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Cite as: [2021] EWFC 97

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		Neutral Citation Number: [2021] EWFC 97
		Case No: ZW18P00161

IN THE FAMILY COURT

Royal Courts of Justice
Strand, London, WC2A 2LL

11/06/2021

B e f o r e :

MR JUSTICE WILLIAMS
____________________

Between:

	A FATHER	Applicant
	- and -
	A MOTHER	Respondent

____________________

Will Tyler QC (instructed by Delphine Philip Law Ltd Solicitors) for the Applicant
Sam King QC (instructed Litigant in Person) for the Respondent
____________________

HTML VERSION OF JUDGMENT APPROVED
____________________

This judgment was delivered in private. The judge has given leave for this version of the judgment to be published on condition that (irrespective of what is contained in the judgment) in any published version of the judgment the anonymity of the children and members of their family must be strictly preserved. All persons, including representatives of the media, must ensure that this condition is strictly complied with. Failure to do so will be a contempt of court.

Williams J :

This is the remitted fact-finding hearing in respect of the father's application for a child arrangements, prohibited steps order and specific issue orders in relation to a child ("A") who was born in 2011. On 6^th January 2020 HHJ Jacklin QC gave judgment at the conclusion of a fact-finding hearing. The father appealed that decision and on the 22 September 2020 the Court of Appeal set aside the decision and remitted the fathers application for re-hearing before the FDLJ for London. The father subsequently sought permission to withdraw his application but this was refused by Keehan J on 10 November 2020 and the case was subsequently re-allocated to me.

The father of A is F. He was born in the early 1970s in Bulgaria. He is a medical doctor who moved to the UK in the late 2000s. He is represented by Mr William Tyler QC. The mother is M. She was born in the mid-1970s in Bulgaria but has lived in the UK since the late 1990s and was granted British citizenship in the late 2000s. She is a bookkeeper. She is represented by Ms Samantha King QC. The maternal grandparents are MGM and MGF.

The parties separated in October 2012 because the mother was convinced that she and her parents had been poisoned by the father and it was HHJ Jacklin QC's finding that the father had indeed poisoned the maternal grandparents and the mother with thallium which was set aside by the Court of Appeal. It is that issue which I have been considering in this hearing.

On the basis of the Scott Schedule [A24] the following is agreed.

i) During the time when the mother, father and the child were staying in the maternal grandparents' home in summer 2012 there were according to the mother and so far as the father can recall no other people staying at or who visited the home. The father was not at the property continuously but left to run errands for short periods of time.

ii) The maternal grandfather, maternal grandmother and the mother had all been poisoned by means of thallium on 11 September 2012.

iii) On 13 September 2012 the maternal grandfather died from acute poisoning by thallium, that being preceded by the rapid onset of severe symptoms caused by severe thallium poisoning.

iv) The mother and the maternal grandmother had similar thallium levels in blood detected at the same time – 210ng/ml and 198 ng/ml respectively.

v) The most likely method by which the maternal grandmother, maternal grandmother and the mother were poisoned was through consuming it/oral ingestion of thallium.

vi) Thallium could be sourced in a number of different ways, including via the father's work, his mother, or over the Internet.

What is not agreed and is vigorously disputed by the father is as follows:

i) The father put thallium in the 2 cups of coffee the maternal grandmother had made for herself and the maternal grandfather and was responsible for the poisoning of the maternal grandparents and the mother.

ii) The father saw the mother drink from one of the cups of coffee into which he had put thallium and did not stop her from drinking it.

iii) The father's primary aim was to kill the maternal grandfather and maternal grandmother.

iv) The toxic levels of thallium found in the mothers and maternal grandmother's bloodstream were not consistent with them having been poisoned by eating vegetables from contaminated soil.

v) The levels of toxicity found in the domestic context in which the poisoning occurred means it is unlikely that the mother and maternal grandmother and maternal grandfather were exposed to thallium from an environmental source.

vi) The fact that neither the child from within the household or any other local resident was poisoned means that water from the local spring can be ruled out as a source of contamination.

vii) The fact that the mother did not use the same tobacco as her parents means that cannot be postulated as the source of the poisoning. The father cannot recall whether the mother is correct in saying that she was not using the same tobacco as her parents.

viii) From 13 September to 30 September 2012 the father, knowing that the mother was suffering ill effects from thallium poisoning did not inform those treating her.

ix) The father did not pursue with any or any sufficient energy appropriate medical treatment/an antidote for the mother including that having researched how to source Prussian blue in the UK he did nothing to obtain any. The father says he did everything he could to obtain Prussian blue by contacting colleagues and friends at the Hospital K but was told he would only be able to obtain it if the mother was diagnosed with heavy metal poisoning and was physically present at the hospital. As the mother was in Bulgaria this could not be done, and the father told the mother so. He also made enquiries with a company in Germany and in the UK, who confirmed the father could not purchase the drug. He says he told the mother this.

x) The father told doctors at Hospital A that he suspected the mother was suffering from Guillain Barré syndrome to deliberately mislead the doctors into thinking it was an alternative illness. The father agrees he referred to the syndrome, but this was his opinion and he had no knowledge that the mother had been poisoned.

xi) From 11 September until 15 October 2012 the father was aware that the maternal grandmother and the mother had been poisoned with thallium. The father says he was not aware they had been poisoned with thallium until the toxicology results established the same in each case.

Thus, the central issue in this hearing has been whether the father deliberately poisoned the maternal grandparents on 11 September 2012, inadvertently poisoned the mother and having done so withheld that information from them and from the medical authorities and failed to take steps to seek to ameliorate the consequences of his actions. The father accepts the fact of the poisoning but denies any responsibility for it or for failing to take steps to this ameliorate the consequences of the poisoning.

The father has not seen the child since May 2013 and the mother remains opposed to any contact given her belief in the father's responsibility for the poisoning of herself and her parents. Her position is that if the court were to contemplate any contact following a finding of the father's culpability that a risk assessment would be necessary.

A criminal investigation was open in Bulgaria between October 2012 and April 2016. That investigation and any prosecution of the father was suspended in April 2016 but following appeals by the mother the investigation has been resumed. It remains open.

The father commenced his application for a child arrangement order in 2018. That made its way to a fact-finding hearing before Her Honour Judge Jacklin QC which concluded with a judgment on 6 January 2020, the hearing itself having taken place from the 7^th to 10 October 2019. The father appealed that judgment.

On 22 September 2020 the Court of Appeal allowed the father's appeal, concluding that the judge had regarded the evidence as to the leaning over finding to be central to her conclusion and that it had not been placed in the context of a rigorous analysis of all of the evidence relevant both to the leaning over issue and other matters. They considered that the judge had inappropriately favoured an aspect of the oral evidence over other material and inappropriately speculated as to motive. The case was remitted for re-hearing.

Keehan J as the Family Division Liaison Judge for London was due to hear the matter but was unable in the event to do so. He refused the father's application for permission to withdraw his application and the matter was transferred to me. I have case managed the matter since including making a request pursuant to the Hague 1960 Taking of Evidence Convention for release of documentation from the Bulgarian criminal investigation.

The Letter of Request was eventually sent to the Bulgarian authorities. A version that was agreed between the father's leading counsel and the mother was later amended by the father's solicitor and to avoid further delay, the mother acquiesced to the changes while not agreeing to them. The letter has met with a refusal. The refusal from the Bulgarian Authorities includes an unwillingness to provide the report of the examination of the father's SD card. Neither will the police or prosecutors release a copy of the report to the mother.

