s medical records should have survived second stage dismissal.” Jacobazzi II, slip op. at 11. We remanded for an evidentiary hearing at which the court was to address issues including, but not limited to: “(1) whether defendant’s trial counsel reviewed Dr. Nadelman’s medical records concerning the victim; (2) whether defendant’s trial counsel forwarded Dr. Nadelman’s records to Dr. Leestma; (3) whether but for defendant’s trial counsel’s alleged errors the outcome of the defendant’s trial would have been different.” Jacobazzi II, slip op. at 11.

On remand, the trial court ordered that the evidentiary hearing be bifurcated. The court would initially hear evidence relating only to issues under the first (i.e., performance) prong of Strickland, specifically, whether defendant’s trial counsel reviewed the Nadelman records and forwarded them to Dr. Leestma for review. Only if defendant proved counsel’s performance deficient under the first prong would the court take evidence relating to Strickland’s second (i.e., prejudice) prong. Of the three issues we expressly identified, the trial court took issues (1) and (2) to relate to the performance prong and issue (3) to the prejudice prong.

On the performance prong, the court heard testimony from Dr. Leestma and from defendant’s trial counsel, attorneys Anthony Montemurro and Richard Butera.

Dr. Leestma testified that, in November 1997, he was retained by Montemurro and Butera as an expert witness in defendant’s case. Dr. Leestma’s billing statements for his trial work, running from November 5, 1997, to May 13, 1999, were admitted into evidence. Dr. Leestma testified that, according to his billing statements, he first met with Montemurro and Butera on November 5, 1997, to discuss defendant’s case. Dr. Leestma recalled receiving the victim’s medical records for the first time at this meeting. The documents he received were photocopies. He was not given an inventory of the medical records and did not create one himself. He simply maintained a folder with all the records. Dr. Leestma brought the folder with him to the hearing, and it was entered into evidence. The Nadelman records were also admitted into evidence. Dr. Leestma testified that he first saw the Nadelman records after trial, in May or April 2002. His folder did not contain copies of the Nadelman records or give any indication that he ever reviewed the records. Dr. Leestma testified that his billing statements also contain no suggestion that he reviewed the Nadelman records before trial. He acknowledged that he had moved his office since trial and may have disposed of some records in his folder. He also noted that his folder was thinner than he remembered it. Dr. Leestma was sure, however, that he would have remembered that the victim had sickle cell trait had he been so informed while preparing for trial. He also would have remembered that the victim had anemia, which he noted is “not terribly unexpected” with sickle cell trait. Instead of taking account of these conditions, Dr. Leestma’s preparation for trial was premised on the victim having been a “normal[,] healthy” child prior to August 11, 1994. Dr. Leestma noted that he always asks defense attorneys in cases of this manner whether the victim had a prior illness, and in this case the answer he received was negative. Consistent with his May 2002 letter to Dr. Speth, Dr. Leestma testified that, had he known of the victim’s sickle cell trait, he would have examined the victim’s hematoma more closely.

Dr. Leestma was then asked about the victim’s medical records from Marianjoy Rehabilitation Hospital (Marianjoy), one of the facilities where the victim was treated after he was hospitalized on August 11, 1994. The Marianjoy records reported in relevant part:

“Past medical history includes sickle [cell] trait. The patient has a history of anemia which was worked up by an outside pediatrician. Laboratory values are unknown but the patient was treated with iron. The patient also has history of left metatarsus adductus.”

Dr. Leestma noted that, though his folder did not contain the Marian-joy records, he remembered reviewing them in preparing for trial. Dr. Leestma acknowledged testifying at trial that he received “ ‘all medical records in relation to this case’ ” and that he “ ‘paged through them.’ ”

Butera testified next. He stated that Montemurro was lead counsel on defendant’s case and had asked Butera to assist with the medical aspect of the defense. During the case, Butera never received a complete set of medical records; rather, he borrowed portions of the records when necessary from Montemurro. Butera testified that his own case file did not suggest, nor did he independently recall, that he ever received, reviewed, or discussed the Nadelman records with Dr. Leestma or Montemurro prior to trial. Butera did not become aware of the Nadelman records until after trial. Butera recalled at least two meetings with Dr. Leestma prior to trial but denied discussing any of the following preexisting conditions in the victim: sickle cell trait, persistent fever, anemia, possible AV malformation, bilateral metatarsal adduct, dehydration, or low hemoglobin and hematocrit readings. Butera noted that the defense theory at trial was that the victim had a prior injury or other medical problem. Butera recalled that the only information the defense team had as to a possible prior problem was Dr. Sullivan’s report that the CT scan revealed a subdural hematoma with both old and new blood. Butera did not remember reviewing any medical records that would have indicated that the victim had any blood disorder or other abnormality prior to August 1994.

