REPRESENTATION
•Kent County Council represented by Jacqui Gilliatt, Counsel, instructed by Graeme Bentley at Invicta Law;•Mother, C, by Paul Storey QC and Stephen Chippeck, Counsel instructed by Max Konarek of Boys & Maughan Solicitors;•Father, D, by Vanessa Wells, Counsel, instructed by Gemma Duckworth of Robinson Allfree Solicitors;•The maternal great grandparents, E and F by Lydia Slee, Counsel, instructed by Andrew Humphries of Patrick Lawrence Partnership LLP;•G by Gemma Taylor QC and Gemma Farrington, Counsel, for Intervener, instructed by Andrew Stone of DSD Solicitors;•B and A through their Guardian SS by Adrian Pidduck, Counsel instructed by Jaqueline Bowry of Rootes & Alliott Solicitors;1.I am concerned with two children A who is four years old on 18th September and her sister B who is five on 10th November. 2.The mother is C and the father is D. The parents are not married. They separated in 2019. 3.These care proceedings concern injuries to A, a child with significant disabilities (autism and chromosome 16 deletion). The risks to B are said to arise from the injuries to A. 4.Proceedings were commenced 23/09/2020. Threshold is based upon A’s admission to hospital on 29/07/2020 with multiple and significant bruises to her face and back together with scratches and blood spots on her eyeballs. There was also concern as to a leg fracture suffered in June 2020 which was at the time assessed to have an innocent explanation and this is confirmed by report of Dr Watt. The Local Authority accept that this injury is not suspicious. It is accepted that A suffered these injuries. The mother says that they are self -inflicted.5.The initial medical evidence in relation to the bruising was contentious between treating experts as to whether A could have inflicted the injuries herself as her Mother suggests, but the position changed following a meeting of those experts and others which is recorded in a letter of 17/09/2020. The earlier leg fracture was also reconsidered although this is accepted as an accidental injury. 6.Following an initial Emergency Protection Order withdrawn when Mother moved to live with the maternal great grandparents, an Interim Care Order was made by DJ Batey (to whom the case is allocated) on 01/10/2020 when he approved the Local Authority plan that Mother should move out. Initially, the approved plan was for contact at the home of the great grandparents four times a week, though this was increased to five at the hearing on 16/10/2020. 7.Mother’s contact was extended at previous hearings and a Child Arrangements Order was made in favour of the great grandparents (who had not been able to be approved as foster carers, due to missing information). Further case management directions were also made.8.At the hearing on 08/03/21 the court listed two further case management hearings, a hearing on 20/04/21 before me and a final hearing commencing on 16/08/21, time estimate 10 days before me. This was later extended to 17 days following a request from the mother’s counsel.9.At the hearing on 20/04/21 I extended the listing for the fact-finding to run from 16th August 2021 through to and including 10/09/21 save that the court will not sit on 27/08/21 and 31/08/21 (time estimate 17 days allowing for the August Bank Holiday).10.I heard evidence from:a.Dr X, a Consultant Paediatrician, b.Dr Y, a Paediatric Consultant with a specialism in autism, c.Dr Z, the treating Paediatric Consultant, d.HH, treating nurse, e.II, Care Coordinator, f.JJ, g.Dr Cartlidge, Consultant Paediatrician. h.PC-KK, i.LL, Head of Safeguarding. MM, j.C, the mother, k.NN, Maternal Grandmother, l.G, the intervenor and mother’s partner.11.Dr X gave evidence. He told me that he was concerned with safeguarding and he had not had any clinical involvement with A or her mother. He said that he was concerned at the bilateral black eyes and the extent of her bruising. He was concerned that A was discharged home without a safeguarding – plan. He said that he had tried to contact Dr Z, but he said that he was not contactable before the strategy meeting. 12.Dr X said that he couldn’t recall any discussions between Dr Z and the safeguarding team.13.He described the peer review meeting and he said that the purpose was to review safeguarding and they worked under the guidance of the Royal College. He said that the Peer review process was part of Continuing Professional Development and was a learning process and every Paediatrician took part in them. It wasn’t to blame doctors nor was it meant to be used for the purposes of legal proceedings and he said that minutes should have been taken and there were around thirty doctors in attendance. Dr Z presented A’s case. Dr X said that he saw the pictures and he gave his opinion that these were non accidental injuries. There was a consensus of opinion from the other doctors that these were non- accidental injuries. He said that someone from safe- guarding attended the meeting.14.Dr X said that after the Peer review he decided to put together a letter together with Dr Z. He said that Dr Z had agreed with his view of the injuries. The letter was started off