60 Canal Street
B e f o r e :
|NORTHAMPTONSHIRE COUNTY COUNCIL||Applicant|
|(A Child, through his Guardian, Suki Gill)||2nd Respondent|
MS J PORTER appeared on behalf of the 1st Respondent Mother
MR J SAMPSON appeared on behalf the Child through his Children's Guardian
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MR JUSTICE KEEHAN:
'One highly important aspect of the Lucas decision, and indeed the approach to lies generally in the criminal jurisdiction, needs to be borne fully in mind by family judges. It is this. In the criminal jurisdiction the "lie" is never taken, of itself, as direct proof of guilt. As is plain from the passage quoted from Lord Lane's judgment in Lucas, where the relevant conditions are satisfied the lie is "capable of amounting to a corroboration'. In recent times the point has been most clearly made in the Court of Appeal Criminal Division in the case of R v Middleton  Crim. L.R. 251. In my view there should be no distinction between the approach taken by the criminal court on the issue of lies to that adopted in the family court. Judges should therefore take care to ensure that they do not rely upon a conclusion that an individual has lied on a material issue as direct proof of guilt'.
The Background: The Mother
The Background: The Child
(a) in the first 20 months of his life, N presented to the general practitioner and other healthcare professionals for a variety of medical issues, most commonly apparent seizures on no less than 90 occasions.
(b) in the same period, he was admitted to Accident & Emergency Department at various hospitals on no less than 13 occasions and, as before, always by and with his mother and
(c) he was admitted to hospital for examination at his mother's behest on no less than nine occasions.
The Expert Evidence
'M has presented with episodic seizure-like activities since the age of 14. Investigations of possible epilepsy have consistently proved negative. Her condition has variously been described as a somatisation disorder or dissociative seizures. More recently, her condition has been described by her treating neurologist Dr S as a non-epileptic attack disorder. All of these diagnoses refer essentially to the same condition. The variation arising principally from the perspective of the treating doctor. For the sake of consistency, I adopt Dr S's diagnosis of non-epileptic attack disorder. N has been described by his mother as exhibiting episodic seizure-like activity since the age of six months. Seizure activity has not been observed by others except perhaps by Ms T, nursery nurse in April 2016. Extensive investigation, including a 24-hour ambulatory electroencephalogram with video monitoring on 9 May 2017 has not revealed evidence of his epilepsy. His condition has been described as factitious or induced illness. This resulting in the safeguarding concerns which have led to N's reception into care. In summary, therefore, based on the available medical information, M exhibits a non-epileptic attack disorder. N exhibits a factitious or induced illness, in this case meaning he does not have epilepsy but his mother is imputing this condition onto him'.
'At the time of my own assessment, M was able to provide a very extensive account of both herself and her son. She seemingly accepted her diagnosis of non-epileptic attack disorder but still remained convinced that she had been experiencing epileptic attacks. For example, she reported having a massive seizure during the course of her pregnancy with N. She also appeared convinced that N also suffers from epilepsy and is at risk of serious harm if not properly managed. For example, when N was in hospital during May 2017, she feared he would become dangerously ill if not provided with oxygen. However, in my opinion, M's beliefs do not have the unshakeable and fantastic quality typical of psychotic dilutions so they are better classified as over-valued ideas. M did not report any other inter-current psychological symptoms such as anxiety or depression. On the face of it, M currently presents with a specific overvalued idea concerning her own health and her son's health. In themselves, overvalued ideas are not diagnostic of any psychiatric condition. In view of the absence of intercurrent psychological symptoms or any diagnostic medical state of abnormalities, I consider that M is not suffering from any overt mental illness at the present time. In summary, M presents with an enduring overvalued idea, not amounting to a delusional belief concerning her diagnosis of epilepsy. She seemingly maintains that she is suffering from such a condition even though at an intellectual level, she can identify the diagnosis of non-epileptic attack disorder. She has also become concerned that her son has suffered from epilepsy since the age of six months and remains concerned about his ongoing health, in spite of the absence of a confirmed medical diagnosis. Although not currently mentally ill, she displays a pattern of behaviour which may plausibly arise from an underlying borderline personality disorder. In terms of prognosis, I consider that by their very nature, M's overvalued ideas concerning both her own and her son's health are likely to persist indefinitely'.
