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England and Wales Family Court Decisions (High Court Judges)


You are here: BAILII >> Databases >> England and Wales Family Court Decisions (High Court Judges) >> A Local Authority v A Mother & Ors [2025] EWFC 193 (10 April 2025)
URL: http://www.bailii.org/ew/cases/EWFC/HCJ/2025/193.html
Cite as: [2025] EWFC 193

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Neutral citation number: [2025] EWFC 193

IN THE FAMILY COURT

Date: 10th April 2025

 

Before

 

MRS JUSTICE ARBUTHNOT

- - - - - - - - - - - - - - - - - - - - -

Between :

 

 

A LOCAL AUTHORITY

Applicant



- and -

 

A MOTHER

1st Respondent

 

 

 

 

- and -

A FATHER

2nd  Respondent

 

- and -

 

A
(By their Children's Guardian)

 

- and -

 

Mr X

 

3rd Respondent

4th Respondent

 

- - - - - - - - - - - - - - - - - - - - -

 

Ms Catherine Jenkins and Ms Lucy Bennett (instructed by Pathfinder Legal) for the Applicant

Ms Debra Gold (instructed by Chapple and Co) for the 1st Respondent
Mr Christopher Bramwell
(instructed by the Family Law Group) for the 2nd Respondent
Ms Fareha Choudhury and Ms Costanza Bertoni (instructed by Adlams Solicitors) for the 3rd Respondent

Mr Andrew Bagchi KC and Ms Jessica Lee (instructed by HC Solicitors) for the 4th Respondent

- - - - - - - - - - - - - - - - - - - - -

Hearing dates: 17th - 28th March 2025.

Judgment handed down via email at 11.44am on 10th April 2025

Judgment

.............................

 

 

Introduction

1.      This is a fact finding in proceedings concerning A who was born in 2017.  He had a sister B who was born in 2021.  Both children lived at home with their mother, the first respondent. The mother and the father, the second respondent, had separated in 2022.  In April 2023, the mother started a relationship with the fourth respondent, Mr X.  In about July or August 2023 he moved in with the mother.  His two children, C and D joined them in September 2023.

2.      B was born prematurely and had been diagnosed with Prader-Willi syndrome, developmental delay, chromosome 9 abnormality and ventriculomegaly (she had two enlarged ventricles).

3.      At the time of B's death, she had low muscle tone, was non mobile although she could wriggle and had recently started to roll over onto her stomach.  She was fed by a gastrostomy (PEG), she had sleep apnoea and was on hormonal supplements, she could not communicate but could make sounds. 

4.      On 2nd October 2023, B had had an MRI scan which showed cortical atrophy in both hemispheres of the brain and moderate ventriculomegaly.  There was also a large cyst in the floor of the cranial cavity.  This was not relevant to the injuries she suffered later.

5.      On 16th October 2023, she was admitted to hospital with an abscess in her throat area which was drained and treated with IV antibiotics.  On 19th October 2023, however, she had to be admitted for an operation to manage the infected abscess.

6.      On Friday 27th October 2023 B fell from her mother's lap onto a hotwheels toy.  She sustained a mark on her head but seemed fine.

7.      On Saturday 28th October 2023 at about 5.30pm, when B was at home with her mother, the fourth respondent and the three boys, a 999 call was made as the little girl was in cardiac arrest.  Prolonged cardiopulmonary resuscitation was administered first by the mother then by paramedics, followed by a doctor.  Spontaneous circulation did return although she suffered another cardiac arrest.  B was intubated and taken to hospital.

8.      Her injuries were found to be multifocal subdural haemorrhages, spinal subdural haematoma, hypoxic ischemic brain injury, multiple bilateral multi layered retinal haemorrhages and ligamentous spinal injury.  Other than injuries caused during the attempts to resuscitate her, she had visible bruising on the left Anti Cubital Fossa and a small bruise under her sternal notch.  At some point she was seen to have a small bruise on her ankle.  There were no bony injuries and significantly in the light of the fourth respondent's explanation that she must have hit her head hard on an object, there was no scalp soft tissue swelling or bruising in the layers of the scalp. 

9.      B was transferred to Hospital B the same night and underwent surgery on 31st October 2023 but she died on 6th November 2023 after all care was withdrawn.

10.  The mother and Mr X were arrested on 30th October 2023.  The police are taking no action against the mother whilst Mr X remains under investigation.

11.  The local authority obtained an interim care order in relation to A on 17th November 2023.  He lived first with his maternal great grandparents, then his maternal grandparents before by agreement A moved into the care of his father on 10th August 2024 where he has remained.   He has been having regular supervised contact with his mother.

Threshold allegations

12.  The local authority's threshold, which it has to prove on the balance of probabilities, alleges significant harm or risk of harm caused in a number of ways, with the relevant date for determining threshold being 31st October 2023 when section 20 accommodation was agreed for A.  

13.  The first set of allegations allege that A was likely to suffer significant harm and neglect:

1)      Given the injuries suffered by and the death of B in the care of the first and fourth respondents.

2)       B's injuries (set out in paragraph 8 above) were inflicted by Mr X. Her underlying conditions did not predispose her to the injuries set out above. 

3)      The injuries remain unexplained by Mr X. 

4)      The injuries were inflicted as a result of abusive head trauma. 

5)      The most likely cause was an episode of shaking involving acceleration/deceleration.

14.  The second set of allegations relate to A.  It is said by the local authority that he suffered significant, physical and emotional harm and neglect whilst in the care of his mother and Mr X:

6)      Given that Mr X held him on his back and bent his body such that his knees were on his shoulders. 

7)      That Mr X made A, aged six, wear a nappy when he did not want to. 

8)      That Mr X told him his father did not love him.

9)      When his mother was downstairs Mr X took him to his bunk and put his hands around A's throat to make it hurt.  It made him cry. 

10)  Mr X punched him and made his nose bleed. 

11)  Mr X swore at A when his mother was not around using words like "fuck and bitch". 

12)  Mr X was harsh in his treatment of A, shouted at him and smacked his bottom.

15.  The local authority alleges that the mother failed to protect A from significant physical and emotional harm and the likelihood of such harm.   

13)  The mother failed to protect A from Mr X's abusive actions set out above.

14)  She failed to protect B from suffering the injuries caused by Mr X and therefore A was at risk from such harm. 

15)  The mother failed to protect A from Mr X's behaviour even when he told her about it.  She told him it had not happened.  

16.  The local authority alleged that the mother neglected A in various ways:

16)  On about 28th September 2022 the mother caused bruises to A's face and legs because he answered back. 

17)  On about 10th October 2023, A was slapped by his mother on his bottom 'very hard'. 

17.  The final allegations are that the mother caused significant emotional harm to A in various ways:

18)  The mother did not prioritise A's needs by moving Mr X into her home in August 2023, two to three months after meeting him despite knowing about the allegations of domestic abuse made by his former partner and knowing his own children were on a child protection plan. 

19)  Further significant emotional harm was caused to A when the mother stopped all contact between A and his father after she had started a relationship with Mr X. 

20)  Finally she had not separated from Mr X despite the medical evidence that he had caused a head injury to B.

18.  The threshold allegations are denied by the mother and the fourth respondent Mr X.  The fourth respondent in his evidence said B was wriggling and he dropped her accidentally although he had hold of her leg.  Her head hit the cot or a car seat.  He denies injuring her intentionally. 