The matter came on for hearing before me on 14 April 2021 and over the course of five days I heard evidence, hearing submissions on 22 April and then adjourning to consider my judgment. I had hoped to deliver that judgment by Monday, 26 April but in the event my consideration of the evidence and arguments required more time and this judgment is being circulated on Thursday, 29 April 2021. As the Court of Appeal noted, the finding sought is the utmost seriousness made in relation to anyone but particularly shocking when made in relation to a doctor. As King LJ noted fairness requires a rigorous analysis of all the evidence. I have sought in the hearing and, in this judgment, to rigorously evaluate the evidence.

The Parties Cases

The mother's case was set out in a position statement at the outset of the case and in a 44-page written submission supplemented by brief oral submissions at the conclusion of the case. It seems to me that the essential elements of the mother's case are as follows;

i) When fitted together in a holistic evaluation the facts established will show that on the balance of probabilities the father administered the thallium poison most probably via the morning coffees

ii) The mother does not say that her case can be proved merely by the exclusion of other possible causes. She accepts the father has to prove nothing. The court could conclude that the mother has not proven her case.

iii) The acute poisoning of three adults itself represents an improbable event. Incidences of thallium poisoning, whatever their cause, are very rare. Thus, in this case the Court is confronted with the equivalent of a lion appearing on the green sward in Regent's Park. What this court has to decide, if the evidence allows, is how it got there/who brought or placed it there.

iv) The mother whilst driven by her wish to see justice done is not a liar and nor are those who have provided evidence in support of her case. The father's suggestion to her supporting witness that they had agreed to lie on her behalf was not established and indeed was surprising given the father accepted he may have been positioned as the mother alleges in any event. The mother has certainly pursued evidence, but she has not manufactured it.

v) The mother has lived with this situation for 8 ½ years and been in proceedings for three years. This should be taken into account in evaluating her evidence. The intensity of her emotions should not lead the court to conclude that she was an unreliable witness. She is of course a different person now to the person she was in September 2012.

vi) She reached the conclusion of the father's responsibility as the building blocks fell into place over time.

vii) Accounts of the mother, maternal grandmother and the mother's supporting witnesses show some diversity in their recollections but that adds to their credibility rather than detracts from it. If they were identical that would suggest rehearsal.

viii) The father's approach to the litigation has been to seek to avoid offering a detailed account in answer to the mother's, to delay (on spurious grounds) putting the matter before the court to enable the court to examine the facts, and subsequently to withdraw his application on spurious or insubstantial grounds. That all points to the father seeking to avoid his conduct being scrutinised by the court.

ix) The father's explanation of the contents of his statement of 10 December may be significant as maybe his attempts to distance himself from awareness of thallium poisoning in particular in his statement to the Metropolitan Police of October 2013 and his untruthful account to Cafcass. There are a variety of lies which may fall outside Lucas explanations and amount to corroboration.

x) Thallium poisoning was the cause of the Grandfather's death and the mother and maternal grandmother being unwell. The first thoughts of those treating the maternal grandmother when thallium poisoning was established was that she had been the victim of a crime. It was the medical practitioners concerns that led to the police involvement; Dr A and Dr B both regarded it as a case most likely of deliberate poisoning.

xi) Other sources of poisoning in coffee or food were contraindicated by the 25^th October forensic tests. Thallium in significant quantities was found only in the hair strands removed.

xii) It is most likely to have been ingested by the mother and her parents as a compound mixed into/secreted in food or drink. The post-mortem of the maternal grandfather found higher concentration of thallium in the digestive tract which is consistent with ingestion rather than absorption or inhalation.

xiii) It is most likely to result from a deliberate and calculated act rather than an accident or innocent contamination; the levels found were consistent with acute rather than chronic contamination.

xiv) The poisoning of the three adults most likely took place on the day on which the symptoms of the toxic doses were first evident, and they were poisoned at the same time. The evidence from Bulgaria and from Dr Douse supports those conclusions.

xv) The conclusions of Dr Douse are relied on (see summary of evidence below)

xvi) She contends that taking all of the information together, including the other possible causes of thallium poisoning, the court has sufficient and compelling evidence to find that the thallium was administered as a result of deliberate contamination of the food or drink the three victims consumed. The father and A were not affected. The alternatives of industrial cause, accidental cause through rodenticide or a chronic accumulation of the toxin can be ruled out. There was no work-related accident. There were no other deaths as a result of some ancient ore mining. The area was free from incident (D2 256) and there were no rats on the maternal grandparents' property that required rat poison to be put down. Neighbour A's evidence suggests that any rats in the surrounding properties were dealt with by traps and not toxins. Neither was the spring water, which so many in the area of Town A drank, responsible for the death of the maternal grandfather and suffering of the mother and maternal grandmother.

xvii) Benign possibilities were discussed and ruled out before the mother and maternal grandmother came to the view that it was deliberate and that the father was the perpetrator. This was an incremental process after she started to rewind the clock and with the aid of a psychologist and speaking about events with third parties. She was reluctant to identify the father as a perpetrator. The identification of the possible significance of the father being in the presence of the coffee was an incremental process.

xviii) The possible perpetrators, if the court concludes that the poisoning is most likely to be deliberate, are limited;

xix) The father and A did not show any symptoms of poisoning even though present at the villa with the three poisoning victims, ate the same food, consumed the same water and breathed the same air;

xx) The conclusion that the father caused the death of the maternal grandfather and poisoned the mother and maternal grandmother is not dependent on the mother seeing the father leaning over the coffee cups; it was an opportunity and the evidence in its entirety allowing for inconsistencies over time and between witnesses identifies, is sufficiently reliable as an opportunity when the father was present in the vicinity of the coffee and would have been able to administer poison. Given the condition of the mother and maternal grandmother at the time the court should take that into account in considering what they may have said to others. The absence of any documentary record from the Bulgarian police file prior to April 2014 should not be taken to be significant. The totality of the evidence including the testimony of the mother's witnesses allows the court to conclude that it was indeed spoken about in October/November 2012.

xxi) The reconstruction as described by the mother and grandmother also supports the leaning over incident as having been considered significant at the time.

xxii) Given the circumstances which prevailed prior to the adults becoming ill, the father is likely to have intentionally administered thallium to the grandparents and was reckless as to the mother's wellbeing in not preventing her from drinking thallium and in initially not telling those treating her that she was suffering from toxic poisoning when he knew that that was the cause of her symptoms.

xxiii) The relationship between the adults is complex and far from straightforward. Whilst a clear motive may not emerge it is part of the broad picture.

xxiv) The court can rely on the provenance of the SD card and that the contents show it was the fathers. The father's attempts to distance himself from it are also significant. The presence on it of the thallium PowerPoint downloaded shortly after an incident in early 2012 when the party's relationship was fragile is significant. The presence of the documents gives the lie to the notion that the father knew nothing about thallium as he reported to Friend A and as he gave evidence.

xxv) The decision to travel to Bulgaria by car is irrational and suggests the father had some other reason. Likewise, the father's refusal to contemplate the mother and A staying behind after 11 September. These are consistent with him having planned to administer poison and to depart before symptoms became evident. Once the mother had inadvertently taken the poison his need to depart became even more evident.

xxvi) The evidence supports the conclusion that no other source of food or water is a likely source of the ingestion of thallium. A and his grandparents were consuming vegetables and food for months prior to the arrival of the mother and father. The food prepared on the 11^thSeptember 2012 was shared by all of the people present. A drank mineral water and the evidence suggests the father also drank mineral water. The father accepted that he drank it during the first fact-finding hearing whether from food cooked in it or washed in it.

xxvii) The difference in the coffee consumed by the parties is not a relevant likely difference given that the mother and maternal grandparents had been consuming ground coffee and suffered no ill effects earlier.