by LL and he said that they jointly agreed the contents of the letter.15.Dr Y gave evidence and confirmed her report. Dr Y is a Consultant Paediatrician with a specialisation of children with autism. She said that A had presented with significant multiple injuries on 29/07/20, including bruises to the face and back, both eyelids and bleeding under the outer covering of the left eye (conjunctiva), abrasion (friction burn) with a linear pattern to her face, bleeding from the mouth, reddening and swelling of the face and extensive bruising to her back. Dr Y considered it is more likely than not that the injuries on A’s face and back resulted from several impacts with a significant force of different types (for example bruises are caused by blunt trauma, but friction burns require contact with an abrasive surface), and possibly at different time points. Therefore, the explanation provided of A causing the majority of those injuries to herself by self-injurious behaviour sometime between midnight and 8 am on 29/07/20, while in a travel cot with soft bedding, was not consistent with the variety, location and severity of the findings.16.Dr Y said that on two occasions previously, in June 2020, she presented with bruising to her ears (pinna) and other injuries to her face and back; the provided explanation of self-injurious behaviour (head-banging) in her opinion is not consistent with the location of injuries, such as injury to her ears.17.Dr Y broadly agreed with Dr Cartlidge’s opinions except in relation to timing where she said that bruising can only be timed or dated by circumstantial evidence.18.Dr Y accepted that head banging could have caused the bruising over A’s forehead. However, the injuries to the ears were not reported on any other occasions despite the Great Grandmother confirming that A tugged her ears, therefore on the balance of probabilities she felt these were not self-inflicted. Dr Y said that she disagreed with Dr Z and it was for me to decide who was right.19.Dr Z, gave evidence. He said that he had seen A at Accident and Emergency. A was constantly running and jumping. She had global developmental delay, she was hypermobile and had ASD. She was hitting her head and banging herself. Dr Z said that he never believed that A’s injuries were caused by another person. He explained that gravity had caused the bruises to develop in the photographs. He said that the concerns related to neglect and whether the child had been left unsupervised.20.Dr Z said that children with autism can’t express themselves and show pain. They might be more irritable, and A was given pain relief as she had significant injuries. The medication she was on to help her sleep, melatonin was effective for some children but can cause others to become hyperactive.21.Dr Z said that Dr X had not contacted him before the strategy meeting.22.Dr Z said that A was a very challenging child and he described the mother as being frightened of being accused of causing her injuries. He had tried to reassure her. He described A hitting and slapping herself, hitting her head on her mother’s shoulder.23.Dr Z said that his view that these were self -inflicted injuries meant that he was in a minority and he didn’t think it was inflicted by anyone else. He said that he was under pressure to reach a consensus.24.HH, a nurse at XX Hospital. She said that A’s mother explained that she had found her in that state. She said that she witnessed A hitting and slapping herself, banging her head and throwing herself backwards and arching her back and pulling out her hair and throwing herself around. 25.HH said that safeguarding had asked her to take out her opinion in the notes that these injuries were caused by A and she did and didn’t record it as NAI but simply didn’t say anything. She said that LL and the Safeguarding team were triumphant and wanted her to agree with them that this were non accidental injuries. She described TT as telling her what to say and she said that TT wasn’t present as she had been, and she hadn’t seen A. She said that she had wondered how A’s mother coped at home and Dr Z had said that the mother deserved a halo. She said that the mother had been upset and crying. She was not agitated or stressed, and she felt that the mother’s responses were perfectly appropriate and there was no sign of any fear from A. HH said that even as A was sedated with morphine she continued to pull her own hair and hit her head and she described A’s mother telling her that she had asked for help from YY Community Centre as the self-injury had been going on for a long time.26.II the Care Coordinator gave evidence. She told me that she worked at YY Children’s Centre. Her role was to support parents with children with severe and complex needs. C told me that A’s mother had told her about A smearing, and she had given advice in respect of clothing to stop A getting into her nappy. The mother had told her about the suspected bone cancer when she had broken her leg. She had accompanied the mother with A to hospital. She described A as slapping herself, hitting herself and throwing herself about. She was a ‘wriggly, squirmy girl’, she had been fretful and agitated until she had been given morphine. 