SQ24C50017 - [2025] EWHC 2078 (Fam)

Professor Fleming gave oral evidence. I have set out much of his evidence in respect of the bruising above.

Professor Fleming identifies no predisposition in P to injury and defers to the other experts in relation to their areas of speciality.

In the absence of an identified episode of significant and complex trauma, or the presence of an underlying abnormality of bone fragility, the combination of multiple bilateral rib fractures, spinal fractures, lower limb and upper limb fractures is strongly suggestive of non-accidental injury.

The subdural haemorrhages, the encephalopathy described by the paramedics and the acute acidosis on admission to hospital were highly likely to have arisen as a result of an acute hypoxic-ischaemic episode shortly before the 999 calls. The CT scan and MRI findings are also strongly suggestive of a recent hypoxic-ischaemic episode. In the absence of a relevant reported accidental episode or any evidence of pre-existing vulnerability, what is described is highly likely to be a consequence of imposed, non-accidental injury.

The episodes leading to the fracture injuries are highly likely to have been accompanied by a period of significant distress, although the duration may have been relatively brief and a person not present at the time the bony injuries were inflicted might not recognise that significant injury has occurred. He therefore accepted that if the M was not present for the incident when the fractures occurred she might not have realised anything had happened.

The most commonly described mechanism leading to the combination of rib fractures, acute encephalopathy and subdural haemorrhage is vigorous shaking, which may also be responsible for spinal compression injuries and metaphyseal fractures, such as the one to P’s left tibia.

It is not possible to state, on clinical grounds, whether the fractures were caused by one, or more than one, episode of injury. All of the reported bony injuries, with the exception of the fractured clavicle, are compatible with one or more episodes of vigorous shaking, with or without impact, and shaking is also the most likely mechanism for the subdural haemorrhage.

The fracture to the left collarbone could have arisen at the time of birth. Professor Fleming notes factors that are both indicative and contra-indicative of that possibility. He said in oral evidence that clavicle fractures were often missed at birth and only showed up later on in x-rays. In the light of this evidence I think it is appropriate to discount the clavicle fracture.

A photographic image dated 25 April 2024 and taken from the F’s phone indicates a lesion to P’s right flank. Professor Fleming acknowledges that he is not an expert on the interpretation of possible human bite marks, but indicates that he is able to say from his own experience that this appears to be the most likely explanation for this lesion. In the absence of any follow-up images, or any visible item with which to assess the exact size of the lesion, he states that it is not possible to state with certainty whether the lesion was inflicted by an adult or a child, and if this question needed to be determined, suggests that it should be put to an expert in forensic odontology.

I suggested to Professor Fleming that this photograph was much more likely to be of the area just below P’s neck, than his flank. He agreed that this was quite possible.

In his final report, dated 14 February 2025, Professor Fleming responds to the schedule of photographic evidence in the bundle. He expresses the view that ‘the lesions listed above are strongly suggestive of repeated inappropriate, very rough violent handling and are not compatible with self-inflicted injuries in an infant of less than three months of age’. He comments particularly on the bleeding from P’s upper lip and the bruising to his cheeks and concludes that ‘there is very clear evidence of recurrent inappropriate or violent handling of P over the preceding weeks’. Professor Fleming also reiterates his view that ‘in my opinion by far the most likely explanation of P’s collapse on May 8 was an episode of imposed hypoxic-ischaemic injury, probably caused by an episode of violent shaking or shaking plus impact by his father whilst alone with P shortly before the 999 call’.