xxviii) The father suggested that GBS might be responsible at a very early stage given what were reasonably generalised symptoms, albeit that they were progressing, and given the rarity of GBS, the fact that the father raised the spectre of GBS with the mother on the morning of 12^th September 2012 was curious.

xxix) The father deliberately misdirected those treating the mother and then failed to actively seek out treatment, made inadequate efforts to obtain an antidote for thallium poisoning and failed to inform those treating the mother when he had identified a source of thallium-the mother ultimately traced a source through the former colleagues of the father: Dr C and Dr D, with whom she was on friendly terms.

xxx) The father's passivity in seeking to assist the mother or finding explanations for her symptoms was intentional and his inactivity in the face of the mother's growing desperation is inexplicable save on the basis that he knew what she was suffering from. He abandoned her in effect to find her own solution within the NHS.

xxxi) His assertion to the mother, having done no research, that she was better than she was feeling is significant.

xxxii) The father laid a number of false trails to divert attention away from the fact that he knew that the mother and her parents had been poisoned with thallium and that he was the perpetrator.

xxxiii) The failure to source Prussian blue was originally explained by the father by saying that he did not know how to contact those treating the mother but now he says he effectively left the mother to source it herself out of a sense of chagrin, she having an effect told him not to bother when he explained his inadequate efforts.

xxxiv) The father has offered inadequate reasons for his delays in seeking a relationship with A and then offered an insufficient explanation for applying to withdraw his application. The actual reason for both was to try to avoid his conduct being scrutinised and the risk of findings being made.

xxxv) Looking at the evidence as a whole, the father had every incentive if he was innocent of wrongdoing to find out what was wrong with his partner. If he had any feeling for her, he would have been moving heaven and earth to locate a reason for her illness and treatment for it. Instead, he first misled the medics about the nature of the illness and then by omission and commission on the one hand undermined the diagnostic process and on the other stood by without so much as a Google search to independently help in finding a diagnosis. The obvious conclusions are that he knew the cause of her symptoms, he did not want the true cause to be known and he was indifferent to his partner's suffering.

The father's case was contained within a position statement but more fully within the oral submissions made by Mr Tyler at the conclusion of the evidence. The principal points made are I think in summary terms these:

i) The court must be alert to the third option identified in the Popi M case; not finding the mother's account or the father's account but that the mother has simply not met the burden of proof which lies on her.

ii) This is not a case where the court can rule out other possibilities and be left with the most likely amounting to the cause on balance of probability. In particular this case amply demonstrates that not all relevant facts are known, and you simply cannot exclude all other possible causes. The Popi M is apposite because in this case the mother's own hypothesis is highly improbable and so ruling out other possibilities and being left with a highly improbable solution is no answer.

iii) The father does not put forward an alternative mechanism and does not have to. He does not know whether anything else was contaminated. There are many other possible, even if improbable explanations

iv) The factors identified in Gestmin are particularly powerful in this case given the intensity of the emotions generated, the passage of time, the deep-seated belief the mother has and the impact of this litigation. She may sincerely believe something to be true and may appear to recollect it strongly and vividly but that does not mean it is reliable allowing for the human capacity to genuinely believe something happened when it objectively did not.

v) The mother accused the father of poisoning the family as early as September 2012 and in terms of his response and whether any lies he has told would amount to corroboration the court must apply the modified Lucas approach with great care. Anything he has said should be viewed against the backdrop of him being falsely accused of committing a most egregious criminal act. There are no proven lies which clearly fall within the modified Lucas direction. What he said to Cafcass clearly has an alternative explanation. Other forms of behaviour should also be approached from the modified Lucas perspective. Is there a reasonable explanation for that behaviour? If there is, it should not be used against the father as evidence of his being the perpetrator.

vi) The court must be very wary of circularity of reasoning.

vii) The mother herself was diagnosed with anxiety and hypochondria symptoms which adds to the difficulty in judging the father's responses at the time.

viii) In evaluating the evidence, the court must be alert to the fact that this was not an impartial enquiry. The Supreme Court identified the difference in the way evidence is generated as between a public law context, with an impartial local authority and a private law context with parents at loggerheads. The mother in this case is the principal investigator, a party and a witness and has been in that position since about 19 September 2012. Is the material before the court the product of an impartial investigation – the answer must be no, it is the product of the construction of a case based on a pre-existing belief. The case against him has been created over a period of, now, 8½ years by someone with established animus against him and a strong, personal belief in his guilt – the very antithesis of the impartial investigator / prosecutor;

ix) There is powerful evidence of confirmation bias in the mother's hypothesising. Any fact is reframed to be consistent with the father's guilt.

x) There is no direct evidence against the father; no evidence of him obtaining thallium, no evidence of him being observed to put something in their coffee or any other form of administration, no admission by him; there is no testing evidence that the father and A did not consume thallium. It is all secondary evidence with much speculation by the mother.

xi) The evidence in the case is very much incomplete. The mother believes that material from Bulgaria has not been disclosed as a result of corruption. Significant omissions include the notes of the maternal grandmother's and the mother's interview in hospital and the notes taken during the reconstruction. The contemporaneous documentation is limited. The evidence as to other tests carried out is incomplete. One must assume that the mineral water and the pumped water were not tested nor is there any evidence of whether rodenticide was in use in the garden or nearby. No testing of the father or A was carried out, it is assumed they did not consume thallium because they did not become ill but it is known that neither were eating and drinking as usual. The absence of material means the court is unusually reliant on oral testimony.

xii) If the father had developed a plan to administer the poison it was not a good one as administering the poison in the morning would result in symptoms becoming evident long before the planned departure time which would have pointed the finger of suspicion at the father. If the consumption of the coffee by the mother was accidental, evidence shows that there was no reaction by the father whatsoever which was in any way suspicious.

xiii) The evidence of Dr Douse recognises the possibility of contamination of foods sources and does not rule it out. The onset of symptoms and their timing is consistent with consumption of the poison significantly later in the morning and indeed could be consistent with consumption several days before. There has been no good reason to focus on the coffee. The conclusions of scientists in Bulgaria that the presence of thallium was deliberate should be ignored by the court. There is no basis on which they could properly reach that conclusion.

xiv) The absence of a motive adds to the intrinsic improbability of the father planning the deaths of the maternal grandmother and grandfather. The nature of his relationship with them in no way suggests a level of dislike consistent with a plan to kill them, indeed his evidence was to the effect that he liked the maternal grandfather and was not unremittingly negative in relation to the maternal grandmother. Their relationship had its difficulties but no more than might be encountered in many, many relationships.

xv) The case against him grows in reaction to the various deficits identified on his behalf in that case, by the serial 'discovery' of evidence seemingly plugging those deficits; for instance, in relation to M's witnesses who now recall her telling them she saw F leaning over the coffees and the discovery of an SD card containing incriminating material.

xvi) It is inherently improbable that the father, a doctor of good character would premeditatedly and after considerable planning and without credible motive poison his in-laws. There is nothing in his character suggestive of cruelty or any other trait which would lend support to the conclusion that he is capable of this act. His personal and professional life is untroubled. The financial motive is almost impossible to see given that he and the mother were not even married.

xvii) The evidence of the father leaning over the coffee cups is unreliable. It emerged in the documentation well over a year afterwards and yet the mother says she was aware of it in September 2012. The evidence from the Bulgarian prosecution makes no mention of it. The father's statement makes no reference to it and that was completed after the reconstruction. The accounts given by the various witnesses are inconsistent with each other as to what she says she saw. In particular the neighbour seems to think that she told him the father was seen serving the coffee. The mother's own evidence about it is unreliable; even before her retraction of the evidence about the curtains in the bedroom that was obviously unreliable. Overall, she saw nothing suspicious at any stage; In particular when she drank the coffee which she now believes was poisoned by him.

