Strand, London, WC2A 2LL
B e f o r e :
|Re T (No.2) (Care Proceedings: Fact-Finding: Genital Injuries: Supplemental judgment for publication)|
Elizabeth Isaacs Q.C. and Kirstie Danton for the First Respondent
Sara Lewis Q.C. and Stuart Lewis for the Second Respondent
Elisabeth Richards for the Third Respondent
Margaret Styles for the First Intervener
Lorna Meyer Q.C. and Nandini Dutta for the Second Intervener
John Vater Q.C. and Dr. Emma Gatland for the Third Intervener
The names of those solicitors who instructed counsel have been omitted for anonymity.
Crown Copyright ©
Mrs Justice Knowles:
a. All of T's injuries had been inflicted by one (or both) of two possible individuals who had care for him at the relevant time;
b. He suffered genital injuries as a result of an inappropriate and excessive force being applied to his genital area;
c. He suffered anal injuries as a result of a penetrative act, or attempted penetrative act;
d. These injuries were caused on one or more occasion by an adult subjecting T to either a sexual assault or a physical assault without sexual motivation.
"… erm, well he's two, I have just changed his bum and erm his balls look really swollen and like so does his penis, and his penis looks like really bruised and red and like obviously he's saying it's hurting him. He's been very grouchy all day but it's only just now that I've noticed it's all of a sudden like ballooned up…"
When asked by the operator whether what she saw was like a rash or like a bruise, the mother said it looked more like a bruise. Having given her details to the operator, the mother answered questions to establish T's symptoms. During that process, the mother confirmed that the whole area around T's testicles seemed swollen and sore. When asked whether this had occurred in the last 24 hours, the mother said as follows:
"Yeah, well like I changed, when we've been to like the park, so like I changed his bum and there was a bit of a like mark I guess but do you know I didn't really think anything of it I just thought he had knocked, do you know knocked it or something or caught it. Erm but then obviously I have got back and just changed his bum and it's just swollen, yeah, really bad."
Hospital Admission and Thereafter
"… Swollen inguinal regions with mild bruising - tender to palpate, no masses, penis appears purple and purpuric, ? bruise like, cannot palpate L or R testicle. Bruising R upper ant. thigh, L hip, R buttock. Full body exam (?), small coin bruise central chest and midcentral back."
a. a 1cm bruise under the chin;
b. four red circular bruises measuring 0.5 cm under the chin;
c. a 1cm that was well circumscribed on his chest;
d. three brown bruises on the left flank measuring 1 cm in diameter;
e. 2 cm blue haematoma (raised bruise) on the left side of the groin that was irregular in shape and tender to touch;
f. 4 cm linear red lines which appeared like scratch marks to the skin in the suprapubic region just above the penis;
g. a 10cm red linear bruise on the left side with skin abrasion towards the knee. The mother explained that T had grazed his leg at the park on a climbing frame;
h. a 1 cm red-blue circular bruise on the left knee which the mother thought was due to a fall;
i. two small brown bruises on the left leg;
j. four small brown bruises on the front of the right leg and knee;
k. a 2 cm blue haematoma (raised bruise) with irregular edges on the right thigh next to the groin that was tender to touch;
l. a 1cm brown bruise on the right groin;
m. a 0.5 cm circular brown bruise on the right arm;
n. a 1.5 cm linear red bruise on the back of the right side;
o. a 1cm black-brown circular bruise on the right buttock;
p. a 2cm transverse brown bruise on the right calf;
q. a 0.5 cm brown circular bruise midway on the back of his left thigh;
r. a 3cm green circular bruise over the left hip;
s. a 1.5 cm circular red bruise midway on the back to the left of the spine;
t. a 1.5 cm circular brown bruise over the lower spine;
u. red-blue bruising around the whole penis including the underside and extending to the scrotum just below the penis; and
v. circumferential redness around the anus which the mother said she thought was due to loose stools though the redness did not look typical of a nappy rash.