19.  I had the help of two reconstruction videos, one made on the day of the injuries suffered by B on a BWV produced by a police officer.  The second was one that the fourth respondent made in response to a court order after one of the experts asked that he do that.  He also showed with his hands what had happened in his first interview with the police about two days after the events and again he showed this court what happened and was cross examined extensively on his description. 

20.  I appreciate that it is sometimes difficult to explain exactly how a very quick accident happens.  I take that into account when I consider what he has said.  I accept he would not have been able to provide a completely accurate account, particularly as time goes by.  I find that probably the most accurate reconstruction of what happened was provided at the time as shown in the BWV. 

21.  The videos have been sent to the various experts instructed.  Significantly they say that the accidental dropping he showed with a striking of the head out of his view during the drop, would not have led to the severity of the brain injuries seen on B. 

Overall

22.  The evidence for the local authority was divided into two parts, first the evidence from the experts instructed to consider B's injuries and second the evidence of the father, school deputy safeguarding officer and social worker who gave evidence of what A had told them had happened to him particularly in the way he was treated by Mr X.

23.  There is also evidence of what the fourth respondent said at the time to police officers and others.  It is alleged that he gave a number of different accounts of what happened. 

24.  The experts who have reported on this case have included a wide range of specialists including: Dr McPartland, the Consultant Paediatric Pathologist with an interest in ophthalmic pathology; Dr Kieren Allinson, a Consultant Neuropathologist; Mr Amedeo Calisto, a Consultant Paediatric Neurosurgeon; Dr Fionnan Williams, a Consultant Neuroradiologist; and Dr Tim Lavy, a Consultant Paediatric Ophthalmologist.  Other specialists have given statements or written reports but were not called.  Dr Curran, Dr Rose and Dr Cary agreed with their colleagues that this was a non-accidental injury and that the explanation given by the fourth respondent would not have caused the severity of the injuries seen.

25.  The evidence setting out what happened to B was given by the fourth respondent.  He also dealt with the allegations made that he had been abusive towards A.  He denied shaking B or causing her head to move forwards and backwards vigorously.  He denied being abusive to A.

26.  The mother in her evidence denied that Mr X was abusive towards A.  Her case is that the threshold criteria are not met.  She did not accept A's allegations that Mr X was abusive towards him nor did she accept she has harmed him in the various ways set out.  She denied moving Mr X into the family home too quickly.  She accepted she stopped contact between the father and his children but said it was after he had been abusive at handovers.

27.  Striking for me was the mother's evidence in relation to Mr X.  She remains in a relationship with him although at one point after she had received the evidence from Dr Williams and it had been explained to her by her solicitor she told me that they split up for a day or two.  She was pressed about her views now about what had caused B's catastrophic injuries and the most she could say was that she had some thinking to do.  It seemed to me that she had had a year to do that. 

Evidence

28.  There is a vast amount of evidence in this case: medical evidence all leading in one direction, police evidence, contact evidence, evidence from the fourth respondent's own child arrangement proceedings as well as the respondents' statements.  I have picked out what I think is the some of the relevant evidence which allows me to consider whether the local authority has proved its case. 

29.  I have been very much assisted by counsel for the parties who have approached this case efficiently and succinctly and unsurprisingly given their experience and ability with a rigorous consideration of the evidence.

30.  The focus of the fact finding has been on what Mr X said happened to B and whether the local authority can prove that his account was untrue and that the injuries were not caused in the way he set out.  I reminded myself that there is no burden on Mr X to prove he did not cause the injuries to B. He has said consistently that he had dropped B and caused the injuries.

31.  Mr X has told a number of people what had happened. He provided a number of accounts and two video reconstructions.  There was a very short account to the 999 operator.  The first video reconstruction filmed by the police on a body worn camera was about an hour or so after the events he was describing.  There was an account that he gave to a witness Mr Y very shortly before that.  He then gave an account to the mother at some point over about 36 hours after the event.  I did find it curious that according to the mother and Mr X they have never discussed what happened in the 17 months since the events.

32.  The overall description that Mr X has given was that he had taken B up to bed for a rest at about 4.30pm.  This was unusual but she needed some quiet time.   He then spoke to his family and about an hour later he had returned to B and she was wriggling in her cot more than usual. 

33.  He picked her up and had her in his arms laid flat, he was cradling her against his body with the head to his left and the legs to the right.  His hands were on top of each other under her.  He took a step back and she then slipped out of his grasp, rolling forwards with her head unsupported before he managed to get hold of her right foot, leg or ankle and twisted it so her head was facing upwards.  Her head then dropped downwards acting as a counterweight or pendulum. Her body fell to the vertical.  Her head came into contact with either the cot, the floor or the car seat because he heard a loud bang. 

34.  He pulled her up by her ankle with his right hand.  Whereas in court he told me that when he took her downstairs he had not noticed anything wrong with her, in another account he had said that B was in distress and was moaning and she let out one or two cries or was crying.  

35.  When downstairs he called the mother and put B on the sofa. The mother who was in the kitchen came out and they found a lot of blood in B's mouth.  B then vomited, her eyes rolled into her head and her head tipped backwards.  This took about 30 seconds.  The fourth respondent called 999.  B was not breathing for 10 or 20 seconds and then she was gasping.  The mother was then instructed to do CPR on her.  The other children were removed from the room.  The ambulance crew arrived very quickly and the police arrived soon afterwards.   

36.  The explanation that it was an accidental drop from a horizontal position just above waist height with an impact causing a bang at the end of the drop was considered extensively by a number of experts.  They were provided with the statements of the fourth respondent (and the first respondent) as well as much other evidence including two reconstruction videos, one made on the day recorded on a BWV and the other a few months later.  Both showed a similar scenario as set out by Mr X in evidence.

 

 

Mr X's evidence

37.  Mr Bagchi KC in his submissions accepted he could not positively suggest that the injuries arose as a result of B's known diagnoses and he contended that no court could ever exclude an entirely as yet unknown cause which would not show up on any test conducted by the range of experts instructed in the case. In my judgment to find something of that sort would be entirely speculative in this case.

38.  The focus of the court and the questioning of Mr X has been on the mechanics and the force of the fall he described on a number of occasions.  The local authority had to prove that his description could not account for the injuries suffered by B.

39.  His case was that there was an accident and that he has given a largely consistent account of what happened in B's bedroom moments before he brought her downstairs.  Mr Bagchi and Ms Lee suggest that the experts' evidence is such that it remains impossible to exclude Mr X's account as the cause of her injures. 

40.  As part of my consideration, I have considered the wider canvas and what is known about Mr X.  I have considered his credibility.  I bear in mind that he has no convictions for any criminal offences and the extensive complaints made against him by his ex-partner, including that of rape and physical abuse of his children were not pursued by the police.  In July 2023 professionals in that case described the accusations made by Mr X's ex-partner as untrue and in the circumstances I do not find they have any bearing in this case.

41.  It was part of the local authority's case that the fourth respondent had said different things to different people about how B had been dropped.  Although I agreed with Mr Bagchi's submissions that he had given a largely consistent account, there were some differences in the detail which mattered. 

42.  A court should never expect an entirely consistent account about an event that happened very quickly but it was a concern that when asked by the 999 operator about what happened, although he was able to say he had picked B up and "accidentally dropped her",  when asked how far was the drop and was it "just" from his arms Mr X repeated "I dropped her" with no more detail.  He then left to take the children either into the kitchen or upstairs.  There was panic.  It would have been frightening but he was not being asked for a complete account but just how far the drop had been.  It would have taken two or three seconds to say, two to three foot but onto the floor or something similar.  He did not.