Butera testified that he did not know which records Dr. Leestma reviewed, because it was Montemurro who kept the records and gave Dr. Leestma, and Butera, access to them. Butera acknowledged that, at trial, he asked Dr. Leestma if he received “ ‘all medical records in relation to this case’ ” and that Dr. Leestma replied in the affirmative. Butera also acknowledged that Dr. Nadelman testified at trial one week prior to Dr. Leestma and that Dr. Nadelman made references to the records of his treatment of the victim. Butera testified that he did not recall that, following Dr. Nadelman’s testimony, the Nadelman records were made an exhibit and ordered to stay in court until the completion of trial.

Montemurro testified that he was lead counsel at defendant’s trial but was not the original attorney to represent her in the case. Monte-murro took over the defense from attorney Louis Elovitz, who provided Montemurro his complete file, including all of the victim’s medical records. Montemurro did not recall obtaining any additional medical records after he began representing defendant. Although he could not remember where all of the medical records were subpoenaed from, he remembered that there were records from Dr. Nadelman. At some point in his preparation for trial, Montemurro had all the medical records assembled into binders. In April 1996, he retained a nurse, Joey Asher-Tamler, to prepare an abstract of the progress notes in the records. Montemurro explained that he did not have Asher-Tamler abstract the Nadelman records because (as he explained later in his testimony) Dr. Leestma “attached no significance to [the records] to indicate that we would use [them] at trial or [they] would be part of our trial strategy.”

Montemurro testified that he reviewed the Nadelman records “many times” in preparation for trial. Montemurro gave varying answers as to what he remembered from the Nadelman records. Asked at one point if he “recall[ed] reviewing the records which indicate that [the victim] had a fever on March 14, 1994,” Montemurro said, “Sure I do.” Elsewhere, however, he testified that “all [he] remember[ed] about [the Nadelman records]” was that the victim had sickle cell trait. When asked whether he had the Nadelman records with him at defendant’s trial, Montemurro testified that he assumed he had them but acknowledged that his recollection could be refreshed by reviewing the trial transcript. Defense counsel then introduced into evidence a portion of the trial transcript of Dr. Nadelman’s testimony. The transcript showed that when Montemurro questioned Dr. Nadelman about when he had treated the victim for illness, Dr. Nadelman stated that he would need to look at his chart to give specific dates. Monte-murro then stated, “I don’t have the chart.” At the evidentiary hearing, Montemurro explained that when he made this statement he was referring to the doctor’s original chart. At trial, he did not have the original chart but had a copy. He assumed the State had the original. Montemurro also explained that, at trial, he had wanted the original chart, rather than a copy, marked as an exhibit and saved for later reference.

Montemurro then testified about the medical records he provided to Dr. Leestma for his trial preparation. Montemurro testified that Dr. Leestma had “access” to all medical records Montemurro had for the case. Dr. Leestma “went through the medical records himself and chose what was significant and what wasn’t significant to pull out and make copies for himself.”

Montemurro described his discussions with Dr. Leestma about the victim’s prior medical conditions:

“Q. Now, did you ever discuss sickle cell — this sickle cell trait with Dr. Leetsma —

A. Yes.

Q. —prior to trial?

A. Yes.

Q. And he had the report at his—

A. Yes.

Q. And he had access to that report prior to trial; is that correct?

A. Yes.

Q. Do you know approximately how many times you discussed this sickle cell trait with Dr. Leetsma?

A. No, but I specifically recall discussing the sickle cell trait with him.

Q. And did he assign any significance to the pre-existing sickle

cell trait in the victim?