a. a graze above left eyebrow;
b. a bump on his forehead (though there were no bumps on the rest of T's head);
c. Ears and frenulum were intact with no injuries in the mouth;
d. two circular bruises on right forearm anteriorly approximately 4mm in diameter;
e. a bruise on right elbow;
f. a few petechiae under the chin;
g. small bruises on the front of the chest;
h. a small bruise on the right sub-costal area;
i. significant bruising on the right groin;
j. significant bruising on the genitals;
k. right knee and lower leg, 3-4 bruises;
l. a bruise on left forearm around 4mm;
m. bruises on the left flank;
n. a bruise on left inner thigh;
o. a bruise on left knee and left lower thigh anteriorly;
p. a bruise on left upper thighs laterally around 5mm;
q. a small bruise on left lower leg around 3-4 mm;
r. several small bruises on the back;
s. a bruise on the right buttock; and
t. redness in the perianal region.
a. a collection of deep purple bruises just below the groin on the right upper thigh. Total area of bruising 4cm by 2cm, comprised of three separate bruises with an area of central clearing. Dr D queried whether this possibly have the appearance of a pinch mark;
b. a small brown bruise on the anterior aspect of the left thigh. This was not of particular concern;
c. extensive deep purple and green bruising to the suprapubic area - an area to the left of the external genitalia measuring 5cm in diameter;
d. a 2cm diameter area of deep purple and green bruising to the suprapubic area on the right of the femur;
e. deep purple bruising to the base of the shaft of the penis;
f. a 2 cm diameter area of deep purple bruising over the upper part of the left scrotum;
g. the lower part of the left scrotum widely discoloured with a fading green colour likely to represent fading bruising;
h. a 2cm fading Brown bruise over the bony prominence of the butter on the right side;
On perianal examination –
i. AV shaped area of erythema at 12 o'clock position on the immediate anal orifice with no evidence of skin breakdown;
j. a healing laceration or fissure at 6 to 7 o'clock position at the lower aspect of the anus;
k. numerous areas of non-specific erythema (redness) over the lower half of the anal margin and, on reflection, the perianal area itself - possibly representing perianal bruising;
l. a 1cm fading bruise on the lower bony prominence of the left rib cage - not of significant concern;
m. two bruises over the bony prominence of the right knee - likely to be accidental in origin;
n. a 1cm and 2cm bruise over the right lower shin - again likely to be accidental in origin;
o. a bruise over the bony prominence of the left knee;
p. over the bony prominence of the left shin, a small bruise - likely accidental in origin;
q. a 1.5cm brown fading bruise to the left lower back;
r. a further 1.5cm brown bruise to the left lower back; and
s. a 1cm fading bruise over the iliac crest on the left side;
a. 2cm by 2cm brown/green/yellow bruise over right groin back;
b. 0.6cm by 0.6cm brown bruise on the back of the right elbow;
c. 0.8 cm by 0.8 cm brown bruise on the back of the right forearm;
d. 0.5 cm by 0.5cm light green bruise over left thigh;
e. 1cm by 0.6cm red bruise on the right side of the chin;
f. 0.5cm by 0.5cm red bruise on the right side of the chin (in front of the previous injury at e) above;
g. 0.5cm by 0.5cm red bruise over the right side of the buttock;
h. redness of more than 1cm in front of the anal opening at 12 o'clock position;
i. a more than 1 cm shiny healed area at the back of the anal opening at 6 o'clock position; and
j. redness round the anal opening (perianal erythema).
a. the skin of the lower third of the perineum had an unusual shiny thickened appearance with blueish discolouration in a V-shaped distribution about the midline, up to the anal verge. There was no anal dilation in 30 seconds of inspection.
b. there were a few hyper-pigmented pinky-brown marks of a few millimetres across on the left and right of T's anus. AB said that these "dots" were left after spots of nappy rash had resolved. There were no lacerations around T's anus.
c. in the 1 o'clock position, near parallel to the median raphe, there was a relatively thick discrete white linear area of tissue radiating from the anus to just beyond the anal verge.
d. at the upper pole of finding C above, and perpendicular to it, there was the impression of a very fine hairline white line, which fell within the V-shaped area of the perineum which had skin texture and colour change (see finding a) above).