43.  Mr X's account of the immediate aftermath of the incident was different to the mother's.  Whereas she noticed he was "panicked" and "shaken" when he came down and called to her.  He told the court that B looked normal after the drop.  I did not accept he was telling me the truth about this.  He had said on other occasions that B had let out a cry or was crying.  If the mother was right and he was in a panic this might indicate he knew that he had caused really serious harm to B either accidentally or intentionally.

44.  Mr X's first account to the police was given to the police at 5.43pm in the kitchen on 28th October.  He said that "when getting her out of the cot, B started to wriggle in [Mr X's] arms and fell, letting B go and while falling [Mr X] has attempted to catch her by grabbing one of her legs although B has still banged her head, with [Mr X] stating it was the floor and from a height of around 2 to 3 feet and made a loud bang".  This account had the wriggling starting in his arms, and B banging her head on the floor.  I think it would be too much for me to rely on the difference between an attempt to catch her by grabbing one of her legs and a grabbing of her leg, although I noted it was the leg not the ankle that Mr X said he took hold of.  I do not consider the difference between a loud bang and a loud thud said on another occasion to be significant. 

45.  Sometime after the police had arrived, the maternal grandmother arrived along with her partner Mr Y.  It is not possible to say definitively whether Mr Y's conversation with Mr X happened before or after the account he gave to the police above. 

46.  Mr Y went upstairs to talk to Mr X where he was with the children.  Mr Y said that Mr X told him that as he picked her up, he turned and she arched her back, stiffened and threw herself backwards.  He did not quite grip her and she fell and hit her head.  He said he had not been ready for her to fling her body backwards.  It caught him by surprise. 

47.  I was concerned about one comment in particular that Mr Y made.  He said that B had a habit of leaning back without warning if she wanted to lie down.  My view of Mr Y's evidence was that he may have been trying to assist Mr X with that account.  Whether I am right or wrong about that, B had just had a rest and it would seem to me to be unlikely that she would want to lie down again.  The mother did not mention that habit described by Mr Y and indeed if there was such a habit known to Mr Y, I would have expected Mr X to know that B did that and to take extra care when handling her. 

48.  Within moments Mr Y repeated Mr X's account to the mother and the maternal grandmother.  The two women understood Mr Y to have been told by Mr X that B had been dropped into her bed or cot.  It was possible that both women could have misunderstood what he said in the panic and distress of the occasion because the significant part for me is that Mr X had told the police that B's head had hit the floor.  

49.  There appeared to be a slightly different account given to Mr X's family when they arrived when he told them that B had bruising and indicated his neck or upper chest and then said he did not think she had hit the cot.  He said he didn't know what she had hit but that she cried and he picked her up.  This was a partial recording made by the police in any event but he had mentioned bruising around her neck during the 999 call. 

50.  The account that B had fallen into her bed or cot was relayed by the mother and maternal grandmother to the hospital doctors.  Once the doctors had said that would not have caused the injuries seen, the mother in her evidence said she spoke to Mr X and he then told her that he had dropped B head first on the floor.

51.  There were various conclusions for the court to draw from that evidence, the first that Mr X had told Mr Y that he had dropped B in the bed or cot and that is what Mr Y told the mother and maternal grandmother.  The second option was that the mother and maternal grandmother misheard what Mr Y told them and he had told them she was dropped on her head. 

52.  There is the possibility of the third option that they heard she had fallen onto her head but did not want to tell the doctors.  That third option is only a possibility because of the way the mother has blindly stood by Mr X in the face of really strong evidence that he had shaken B.  This has led me to question how far she would go for him. I noted that the maternal grandmother is very close to the mother.

53.  My view on it was that Mr X told Mr Y that he had dropped B on her head and that this is what he told the two women. 

54.  Mr X demonstrated his actions to the police again in his first video interview in the early hours of 31st October 2023 when he had been arrested for grievous bodily harm.  He has provided a response to threshold, and a statement.  His second video reconstruction using a soft toy was in 2025. Finally, in his evidence he showed the Court how B fell. Apart from the last piece of evidence the experts were able to examine the written evidence and the reconstructions and come to conclusions about his account.

55.  In his video interview on 31st October 2023 three days after the injuries were caused, the fourth respondent said that when he went up to bring B down after a nap she was wriggling around more than she usually did, her arms and legs were moving and she was still wriggling quite a lot when he picked her up and held her in his arms.  She then fell sideways (he indicated her rolling forwards away from his body) and he then managed to grab her right ankle with his right hand whilst her head acted like a counterweight and it came around, "she's kind of corrected herself so she's laying, I think she's going down flat (gestures with hand), she then come down flat, there was a loud noise and he then picked her up as he still had hold of her leg.  He pulled her up by her leg and put his left arm beneath her head/neck. She let out one cry or two.

56.  In his evidence to the Court, Mr X explained that when he picked her up he cradled her into his body with his hands overlapping each other.  Yet when he says she rolled forwards and out of his grasp, his left hand had no role to play.  In the reconstruction videos, the left arm which would have been cradling the head end of B does nothing until she is pulled up. Her head swings down and his right arm has hold of her leg or ankle area.  I asked him what his left arm was doing when the head was swinging down and he said he did not know.  In the same way that he essentially says he instinctively grabbed her by the leg with his right hand, I would have expected the left hand to be grabbing her upper chest or shoulder. Instead the left arm does nothing to help until he has brought B back up to a horizontal position.  I questioned that explanation.

57.  I come next to the expert evidence which considered the explanations from Mr X I have set out above.  The impression I was left from his descriptions of what happened is that if there had been a fall, it was a short one onto carpet and it seemed to me anyway that he would have had trouble fitting her between him and the cot.  If he had seen her wriggling he would have been prepared to hold her appropriately and I questioned the plausibility of his description.  I questioned how he could not explain what his left arm was doing in the events.  I did not give much weight to the different accounts he gave at the scene. 

Expert Evidence 

58.  From the doctors caring for B on 28th October 2023 onwards, the preponderance of medical opinion was that the cause of her injuries which I have set out at paragraph 8 above was unlikely to be what was called a "domestic fall".  The mother in her evidence had questioned whether B's Prader-Willi syndrome and other vulnerabilities may have been the cause of, or exacerbated, her injuries and this was considered by the experts.

59.  There were many specialists who had given statements including the Forensic Pathologist Dr Nathaniel Cary who conducted the postmortem on 10th November 2023.  He removed various parts of B's body which were sent to specialists.  His conclusion was that there was no evidence that Prader-Willi syndrome and or any other natural disease causing or contributing to death.  Having considered the evidence later provided by Dr McPartland and Dr Allinson (see below) he concluded that this was "an example of head injury of the shaking/impact type".  He went on to say that "in my opinion the forces involved would have been well in excess of those occurring in everyday handling.  No adequate explanation is provided in the history". 

60.  Although Dr Cary (and others) were not called, I heard oral evidence from experts with different specialisations.  This was provided by Dr Allameddine, the Consultant Haematologist; Dr Kieran Allinson, the Consultant Neuropathologist; Mr Amedeo Calisto, the Consultant Paediatric Neurosurgeon; Dr Jo McPartland, the Consultant Paediatric Pathologist and Dr Fionnan Williams, the Consultant Neuroradiologist.  Dr Rose was the Consultant Paediatrician who gave an overview of the case.