***

A. No.

# * #

Q. *** [N]ow you indicated also that you had a nurse abstract certain medical records; is that correct?

A. Correct.

Q. And you did not have the Nadelman records abstracted; is that correct?

A. Correct.

Q. And would you explain why?

A. Well, she just basically did the surgeries and the admittance to Lutheran General Hospital, plus when we ran all of this by Dr. Leetsma, he attached no significance to this to indicate that we would use this at trial or it would be part of our strategy.

* * *

Q. Now, do you recall specifically what you discussed about the child’s prior medical history with Dr. Leetsma?

A. No.

Q. You said you mentioned sickle cell trait; is that—

A. For some reason I remember that conversation.

Q. Now prior — earlier you testified that you don’t remember that the child was also diagnosed with being anemic prior to August—

A. That’s correct. I don’t remember talking about that.

Q. And you didn’t talk about the persistent fevers with Dr.—

A. I — I don’t recall speaking about that.

iji * #

Q. When you had these — was it just one occasion you discussed this prior history with Dr. Leetsma?

A. I can’t recall.

Q. You don’t — you don’t know?

A. As I sit here today I can’t recall.

Q. Okay.

Q. Do you recall who was present at the meeting when you had this—

A. It would be myself and Mr. Butera.

Q. Okay. And Dr. Leetsma?

A. And Dr. Leetsma.

Q. All right. Now, when you discussed the sickle cell trait with Dr. Leetsma, was it in a conversation you had or do you specifically recall pulling out some medical records to show him?

A. I don’t recall pulling out specific medical records.

Q. Okay. So you might have just mentioned to him that hey, the child had sickle cell traits. Does this mean anything to you.

A. Well, I think we read through the — the records.

Q. Okay.

A. I mean, let me say that I’m an attorney not a doctor.”

Montemurro testified that the defense theory he and Dr. Leestma eventually settled on was that the victim died of a prior injury that caused a slow bleed. Dr. Leestma supported this theory with the report of Dr. Sullivan indicating that there was both acute and chronic bleeding on the victim’s brain.

Joey Asher-Tamler testified that Montemurro hired her in April 1996 to transcribe a set of medical records. Asher-Tamler testified that she finished the transcription in June 1996 and has not done any work for Montemurro since.

Following this testimony, defendant filed a motion requesting that Butera’s case file be entered into evidence. At a hearing on that motion, Butera argued that his case file contained, in part, privileged information and requested that the whole case file not be entered as evidence. The trial court decided to conduct an in camera inspection of the case file. As a result of that inspection, the court allowed certain portions of Butera’s case file to be admitted into evidence.

Thereafter, defense counsel recalled Butera to answer questions relating to his case file. Butera testified that his case file had remained intact in his office since trial. Butera identified various portions of his case file. Defendant’s exhibit No. 14 was three pages of the victim’s mother’s discovery deposition that was taken in the related civil case for wrongful death. Defendant’s exhibit No. 15 was one page of a transcript from the victim’s father’s discovery deposition in the wrongful death case. The testimony on these pages contained no references to the Nadelman records but did mention that the victim suffered from sickle cell trait and an iron deficiency. Butera did not attend these depositions but copies of the transcripts were in his file. He acknowledged that one of the pages of exhibit No. 14 had a handwritten note in the margin stating “sickle cell, anemic.” Butera acknowledged that the handwriting “may” be his.

Defendant’s exhibit No. 16 was six pages of handwritten notes titled “General Notes — People v. Jacobazzi.” Butera explained that these were notes he made near the beginning of defendant’s case, before he had reviewed all the medical records in Montemurro’s office. Butera was becoming acquainted with the case and focused on records relating to the treatment of the victim after his hospitalization on August 11, 1994.

Defendant’s exhibit No. 17 was a one-page document titled “Questions of Dr. Leestma.” Butera identified it as notes he made to himself relating to questions for Dr. Leestma. One note fragment read: “Pin Point: Where or when would be exactly based on slide did this happen. How old.” Another fragment read: “How does diabetes and sickle cell trait [affect].” Butera believed that he created this document as well near the beginning of the case. Butera believed that the information in the notes, such as the victim’s sickle cell trait, came from conversations with Montemurro, not from Butera’s own review of the victim’s medical records.