a. the anal laceration described by Dr D at 7 o'clock appeared to have healed without scarring "as would be a typical clinical course";
b. the anal scar at 1 o'clock was suggestive of sexual abuse in the absence of a history of exceptional trauma such as anal impalement;
c. the scar could predate T's hospital presentation but have been obscured by acute injuries or have been missed by non-specialist examination. Scars can be easily missed if hidden between puckered anal skin folds and visibility can be dependent upon the degree of the child's relaxation and cooperation. The scar could have arisen from an acute injury sustained after the 24 July 2020 examination, although this was the least likely explanation. The most likely explanation was that the laceration was sustained shortly before admission and "had healed to a point of mucosal adhesion within this time but not yet undergone fibrous organisation to visible scar"; and
d. the skin in the adjacent area was of an unusual appearance, with uncertain significance and a possible fine line scar in the horizontal plane. Magnified views using video colposcopy might assist with the clinical interpretation. No subsequent colposcopy took place.
The Medical Evidence
a. three brown bruises on the left flank measuring 1cm in diameter, caused by a possible grip or grasp mark or general blunt force trauma;
b. a 2cm raised blue haematoma on the left side of the groin which was irregular in shape and tender to touch, caused by inflicted blunt force trauma;
c. a red 4cm linear bruise to the front of the right thigh, caused by blunt force trauma such as a blow, punch or kick;
d. a red 1.5cm linear bruise on the right side of the back, caused by a slap or blunt force trauma with a linear implement;
e. a black brown circular 1cm bruise to the right buttock, caused by blunt force trauma such as a blow, punch or kick;
f. a brown 2cm transverse bruise on the right calf, caused by blunt force trauma such as a blow, punch or kick;
g. a red 1.5cm circular bruise midway on T's back to the left of his spine, caused by blunt force trauma such as a blow, punch or kick;
h. a brown 1.5cm circular bruise over T's lower spine contiguous with the left spinal bruise listed above, caused by blunt force trauma such as a blow, punch or kick; and
i. occult trauma to the abdomen, skeletal muscle or other organs evidenced by raised ALT (alanine aminotransferase). Raised ALT can be a marker for liver injury and may also be indicative of trauma to other tissues such as skeletal muscle, heart, kidney, pancreas, spleen or lung. Though an abdominal ultrasound scan was not undertaken at the time of T's admission to hospital, the raised ALT level seen in T was 159 units per litre (reference range 10-50) indicating the presence of inflammation of or damage to the liver or other organs.
a. a blue 2cm bruise on the right thigh next to the groin which was irregular and tender, caused by blunt force trauma such as a blow, punch or kick;
b. a brown 1cm bruise on the right groin, caused by blunt force trauma such as a blow, punch or kick;
c. a blue 2cm bruise on the left side of groin, caused by blunt force trauma such as a blow, punch or kick; and
d. linear 4cm red scratches in the suprapubic region above the penis, caused by scratching or scraping;
e. The injuries to T's head, limbs, torso and groin were impossible to date from appearances alone and it was thus difficult to say when they might have been caused.
a. severe, extensive, red/blue bruising around the whole penis including the underside and over the foreskin, extending to the scrotum, caused by blunt force trauma such as a blow, punch or kick. In her oral evidence, Dr Ward considered that there was an element of grabbing, grasping, squeezing, twisting or pulling in the causation of these injuries;
b. a V-shaped redness at the 12 o'clock position in the immediate anal orifice;
c. circumferential perianal redness extending into the natal cleft;
d. wedge-shaped redness and inflammation between 11 o'clock and 1 o'clock peripherally with apparent loss of superficial tissue between 11 o'clock and 12 o'clock peripherally;
e. an area of marked excoriation between 4 and 8 o'clock on the anus;
f. a brown/blue fading bruise at 2 o'clock;
g. a healing laceration at the 6-7 o'clock position at the lower aspect of the anus;
h. a white fine scar extending from the anal verge to the perianal skin at the 1 o'clock position with an extension creating an inverted, reversed L-shape.
c) Injuries to Genitals
d) Anal Injuries
The Medical Investigation of T's Injuries