'Over-valued ideas can prove debilitating for the person experiencing them, but usually do not become seriously dysfunctional, unless they extend to involve other people such as, for example, in cases of harassment and stalking. Currently, there is no medical treatment which can reliably alter the course of over-valued ideas. Psychological approaches such as cognitive behavioural therapy have been attempted, but the academic literature provides little evidence for sustained benefit. Counselling approaches have also been attempted but this is more supportive in nature, rather than a method for altering the course of a strongly-held idea. Overall, there is currently no clearly beneficial therapeutic approach which can be recommended. In respect of prognosis, over-valued ideas typically persist for years and sometimes for life. In M's case, Dr S's nudge approach to anti-convulsant medication withdrawal seems entirely appropriate, although it appears that little act or progress has been made to date. M's over-valued idea concerning her own epilepsy has resulted in her extensive involvement with medical services, including both emergency services and investigative procedures. If this pattern were to continue, it would reduce her availability to provide continuity of care for her child. This could have a substantial negative impact in the absence of a supportive partner. In M's case, her over-valued idea has extended to incorporate her son. Consequently, from the age of six months, N has experienced a substantial number of hospital attendances for both emergency and investigative purposes. However, in respect of possible epilepsy, these attendances cannot have been beneficial, except only to exclude the condition. This also reduced N's opportunities for more normal family life and participation and developmental opportunities. The impact is likely to become more significant as N grows older. For example, through failed nursery or school attendance. Overall, M's specific over-valued idea concerning epilepsy is likely to distract her away from her parenting role and cause her to pursue a course of action in respect of N which could not be positively beneficial for him. Inevitably, assessment of future risk is somewhat speculative. The most likely outcome could be N's withdrawal from appropriate, developmental or educational opportunities through unnecessary medical attendances. This could arise particularly if M were to seek a succession of further opinions in support of her own idea. This could also include frequent relocation in her search for support. Somewhat more speculatively, M could seek to treat N for epilepsy by sharing her anti-convulsant medication with him. Furthermore, M's current overvalued idea could plausibly extend to other medical conditions for which she may seek medical attention. For example, she was briefly concerned that N may have a hole in his heart. I emphasis the extent of these possible risks is unquantifiable'.
'N has had a high number of contacts with health professionals in his 21-months of life. This is unusual for a child who has no diagnosed long-term disorder and no objective persisting clinical signs. This pattern of contact is also unusual because of the high occurrence of normal physical signs of investigation results, despite being presented frequently as unwell. There are an unusually high number of health contact for which there is no documented corresponding clinical signs identified by the assessing health professional. N has recently been confirmed to have iron deficiency for which he is receiving iron supplements. The cause is usual nutritional in toddlers, N is otherwise in good physical health and is meeting his developmental milestones. There are long-standing concerns by the mother that N has seizures, despite assurances to the contrary by his paediatric medial team. Reported events have not been verified by third party observations and clinical observations. There have been diagnostic challenges as the pattern of description of these movement seizures have not tallied with known medical conditions such as epileptic seizures or epilepsy mimics. Epilepsy is a common neurological disorder characterised by a high incident of inaccurate diagnosis and up to a third of people with a diagnosis of epilepsy have indirect diagnosis. Video telemetry done in N did not identify any abnormal movement or behaviour and the EEG was reported as normal. In my opinion, there is no evidence to suggest N has epilepsy seizures'.