27.C described the mother as being sensible and thoughtful. A, she said was at the forefront of her mother’s mind and she was very concerned for her and she didn’t want her to come to any harm.28.During lockdown C had phoned the mother and she said that previously there had been home visits, but they had stopped during the lockdown.29.JJ who worked for the Portage at the ZZ Centre. She worked with the mother from March 2020 and she had video calls during lockdown. She described the mother as very open and they had got on well. She said that the mother used the service well although she said that the mother had found A’s behaviour challenging. She described A head banging, smearing and eating her faeces, pulling her hair out with a visible bald patch and hurting herself. She said that the mother had reported the stress fracture herself.30.Dr Patrick Cartlidge gave evidence. He is a Paediatrician who said that A’s injuries could not be measured in the same way as a ‘normal child’ without A’s disabilities which include a chromosome deletion, severe autism with no speech or language, global developmental delay, hypermobility and a tendency to bruise easily. 31.Dr Cartlidge said that A’s behaviour was at the far end of the scale and he told me that the sub conjunctival haemorrhage can be caused if something impacts with the eye. This contrasted with Dr Y’s evidence who said there would have to be a blow to the eye, like a punch or a ball hitting her in the eye. Dr Cartlidge said a small scratch could cause it.32.Dr Cartlidge also told me that in contrast to the evidence of Dr Y who told me that ear injuries were almost always non accidental injury that A could have caused the marks to her ears by throwing herself around side to side, as if she had been pinched on the ear the marks would have been wider spread. Dr Cartlidge told me that these injuries could have been caused by A injuring herself. 33.Whilst Dr Cartlidge said that he did not look after children with autism and having read Dr Y’s conclusions he had a lot of ‘unease’ about her conclusions having considered other people’s descriptions of A’s behaviour and he said he didn’t agree with her. He said that the abrasions on the face could be caused by rubbing against something or fingernails. Dr Cartlidge questioned the validity of literature review by Dr Y when A’s behaviour was so extreme and she was so far outside the normal range of behaviour for a child. She also appeared to have some strength for her great grandmother’s description of A overturning the television and table. He said that the mother had documented her injuries including significant bruising34.PPB, A’s Health Visitor first met the mother and A at home in June 2019. She described the children as clean and well dressed. She said that when she first met A, she was different to her sibling and she was concerned about her behaviour. She described C her mother as very loving towards her.35.PC-KK gave evidence. She told me that she had been at the hospital and Dr Z had made it known that he wanted to speak to the Police. She said that he had told her that he was in no doubt that he believed that A had inflicted these injuries herself. PC-KK said that as the safe-guarding team had concerns she went to the home and examined the cot. They put it up and had an inspection of it. She said that the netting and the size and shape of the mesh matched the marks on A’s face. She described the mother as being very welcoming to her. 36.PC-KK said that she decided not to take any further action. This was reviewed by a Senior Officer and the mother informed and because of the crime report had been reopened and the case was allocated to another Officer just in case she had not something correctly or she had missed something. This was standard practice.37.PC-KK described the lay out of the house and said that although there were steps between the mother’s bedroom and A’s room it was much closer than it seems.38.DC-QQ from the Child Protection Unit gave evidence. DC-QQ said that the mother was very upset and emotional about the re-opening of the Police report, but she maintained a good attitude. She said that the mother had begged them not to take her children away from her. 39.DC-QQ told the mother by telephone that the police investigation was discontinuing their investigation and she described the mother as very upset about the whole matter. She remained worried about any of her children sustaining an injury.40.LL gave evidence. LL is head of the Kent Safeguarding team and she told me that she had attended the peer review meeting which Dr Z had presented. She told me that she had noted that the Clinicians had agreed unanimously that the injuries A sustained were non accidental. LL agreed with this. No minutes of this meeting were taken.41.Following that meeting she had telephoned RR, the social worker and told him the outcome and she participated in a strategy discussion. LL said that she helped facilitate the joint report from Dr Z and Dr X. She said that as both doctors