61.  Dr Allameddine said that B had a mild underlying bleeding tendency "type mild factor VII deficiency although she had been completely asymptomatic from this aspect based on all the previous medical and surgical interventions".  It was unlikely that the condition would have led to multiple intracranial and retinal bleedings but the bleeding disorder which was mild could have contributed to "lower the threshold necessary to trigger this bleeding and its extension following trauma or injury".  The haematologist said that the bleeding tendency was very mild and nearly not significant.  It had not been picked up when she had had surgery and she had not history of bleeding or bruising in other contexts.

62.  In cross examination, Dr Allameddine said that where there is a severe clotting disorder, there might be spontaneous bleeding without trauma (such as with haemophiliacs).  The intensity of the force needed was inversely proportionate to the clotting disorder deficiency.  This was not applicable to B's case.

63.  As to the volume of bleeding, the specialist explained that it is measured by the time it takes a bleed to stop.  A spontaneous bleed takes 10 to 13 seconds to stop.  In B's very mild case she might continue to bleed for up to 13.5 seconds which was borderline normal.  A greater production of blood would depend on the severity of the clotting factor deficiency. 

64.  The specialist said it was "very unlikely" that the application of less force to B might trigger bleeding.  He said minor force would be very unlikely to trigger any bleeding and he could say that relying on the minor surgical procedures she had had in the past when she had not got bleeding.

65.  It was possible that with her very mild blood disorder that the volume of bleeding could be enhanced but he said that this would not have a severe effect on the child as it was a mild disorder.  The way the haematologist expressed it was that with a mild clotting factor deficiency "it is my opinion that would not have any clinical significance in triggering bleeding or making it worse, if it would happen". 

66.  I had no reason to doubt Dr Allameddine when he said it was the trauma that triggered bleeding and the clotting was not significant enough to affect or contribute to the outcome.  In summary, clotting was not a factor in the case.

67.  Dr Kieran Allinson, the Consultant Neuropathologist, had examined the brain, spinal cord and dura of B on 29th November 2023.  These had been removed by Dr Cary in the postmortem on the 10th November 2023.

68.  Dr Allinson found bilateral "thin film" subdural haemorrhage in the brain which was "most commonly traumatic in nature and only rarely shown to be associated with natural conditions such as a clotting disorder".  He also found spinal subdural haemorrhage.  This too was more associated with non-accidental traumatic injury than with an accidental traumatic injury.  He found brain swelling which was diffuse due to cerebral oedema as a consequence of the original traumatic injury as well as the lack of blood and oxygen supply "secondary to the injury".

69.  Dr Allinson said there was no evidence of a natural non-traumatic disease which may have caused or contributed to the subdural bleeding in the case.  Other findings were as a result of injury to the brain and spinal cord due to a reduction or cessation of its blood and oxygen supply. 

70.  The specialist also found enlargement of some of the ventricles which was evidence of natural disease.  In his opinion the neuropathological findings were not explained by B being dropped after being picked up from her cot.  The brain and spinal cord injuries were better explained by non-accidental injury.

71.  In his evidence to the court, Dr Allinson said that the brain swelling and spinal subdural haemorrhage as well as the bilateral retinal haemorrhages would not be expected in "normal child handling" which includes slips and accidents.  The injuries were much more severe.  He would include in normal child handling, picking a child up by the legs and swinging her around.  Even that sort of handling did not cause the catastrophic injuries such as were seen in B's case.  

72.  He was asked about the "thin film" subdural haemorrhages in the brain and said they were not the cause of death but were typical of the mechanism of injury.  They suggest the degree and type of force needed to rupture the bridging veins.  The significance was that they were bilateral haemorrhages. 

73.  In relation to the spinal subdural haemorrhage, Dr Allinson said that has come to be regarded as even more suggestive of non-accidental injury than intra-cranial haemorrhage as it required a more severe force.  There was no evidence of direct impact or injury to the spinal cord, suggesting that the cord had been shaken around in the spinal canal which led to the tearing of the small blood vessels around it.

74.  In cross examination Dr Allinson explained to Mr Bagchi KC that the cervical junction would not be expected to show injury because B did not have a broken neck or bony injury and there was no evidence of any blows there, the damage was to the central nervous system within the spinal canal. 

75.  Dr Allinson also explained that although there was some evidence generally that intra cranial subdural haematoma can track down the spinal cord, in B's case this was implausible.  This was because there was blood in the skull and some at the bottom of the spinal cord, with no blood in between which you would expect to see if it had moved down.  He said the blood at the base of the spine was from bleeding at the site. 

76.  What he called the "triad", the subdural haemorrhage in the brain injury and the retinal haemorrhage coupled with the spine injury that had been found in B, a non-mobile child, was more closely associated with traumatic injury and non-accidental injury rather than anything else.

77.  Dr Allinson in cross-examination said that the description given by Mr X of the forces and mechanism leading to the injuries was implausible.  It was not an outlier or a freak accident which may have caused the injuries.  He thought the proposed scenario was "highly unlikely".  Dr Allinson had never seen a fall in the domestic setting which recreated the triad of injuries seen in B's case.  He was asked in detail about the mechanism and force set out by Mr X but said the severity of the forces was "outwith normal child handling". 

78.  I have no reason not to accept the clear evidence of Dr Allinson that the injuries and in particular the spinal haemorrhage made it more likely that they were inflicted non-accidentally.

79.  There was an overlap between the evidence of Dr Allinson and that of Dr Fionnan Williams the Consultant Neuroradiologist.  The latter, who specialised in paediatric neuroimaging, gave significant evidence in relation to the lack of swelling and bruising in the scalp.  He was shown the MRI and CT scans taken of B's brain on 2nd October 2023, 28th October 2023, 31st October 2023, he also examined the MRI of the brain and spine of 2nd November 2023. 

80.  Dr Williams said imaging would not pick up bruising or marks on the skin but would pick up any swelling in the soft tissue of the scalp or of a bruise in the layers of the scalp.  There weren't any. There was no skull fracture.  The presence of soft tissue swelling was a marker of blunt impact trauma. He said "less soft tissue swelling is observed in less forceful impacts and impacts against softer, more yielding surfaces".

81.  Mr Bagchi KC in his closing submissions relied on a yellow/purple bruise on B's forehead as support for the head impact described by Mr X.  I was assisted by Ms Jenkins this morning reminding me that the mother explained to the doctors at hospital that that was an old bruise which predated the events in B's bedroom.  That bruise had no relevance and did not support Mr X's account.  The bruise to the ankle seen by the ambulance crew could have occurred at any stage with this child who had fallen on to the hot wheels toy the day before.  As Dr Williams made clear in evidence there was no other swelling or bruising in the layers of the scalp.

82.  Dr Williams said the absence of any soft tissue injury and a skull fracture militated against a "forceful impact against a hard surface or a hard object especially in the setting of where there is a suggested history of accidental blunt impact trauma".  There were no features of impact which he would have expected.

83.  What Dr Williams did see which was not present on the 2nd October 2023 scan were subdural collections which were likely to represent acute traumatic effusions.  He looked at the possible causes for his findings in the MRI and CT scans, he ruled out a birth injury and said that "to encounter the pattern of injuries seen in this case from domestic trauma is considered to be highly unusual". 

84.  The description given by the fourth respondent was that he broke B's fall by grabbing her by the ankle and pulling her up.  This lessened the impact in Dr Williams' view.  Dr Williams said that even had there been full "weight head first impact on the floor" it would be unlikely to result in the injuries seen also he would expect evidence of the impact to be shown radiologically. 