'There are concerns by the mother that N has seizures, reported events such as vacant episodes and responsiveness and abnormal motor movements have not been verified by either third party observations or clinical investigations. There have been diagnostic challenges as the pattern description of these movements or events do not tally with known medical conditions. Clinical and laboratory examination after these events have been normal. The events have not been independently observed and there was a normal EEG. EEG is a test that detects electrical activity in the brain. The EEG during reported events and in between events have been reported as normal. A reported event by the mother during the video telemetry did not reveal any abnormal movements. The view of his local medical team is that the reported events are not epilepsy fits. N is now 24-months-old he has an unusually high number of contact with health professionals, 13 A&E attendances, nine in-patient admissions and 90 communications with health are quite unusual for a child that has no diagnosed long-term disorder and no persisting clinical signs. This is also unusual because the absence of abnormal verified symptoms and normal physical signs investigation results. The challenges of medicine are usually more of interpretation over normal physical times and abnormal laboratory investigation results that do not fit recognised physiological processes. From the medical records made available to me, there is no evidence to suggest that N has any long-term disorder. He has iron deficiency and iron deficiency in a toddler is a time-limited condition and would resolve once his iron stores are replenished with iron supplementation. N's daily life and function must have been confusing and chaotic with frequent contact with multiple stranger professionals. The impact of the frequent health physicians he visits, and physical examinations may be difficult to fully understand because of his very young age. N was reported to be very distressed when an ECG was attempted in April 2017. Whilst this is not unusual in children, it cannot be ignored. The impact on interaction with peers due to frequent clinical appointments may lead to poor stimulation with potential to socialise isolation and poor social communication skills. It is unclear what opportunities N has for regular peer interaction, apart from the play activity he was reported to attend at a play centre in Milton Keynes. There is a very strong danger of perpetuating and medicalising the unknown with further risk of subjecting N to unnecessary anxiety by further investigations. FII is a diagnosis continuing. The factors that cause carers to progress along the continuum are not fully known. N is at risk of induction of symptoms'.
(a) the video of the EEG on 3 May 2017 showed no signs whatsoever of N suffering any form of seizure;
(b) even where there were legitimate reasons for N's presentation, the mother exaggerated his symptoms;
(c) breath-holding in a baby or young child always has identifiable triggers which, if frequent, a parent can recognise the trigger and avert the breath-holding. She described the mother's accounts of N breath-holding as unlikely;
(d) at no time did N suffer severe reflux or associated back pain, Sandifer Syndrome as asserted by the mother; and,
(e) there is no evidence that N suffers seizures.
The Evidence: Treating Clinicians
(a) on physical examination the consultant found no problems with N's upper limbs and fine motor skills. He was developmentally normal and;
(b) the mother never mentioned either of these issues to her health visitor S. Dr H told the mother she did not have any concerns about N's development or the power of his upper limbs.
(a) N did not suffer from epilepsy;
(b) the video of 3 May 2017 did not show any of the seizures alleged by the mother or, indeed, any abnormal movements at all. At the material time, N was a quiet baby, seeking to sleep;
(c) the EEG does not show any abnormal brain activity and, in particular, no evidence of a seizure;
(d) the EEG would have detected movement by N if it involved his head and neck. At the material time, no movement was detected.
(e) the mother had been told to press a button on the EEG control panel if there was any sign of abnormal movement. This would place a marker on the trace recording. Although the mother opened the bag containing the control panel immediately after she alleged N had suffered three seizures, she did not press the button;
(f) further, the mother had been instructed to press the call button to summon a member of the nursing staff if N had any abnormal movements. The mother approached the call button after she said there was alleged shaking by N, but she did not press it. Instead, she left N's side room to summon the nursing staff;
(g) without any adverse history, the mother demanded of Dr HW that N undergo an ECG procedure. In doing so, she was very assertive and verging on complaining;
(h) Dr HW, has had very considerable experience of interacting with parents of unwell children. He was of the firm view that the mother enjoyed the situation of N being in hospital. She was preoccupied with medical procedures and she did not come across as concerned or worried about her child; and
(i) he was of the view, especially after the video of 3 May 2017, that the mother was and had been exaggerating and fabricating symptoms in N. They, the clinical staff therefore intervened very quickly because an FII parent who is not believed can very quickly escalate matters and move from exaggerating and fabricating symptoms to inducing symptoms. Dr Vaughan was in complete agreement with this analysis.
(a) so far as she was aware, N had never had a breathing monitor attached to his nappy;
(b) she had never seen N have a seizure or a tremor;
(c) she had never criticised the mother's care of N and never sought to undermine the mother as a parent;
(d) at N's eight-month developmental check-up the mother agreed with her assessment that N was developing well and his limb movements, etc., were satisfactory;
(e) the mother had never reported to her that N could only tolerate certain makes of nappies or that he had a significant problem with developing rashes on his body.