Butera identified defendant’s exhibit No. 19 as more notes he had taken about the theories of the defense. He acknowledged that one note read: “normal baby, something happened, go along with prosecution on normal [and] flip on them.” Butera noted that, by “normal baby,” he meant “a baby that didn’t have any medical condition to explain his injury.” Butera said that the note was in reference to Dr. Leestma’s theory that the victim “seemed to be normal but there might be something else going on to cause” the bleeding. Butera testified that exhibit No. 19 was prepared “closer to trial.”

Butera identified defendant’s exhibit No. 21 as notes he made based on discussions with the attorney handling the civil case. Butera generated the notes “[s]omewhere between the beginning and the middle portion of the case.” The purpose of the meeting was to discuss the case and develop a theory. However, Butera did not recall ruling out any defense theories during or after the meeting with the civil attorney. The only documents discussed at the meeting were the discovery depositions of the victim’s parents. Butera acknowledged that there were notes stating “Pre-Existing Conditions” and “Look to pre-existing chronfic] symptomology” on the exhibit. Butera explained that these entries were intended as a reminder to look at these areas in conjunction with Dr. Leestma. Butera testified that these entries led to no exchange of records between the civil attorneys and Butera’s team.

Butera identified defendant’s exhibit Nos. 18, 20, 22, and 23 as more of his notes. He acknowledged that the handwriting on exhibit Nos. 16 through 23 was his handwriting. Butera noted that, though there were references in exhibit Nos. 16 through 23 to the victim’s preexisting conditions, there was no specific mention of the Nadelman records. Butera further testified that he “did not know if he saw the Nadelman records or not” prior to trial.

Following this testimony, the trial court denied the defendant’s postconviction petition. The trial court first determined that trial counsel reviewed the Nadelman records prior to trial. The court found the evidence “overwhelming” that both Montemurro and Butera reviewed the Nadelman records. The court found “clear, credible and convincing” Montemurro’s testimony that he reviewed the Nadelman records and discussed them with Dr. Leestma. The court noted that although Butera “did not recall, frankly, simply wasn’t sure” whether he reviewed the Nadelman records, Butera’s pretrial notes made it “abundantly clear” that Butera reviewed the Nadelman records. The notes were “replete” with references to the victim’s preexisting conditions. The court noted specifically (1) defendant’s exhibit No. 15, the deposition testimony of the victim’s father, which was in Butera’s file and indicated that the victim had sickle cell trait and an iron deficiency; (2) defendant’s exhibit No. 17, which contained a notation from Butera referencing sickle cell trait; and (3) Butera’s references in defendant’s exhibit No. 21 to preexisting conditions and preexisting chronic symptomology. The court also determined that the reference to “sickle cell, anemic” on page 3 of defendant’s exhibit No. 14 was in Butera’s handwriting.

The court then found that the Nadelman records had been provided to Dr. Leestma. According to the court, Dr. Leestma acknowledged that “he had access to all the records that [Monte-murro] had.” As for Dr. Leestma’s assertion that he would have remembered the victim’s sickle cell trait if he had read the Nadelman records, the court found it “destroyed” by his admission that he reviewed the Marianjoy records, which themselves referenced sickle cell trait. The court thus found “incredible” Dr. Leestma’s claim that he never saw the Nadelman records. The evidence was clear, the court found, that Dr. Leestma was given access to and provided with the Nadelman records. Accordingly, the trial court determined that there was no ineffective assistance of counsel and denied defendant’s post-conviction petition. Defendant filed a timely notice of appeal.

ANALYSIS

I. The Factual Findings on Remand

Defendant’s main argument on appeal is a substantive attack on the trial court’s factual findings that defendant’s trial attorneys reviewed the Nadelman records and provided them to Dr. Leestma. She prefaces it, however, with a challenge to the procedures the trial court employed on remand. She argues that the court erred in bifurcating the evidentiary hearing. In this part of our analysis, we affirm the trial court’s factual findings concerning the Nadelman records. In Part II, we hold that the bifurcation was erroneous and remand for a further evidentiary hearing.