xviii) Accounts of the reconstruction differ. There is no basis on which the court can rely on the oral testimony of the mother and the maternal grandmother as to what took place and what inferences flow from that. If the police were told during the reconstruction that the father had lent over the table, it is most unusual that they did not act on it.

xix) The mother imbues everything that happens with suspicion. In fact, the decision to drive to Bulgaria has a reasonable explanation, the decision to return early has a reasonable explanation, the father's disinclination to leave A and the mother behind has a reasonable explanation. His failure to research the mother symptoms have to be viewed in the context of him having been accused of being responsible. The contents of the SD card, even if they are his, demonstrate nothing. The mention of thallium in a price list of many, many pages of chemical compounds and dated in 2011 is a red herring. If the thallium PowerPoint was downloaded by the father. which he cannot recall. his explanation that at one stage he was concerned about copper pipes in England might account for it. Many individuals will have many files on their computers which they have not read. It is not a coherent building block in the mother's case.

xx) The father's response to the accusation does not provide any foundation for inferring guilt. He delayed his application for good reason having in effect been invited to do so initially by the mother and advised by his lawyers about making an application when a pending criminal investigation was in play. He sought to withdraw his application as he had come to the realisation that whatever the court said the mother was so hostile to him that she would not allow him to see A and there was no point in going to the expense and trouble of pursuing the application to no ultimate outcome.

xxi) In its final analysis the mother's case amounts to no more than speculation, inference, possible fabrication and hypothesising against a confirmation bias of the strongest kind.

Fact Finding: Legal Framework

The burden and standard of proof

In respect of the task of determining whether the 'facts' have been proven the following points must be borne in mind as referred to in the guidance given by Baker J in Re L and M (Children) [2013] EWHC 1569 (Fam) confirmed by the President of the Family Division in In the Matter of X (Children) (No 3) [2015] EWHC 3651 at paragraphs 20 – 24. See also the judgment of Lord Justice Aikens in Re J and Re A (A Child) (No 2) [2011] EWCA Civ 12, [2011] 1 FCR 141, para 26

The burden of proof is on the mother. It is for her to satisfy the court, on the balance of probabilities, that she has made out her case in relation to disputed facts. The father does not have to prove anything, and the court must be careful to ensure that it does not reverse the burden of proof. As Mostyn J said in Lancashire v R 2013] EWHC 3064 (Fam), there is no pseudo-burden upon a parent to come up with alternative explanations [paragraph 8(vi)]. I am acutely aware of this given the fact that it is agreed that the maternal grandfather died of thallium poisoning and the maternal grandmother and mother both became ill from thallium poisoning. It is not for the father to prove what the source of the poison was although it is of course open to him to advance alternative explanations. However ultimately it is for the mother to prove that it is more likely than not that the father put thallium into the coffee prepared for the maternal grandparents. As Mr Tyler submits, the court is not somehow bound to choose between M's (inherently improbable) explanation and whatever alternative F can summon up; rather, it must simply determine whether or not M has discharged the burden of proving that F poisoned M and the MGPs.

The standard to which the mother must satisfy the court is the simple balance of probabilities. The inherent probability or improbability of an event remains a matter to be taken into account when weighing probabilities and deciding whether, on balance, the event occurred [Re B (Care Proceedings: Standard of Proof) [2008] UKHL 35 at paragraph 15]. Within this context, there is no room for a finding by the court that something might have happened. The court may decide that it did or that it did not [Re B at paragraph 2]. If a matter is not proved to have happened, I approach the case on the basis that it did not happen.

Findings of fact must be based on evidence, and the inferences that can properly be drawn from the evidence, and not on speculation or suspicion. The decision about whether the facts in issue have been proved to the requisite standard must be based on all of the available evidence and should have regard to the wide context of social, emotional, ethical and moral factors [A County Council v A Mother, A Father and X, Y and Z [2005] EWHC 31 (Fam)].

The court must take account of a wide range of matters which include the expert evidence but also include, for example, its assessment of the credibility of the witnesses and the inferences that can properly be drawn from the evidence. The court must take into account all the evidence and furthermore consider each piece of evidence in the context of all the other evidence. The court invariably surveys a wide canvas. A judge in these difficult cases must have regard to the relevance of each piece of evidence to other evidence and to exercise an overview of the totality of the evidence in order to come to a conclusion.

Thus, the opinions of scientific experts need to be considered in the context of all of the other evidence. It is important to remember that the roles of the court and the expert are distinct, and it is the court that is in the position to weigh up the expert evidence against its findings on the other evidence. It is the judge who makes the final decision. When considering the medical evidence in cases where there is a disputed aetiology giving rise to significant harm, the court must bear in mind, to the extent appropriate in each case, the possibility of the unknown cause [R v Henderson and Butler and Others [2010] EWCA Crim 126 and Re R (Care Proceedings: Causation) [2011] EWHC 1715 (Fam)]. Today's medical certainty may be discarded by the next generation of experts. Scientific research may throw a light into corners that are at present dark. That affects neither the burden nor the standard of proof. It is simply a factor to be taken into account in deciding whether the causation advanced by the one shouldering the burden of proof is established on the balance of probabilities." I refer to this because clearly there is in this landscape the possibility that thallium exposure arose from an entirely unknown cause.

The evidence of the parents and of any other carers is usually of the utmost importance. It is essential that the court forms a clear assessment of their credibility and reliability. They must have the fullest opportunity to take part in the hearing and the court is likely to place considerable weight on the evidence and the impression it forms of them [Re W and Another (Non-Accidental Injury) [2003] FCR 346]. In a case such as the present where so much time has passed and where the circumstances of the events require the court to look back so far and through so much Gestmin mist of time and circumstance the evidence and credibility of the parties becomes less central.

Although not of direct relevance to this case, I am alert to the dangers of identification of a perpetrator by a process of linear exclusion of possibilities and the trap for the unwary of identifying the most likely of a number of possible causes as the probable cause. In Re B (a child) [2018] EWCA Civ 2127 Lord Justice Peter Jackson in the context of the pool of perpetrators concept said,

[19] The proper approach to cases where injury has undoubtedly been inflicted and where there are several possible perpetrators is clear and applies as much to those cases where there are only two possible candidates as to those where there are more. The court first considers whether there is sufficient evidence to identify a perpetrator on the balance of probabilities; if there is not, it goes on to consider in relation to each candidate whether there is a real possibility that they might have caused the injury and excludes those of which this cannot be said: North Yorkshire County Council v SA [2003] EWCA Civ 839, per Dame Elizabeth Butler-Sloss P at [26].

[20] Even where there are only two possible perpetrators, there will be cases where a judge remains genuinely uncertain at the end of a fact-finding hearing and cannot identify the person responsible on the balance of probabilities. The court should not strain to identify a perpetrator in such circumstances: Re D (Care Proceedings: Preliminary Hearing) [2009] EWCA Civ 472 at [12].

[21] In what Mr Geekie described as a simple binary case like the present one, the identification of one person as the perpetrator on the balance of probabilities carries the logical corollary that the second person must be excluded. However, the correct legal approach is to survey the evidence as a whole as it relates to each individual in order to arrive at a conclusion about whether the allegation has been made out in relation to one or other on a balance of probability. Evidentially, this will involve considering the individuals separately and together, and no doubt comparing the probabilities in respect of each of them. However, in the end the court must still ask itself the right question, which is not "who is the more likely?" but "does the evidence establish that this individual probably caused this injury?" In a case where there are more than two possible perpetrators, there are clear dangers in identifying an individual simply because they are the likeliest candidate, as this could lead to an identification on evidence that fell short of a probability. Although the danger does not arise in this form where there are only two possible perpetrators, the correct question is the same, if only to avoid the risk of an incorrect identification being made by a linear process of exclusion.