(a) N had been diagnosed as suffering from palliative breath-holding spells;
(b) she, the mother, had been diagnosed with epilepsy. She made no mention of having in fact been diagnosed with non-epileptic attack disorder;
(c) prior to N's birth, the mother had been told that he had brain and heart defects and may die within six weeks of his birth;
(d) armed police were present on the maternity unit when she gave birth to N for her protection in respect of alleged threats made by Mr T;
(e) she had been advised by a specialist that it was likely N would get epilepsy at six to 12 months; and
(f) she administered physiotherapy to N and limb therapy because of N's difficulties in using his limbs. He would not use both simultaneously.
(a) the mother has no insight into her behaviour or actions as was demonstrated by her oral evidence;
(b) she has consistently expressed a view to the Guardian that apart from being an overly anxious mother, she has done nothing wrong;
(c) there is no prospect of the mother gaining any insight;
(d) the mother has shown herself to be very manipulative;
(e) there was no safeguard which could be put in place which would enable the mother to resume the care of N. The risks were too great and the risk of the mother moving on to induced symptoms in N was real;
(f) it is essential for N's welfare that his maternal grandparents have a special guardianship order in their favour so that they have the upper hand in exercising parental responsibility; and,
(g) it is necessary that an order is made for contact at a frequency of once per month plus such other occasional holiday periods as the maternal grandparents may agree so that they and the mother are clear about what level of contact has been approved and permitted by the court.
(a) at the beginning of her evidence, the mother wished to amend an account in her second statement of N having suffered a collapse on one occasion at home. She told me he had not collapsed but had a shaking episode and became floppy. Why the difference in the mother's account? She could give me no explanation;
(b) the mother told me she was devastated by N's presentations and sometimes cried her eyes out. This account is wholly contrary to the weight of the evidence of the clinicians and healthcare professionals, many of whom described the mother as enjoying talking about N's medical history and not exhibiting any stress about him or concern for him. These observations chime with my own observations of the mother over the course of this hearing and during her time in the witness box. Save for two very brief occasions when she became emotional, she smiled throughout most of the evidence;
(c) in April 2016, the mother made an application for disability living allowance in respect of N. She said she was assisted to complete the form by a voluntary organisation. The mother accepted that she gave the information to a person who completed the form for her. She claimed that she had never previously seen the completed form, although she accepts that her signature appears twice on it. The alleged symptoms and conditions suffered by N is set out in the application form, there are no relation to accounts given by the mother from time to time to the clinicians;
(d) the maternal grandmother told the Guardian that the mother had said she could not attend the wedding of the maternal grandmother and maternal step grandfather because she had cancer. The mother denied this and told me she had been banned by the maternal grandmother from attending the wedding. No reasons for the ban were given to me. I note, however, on 9 April 2014, Dr M, a consultant oncologist, reassured the mother she had not got breast cancer. Thirteen days later, on 22 April 214, the mother is recorded as telling the doctor at Kettering General Hospital that she had recently been diagnosed with breast cancer. The mother denied saying this. Where there is a conflict between the evidence of the mother and a clinical note, I prefer the latter. Accordingly, I am quite satisfied that the maternal grandmother is telling the truth and the mother is lying;
(e) the mother told me, as she repeatedly told others, that N suffers from palliative breath-holding spells. She said the diagnosis was made by a consultant treating N, but she could not remember the name, other than it was a male doctor. When I asked her how many male consultants had seen N, she gave the utterly absurd and false answer of 10 to 15 consultants. The condition of palliative breath-holding spells is unknown to medical science. The mother was, once again, lying;
(f) the mother has repeatedly told clinicians and health professionals that she has been diagnosed with and/or suffers from epilepsy. The mother has known since 2010 that she does not have epilepsy. She has been diagnosed with non-epileptic attack disorder, as confirmed by her treating neurologist, Dr S. The mother may not like this diagnosis and, indeed, she said she was angry when first told of it, but I do not accept the mother's account that she tells professionals she has epilepsy because they will not or do not understand NEAD. She was deliberately seeking to mislead professionals into believing she had epilepsy;
