Case No. ZE22C50109

90.It is possible from the parents’ written evidence, the timeline they prepared in hospital, the documentary evidence, and the evidence of Mrs O and Mrs N, to build up a fairly detailed picture of life in the family home between S’s birth and his admission to hospital. Ms Cheetham has assisted me hugely, in terms of dates and timings of individual events, with a chronology prepared ahead of the hearing, and I have been able to fill in further detail as I have assimilated the evidence during the hearing. 91.The father’s paternity leave started on the day that S was born and he returned to work on Monday 4 April. After his return to work he was out of the home on weekdays from 6.45 in the morning until between about 6 and 6.30pm. 92.S slept in his parents’ bed from his first night at home. The parents explained that they were aware of the risks of co-sleeping, but had not been able to settle either of their children in a cot; they had co-slept with T and therefore took the same approach with S. He was positioned at the head of the bed, on his back, with his head between his parents’ pillows. 93.S is described by his parents as a little harder to settle than T, who was a particularly placid baby (Mrs N described him as “quiet”; in contrast, she said, S cried a little more). The father explained that S’s “cycle” of feeding, sleeping and waking seemed to be a little shorter than T’s. Both parents emphasised that at five weeks S was changing from week to week, if not from day to day. 94.In S’s early weeks the family were surrounded by family and friends all keen to see the baby. During the period of the father’s paternity leave the chronology records four visits to the family home, and two visits by the family to others; having heard the oral evidence I consider it likely that there were further unrecorded occasions when the mother saw her own parents, and at least one visit by Mrs O and her husband that has not made its way into the chronology. 95.After the father returned to work on 4 April the mother took on the sole care of both children during the day. However the parents kept up T’s childcare for the sake of routine, so T was at nursery on Tuesdays and Wednesdays, and spent Thursdays with Mrs N. It was therefore only on Mondays and Fridays that the mother had a full day with both children together. In fact, it appears that she often used these days to meet up with friends: for example, on 4 April she took the children with her sister for a photoshoot, and on 22 April she went to visit Mrs O and her daughter and granddaughter. 96.On Tuesday 19 April 2022 the mother had a dental appointment. Mrs N came to the family home to look after S (T was at nursery). She was there for about two hours. S slept in her arms throughout this time. She noticed nothing unusual about his presentation. I record that it is almost certainly the case that the first fracture was present by this time. 97.There were two weekends between the end of the father’s paternity leave and S’s admission to hospital. On the first of these weekends the father went to a wedding and was away overnight. The second weekend was the Easter weekend. On Saturday 16 April there was a family gathering at the paternal grandparents’ home. On the Sunday and Monday the family spent the day at home, save that on both days they went together to a local park to feed the ducks. 98.The period of Friday 22 – Saturday 23 April was subjected to careful scrutiny during the course of the evidence. In respect of this period I am, of course, reliant primarily on the parents’ account, but for the reasons I have given I consider that their evidence is reliable at least in terms of the overall chronology of events.99.Both parents said that on the morning of 22 April when they woke up, S was presenting normally. F went to work and M was at home with the children in the morning. After lunch she took them both to visit Mrs O, travelling by bus. Also there was Mrs O’s daughter, the mother’s close friend, and her 6 month old daughter. The mother and children arrived at about 1.30. Mrs O drove them home at about 4.30. 100.The father arrived home at about 6.15pm. It was his turn to cook. He took the shopping into the kitchen, where T helped him unpack it and they started peeling carrots. At 7pm the mother went upstairs to run T’s bath. At this point the father was downstairs in the living room with both children. The father described S at this point as unsettled and crying. He changed his nappy. T then asked for a drink and the father put S on his mat on the floor, on his tummy, and went into the kitchen, closing the kitchen door behind him because, he explained, the mother does not like the smell of cooking permeating the house. The extractor fan was on. 101.The father’s written evidence was that he was in the kitchen for five minutes. He made T’s drink and then chopped two carrots to make progress with dinner. In oral evidence he said that on reflection he thought the time he was out of the living room was about three minutes. When he returned S was still crying. In oral evidence the father was asked to describe S’s crying before and after he left the living-room, on a scale of one to 10. He said that the crying was at about five or six on each occasion: there was no significant difference in the nature of the cry before the father left the room and when he returned. 102.During the course of the evening both parents say that they noticed S becoming increasingly unsettled. Neither, unsurprisingly, was able to pinpoint a moment when he was clearly not his normal self; but both describe him as being difficult to settle and when they ate dinner, after T had gone to bed, the mother was unable to put S down and continued to breastfeed him as she had her dinner. After that the father took him out in the sling for a walk. This seemed to settle him, but when they returned and S was taken out of the sling he started crying again. 103.At some point during the evening the parents noticed what they later described as a “popping” or “crackling” sound coming from S’s chest as he breathed. Their accounts as to when this first became apparent have varied slightly, in a way that is entirely consistent with natural recollection. They discussed (and googled) S’s symptoms, thought he might have a chest infection, and decided to wait to see how he was overnight. The night was uneventful. 104.In the morning, however, S’s chest still “did not sound right”, as the mother put it in her statement, and he was still unsettled. The parents decided to call 111; the father made the call and described S’s symptoms. During the course of the call the handler asked whether either of S’s arms was floppy; both parents say they had not noticed this until then, but when the mother lifted his right arm it flopped back down, in contrast to the left. The notes of the call read:“1/7 parents noted grunting on breathing as if in pain. No obvious traumatic history.PMHx: Born at 40/40 vaginal delivery. Required resus initially du to pH imbalance.Patient asleep but rousable.Parents aware of a popping noise when the patient.Right arm not mobile.Nil obvious bruising or swelling.Popping in chest.Crying but ?pained.No obvious declared injury.Father offering genuine concern.Discussed possibility of front facing sling causing issue.No concerns re: safeguarding at present.?shoulder injury?rib injuryRefer to ED.To call ED to ensure attendance.Worsening and watch fors given.”105.The call ended at 08.16. In accordance with the advice given, the mother left for the hospital with S almost immediately.