In this case there are plainly many possible causes of the acute thallium poisoning. The exclusion of possible causes leaving only the father standing and by that process of elimination identifying him as the probable source would be entirely wrong.

Mr Tyler referred to the well-known passage from the Popi M case [1985] 1 WLR 948 where Lord Brandon said,

My Lords, the late Sir Arthur Conan Doyle in his book The Sign of Four, describes his hero, Mr. Sherlock Holmes, as saying to the latter's friend, Dr. Watson: "How often have I said to You that, when You have eliminated the impossible, whatever remains, however improbable, must be the truth?" It is, no doubt, on the basis of this well-known but unjudicial dictum that Bingham J. decided to accept the shipowners' submarine theory, even though he regarded it, for seven cogent reasons, as extremely improbable.

In my view there are three reasons why it is inappropriate to apply the dictum of Mr. Sherlock Holmes, to which I have just referred, to the process of fact-finding which a judge of first instance has to perform at the conclusion of a case of the kind here concerned.

The first reason is one which I have already sought to emphasise as being of great importance, namely, that the judge is not bound always to make a finding one way or the other with regard to the facts averred by the parties. He has open to him the third alternative of saying that the party on whom the burden of proof lies in relation to any averment made by him has failed to discharge that burden. No judge likes to decide cases on burden of proof if he can legitimately avoid having to do so. There are cases, however, in which, owing to the unsatisfactory state of the evidence or otherwise, deciding on the burden of proof is the only just course for him to take.

The second reason is that the dictum can only apply when all relevant facts are known, so that all possible explanations, except a single extremely improbable one, can properly be eliminated. That state of affairs does not exist in the present case: to take but one example, the ship sank in such deep water that a diver's examination of the nature of the aperture, which might well have thrown light on its cause, could not be carried out.

The third reason is that the legal concept of proof of a case on a balance of probabilities must be applied with common sense. It requires a judge of first instance, before he finds that a particular event occurred, to be satisfied on the evidence that it is more likely to have occurred than not. If such a judge concludes, on a whole series of cogent grounds, that the occurrence of an event is extremely improbable, a finding by him that it is nevertheless more likely to have occurred than not, does not accord with common sense. This is especially so when it is open to the judge to say simply that the evidence leaves him in doubt whether the event occurred or not, and that the party on whom the burden of proving that the event occurred lies has therefore failed to discharge such burden.

Lies/Withholding Information

It is common for witnesses in these cases to tell lies in the course of the investigation and the hearing. The court must be careful to bear in mind at all times that a witness may lie for many reasons, such as shame, misplaced loyalty, panic, fear, and distress. The fact that a witness has lied about some matters does not mean that he or she has lied about everything [R v Lucas [1981] QB 720]. It is important to note that, in line with the principles outlined in R v Lucas, it is essential that the court weighs any lies told by a person against any evidence that points away from them having been responsible for harm to a child [H v City and Council of Swansea and Others [2011] EWCA Civ 195].

The family court should also take care to ensure that it does not rely upon the conclusion that an individual has lied on a material issue as direct proof of guilt but should rather adopt the approach of the criminal court, namely that a lie is capable of amounting to corroboration if it is (a) deliberate, (b) relates to a material issue, and (c) is motivated by a realisation of guilt and a fear of the truth [Re H-C (Children) [2016] EWCA Civ 136 at paragraphs 97-100].

The Reliability of Memory

Especially important since so many years have elapsed between the events I am examining and the time of this hearing, as Mr Tyler reminded me, is the need to be alert to the fallibility of human memory; the sincere and honest but mistaken recollection in particular.

In Lancashire County Council v The Children [2014] EWFC 3 (Fam), at paragraph 9 of his judgment and having directed himself on the relevant law, Jackson J (as he then was) said:

"To these matters I would only add that in cases where repeated accounts are given of events surrounding injury and death, the court must think carefully about the significance or otherwise of any reported discrepancies. They may arise for a number of reasons. One possibility is of course that they are lies designed to hide culpability. Another is that they are lies told for other reason. Further possibilities include faulty recollection or confusion at times of stress or when the importance of accuracy is not fully appreciated, or there may be inaccuracy or mistake in the record-keeping or recollection of the person hearing and relaying the accounts. The possible effects of delay and repeated questioning upon memory should also be considered, as should the effect on one-person hearing accounts given by others. As memory fades, a desire to iron out wrinkles may not be unnatural - a process that might inelegantly be described as 'story-creep' - may occur without any necessary inference of bad faith."

Leggatt J (as he then was in the Gestmin case [2013] EWHC 3560 (Comm) said,

Evidence Based On Recollection

[15] An obvious difficulty which affects allegations and oral evidence based on recollection of events which occurred several years ago is the unreliability of human memory.

[16] While everyone knows that memory is fallible, I do not believe that the legal system has sufficiently absorbed the lessons of a century of psychological research into the nature of memory and the unreliability of eyewitness testimony. One of the most important lessons of such research is that in everyday life we are not aware of the extent to which our own and other people's memories are unreliable and believe our memories to be more faithful than they are. Two common (and related) errors are to suppose: (1) that the stronger and more vivid is our feeling or experience of recollection, the more likely the recollection is to be accurate; and (2) that the more confident another person is in their recollection, the more likely their recollection is to be accurate.

[17] Underlying both these errors is a faulty model of memory as a mental record which is fixed at the time of experience of an event and then fades (more or less slowly) over time. In fact, psychological research has demonstrated that memories are fluid and malleable, being constantly rewritten whenever they are retrieved. This is true even of so-called "flashbulb" memories, that is memories of experiencing or learning of a particularly shocking or traumatic event. (The very description "flashbulb" memory is in fact misleading, reflecting as it does the misconception that memory operates like a camera or other device that makes a fixed record of an experience.) External information can intrude into a witness's memory, as can his or her own thoughts and beliefs, and both can cause dramatic changes in recollection. Events can come to be recalled as memories which did not happen at all or which happened to someone else (referred to in the literature as a failure of source memory).

[18] Memory is especially unreliable when it comes to recalling past beliefs. Our memories of past beliefs are revised to make them more consistent with our present beliefs. Studies have also shown that memory is particularly vulnerable to interference and alteration when a person is presented with new information or suggestions about an event in circumstances where his or her memory of it is already weak due to the passage of time.

[19] The process of civil litigation itself subjects the memories of witnesses to powerful biases. The nature of litigation is such that witnesses often have a stake in a particular version of events. This is obvious where the witness is a party or has a tie of loyalty (such as an employment relationship) to a party to the proceedings. Other, more subtle influences include allegiances created by the process of preparing a witness statement and of coming to court to give evidence for one side in the dispute. A desire to assist, or at least not to prejudice, the party who has called the witness or that party's lawyers, as well as a natural desire to give a good impression in a public forum, can be significant motivating forces.

[20] Considerable interference with memory is also introduced in civil litigation by the procedure of preparing for trial. A witness is asked to make a statement, often (as in the present case) when a long time has already elapsed since the relevant events. The statement is usually drafted for the witness by a lawyer who is inevitably conscious of the significance for the issues in the case of what the witness does nor does not say. The statement is made after the witness's memory has been "refreshed" by reading documents. The documents considered often include statements of case and other argumentative material as well as documents which the witness did not see at the time or which came into existence after the events which he or she is being asked to recall. The statement may go through several iterations before it is finalised. Then, usually months later, the witness will be asked to re-read his or her statement and review documents again before giving evidence in court. The effect of this process is to establish in the mind of the witness the matters recorded in his or her own statement and other written material, whether they be true or false, and to cause the witness's memory of events to be based increasingly on this material and later interpretations of it rather than on the original experience of the events.