(g) the mother said in evidence that she accepted the report and opinions of Dr Vaughan. Given that Dr Vaughan is of the opinion that the mother exaggerated and fabricated symptoms in N which the mother adamantly does not accept, the mother plainly does not accept the opinions of Dr Vaughan;
(h) the mother asserted that Dr Hewittson had told her in December 2015 that N had a bacterial infection. First, there is no reference in any of N's medical records of him ever having suffered a bacterial as opposed to a viral infection. Second, this assertion was not put to Dr Hewittson when he gave evidence. It is a lie by the mother;
(i) the mother said in evidence that she was worried that N may have an immunosuppressive disorder because he had suffered, 'So many viral infections'. There is no evidence that N has ever had an immunosuppressive disorder and no clinician has ever suggested the same. Further, at the time the mother raised this issue with the clinicians, N had only suffered two mild viral infections. This is a clear example of the mother exaggerating symptoms and medical conditions;
(j) on 3 May 2017, the mother told the nursing staff that N had just suffered three short episodes of shaking along the whole length of his body. This account was given before the mother had viewed the video recording. In her evidence, after she had viewed the video, she gave a different account. She said his head and one arm, which cannot be seen on the video, was shaking. When asked why she told the staff it was the whole body, she gave the wholly implausible answer that she had told the nursing staff what she thought she had seen. When asked why she was giving a different account in her oral evidence, which she had never given before, she had no answer. She was lying and giving a false account against overwhelming evidence to the contrary. Not just the video recording, but Dr HW's s evidence that the equipment would have detected N's head and neck shaking or moving, and it did not;
(k) in her oral evidence, the mother asserted she had been told by a doctor in 2015 that she had erroneously been informed at an early scan of N in-utero, had revealed that he had two holes in his heart. A few matters arise. First, the mother has never before said that the information about N's heart was given to her in error. Hitherto, she has always asserted that pre-birth scans had shown he had a hole in his heart. Secondly, previously, the mother has asserted N had a hole in his heart. In her oral evidence for the first and only time, she has referred to being told in error or otherwise of two holes in his heart; and
(l) she had asserted in the disability living allowance application forms that N had eczema over the whole of his body. He has never had such extensive eczema, only small patches in some of the folds of his skin. When challenged about this, the mother sought to explain the contradiction by claiming that the phrase, 'whole body' meant the small patches in some folds of his skin. A quite incredible explanation but the mother was lying.
(a) the video made by the mother with a neurophysiologist which the mother asserted demonstrated N suffering a seizure event but which the doctor recorded as 'N sitting quietly'; and,
(b) during video telemetry on 3 May, when the mother asserted and continued to assert at this hearing that N had suffered three three-second seizure events.
(a) a number of N's appointments with medical professionals were quite normal and routine medical appointments; and
(b) a number of hospital admissions in the early months of N's life were the result of feeding problems and of him suffering two bouts of bronchiolitis in December 2015 and January 2016.
Findings of Fact
(a) the mother exposed N to unnecessary medical treatment and procedures;
(b) she has fabricated and exaggerated medical symptoms in N;
(c) she has asserted repeatedly and contrary to the unanimous medical opinion that N suffered seizures;
(d) she has an admitted history of violent and abusive relationships;
(e) she has an admitted diagnosis of non-epileptic attack disorder;
(f) she has been diagnosed with suffering from over-valued ideas; and,
(g) she has repeatedly demonstrated volatile behaviour.
Welfare Best Interests of N
(a) suffering unnecessary painful and/or distressing medical assessments and procedures;
(b) with frequent presentation as to GP surgeries and hospitals where he would be exposed to a wholly unnecessary risk of acquiring illnesses and infections;
(c) would suffer unnecessary disruption to his school and daily life and routines; and
(d) a risk of him coming to believe that he does suffer from epilepsy and/or a range of other medical conditions when he is, in fact, a perfectly normal and healthy child.