were busy in clinic, she typed this and went backwards and forwards by email and telephone, until they agreed the draft. She said that Dr Z had changed his view that the injuries were self-inflicted 42.LL said that she had not had any clinical care of A and had not met her or her mother.43.LL said that there had been a level 3 referral which was a referral to social services for support when she said that as the bruises were unexplained she would have expected a level 4 referral as a child protection investigation needed to take place and she explained that she escalated this. In respect of HH she said that she had been given specific advice about the referral to Social Services. She denied that HH had been rebuked and said that was a very strong word, but she said that if people don’t undertake the safeguarding action expected that their practice would be questioned. 44.CT told her that Dr Z was upset that he hadn’t been invited to the strategy meeting, but her colleague TT had been unable to contact him. CT didn’t believe that Dr Z was put under pressure to change his view of the injuries.45.C, the children’s mother gave evidence. She told me about her children that B is very chatty, she likes school, the film Frozen and she loves her sister. She said as a result of the trauma of being separated from her that B had now got a stutter. C described A as hyper, quite angry at times, very loving and she described her as a baby in a toddler’s body. She described her punching and hitting her and smearing and eating her faeces. She said that she had documented bruising that A had caused. A had drawn blood on her Grandfather and she still pinches herself and whoever is close to her and she said that she had pulled over a coffee table and a television off the wall. She is very strong, and Dr Saggar had remarked upon that and also when he had examined her that he had caused her red marks even though it was an ordinary examination. She pulled her hair out and poked herself in the eye. She said that she throws herself around, bangs her head and has no fear. She had bitten through her lip. She doesn’t sleep and when she was given melatonin this seemed to make her more hyperactive and it was much better now, she was on Phenergan.46.C explained how she had come to find A injured and said that she had sustained some of the bruising previously. She said that it looked much worse in the photos. She told me that she had recently moved to a new house, and she put A in an upstairs bedroom as previously she had kept B awake and the bedroom she was in was unsuitable for A as it had the electricity meter and near to the front door. It wasn’t very far away, and she hadn’t got a baby monitor. She had checked on her around midnight and then at about 8 am. Her mother had come around to see her on the way back from her early morning job.47.B had been staying with her grandmother B and A’s great grandmother. Her partner, G was also staying over. She had gone in to find A covered in blood. She had bathed her to see where the blood was coming from and she rang her key worker to accompany them both to hospital. She said that she had been very upset, she had not hurt A nor had her partner and she was upset at the suggestion that she might have done so.48.G supported by an intermediary, gave evidence. He told me that he had stayed over with the mother and he normally left the care of A to her mother and he had his own children one of whom who lived with his mother and himself. He had to leave on the morning of the injuries, as he had to take his son to school. He told me that he would not hurt a baby and neither he nor the mother had caused the injuries. He described A as being very happy and then suddenly really angry and he described it like a light switch, and she would be biting or kicking or hurting herself. He said that he got on well with B and hadn’t seen her or A. 49.F the maternal great grandmother who is looking after the children gave evidence. She described A as biting, bumping herself and bruising herself. She had rubbed her face against the cot which was rough and hurt herself. She said she was very strong and had pulled furniture over and off the wall. Things had to be tied down. She said that she had never realised that A was so bad. She told me that C the mother is very calm and loving and that A was terrible when she was taking melatonin. 50.D, A’s father did not give evidence as no one required him to be cross examined. He made it clear that he didn’t think that the mother or G would have hurt A. This is despite G being a friend previously and there being initial difficulties when he was aware that the mother and G were in a relationship.51.Dr Saggar was not required to give evidence nor were a number of other witnesses who were asked to give evidence and were then not required which is why we did not sit for the 17 days. I have considered their evidence and that of the seven lever arch files. If I don’t mention some of the evidence, it is not that I haven’t considered it but that there is so much evidence that it is impossible to refer to every part of this evidence in detail.