[21] It is not uncommon (and the present case was no exception) for witnesses to be asked in cross-examination if they understand the difference between recollection and reconstruction or whether their evidence is a genuine recollection or a reconstruction of events. Such questions are misguided in at least two ways. First, they erroneously presuppose that there is a clear distinction between recollection and reconstruction, when all remembering of distant events involves reconstructive processes. Second, such questions disregard the fact that such processes are largely unconscious and that the strength, vividness and apparent authenticity of memories is not a reliable measure of their truth.

[22] In the light of these considerations, the best approach for a judge to adopt in the trial of a commercial case is, in my view, to place little if any reliance at all on witnesses' recollections of what was said in meetings and conversations, and to base factual findings on inferences drawn from the documentary evidence and known or probable facts. This does not mean that oral testimony serves no useful purpose – though its utility is often disproportionate to its length. But its value lies largely, as I see it, in the opportunity which cross-examination affords to subject the documentary record to critical scrutiny and to gauge the personality, motivations and working practices of a witness, rather than in testimony of what the witness recalls of particular conversations and events. Above all, it is important to avoid the fallacy of supposing that, because a witness has confidence in his or her recollection and is honest, evidence based on that recollection provides any reliable guide to the truth.

I have, in the particular circumstances of this case reminded myself when assessing and weighing the impression I form of the parents of the observations of Macur LJ in Re M (Children) [2013] EWCA Civ 1147:

[12] Any judge appraising witnesses in the emotionally charged atmosphere of a contested family dispute should warn themselves to guard against an assessment solely by virtue of their behaviour in the witness box and to expressly indicate that they have done so.

The need for caution in how one evaluates the credibility of a witness and the reliability of their evidence by reference to demeanour and the need for caution in the weight to be given to demeanour in the evaluation of evidence was also articulated by Leggatt LJ in Sri Lanka v Secretary of State for the Home Department [2018] EWCA 1391.

Although the general approach is that any fact which needs to be proved by the evidence of witnesses is generally to be proved by their oral evidence (r22.2(1)(a) FPR 2010) facts may also be proved by hearsay evidence. The effect of Children Act 1989 s.96(3), Children (Admissibility of Hearsay Evidence) Order 1993 is to make all evidence given in connection with the welfare of a child admissible notwithstanding its hearsay nature. This would commonly include Local Authority case records or social work chronologies which are very often hearsay, often second- or third-hand hearsay but also extends to witness statements. The court should give it the weight it considers appropriate: Re W (Fact Finding: Hearsay Evidence) [2014] 2 FLR 703, and where hearsay goes to a central issue the court may well require the maker of the hearsay statement to attend to give oral evidence.

The provisions of section 1 and 4 of the Civil Evidence Act 1995 also make provision for the court to admit and rely on hearsay evidence and set out a range of factors that the court should consider in assessing the weight to be given to and the reliability of hearsay evidence. These include matters such as the circumstances in which the statement was made and whether the circumstances suggest an attempt to prevent proper evaluation of its weight.

When I turn to the evidence, I bear all these factors in mind in reaching my conclusions.

The Evidence

My summary of the factual evidence is contained within the detailed chronology attached to this judgment and which forms a core component of it. Long and detailed though it is, it does not purport to be a complete record of the evidence in this case or indeed of the evidence that I have pondered over.

In evaluating the witness evidence, I have been alive to the issues relating to memory reliability many years after the event and the factors which might operate on the parties and the witnesses' memories to shape their current memory and thus their current testimony.

I heard oral evidence from;

i) The Mother

ii) The Maternal Grandmother

iii) Friend A,

iv) Friend B,

v) Friend C,

vi) Neighbour A,

vii) The Father

The mother's evidence is contained in her statements, in the transcript of her evidence and in the evidence which she gave to me. The essential elements of that are recorded in the chronology. She gave evidence first and over a lengthy period of time. The content of her evidence and the emotions it engages are of the utmost sensitivity. The fact that this is a rehearing with the burdens that brings with it in terms of what she clearly feels responsible for (i.e. introducing the father to her family) must exacerbate the inherent pressure and anxiety that accompanies giving evidence on such profoundly important matters. Giving an account again after the passage of such a lengthy period of time brings with it the risk both of memory creep and inconsistencies emerging; the mother I think feeling some additional pressure as a result of this. Thus, the context in which she gives her evidence contains within it many factors which might impact upon the reliability of her account. Judging honesty and reliability by demeanour is a tool to be deployed with care particularly in the context I have set out. The mother was at times composed, detailed and measured. At times she was careful to cross-reference with documents. She did not seek to elaborate on what she had seen the father doing on the morning of the 11^th but she clearly did speculate in relation to the curtains. Her evidence of the precise detail of whether the father had a cigarette in his mouth or whether he was lighting it was unclear; but in a sense it would be more worrying if she claimed to recall every detail which she did not. That would suggest a rigidity more likely to arise from sticking to a script than any genuine intent to recall the events. Her account of the involvement of her detective friend I found hard to follow and that was one of the few occasions when the nature of her evidence and how it was delivered made me wonder how frank and honest, she was being. In respect of many parts of the detail her account was consistent with that of the MGM and indeed the father. At other times she was argumentative, obtuse and irrational; these most clearly emerging after lengthy cross-examination. There were occasions where she almost appeared to have given up seeking to give her account. She was appropriately upset (albeit I think sought to suppress it) when recalling the last time, she saw her father alive. The mother feels intensely and passionately about the situation and now believes fiercely that the father is responsible for killing her father and poisoning her and her mother. Having reached that conclusion, the intensity of her emotions is hardly surprising. A consequence of that firm belief is it seems that she has now lost the ability to look into the past and to assess the situation objectively. I do not think that this lack of objectivity was necessarily present in the latter part of 2012 but, as time has passed, she has reached a position where, when it comes to seeking explanations for anything that happened at that time she is prone to speculation, irrational conjecture and, as Mr Tyler would put it, confirmation bias, where everything is viewed through the prism of the father's guilt and where an innocent explanation is rapidly cast aside and a guilty theory propounded. Her evidence about the father's role in A developing a cold or corruption explaining the shortcomings of the Bulgarian prosecution were both examples of this. This tendency to speculation and conjecture and indeed wild or irrational conjecture, together with the passage of time, repeated accounts and the cauldron of emotional intensity both of the situation itself and the litigation does inevitably mean that her current recollection of events must have been subjected to quite intense internal psychological processes in Gestmin terms. The evidence of her other witnesses suggests that if one were to strip away the intensity that has developed, that the mother is rational, objective and empathetic and I thought this was discernible at times during her evidence before me. I did not get the impression that irrationality, ungoverned emotion, self-centredness or any other aspect of her personality which might hinder her ability to give reliable evidence absent those Gestmin pressures was apparent. That might have some bearing on how one approaches what she said and did in late 2012 albeit immensely anxious as well as seriously ill and this must also be factored in. Overall, one must look to contemporaneous accounts or to corroboration from other sources to get a sense of how reliable the mother's current recollection is. What I am clear about is that the mother's tendency is to seek to abide by law and process. Her evidence of how she dealt with the SD card in relation to offering it to the UK police and then passing it to the Bulgarian police and not telling this court because of obligations to the Bulgarian process seemed to be correct. She made applications in the Bulgarian courts to right what she perceived as wrong decisions and her approach to these proceedings has been to seek to comply with procedural obligations. This tends to undermine the suggestion that she has fabricated evidence, in particular the SD card, or has suborned friends and a neighbour to give false testimony in relation to when she spoke about the father's presence on the veranda by the coffee. Thus, I consider that the mother is in general an honest and sincere witness albeit of course her memory may be given honestly but mistakenly. Nor was there evidence of an animus towards the father that would have caused her to wish to identify him as a perpetrator; her friends seem to think she was still in love with him then. Nor were they encouraging her to believe the father was the perpetrator; to the contrary they thought her belief that she had been poisoned and perhaps by him was irrational until it became clear that she had been poisoned. Trying to strip away the accumulated layers that have been generated by the passing years seems to leave the evaluation of the mother as an individual who would be unlikely to jump to irrational conclusions.

