Background
5P’s parents are first cousins. The father was brought up in the Middle East and the mother in London. They married in 2012 and the mother moved to the father’s home country to live with him. P was born in London in 2013. Shortly after her birth she was diagnosed with an extremely rare genetic disorder, Tyrosinemia Type II. The condition was inherited from the mother who also has it. Tyrosinemia Type II can affect the eyes, skin and intellectual development. Management involves a protein restricted diet with amino acid supplementation. The patient’s tyrosine and phenylalanine levels are monitored through weekly blood spots which are taken at home and sent to the hospital overseeing the care, which in P’s case is Great Ormond Street. It is necessary to adjust both the patient’s dietary intake and the supplements in response to fluctuations in tyrosine and phenylalanine levels. P also has Raynaud’s Syndrome, a condition which causes pain and swelling to the feet. That is not connected to the Tyrosinemia Type II.6For the first two years of P’s life the mother travelled between London and the Middle East with P. The parents’ relationship came to an end in 2015 and at that point the mother returned permanently to London to live in her family home with her own mother, P’s maternal grandmother. She has remained living there with P since 2015. The mother’s relationship with her own mother has been strained in the past and P has witnessed arguments, although things have been more stable in recent months.7The mother has a history of poor mental health dating back to her teenage years. She has been diagnosed with anxiety and depression and has self-harmed, most recently in late 2019 or early 2020.8P’s contact with her father after her parents separated was limited. He has not seen her face to face since 2015, when she was two years old. In 2020, the local authority made contact with him and since then virtual contact has taken place fairly frequently by Facetime facilitated by the mother. The father has remarried and has another child, a little girl called S, who is now aged two.9The local authority became involved with the family in 2018 after a referral made by Great Ormond Street. The hospital reported that the mother had not been consistent in attending appointments for P and monitoring her health condition. In particular, the blood spots were not regularly returned to the hospital which meant that they were unable to monitor and respond to changes in P’s levels. The hospital had tried to provide support from a community nurse but the mother resisted and there were occasions when professionals were not permitted entry into the home.10P was placed on a child protection plan in April 2019 and support from a family support worker was put in place. This led to improvements in the management of P’s condition and the case was stepped down to a child in need plan in November 2019. However, the situation deteriorated almost immediately and, in particular, the mother stopped returning the blood spots to the hospital between November 2019 and January 2020. The mother initially argued that she had been sending the blood spots but they had got lost in the post, but that is not a position that she has maintained in these proceedings.11In March 2020, P was placed on a child protection plan again, and shortly afterwards the local authority started the pre-proceedings process. A report was commissioned from an independent social worker, Liselle Harold, who considered that the mother would require a lot of support but was cautiously optimistic about her ability to make improvements in P’s care. In particular, Ms Harold made some recommendations for strengthening the mother’s support network. A family group conference was held and family members, including the father and P’s maternal aunt, agreed to offer support. Once again, some improvements were made and the local authority decided at that stage not to issue proceedings.12The decision was taken to issue care proceedings in April 2021. That followed a pattern of increasing concerns, including reports from Great Ormond Street that P was not taking her supplements regularly and reports from the family support worker that the mother was not engaging with the advice and support offered and that she had not been compliant with her own mental health treatment. On 27 July 2021, P was made subject to an interim supervision order.13On 9 February 2022, the local authority filed its final evidence and a care plan, in which it sought a final care order for P on a plan for placement in foster care. That was not agreed by either parent and the case was listed for final hearing. This hearing date is the earliest that the court was able to achieve.