MY FINDINGS
60.I have read the extensive evidence and it is of course my role to consider all the evidence. I have seen the photographs of the injuries A sustained and I was shocked by the extent of them. My initial view on looking at them was that someone must have done this to A. I reminded myself before the start of the case that I had to hear all the evidence before making any decisions about any of the injuries.61.I have considered the medical evidence very carefully. The Local Authority are still seeking for me to decide whether the mother and or G caused all or some of the injuries. The Guardian in her closing submissions having heard all the evidence is unusually not supporting that position and has said that it would cause her anxiety if I do make findings against the mother.62.In considering the evidence I am aware that the change of mind by Dr Z was the pivotal point in this sad case. When Dr Z gave evidence, he was very clear that he didn’t believe that the mother had caused these injuries. Despite this he was unable to really explain how the joint statement of himself and Dr X came about and more mysteriously why he had made a Police statement saying that the injuries were non accidental in nature. He said that he was put under pressure by the Peer review meeting to change his mind. It was this change of opinion which led of course to the Local Authority bringing proceedings to remove these children from the mother’s care. 63.The Local Authority in my view acted entirely properly based on the evidence presented to them. The photographs are very shocking. They point to the fact that the mother said that the injuries were not out of the ordinary when they clearly were worse than usual. Her response to A’s injuries was to give her a bath and not seek medical attention for some time roughly an hour and a half. There appeared to be no mechanism for bruising on A’s back as the travel cot was soft. The abrasions on her face looked like grazes when she had never had such injuries since or before. Nor had she sustained so many injuries. She had been left in her cot for some eight hours without a baby monitor. A’s challenging behaviour and the difficulties during lockdown of very limited support it was suggested might have meant that she or G acted inappropriately64.I also have to consider the evidence of Dr Y who specialises in children with autism. I bear in mind that neither she nor Dr X had seen A with her mother and that seems to be the most important evidence in this case. Whilst Dr Cartlidge said that he deferred to Dr Y’s expert opinion it was clear when he gave evidence that this was not the case. He was highly critical of her approach and cautioned concluding that any of the injuries were inflicted when A’s behaviour was considered. He told me that I couldn’t consider her case without consideration of her disabilities and her behaviour that was far outside that of a normal child.65. Whilst of course Dr Y specialises in children with autism, I think the effects of the melatonin and A’s extreme behaviour even for a child with this condition mean that even an experienced Paediatrician would have been surprised by A’s capacity to hurt herself. Whether she could feel pain in the same way as any other child is debateable of course but what does seem to be apparent she didn’t have the connection between causing herself pain and being able to stop herself doing it. The doctors describe her as being miserable and seemingly in pain.66.I have considered all the evidence in this case, as I must. The most significant and compelling evidence is that of the people who had seen A with her mother.67.The health visitor, PPB gave very positive evidence about the mother and her care of the children. JJ was very positive about her and whilst it was clear that she was struggling with A’s behaviour and there was little support during lockdown the mother had taken pictures of A’s injuries. II was an extremely important witness as she had a lot of contact with both the mother and A. Again, she was uniformly positive both about the mother’s care and the mother. HH and Dr Z were alarmed by A’s behaviour and very supportive of the mother. They were very experienced professionals. Then there were the two very experienced Police Officers PC-KK and DC-QQ. Whilst of course the criminal proof is beyond reasonable doubt and the civil and family proof is on the balance of probabilities, so it is more likely than not it happened as the Local Authority say, these two Police Officers did not consider that the mother caused these injuries. The Guardian also saw the mother with the children and her view is that the mother did not cause these injuries.68.Of course, I am aware that even a loving mother under strain and pressure may act in a way that is completely out of character. However, in this case having heard the mother and Mr G give evidence I do not think that this is remotely likely. D was also an important witness and despite the difficulties in his relationship with Mr G did not consider that either of them would have hurt A.69. I accepted both the mother and G’s evidence that because of A’s autism he left her care to her mother. B’s evidence of saying that Gwas nice, and kind was also important. She is a young child and young children very often tell adults as it is. The Guardian described her as delightful and there is clear evidence of high- quality parenting. Whilst the mother is very young, I was impressed by her maturity and her dedication to her children.70.Dr Y, Dr X and LL had not seen A with her mother. The description of A’s behaviour is shocking, and I consider at the most extreme end of the spectrum as Dr Cartlidge suggests. 71.One of the early social work statements says it is strange that the mother didn’t seem surprised by the extent of A’s injuries. Whilst of course they were more extensive than they have been before or after this incident I bear in mind that the mother had been documenting A’s injuries. She was not surprised by them because she was aware that A did cause herself significant injuries. Documenting injuries would be a remarkable thing to do for a parent who had caused them. I also bear in mind that it was the mother who had to pursue A’s broken leg and she was persistent in getting help for A. She had also requested a helmet which I was told was not available except for children who fell over because of mobility issues. I also consider that A had been prescribed Melatonin and I accept the mother and Dr Z’s evidence that this can make a child hyperactive and that is why she was changed back to Phenergan which has made a difference in calming her. 72.I have considered the point the Local Authority have made about the time A was in her cot. The mother checked her at midnight and then around 8 am. Whilst the bedroom was not next door to the mother, from the Police and the mother’s evidence it was not far away from her room. It is understandable that the mother would not want to put A or B in a room with an electrical meter or near the front door. I also bear in mind there are no perfect parents in the world although this mother appears to score very highly at all other times. She had left A in a travel cot. It might have been slightly longer than usual but a parent in this situation could not imagine the injuries that might have resulted. I take the mother’s point that A was a bad sleeper and listening to her on a baby