85.  Dr Williams said to "encounter multifocal subdural bleeding, spinal bleeding, subdural effusions, a severe hypoxic-ischaemic brain injury and possible spinal ligamentous injuries from such a fall would be very atypical".  He thought the event described by the fourth respondent where her head hit the floor or a car seat was unlikely to have caused a significant injury.  Shaking was a more likely explanation.

86.  Dr Wiliams underlined the importance of the finding of the spinal subdural haematoma on the MRI scan as it is considered "quite uncommon" in routine accidental injury.  It is seen typically in abusive head trauma/non accidental injury.  Another uncommon injury seen was that to the end of the spinal cord (the conus).  This would indicate a high force trauma not commonly associated with accidental injuries.

87.  He concluded that non-accidental injury was the most likely explanation for the findings and was likely to have involved shaking and although he could not find any neuroradiology evidence of a blunt impact head injury against a hard surface that did not exclude an impact and "there may have been one against a softer surface".  He said that the imaging was consistent with one episode of trauma which would have been immediately before her deterioration. 

88.  Although there was slightly conflicting evidence about the possible timing of the injuries to the brain, I accepted Mr Bagchi's submissions based on the evidence given by Dr Wiliams that the most likely time for B sustaining the injuries was about 5.30pm just before she was brought down the stairs.  Dr Williams had suggested that she would not have been alive had she been injured an hour before. 

89.  Dr Wiliams said that shaking injuries are usually done in a backwards and forwards motion where the head moves in an unsupported way.  The forces would lead to acceleration/deceleration and rotational forces.  They would oppose the brain to the skull which would lead "to stretching of the subdural veins which cross the subdural space and it is the rupture of these veins which leads to subdural bleeding".  It is these forces which cause other injuries including tearing of the arachnoid membrane shearing type injuries and hypoxic-ischemic brain injury.

90.  Dr Williams was not able to say from the literature or his experience, the degree of force required to produce the injuries but that it was not normal or domestic force or rough play.  He described it as the type of force that would cause an observer to realise that the force was "obviously inappropriate".   He said it was the hypoxic-ischaemic brain injury which decides the severity of the outcome.

91.  In cross-examination Dr Williams was asked about the injury to the conus, which was at the bottom of the spine.  It as a relatively unusual injury but he told Mr Bagchi KC that the fact of an injury at the conus but not at the cranio cervical junction did not mean the former was a pre-existing injury because of disability rather than as a result of trauma.  The conus injury was acute and conus abnormalities were not found in Prader-Willi syndrome. 

92.  Dr Williams was pressed about the reconstruction video taken by a police officer on his body worn camera on 28th October 2023.  He was asked about a whiplash effect as B rolled forwards and then her head travelling down unsupported with a risk of deceleration when he stopped her from falling further.  Dr Williams was blunt and said he completely disagreed.  There would have been no deceleration acceleration force produced because it was a low level fall in a small space comparable to a child rolling off a bed.  The "hard stop" after a drop at low height, would not explain the conglomeration of injuries seen in this case.

93.  Dr Williams said the child's hypotonia would not provide an explanation for the injuries in the case.  Hypotonia was common and was not susceptive to the sorts of injuries caused to B.  If there was an impact with something soft it would have been less likely to lead to any injury.  There could be no research on force and mechanism in injuries in young children but what Dr Williams could say was that the B who was aged two had had no such intracranial injuries before and had no traumatic features in the 2nd October 2023 scan. 

94.  He underlined the importance of the conglomeration of injuries found, if it was a single site haemorrhage that would be different but with the degree of injuries it was "increasingly unlikely that being an outlier is the explanation for them".

95.  Mr Amedeo Calisto is a Consultant Paediatric Neurosurgeon.  He had considered scans of B's brain, head and spine taken on various dates some pre-dating the 28th October 2023.  In the 2nd October 2023 scan he observed the abnormalities including the worsening of the ventriculomegaly compared to a scan taken on 28th May 2021.  Dr Calisto also examined the CT scan made on 31st October 2023, the MRI scan of 2nd November 2023 and the post mortem one of 9th November 2023.

96.  Mr Calisto summarised the differences in this way, he said that in B's post trauma scans there was evidence as well as of the pre-existing congenital abnormalities, of "extensive, bilateral extracerebral and spinal acute bleeding and vast areas of hypoxic ischemic injury in keeping with her prolonged 'down' time". 

97.  In response to questions, he said that head trauma involving "a considerable amount of energy would explain all of B's symptoms".  He said that severe and sudden acceleration/deceleration was most likely to have caused some of the damage.

98.  In Mr Calisto's report he set out the different expert approaches to the type of injuries seen in B.  Although there is a minority of experts who do not accept that they are inflicted by strong head acceleration/decelerations, the majority of experts accept that such a mechanism with or without impact can result in the severe intracranial injuries seen on B's scans.

99.  Mr Calisto adopted the majority view and said that she had suffered head trauma "involving very significant acceleration/deceleration, of such severity to cause a profound alteration of her life supporting functions.  This very likely resulted in loss of oxygen supply to the brain for a sufficient period of time to cause profound and irreversible damage". 

100.      In his initial report, he had the written account of the fourth respondent about what happened but not the video reconstructions.  At that point, he accepted that the written account could provide an explanation for the severity of the injuries.  He described it as unlikely but not impossible.  A relevant factor for him was the account that she fell off the bed to the floor in May 2023 without suffering any particular injury.  He said the mechanism described by Mr X must have generated therefore a greater amount of force.  He also said that B had a larger than normal amount of fluid in her head which would allow for more movement of the brain on impact and was more likely to result in subdural and subarachnoid/subpial bleeding.

101.      His opinion changed after seeing the video reconstruction.  He said the fall was suggestive of less force than he had previously thought when he had based his opinion on the written account of Mr X.  This made it less likely that B's subdural bleeding resulted from the fall as shown by Mr X but he said she may have a preexisting vulnerability to such injury.  He said it was for the court to decide whether she had a preexisting vulnerability which would make a difference to the force required to cause such serious damage to her brain. 

102.      Dr Jo McPartland was the Consultant Paediatric Pathologist who has specialised in Paediatric Ophthalmic Pathology for a number of years.  She was instructed by the police to examine B's eyes.

103.      In the hospital on 29th October 2023, another ophthalmologist said B had "bilateral multiple retinal haemorrhages (multi-layer) affecting all four quadrants, too numerous to count".  On 31st October 2023, the same description was used when B's eyes were examined on that day by another specialist who said that there were comparatively more extensive haemorrhages in the right eye than the left.  The consultant on that date said the retinal findings "would be in keeping with the findings in cases of abusive head trauma (non-accidental injury)". 

104.      Dr McPartland examined B's eyes postmortem on 12th December 2023.  There were a number of normal postmortem changes observed.  There were "multifocal areas of resolving retinal haemorrhages consistent with the marked reduction in the numbers of retinal haemorrhages noted between those present in the clinical examinations 8 and 6 days prior to death and on my macroscopic examination of the eyes removed at autopsy".  The retinal haemorrhages had reduced from those seen before B died.  This gradual resolution was normal.  They were both in the deep and superficial layers of the retina and could be distinguished from the pre-retinal haemorrhages that could be seen in both eyes.

105.      Her summary of her findings was that there were no congenital abnormalities in the eyes.  There were the resolving retinal haemorrhages in both eyes with a greater extent in the right eye in number and size. 

106.      In her comments she pointed out that the presence of the retinal haemorrhages along with the thin film intracranial haemorrhage, spinal subdural haemorrhage and encephalopathy was consistent with a "severe traumatic head injury".  She said that the pattern of retinal bleeding which was "bilateral, severe, multi-layered and extending to the periphery of the eyes, is very characteristic of abusive head trauma".  She said it could be caused by way of the shaking of the head back and forth or a combination of that and an impact.   