The father gave evidence in English although had an interpreter available who he used on a couple of occasions. All that I have said in relation to the mother and the influences on memory apply to the father although the pressures are from different sources. The consequences for the father if a finding were made are potentially catastrophic in terms of his reputation, his career, his relationships and perhaps even his liberty were the outcome to sound in the Bulgarian investigation. Thus, the pressure he was under giving his evidence to me or indeed historic accounts must be taken into account. In contrast to what appeared to be the mother's openness and spontaneity the father was much more deliberate, requiring constant cross reference to the documents which on occasions was somewhat surprising given how familiar one would expect him to be with them. I wondered at times whether this was a habit to give himself time to think. I am cautious about placing any reliance on his demeanour given the pressures he was giving evidence under. His presentation was often rather affected, what he said being accompanied by rather dramatized facial expressions or gestures which tended to detract from the content of his answers and gave the appearance of insincerity but I note this as an aide memoir to myself not to place much if any reliance on his demeanour. His evidence was rather fractured as throughout he said he could not remember or had forgotten which again at times gave the impression of his preferring to say that as the safer course of action rather than to try to remember. This was I thought consistent with an aspect of his general approach to the case which was most obviously articulated in his first statement which was to put the mother to proof of her case and to make no comment so far as was possible. I can understand the logic underpinning this but, inevitably, a more limited picture emerges from the father's position which affects the view of the overall landscape. His position on the SD card was that he could not find evidence to confirm it was his and thus his position was that he could not accept it was his and he made the suggestion the mother had tampered with it to introduce the 2 thallium referring documents. Whilst that position is entirely legitimate and understandable in the forensic context it is much harder to understand within the relationship dynamic that existed between the mother and father at the material time. His evidence that he did not move heaven and earth to find out about the possible source of the mothers condition between 12 September and 27 September but relied on his medical colleagues; that when poisoning became a real issue with the hair loss of the mother and grandmother and thallium hove into view that he did not move heaven and earth to find out more about thallium, and most pertinently that, in that context, he did not turn over every stone (or indeed on his evidence any stone at all) to try to work out how the woman he professed to love and the mother of his son had become the victim of an extraordinarily rare and dangerous poisoning, is very hard to understand. His explanation that he had been accused of being the source of poison and that this so outraged him that he withdrew would suggest a remarkable self-centredness and lack of empathy if it were true; of which more below. However, he did continue to assist in a practical way by driving the mother to hospitals and indeed travelling to Bulgaria with her. What he did not do was to deploy his medical and intellectual skills to assist. It begs the question of why he was prepared to help in some ways but not in others.

Another feature of his evidence which emerged very frequently was his unwillingness to accept responsibility for events whether it was A getting a chill, the maternal grandmother insisting on overloading the car, the mother sourcing Prussian Blue herself or his Bulgarian lawyer checking the statement on 10^th December. Throughout his oral evidence but also largely in his written evidence he displayed very little if any emotion or empathy. In his Bulgarian police statement, he referred to his eyes filling with tears when he heard the news about the maternal grandfather, but in his oral evidence he displayed almost no emotion, particularly in relation to the poisoning and how it impacted on the mother and this would be consistent with his attitude at the time according to the evidence of the mother, maternal grandmother and Friend A. It was also a feature of his description of the relationship that he had with the mother; he struggled to describe it as anything other than 'normal' and showed very little capacity for self-reflection, even when talking about the counselling the couple had undergone. The mother described them as having fundamental differences which led her to conclude that the relationship had no future albeit she agreed to remain in it for the sake of A. I do not think the father's description of the relationship as normal was anything close to what most would associate with that expression. There seemed on the father's part to be very little warmth or affection for the mother although at that time I accept the mother's witnesses' evidence that she was herself still in love with him and there was no sexual relationship, that seemingly not being wanted by the father. At times his evidence was detailed, and he appeared to show a good and authentic recall of events of the material time. His evidence about the state of his relationship with the maternal grandmother and maternal grandfather seemed to be sincere and to accord with the evidence of the mother and maternal grandmother herself. At others, his evidence felt like a construct – when he described getting up on 11^th and going into the kitchen and his eyes still being closed and he not being with it (my phrase) did not seem authentic at all but a dramatised version. At others his evidence was very hard to follow and inconsistent, for instance when he gave evidence about whether he sought to give A antibiotics for his chill which varied from his having suggested giving them on two occasions to him not having suggested it at all, nor in relation to why he didn't tell the mother about his trip to Bulgaria in April 2012 or his evidence about how his statement to the Bulgarian police came to be finalised. Overall, I found him to be a quite unsatisfactory witness – less open and frank than the mother, more artificial, with more of an underlying plan to his evidence and someone whose evidence was less sincere and less reliable than the mother's. In her case unreliability emerges from the Gestmin issues – with the father they are present, but his strategic approach also impacts on his reliability. If one claims to be telling the truth, the whole truth and nothing but the truth but one is not telling the whole of the truth, which was the impression I got, then that leaves an incomplete picture.

Having said that, this is far from saying that where their evidence might conflict that I could rely on the mother's and not the father's. It is far more nuanced than that and may simply amount to a piece or two pieces of the jigsaw when it comes to my overall interpretation of the landscape. In respect of both parties' evidence it seems to me that one needs to place it in the overall evidential context and to see how it fits with contemporaneous evidence or other corroborative material and to stand back and evaluate the whole rather than the individual parts.

The maternal grandmother gave evidence over about half a day. Given that both the mother and father had described her as somebody who spoke her mind, she was less outspoken in her evidence than I had perhaps been expecting. She gave quite detailed descriptions of matters relating to the property, to the packing of the car and what they were taking and to routines. She was not particularly demonstrative but quite matter of fact and did not seem to embellish her account with exaggerated language even when it came to describing the onset of the maternal grandfather's symptoms. When cross-examined about the extent to which she and the mother had discussed the case since the Court of Appeal or indeed over the weekend I did not get the impression that they had put their heads together to develop a joint narrative. Her description of how the mother had been upset on the Friday and had focused on A and did not want to talk about the hearing seem to me to be consistent with the way the mother was likely to have been feeling at the conclusion of her evidence. Her account of the police visit to the villa appeared to be spontaneous and without her having been rehearsed. It did not have the appearance or feel of being scripted in any way but appeared rather to be her attempting to recall something. Of course, I bear in mind that her recall may have been shaped by her state of belief as to what happened. During the course of her evidence she said on a number of occasions that there were things she could not remember or that if she tried to be precise, she would be lying or after having answered she went back and corrected herself spontaneously. There were some inconsistencies in her account of what had been said at the hospitals when she and the mother were in patients but she did not seek to infill by suggesting the mother had told the police about the father leaning over the coffee cups when she had the opportunity to do so. She also on occasion sought to justify why she had not mentioned what she now says the mother told her which I was not persuaded were accurate; saying that she did not think it was important to tell the police in 2014 what the mother had told her about seeing the father through the bedroom window seems to me defensive rather than accurate. Her description of the relationship with the father was to the effect that they had arguments but that it was not all bad. She said that she can forgive but she does not forget. My overall impression of her was that she was not embittered and seeking at all costs to condemn the father in the eyes of the court but rather was seeking to give an accurate account of what she could recall. Of course, while she may be sincere and honest in the evidence she is giving that does not necessarily mean it is reliable given the passage of time and the context in which her memories were formed and what she has been through both in her life and in litigation since.