monitor would probably have meant that she never had any sleep. We all must live in the real world and be realistic about what the mother could manage in the circumstances. I don’t think this is a failure to protect point. A harmed herself in her mother’s arms in front of doctors and her behaviour, as I have said, is off the ordinary scale.73.It did take the mother some time to take A to hospital, but I bear in mind A’s disabilities. The mother had phoned her support worker. A was extremely distressed. The mother gave her a bath which the Local Authority say was unnecessary as she could have simply wiped away the blood. For a child without A’s difficulties this might be true. I have never met A but the description of her would suggest to me that the mother was trying to calm her before taking her to hospital bearing in mind she didn’t like strange places and trying to get her ready must have been difficult in this state. There is no suggestion by her support worker that there was any undue delay.74.From all the evidence presented to me I am satisfied that all the injuries were caused by A. Dr Z describes A throwing herself about which could have caused the bruising to the face and head. HH described her hitting herself and putting her fingers in her eyes. I accepted the evidence of Dr Cartlidge that the injuries to her eyes were most likely caused by A by her fingernails or hands. The bruising to her back could have been caused the day before. I am satisfied that the mother could not necessarily document every injury because A regularly hurt herself. The bruises seem to be bruises on bruises. Whilst ordinarily I am told that bruises to ears will most usually indicate abuse, I rely on Dr Cartlidge’s evidence that pinching would give a bigger bruise. A throwing herself to side to side could account for bruising to her ears. In any event I am not obliged to say how they were caused but I don’t think the mother or G caused them. Dr Saggar said that she may have bruised more easily and Dr Cartlidge said he caused red marks by normal handling.75.In respect of the abrasions the Police Officers were satisfied that the cot mesh could have caused these and I am grateful to them for their thoroughness in investigating this matter. I have no hesitation in accepting their evidence that the pattern of the mesh accorded with marks on A’s skin.76.The doctors and LL were subjected to fierce cross examination about the peer review meeting and the guidance from the High Court where there are potentially issues of non-accidental injury. I take the point that these are doctors not lawyers. However, it does seem to me that although it is said that it didn’t affect the evidence ultimately, I was concerned that Dr Z and HH did feel under pressure to agree that these injuries were non-accidental and therefore inflicted by someone .It is difficult to reconcile Dr Z’s written evidence and statement to the Police with his very clear evidence that this was a loving mother who coped extraordinarily well and deserved a halo.77. Dr Z’s evidence did cause these proceedings to be issued and for this poor mother and her children to be separated. I don’t blame the Local Authority for issuing them because the photographs do present a very serious picture. I am aware of the trauma both children and the family must have suffered because of this and I am very sorry that they have had to wait for so long for this to be rectified. I am aware that Dr Z was placed under pressure and of course it is easy for someone not involved directly to ask why he did what he did? However, safeguarding is very difficult at times, we all make mistakes and the consequences of getting a decision wrong have enormous ramifications, sometimes in the death of a child and this was a very difficult case. Dr Z is a kind and hardworking Paediatrician and that was evident in his evidence.78. I do think the Peer review was unfortunate in the circumstances. I fully accept that it is a tool for teaching and learning but I would like the hospitals to be aware of cases such as this one where there might be issues of non -accidental injury and the dangers of a group of doctors in effect deciding what has happened to a child. I can well understand if there are issues of treatment or other medical matters which may need to be discussed and I can see the advantages of a peer review meeting as a tool for teaching and learning in those circumstances. There is a very real issue of doctors and other professionals being swayed by a group opinion when the members of the group haven’t had any clinical care of that patient.79.On behalf of the mother I am asked in effect to censure LL for her role in this case. LL is of course head of safeguarding. I can well understand her anxiety when she saw A’s photographs which all the professionals say made the injuries look so much worse than when they were presented. I was very shocked when I saw the extent of her injuries. I bear in mind this is an extraordinary case because of A’s extreme behaviour and disabilities. LL was not responsible for the Peer Review meeting, but I do think that she should have been aware of the dangers involved in holding something of this nature. I do understand that she was in a very difficult position because it is in effect a continuing professional event for the doctors, but I do hope that this can be reflected upon. She was absolutely adamant that these were inflicted injuries. Whilst I fully accept that they had to be investigated sometimes life is stranger than fiction.80.I fully accept that this has been the worst nightmare for the mother and G because they of course knew that they had not caused these injuries and they fully aware of A’s behaviour. This of course would have been much less apparent to the people who had no actual knowledge of A’s behaviour. Sadly, parents do cause their children injury and it must be borne in mind that this is an exceptional, rare case where a child has caused herself significant injuries. The mother has to her credit worked well with social workers and the Guardian and she will continue to be involved with the Local Authority which will be necessary to support her with looking after A. I do hope the current difficulties can be resolved. All the parties conducted themselves very well. 81.I would like to commend HH, whilst of course I accept that safeguarding wanted this investigated and this was a proper exercise of their function, I do think some pressure was put on her and Dr Z. It is never easy when everyone else believes you to be wrong. Dr Z did of course accept his evidence to the Police was wrong and he did ensure that his original evidence stood and that was brave of him in the circumstances.82.I would also like to thank the Great Grandparents E and F. They saved these children going into care and the consequences for these children would have been far worse than the trauma caused to them already by being removed from their mother.83.All the advocates worked very hard on behalf on behalf of their clients and I am extremely grateful to them for the way this trial was conducted. Mr Storey QC, Mr Chippeck, Miss Taylor QC and Miss Farrington for the mother and G could not have worked harder for their clients. Ms Gilliatt for the Local Authority had an unenviable job, but she acted professionally and with great skill. Mr Pidduck for SS, the Guardian for the children is always the calm voice of reason.