“Following an evidentiary hearing where fact-finding and credibility determinations are involved, the trial court’s decision will not be reversed unless it is manifestly erroneous.” People v. Beaman, 229 Ill. 2d 56, 72 (2008). This deferential standard is appropriate because the trial court is in the best position to observe and weigh the credibility of the witnesses. People v. Ortiz, 385 Ill. App. 3d 1, 6 (2008).

First, we hold that there was no manifest error in the trial court’s determination that Montemurro and Butera reviewed the Nadelman records. First, we note Montemurro’s testimony. Montemurro testified that the Nadelman records were part of the original medical records that he had obtained in the case from Elovitz. He also testified that he reviewed the Nadelman records “many times” in preparation for trial. The trial court specifically found that Montemurro was clear, credible, and convincing in his testimony that he discussed the issue of sickle cell trait with Dr. Leestma before trial.

Defendant argues that Montemurro’s testimony was not credible. First, defendant claims that Montemurro’s testimony was inconsistent. Defendant points to Montemurro’s testimony that the reason he did not have Asher-Tamler include the Nadelman records in her abstract of progress notes was that, “well, she just basically did the surgeries and the admittance to Lutheran General Hospital, plus when we ran all of this by Dr. Leetsma [sic], he attached no significance to this to indicate that we would use this at trial or it would be a part of our strategy.” Defendant notes that Dr. Leestma did not become involved in this case until November 1997 and that Asher-Tamler completed her work in June 1996. We do not see the inconsistency. Defendant appears to believe that Montemurro’s statement implied that Asher-Tamler and Dr. Leestma were working contemporaneously. In fact, Montemurro spoke of two different time periods. Montemurro indicated that he did not have Asher-Tamler transcribe the Nadelman records and that later, when Dr. Leestma came on the case (after Asher-Tamler had finished), Dr. Leestma assigned no significance to the records. Defendant confusedly sees a temporal overlap and an implication that, based on Dr. Leestma’s assessment, Montemurro decided not to recall Asher-Tamler in 1997 to have the Nadelman records transcribed.

Second, defendant argues that Montemurro’s testimony was deceptive. Defendant claims that, when asked whether he had the Nadelman records in court when he examined Dr. Nadelman, Montemurro “attempt[ed] to confuse the issue and try to distinguish whether he had the original or a copy of the Nadelman records during the trial.” It was indeed Montemurro’s remark to Dr. Nadelman, “I don’t have the chart,” as well as his later comment to the trial court that the defense team “may” have had a copy of the chart, that led us in Jacobazzi II to remand for an evidentiary hearing on whether trial counsel had the Nadelman records prior to trial. See Jacobazzi II, slip op. at 10. At the evidentiary hearing, Montemurro explained that, in stating, “I don’t have the chart,” he meant that he did not have Dr. Nadelman’s original chart but had only a copy. Defendant’s point is that, if Montemurro had a copy of the Nadelman chart, he could have, and indeed almost certainly would have, provided it to Dr. Nadelman if he wanted him to answer questions based on the chart. Defendant also argues that Montemurro’s further explanation, that he wanted the original chart marked as an exhibit and left in court for future reference after Dr. Nadelman completed his testimony, is beside the point. We understand defendant’s concerns, but we are equally mindful that the trial court was better positioned to judge the credibility of the witnesses. It was the province of the trial court, as fact finder, to resolve tensions and even outright conflicts in Montemurro’s testimony. See People v. Evans, 209 Ill. 2d 194, 211 (2004). This included, of course, assessing the credibility of Montemurro’s explanations for his remarks at trial. We see no ground for upsetting the court’s determination.

Third, defendant notes that Montemurro admitted that the victim’s sickle cell trait was the only condition he remembered from the Nadelman records. Montemurro’s testimony was not unequivocal here, for at one point he testified that he remembered that the victim had a fever in March 1994. Again, the trial court is the superior judge of the credibility of the witnesses. See Evans, 209 Ill. 2d at 211. In conclusion, we find nothing in Montemurro’s testimony on which we can override the trial court’s express credibility determination.