107.      She said the absence of some additional features sometimes seen did not exclude a diagnosis of abusive head trauma.  In her consideration she excluded other explanations for the retinal haemorrhages.  Dr McPartland said some medical conditions could cause retinal haemorrhages including severe blood clotting disorders but none of the possible conditions had been diagnosed.  B's diagnosis of Prader-Willi syndrome could not explain the retinal haemorrhages.

108.      Dr McPartland explained about retinal haemorrhages in accidental head trauma.  She said they were rarely seen and if present were few in number and in a particular position and on the side of the head where the impact was.  The sort of retinal haemorrhages seen in B's eyes would only be seen in the cases of severe accidents and she gave examples of multi-storey accidental falls or a fatal car crash.

109.      After considering other possible causes for the retinal haemorrhages observed, Dr McPartland said that in the context of "her clinical presentation and the neuropathology findings and in the absence of an accident of appropriate severity or an identified medical cause, B's retinal haemorrhages are in keeping with a non-accidental/abusive traumatic head injury".

110.      Dr McPartland said that the eye findings should not be treated in isolation but she said that in short falls retinal haemorrhages were very rare and more often related to an impact with a skull fracture and would be on the same side as the impact.  In those cases they would be few in number, superficial and would be seen in the back of the retina.  The patterns in B's eyes were "much more extensive" and the accident was not severe enough to explain the findings in the eyes.

111.      Dr McPartland was sent the reconstruction video.  She said that such a domestic fall was not "of the typical severity that could explain the pattern of bilateral, numerous, multilayered and extensive retinal haemorrhages seen". 

112.      In cross examination she explained the physiological sequence of changes in the eyes where there had been severe acceleration and decelerations producing this type of retinal haemorrhage.  In summary the vitreous thick jelly would pull on the retina in a vigorous shake and sheering forces would be created which would damage the blood vessels which would lead to bleeding.

113.      Dr McPartland agreed with the suggestion that there was such a thing as a freak accident or a rare event, where injuries sustained would be very unusual for the nature of a short fall.  Many of them involving a rotational component in the injury.  The particular paper referred to focussed on children falling backwards and an injury to the head. 

114.      Having seen both reconstruction videos, her evidence was clear that the distance fallen was not that great and the fact that the ankle was caught meant that the fall was broken and she would expect there not to be a significant impact.  It was very unlikely that a severe retinal haemorrhage would be caused by a soft impact.  When it was suggested to her that it was not impossible she said it was an unlikely explanation and she had not seen a similar case described before.

115.      Dr Rose was the Consultant Paediatrician who gave an overview of the case once a number of reports had been obtained from various experts.  He had viewed the reconstruction video provided by Mr X and said it did not provide a plausible explanation as the suggested mechanism would not cause the devastating head injury nor the retinal haemorrhages.  He said he deferred to Dr Williams and Mr Calisto but he thought that such a low level fall "is unlikely to have caused the extensive subdural haemorrhage although he could not exclude it as an unlikely possibility".

116.      Dr Rose said the cause of B's head injury and cardiac arrest remained unexplained.  The injury caused the cardiac arrest.  He said that the injuries included an impact injury to B's forehead and the injuries were most likely caused by shaking with an impact injury to her forehead which happened immediately before she went into cardiac arrest.  He said it was his opinion that B had suffered a deliberate shaking and impact injury which resulted in her death.   He did not know of course that the forehead bruise was an old one as the mother said to the doctors at the hospital.

117.      In cross examination he said that the reconstruction showed forces which would be mirrored in parental games with children when a parent swings a child by the arms and legs.  Dr Rose said retinal haemorrhages required significant force from a high impact collision, for example.  He said the force described by the fourth respondent was "gentle" and would not have caused the injuries seen.

118.      Dr Rose disputed Mr Bagchi KC's description of the fall as involving a whiplash effect.  He said it was the force of gravity and there was not flicking up and down.  He accepted that in some shaking cases there were other injuries found such as fractures to the ribs and back but he said the absence of these "tells us nothing at all". 

119.      Dr Rose said that the description given by Mr X "in no way produces an explanation for the injuries suffered and the cardiac arrest".  He described it to Ms Choudhury as a "low impact fall".

The Experts' Meeting

120.      The experts' meeting on 6th February 2025 was attended by Dr Allameddine, Dr Allinson, Dr McPartland, Mr Calisto, Dr Lavy, the Consultant Paediatric Ophthalmologist and Dr Williams. 

121.      A number of questions were discussed, including one raised by Dr Calisto which was: "how can acceleration/deceleration head trauma be so severe to cause death without any neuropathological evidence of mechanical injury to the brain or the spinal cord/nerve roots".  He was concerned about the lack of neuronal disruption and shearing injuries.  In the experts' meeting he raised the possibility that there was "a vulnerability in the child's brainstem, meaning that her respiratory centres were weaker compared to another child of that age, so their function got disrupted with a lesser degree of energy or force". 

122.      This was considered by the experts at the meeting.  Dr Allinson said he was not surprised not to see them. He said there was a diffuse axonal injury which was hard to interpret alongside the severe secondary hypoxic brain injury which would cause diffuse injury to axons.  Dr Allinson said that the global hypoxia meant that you could not distinguish between what was caused by traumatic axonal injury and what was secondary injury caused by the lack of oxygen to the brain.

123.      Dr Allinson also explained to Mr Calisto that when there was the triad, the thin film subdurals, the encephalopathy and the bilateral retinal haemorrhages and also in this case spinal subdural haemorrhage in a previously well child with unexplained cardiorespiratory collapse then that was closely associated with non-accidental injury. 

124.      The experts considered the question of whether B had a pre-existing vulnerability, her Prader-Willi syndrome, which meant she could not maintain her breathing and heart rate following minor head trauma.  Thus making her more susceptible to fatal injury following the fall impact and rapid rescue manoeuvre.

125.      Dr McPartland's response was that there was nothing about her eyes which showed there would have been a predisposition to bleeding.  It was pointed out that Dr Curran had concluded that B had no vulnerability.  Dr Williams said it was possible but unlikely that her brainstem was significantly abnormal something that Dr Allinson agreed with.  If the court found a vulnerability the point was that there would still have to have been a significant trauma to explain the findings of multifocal subdural haemorrhage, the subdural effusions, the spinal subdural haemorrhage and the ligamentous injury which in Dr Williams' view had not been explained.

126.      Dr Allameddine in the meeting said that it was the injury which caused the bleed rather than the bleeding tendency which caused it and the risk of bleeding was extremely minor, the factor VII was 50% so it was unlikely.   He said that he thought it was a non-accidental bleeding.  Dr Calisto said the earlier fall from a bed was a minor energy event and everyone at the experts' meeting agreed that the incident that led to B's death was not a minor energy event.

127.      The experts considered whether any vulnerability would explain all of B's injuries as well as the cause of death.  Mr Calisto and Dr Williams said no, Dr Lavy said it was very unlikely and Dr Allinson said it was the totality of the findings that suggested non-accidental trauma.  A vulnerability in the respiratory centres did not explain all the injuries of the spinal subdural, intracranial subdural and the retinal haemorrhages. 

128.      The experts were all agreed that the injuries could not arise from the events as described by the fourth respondent.  Her death was not caused by a minor energy event.  There was also a consensus that even if B had a vulnerable brainstem, the would not explain the totality of the injuries seen.

