202403291 B4 - [2025] EWCA Crim 1135

Summary of the evidence:

Each of the two counts alleged wilful ill-treatment of C “on or before the 13^th day of December 2019”.

The particulars of the offence charged in count 1 alleged that the appellant had wilfully ill-treated C, in a manner likely to cause C unnecessary suffering or injury to health, by “interfering with the gastronomy and PEG-J tubes restricting the administration of feed” to C. A note on the indictment explained that this count related to

“Detaching the giving set causing milk to leak from the gastronomy tube.

Clamping/unclamping of the gastronomy and PEG-J tubes when not appropriate to do so.

Physically kinking/pinching the gastronomy and PEG-J tubes preventing it from functioning properly.”

The ill-treatment alleged in the particulars of the offence charged in count 2 was that the appellant had deliberately administered fluids to C’s PEG-J feeding and/or gastro tube –

“… resulting in excessive aspirates to be collected in the gastric losses bag. This caused the medical team to incorrectly calculate the amounts of replacement fluids to be administered to [C]”

The prosecution adduced evidence in support of those charges from a number of nurses and members of hospital staff, and from the mother and grandmother of another patient on the ward, who had become concerned about the appellant’s behaviour and had used their mobile phones to film her actions.

In brief summary, the prosecution case on count 1 included the following features:

Whilst C was an in-patient at the E hospital, the pump that should continuously administer feed to her frequently sounded an alarm to indicate that it was blocked. The evidence of medical professionals was that this was unusual. After a time, a log was kept of who was present and what (if anything) was seen when the alarm sounded.

The alarms predominantly sounded during the daytime, when the appellant was with C. At night, when one of C’s grandparents was present, alarms were rarely recorded.

The records showed that on occasions when the alarm sounded, nursing staff found that the tubes carrying the feed were kinked or bent, preventing the feed from flowing and causing a blockage.

On occasions the appellant was observed disconnecting the feed tube, leaving the feed to seep into a tissue and not reach C.

The appellant would sit with C on her lap or between her legs and with a blanket over them both. Her hands, frequently under the blanket, were seen by nurses to be moving or “fiddling”. This happened even when the nursing staff asked the appellant to uncover C and/or to keep her hands visible.

After the appellant had been arrested, she was prohibited from having unsupervised access to C. It was noted that C absorbed nutrition well and gained weight rapidly. By February 2020 the jejunal feeding had stopped and C was taking nutrition orally.

Although the appellant suggested that C’s dystonia had caused the difficulties with her feeding, Dr Bunn provided expert evidence that dystonia (which affects the skeletal muscles of the limbs) could not have affected the muscles of the stomach and small bowel in such a way as to prevent the administration of feed.

Dr Bunn further gave evidence that there was no natural, organic or medical explanation for C’s failure to absorb nutrition and to gain weight.

On 4 December 2019 C was prescribed the drug Gabapentin. From 8 December, the pump ceased to alarm. It was the defence case that the improvement was attributable to the Gabapentin. Dr Bunn, however, discounted that as an explanation. Her evidence was that the prescribed dosage of Gabapentin was not strong enough to treat dystonia, and in any event Gabapentin would normally take ten days to take effect, not four. Moreover, C continued to improve steadily after the Gabapentin was withdrawn on 31 December 2019.

The prosecution invited the inference that the blockages of the feed tube, and C’s failing to gain weight, were caused by the appellant interfering with the administration of the feed.

The defence case was that the feeding pump had frequently occluded over a period of more than a year before C’s admission to hospital, when C was predominantly being cared for by her grandmother and the appellant: the pump would block, the alarm would sound, and the pump would record that feed was being delivered when in fact it was not. The jejunal tube had had to be changed at least every six months. The appellant, and members of her family, gave evidence to that effect, and stated that problems with the pump occurred whether the appellant was present or not.

The appellant suggested that the occlusions of the feeding tube had been caused by C’s dystonia. She further suggested that the pump had ceased to alarm after 8 December 2019 because of the prescription of Gabapentin with effect from 4 December.

The prosecution case in relation to count 2 was that the appellant had added fluid to the gastric drainage bag, with the result that medical staff administered additional fluids to C, thereby unwittingly exposing her to a risk of overhydration which could lead to organ failure. Features of the prosecution evidence included the following:

Overnight, when the appellant was absent from the ward, there was almost no drainage, and it was rarely necessary to empty the gastric drainage bag; but when the appellant was present during the daytime, the volume of fluid in the bag was greatly increased, and it was sometimes necessary to empty it twice within one hour.

The appellant’s “fiddling” with her hands beneath the blanket which covered C often coincided with the gastric drainage bag being full.

The fluid in the bag was often lighter in colour, and colder, than would be expected of fluid discharged from C’s body.

The relatives of another patient on the ward made video recordings of the appellant using a syringe to inject fluid from a cup into the gastronomy port, and of the appellant appearing to squeeze C very hard whilst looking at the gastric drainage bag.

Dr Bunn’s evidence was that for a child of C’s weight, the gastric losses which had daily been recorded (up to a maximum of 1,039 ml) could not occur naturally, being almost equal to the fluid and feed administered.

During the period when the appellant was prohibited from having unsupervised contact with C, the volume of fluid in the gastric drainage bag decreased substantially. By 22 December 2019, the drainage was less than 10ml per day.

The defence case in relation to count 2 was a denial that the appellant had artificially inflated the contents of the gastric drainage bag, and a denial of responsibility for C’s high gastric losses. The appellant gave evidence that she had occasionally used boiled water to flush C’s gastronomy, which she believed she was not only permitted, but encouraged, to do.

It was further the defence case that there had been many occasions when a high quantity of gastric losses had been recorded. The appellant and her witnesses gave evidence that medical professionals had commented on this, but had never suggested that there was a danger to C’s health or that the quantity of gastric losses was impossibly high. The appellant suggested that the large amounts of gastric losses occurred naturally.