We also find no ground for disturbing the trial court’s finding that Butera, too, reviewed the Nadelman records. Although Butera testified that he was not aware of the Nadelman records prior to trial, Butera’s case notes, as pointed out by the trial court, made multiple references to the victim’s sickle cell trait and anemia. Butera’s case file also contained transcripts of the civil discovery depositions of the victim’s parents. Their testimony referenced the victim’s sickle cell trait and anemia. The transcript of the father’s deposition contained a margin note, “sickle cell, anemic,” which the court found was in Butera’s handwriting. We recognize that nothing in the record eliminates the possibility that Butera learned of the sickle cell trait and anemia from the civil depositions or from conversations with Montemurro rather than from his own review of the Nadelman records. Neither, however, is the latter scenario foreclosed by the record. Montemurro testified that, at one point in their preparations for trial, he and Butera met with Dr. Leestma. Asked for the particulars of this meeting, Montemurro testified, “I think we read through the — the records” (emphasis added). Given this testimony, we find no manifest error in the trial court’s conclusion that Butera himself reviewed the records.

We affirm as well the finding that Dr. Leestma was provided with the Nadelman records. Dr. Leestma testified that he must not have seen the Nadelman records prior to trial because if he had seen them, he would have remembered the sickle cell trait and the anemia. The trial court found this testimony incredible because Dr. Leestma acknowledged that, prior to trial, he reviewed the Marianjoy records, which themselves indicated that the victim had been diagnosed with sickle cell trait and anemia. The trial court also found Montemurro’s testimony, that he had provided the Nadelman records to Dr. Leestma and that they had discussed the sickle cell trait, to be particularly credible. Montemurro testified that the Nadelman records were contained in the medical records he received at the beginning of the case from Elovitz. Dr. Leestma acknowledged that he testified at trial that he was provided with and reviewed “ ‘all medical records in relation to this case.’ ”

Defendant argues that the trial court improperly focused only on whether the attorneys and Dr. Leestma had “access” to the Nadelman records. Defendant misconstrues the court’s findings. The court spoke of Butera and Dr. Leestma having “access” to the records because, according to Montemurro and Butera, the records were stored at Monte-murro’s office and Butera and Dr. Leestma borrowed and made copies of them. The court found not just that counsel and Dr. Leestma had “access” to the records but that they reviewed them as well.

Defendant also argues that the trial court erred in focusing only on whether defense counsel and Dr. Leestma were aware of the sickle cell trait, since the Nadelman records showed that the victim suffered from a plethora of other medical conditions. The trial court did not mention only sickle cell trait. Rather, the court relied on (1) Butera’s case notes that referenced both the victim’s sickle cell trait and anemia; (2) Montemurro’s testimony that he reviewed the Nadelman records and discussed the victim’s medical history with Dr. Leestma; (3) Montemurro’s testimony that the Nadelman records were included in the victim’s medical records at the time he took over the case from Elovitz; and (4) Dr. Leestma’s acknowledgment that, at trial, he testified that he had paged through all of the victim’s medical records.

For the foregoing reasons, we affirm the trial court’s determination that trial counsel and Dr. Leestma reviewed the Nadelman records. As we explain in Part II, we remand for an evidentiary hearing on additional issues. We do want to point out that, in our analysis above, we noted several conflicts and tensions within the testimony below. While they do not suffice for us to upset the trial court’s factual determinations, nothing in our analysis should be construed as a bar to the court revisiting those findings on remand if it sees fit.

Next, we address defendant’s argument that the trial court’s bifurcation of the Strickland hearing was erroneous.

II. The Bifurcation on Remand

Defendant argues that the trial court erred by barring her from producing evidence, consistent with the affidavits of Drs. Speth and Subramanian, that the preexisting conditions identified in the Nadelman records would have been beneficial to the defense. Defendant contends that the court operated on the false assumption that the bare fact that trial counsel and Dr. Leestma reviewed the Nadelman records would be evidence enough that “trial counsel employed a trial strategy not to raise any pre-existing conditions as part of their defense at trial.” Defendant argues that the only way she could have proven that the failure to use the Nadelman records was not sound strategy was

“to demonstrate the importance of the information contained in the Nadelman Records. This is exactly the type of testimony and evidence contained in the Affidavits of [Drs. Speth and Subrama-nian