Discussion - Allegations above paragraph 13 1) to 5)

129.      Mr Bagchi KC had made suggestions which have been conveniently summarised in his final submissions about the possible mechanism for a fall resulting in the injuries found.  He suggested it was a freefall with a pivot on the ankle which acted as a fulcrum, which might involve possible rotation of the upper body, with an unsupported head or neck and possible flexion of the neck on the way down and on the way up and a possible impact causing possible reverberations in the head. 

130.      In his final submissions he said it was impossible to say how many movements there were back and forth.  As for the latter, that was not his client's evidence.  According to Mr X there was one drop and a catch immediately bringing B up, to suggest a movement back and forth in my view was not the evidence given by Mr X.

131.      I also rejected Mr Bagchi's submissions that this was a case of medical uncertainty.  All the experts were agreed and the account of how the fall happened was implausible in my view. 

132.      The expert evidence leads in one direction only.  On balance the description of the events as set out by Mr X would not have led to the catastrophic injuries leading to the death of B.  He has not described the force or mechanism which would lead to such severe injuries.  What he described was a domestic fall such as is suffered by children on a regular basis.  This would not have led to the triad of injuries seen.  They need to be taken together but doing so leads to the conclusion that Mr X's explanation is untrue.  A more likely explanation is head trauma from one episode of shaking.

133.      The combination of the medical evidence and in my view what is the unlikeliness of the incident he describes leads me to find that on balance he shook B vigorously and knew instantly that he had caused her a significant injury.  That explains his panicked arrival downstairs. 

134.      When it came to the events of 28th October 2023, I cannot speculate on what led Mr X to cause the injuries that I have found he caused but I note that B's nap was unusual at the time it was (4.30pm) and that it was at the suggestion of Mr X. 

135.      I observe that he said that she was wriggling before he picked her up and it would seem to me that any carer would take particular care in picking a child up if she was wriggling.  This was not a case where the carer would have been taken by surprise by a sudden movement.  The mother's description of whether B could wriggle was different as she spoke about movement of her arms and legs rather than a body movement.

136.      I have set out above that in my view the shaking occurred just before Mr X came downstairs.  I accept Mr Bagchi's submission that there is not sufficient evidence of any advance plan made by the fourth respondent but what I find is that there was a sudden loss of self-control.   

Discussion - A - Allegations above at paragraph 14. 6) to 12)

137.      The local authority has to prove that on balance the fourth respondent abused A in the various ways set out in the threshold.  At a contact with the mother when he was still living with the maternal grandmother, on 8th August 2024, he told her that the fourth respondent had ripped his top.  A said "he told me to keep it a secret and not tell my mum".  The mother told him it wasn't like that and he said it was not that time that he was talking about.  I took from that that two of A's tops had been ripped by the fourth respondent, one in front of the mother and the second behind her back, secretly. 

138.      A went on to say that he did not want to live with the fourth respondent.  He said he did it and he was upstairs and the mother was downstairs when it happened.  The contact supervisor said he sounded quite adamant.  A went on to say to his mother that Mr X "did things to me, and I think it was because I was naughty at school.  If I was good, then he wouldn't".  This was during the beginning of contact. 

139.      A moved into his father's care on 10th August 2024.  After the move and not just to the father but to the social worker too he made a series of allegations against Mr X.  He said Mr X had held him on his back and bent his legs so that his knees were on his shoulders.  A showed how this was done to his father and separately to his social worker. 

140.      He said that Mr X would take A to the bunk bed and strangle him which would hurt his throat and described the way this strangling would make his throat sore when he spoke.  He said that Mr X had punched him and made his nose bleed.  He would say "fuck" and "bitch" to A. 

141.      The social worker had spoken to A on 11th September 2024. She had used a worry monster where A chose an angry face which represented Mr X.  A said he was not nice and made him wear nappies but that his mother did not know.  He told the social worker that Mr X hurt his voice and pointed to his neck.  It made him cry.  He said he wanted Mr X to go to jail and he thought he was going to kill him.  He said Mr X was nice at the beginning.   Ms Jenkins relied on the fact that A was sombre when he said what was happening.  I am not sure whether I would give much weight to that but the description of the placing of the legs is unusual and seemed to me to be likely to be truthful.  

142.      On 21st September 2024, in contact with the mother, on the face of it out of blue she asked A if Mr X punched him on the nose and he said he did it gently "but don't tell him I told you".  He said he had told the father about this.

143.      Mr X denied abusing A in the way the local authority says he did.  In submissions Mr Bagchi KC and Ms Lee pointed out with justification that A had been through many changes in his short life particularly over the past 18 months.  He had lost his sister and his father for a period. 

144.      I noted too that the teacher from A's old school said that he felt like the man of the family and I suppose may have felt put out about this new man suddenly coming into the household.  The mother said in her evidence that A was using words he did not usually use. On the other hand, a punch on the nose is an easy thing to say for a child of A's age and he showed the social worker and his father how his legs were put up to his shoulders. 

145.      Having seen the evidence of the father, I did not accept the mother and the fourth respondent's contention that he had put his son up to making a complaint about Mr X.  Why would he need to? The fourth respondent has been accused of killing B, the physical abuse of A is really neither here nor there compared to a killing. 

146.      In Mr Bagchi's submissions he criticised the father for referring A's complaints to the police and children's services.  Why should he not?  On the face of it Mr X has killed his daughter, it is hardly surprising that he would be very concerned about any abuse of his son by the fourth respondent.

147.      There was evidence that Mr X could get angry and suddenly.  There was a case note in the local authority B proceedings concerning Mr X's children that he had suddenly changed his personality and "got extremely angry and aggressive towards the social worker and Mr X's ex-partner" in front of the children (C and D).  I treated this information with some caution as the note was not made by the social worker who witnessed this behaviour.  

148.      The mother seemed not to find it concerning that he had smashed photograph frames and then torn up the photographs as no one else was present but I found it rather worrying. The evidence in my view, however, shows a lack of self-control.  I have found above that Mr X seriously harmed B by shaking, leading to her death.  It is likely to have happened within a very short period of time, between a friendly family telephone call and the call to 999 a few minutes later. 

149.      I noted too that A was able to say a number of nice things about Mr X.  His descriptions of Mr X were not all bad. I wondered whether in the fourth respondent's relationships with the mother and A there was an echo of what the local authority B case note said which is that he comes across "exceptionally well" before his character suddenly changes.  

150.      Finally this, as set out by Mr Bramwell for the father. It was the mother who raised first with A the question of whether Mr X had punched A in the nose.  She was not able to say why this was.  I agree with his submission, it must have been because she had been told about this by A before, or that she witnessed this or that Mr X told her he had done that.  I bear in mind too that she herself had described Mr X's behaviour towards A as "harsh".  In evidence she tried to play down the significance and said it was meant in the sense that his parenting style was different to hers.  I find the punch to the nose proved.

151.      The mother in her evidence suggested that she had not told police she had seen Mr X slap the boys' bottoms but on reading the police interview it was clear that she had.  It went alongside her evidence that he was harsher than she was with the boys. 

152.      Overall, I found A's account that Mr X was doing things to him when his mother was either out or downstairs as well as telling him to keep it a secret compelling.  I find he also smacked him which was part of the harshness described by the mother.  I reject the fourth respondent's evidence that he was only tapping A on the bottom.  He was imposing discipline.

153.      I do not find the nappy incident proved.  I accept that A started wetting the bed when Mr X moved in and would really have not liked to be wearing pull ups again.  It is not clear to me quite what A was saying about this and it may have been related to his dislike of the nappies.  If Mr X tricked him into wearing them it was possibly because he was refusing to wear them. 

154.      My impression of Mr X assists me in relation to whether he told A that his father did not love him, swore at him and shouted at him.  The mother had said that the parenting styles of the couple were different.  She said that Mr X was harsher than she was and used to smack the children.  There were concerning text messages where they talk about discipline.  Although the mother denied that the fourth respondent would smack A she said that he shouted at him.  I find that Mr X swore at A and shouted at him.

155.      As to the comment that his father did not love him I noted that they called the father an arsehole.  There was no love lost between them and I am of the view that Mr X was more than partly responsible for the end of contact between A, B and their father in July 2023.  I find that Mr X did say what he is alleged to have said.

Discussion - The mother's failure to protect, allegations above at paragraph 15. 13) 14) and 15)

156.      Mr X moved in with the mother very quickly.  She was somewhat vulnerable.  A victim she says of domestic abuse, she had separated recently from the second respondent and had the care of a child with disabilities.  The difficulties of her life should not be underestimated before Mr X came into it and immediately took on an essential role. 

157.      Having met on Tinder in late April 2023, by 3rd May 2023, the mother had left Mr X alone with B whilst she collected A.  Very quickly the relationship moved on.  Within days, Mr X and the mother were in a very close relationship. 

158.      He got his children back in August 2023 and they lived for two weeks at his parents' home before he moved them into her home.  I do not accept Mr X and the mother's evidence that there was no stress in that house.  Anyone who has had the responsibility of a number of young children will know the chaos and stress involved which would have been increased by a disabled child to cope with. 

159.      The BWV showed a couple of lively little boys and a toddler upstairs at the address on 28th October 2023.  Mr X worked and although he helped the mother, it must have been a stressful situation.  I reject as implausible the description of the household as calm and stress-free.  He said it was not stressful and when asked in evidence he said the children were not a bit of a handful.  That seemed unlikely to me when there was evidence of smacking.  If there was calm I wondered how much of it was due to the threat of physical punishment.

160.      It crossed my mind that it was possible that Mr X was manipulating the mother who will have needed emotional support in coping with her young family, and no doubt she would have been only too pleased to find someone to help her with the burdens she was shouldering, but that is in the realm of psychology and is not needed to determine facts. 

161.      What I could say from the evidence I heard is that most women would have separated from Mr X in the circumstances, particularly after the medical evidence came in.  The mother said that they separated for a day or two after she had had a conference with her solicitor after Dr Williams' statement came in, but she has remained steadfast since. 

162.      I thought it was highly unlikely that the mother had not discussed the 28th October events with Mr X.  Their whole life had been changed.  She was not directly responsible for the death of her daughter or the loss of her son to his father and I find that she would have wanted to know exactly what had happened that had led to her life being turned upside down.  If she did not ask, I accept the submission made that she had guessed what he had done but could not face the anxiety of knowing that she had let him into her family's life and was indirectly responsible for the events that followed.

163.      In terms of the allegations the local authority makes that the mother failed to protect B from significant harm and that therefore A was similarly at risk.  B was killed in a sudden event. This would never have been anticipated by the mother.  I accept the submissions of Ms Gold, I do not find a failure to protect B from being killed.  The mother was relying on the professionals' assessment of Mr X.  I accept she did not take up the advice to use Clare's Law but she had something better, the professionals from local authority B who were involved.   

164.      I do find however that she knew that Mr X was being harsh with A and that his method of discipline was over the top.  I accept Ms Gold's contention that A had not told his mother that Mr X was abusing him.  I also accept that the mother was taking steps in relation to the harsh parenting of A but she should have stepped in and prevented him from dictating to her how she should discipline A.  

165.      As Ms Jenkins has reminded me in her final submissions from 16th May 2023, when the relationship between the mother and Mr X had been going for about three weeks he was apologising already for upsetting her in respect of his approach to disciplining A.  Two weeks later he is proud of the way she is standing her ground with the little boy, who I remind myself was only five at the time.

166.      I find therefore, she failed to protect A in that way.  Her more general failure to protect A is that she is still in a relationship with a man who on balance I find has killed her daughter.

167.      In terms of a failure to protect A from Mr X's behaviour even when he told her about it.  I do not find it proved.  If this is a reference to a conversation in contact then the supervision of contact was protection enough. 

Discussion - the mother's neglect - allegations above paragraph 16 16) and 17)

168.      There are allegations made by the local authority that the mother neglected A in various ways.  A said on 28th September 2022, that a bruise to his leg was caused by his mother hitting him.   He said specifically in relation to the bruise to the face "mummy bashed me because I answered back".  This was some time ago and was not taken further.  I do not make any findings in relation to this. 

169.      On about 10th October 2023, A said his mother smacked his bottom very hard.  When I combine this allegation with the mother's approach to discipline I find she did act in that way.  The local authority has alleged this was neglectful.  I do not consider it was, this was physical abuse.  So to that extent, the local authority allegation that it was neglectful is not found.  It is poor parenting and the sign of someone coping with the great pressure of a new blended family and a daughter with disabilities.

Discussion - Allegations above paragraph 17 18), 19) and 20)

170.      Finally, the allegations are made that the mother caused significant emotional harm to A in various ways.  The first way is that she did not prioritise A's needs by moving Mr X into the home in August 2023.  I find that is proved. 

171.      She did move him in very quickly but as she said she had not been told by a  social worker at local authority B and a guardian that she was putting her own children at risk. The social workers overseeing Mr X's children visited regularly. There was no suggestion that he was a risk to her.   

172.      In July 2023, professionals had said that the very serious allegations made by Mr X's ex-partner were likely to be untrue.  That would have further supported the mother's decision to move in this man who was going to help her look after her children.  As against that there were warning signs, in relation to his attitude to punishment of A.  It all happened too fast and the move of his children into a relatively small house can only have put a lot of pressure on this couple.

173.      I find that the local authority has proved too that that mother caused emotional harm to A and B by stopping contact in July 2023 between them and their father.  Contact had been continuing until Mr X moved in.  The father had been staying over on a sofa bed before March 2023 to see the children despite the allegations the mother had made of domestic abuse.  She then obtained a non-molestation order to deal with the difficulties. 

174.      I find it was Mr X who was behind the mother's decision to stop contact.  He may have given her options but in my view I find it was more likely to be that he encouraged her to stop contact and go to court.  They had both described the father as an arsehole and Mr X had experience of what the courts could do.

175.      A wanted to see his father and the safeguarding deputy lead from school who gave evidence said how much he missed his father.  From July until November 2023, the children did not see their father and B never saw her father again as the mother stopped him from visiting to say goodbye as his little daughter lay at death's door.

Conclusion: Findings

176.      On balance using the paragraphs and numbering I have set out above in paragraphs 13, 1), 2), 3), 4) and 5).   I find the following proved: paragraph 14 6), 8), 9), 10), 11) and 12).  Paragraph 15, 13).  Paragraph 16, no findings.  Paragraph 17,  18), 19) and 20). 

177.      Finally is this, the mother has not separated from Mr X despite a vast amount of evidence indicating that on balance he had caused B's death.  She has put him and their relationship before A.  It seemed to me she has chosen to ignore the medical evidence and continue with a relationship that has caused her a lot of harm in the past and will continue to do so.

178.      The threshold has been crossed at the relevant dates as set out above.

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