Friend A gave a statement to the Bulgarian police on 16 October 2012. Although the mother and grandmother had been interviewed prior to that no documentary record of their interviews are available to me. Thus, of the lay parties or witnesses this is the most contemporaneous of the statements available. It was made whilst the mother was still in hospital. Friend A is a lawyer practising in Bulgaria in civil law. She gave evidence in accordance with her October 2012 witness statement but also arising out of a further witness statement she had given on 6 January 2021. Her January 2021 statement deals with her recall of what the mother told her following her return to Bulgaria on 3 October 2012. In her evidence the witness was careful to ensure that she understood the question and she also emphasised that she could not quote what was said or the precise context but rather the general sense of what had been said either by the mother or by the father. It was put to her that she had fabricated her account that the mother told her in 2012 of her having seen the father leaning over the coffee cups. The witness rejected this saying that the mother had never asked this of her and that she was not prepared to lie for the mother. I am satisfied that Friend A was not fabricating this evidence. The quality of the rest of her evidence and the caveats that she placed on it were marks of a witness seeking to give as honest an account as they were able and not those of a witness seeking to fabricate or mislead to assist a friend. She said it took some time for the mother to reach the position that she came to believe that the father was responsible.

Friend C is another old friend of the mothers who was also called to give evidence in relation to her involvement with the mother and what the mother had said, if anything, in the latter part of 2012 about the basis for her suspecting the father. She is clearly close to the mother and supportive of her but did not seem unconditionally supportive; she said it was not for her to judge whether the father had poisoned the family. Her statement in its recall of dates and in the sequence of events seemed broadly to align with the established chronology. She said, and I accept that she had not been given a template or otherwise given assistance by the mother or in that period of time spoken over the weekend in order to rehearse her account. She was clear that it was at some point when the mother was in Hospital A that the mother first mentioned her suspicion that the father had poisoned the family. Her response at first was that she told her she was not thinking straight and that she thought she was out of her mind. She said that later the mother, when she returned to England, came to stay with her and another friend for about a week and she said that she was by then sure that the father had administered the poison through her parents' coffees. She said that they spoke about a lot of things when she was staying there but she recalled the mother saying that when she woke up she saw him over the table and that later when she went outside he was still there. She said she was unable to recall precisely what the mother said about matters but was clear that the mother had seen him when she woke up and later when she went outside. She also said that they had discussed accidental causes and that she still found it hard to believe that it was possible. She said she thought the mother was still in love with the father at the time. Overall, I thought she did her best to assist the court by recalling conversations she had at that time. I am satisfied she is not fabricating the evidence about those conversations to assist the mother and that on balance conversations along those lines were held. She said that the mother had not wanted them to talk about the subject of her family's poisoning.

Friend B shared a house with Friend C in 2012 and was also a close friend of the mother's. They were pregnant at roughly the same time and their children are similar ages. She said that she had asked what format the statement should be in but the only guidance the mother gave her was in relation to the statement of truth. She said she did not believe it was necessary to lie to support the mother as telling the truth was good enough. She said that when she saw the mother before she returned to Bulgaria she was in a terrible state and she was very concerned about her health and what was going to happen to A. She thought the mother had mentioned being poisoned shortly after her return from Bulgaria on 14^th September. She recalled when the mother was staying with them because it was very close to her daughter's birthday on 15 November and the mother was with them shortly before that. During her evidence she took care in answering questions pausing if she could not immediately recall something in order to see if she could remember or to say that the mother had for instance seen the father doing something. She also said she could not recall the mother saying anything about the curtains in the bedroom. She stopped being flatmates with Friend C at the end of February 2013. She said the subject was a constant source of conversation between them when she stayed. She said the mother was not so much angry as let-down. She said that the mother told her that she recalled looking out of the bedroom window and seeing the father over the coffee and she thought that was when he had put it in. The witness said she recalled questioning the mother about how she could be so sure and the mother said that they had put all the facts together and that must have been the moment he did it. She said the discussions were in the very early days afterwards and she thought the mother was trying to work out what was happening in her life. This witness also recalled the mother finding the SD card shortly after lockdown began in that she had found some material on the SD card referring to thallium. Again, I thought in relation to this witness that her account of the conversations they had in November 2012 were truthful in that they happened and in relation to the general tenor of what the mother had said. I am satisfied this witness is not fabricating evidence to support the mother nor is it likely that she has honestly but mistakenly recalled conversations over what the mother said she saw.

Lastly, Neighbour A gave evidence from Bulgaria by remote video link. He lives next door but one to the maternal grandparents. He saw the ambulance outside on the night of the 11^th/12^th September 2012 and recalled a few weeks later seeing the mother and maternal grandmother outside their home and speaking to them, he thought they looked like people undergoing chemotherapy and they told him that they had suffered thallium poisoning. He also recalled the mother saying that she had seen the father on the porch next to the table where her parents' coffees stood. He recalled her saying that the father served the coffee although that did not appear in his statement and no other witness suggested this. This would appear to be almost certainly an example of memory creep as the mother has at no stage, nor has any other witness suggested that she saw the father doing anything with the coffee still less serving it. He also gave evidence in relation to his well and the quality of water from it and his knowledge from his position as a professor of quality management about water quality issues across the region. He said he had not come across thallium contaminated groundwater or surface water himself. Although his evidence about the mother saying the father having served the coffee would appear to be an unreliable memory his evidence of the general nature of the conversation is consistent with what the mother said to two other witnesses and as he emphasised this was an unusual conversation and he remembered its general content. In general, he appeared to be a careful witness who sought to try to recall what had happened and was measured. However, this again illustrates the problems with honest and sincere witnesses who may be mistaken. He also said that one of their neighbours had had problems with rats but they laid traps for them and did not use rat poison.

I'm satisfied that the mother's supporting witnesses were not part of a plan with the mother and grandmother to fabricate evidence about the father being seen next to the coffee table or in any other respect. Whilst there may be areas where their recall is inconsistent or imperfect the general impression that they gave was of close consideration being given to the circumstances by the mother. That is entirely in accordance with common sense; somebody subject to such a rare and dangerous event would of course be likely to dwell on it and to discuss it with those close to them and to look for answers. It would be improbable that the mother had not discussed it and I'm satisfied that notwithstanding some minor variations (or in the case of Neighbour A a quite significant difference) the consistency of their recollections and their overall credibility based on the consistency of their accounts with known facts and their character as displayed in court are such that I cannot accept that either they have deliberately made this up or that all of them have been subject to a communal moulding of their memories which would be required if the mother had not actually told them that the father was seen in the vicinity of the table.

Scientific Evidence

A report was obtained from Dr Douse, a forensic toxicologist. This was obtained on the joint instruction of the father and mother. Dr Douse is a doctor of organic chemistry from Oxford University and a fellow of the Royal Society of chemistry, of the Forensic Science Society and of the Chromatographic Society. He is also a member of the Institute of Explosives Engineers, a member of the Expert Witness Institute and a member of the British Mass Spectrometry Society. He regularly provides expert witness evidence and has a background in pharmacology and the police forensic science service with particular expertise on the effects of alcohol and drugs and in alleged poisoning cases.

The report he has provided is lengthy and thorough running to some 106 pages. It was to be finalised following the answers to further questions, but I think issues relating to cost and further enquiries may have prevented a final version being produced. Although I gave directions which would have permitted further questions to be asked of Dr Douse and indeed for him to attend to give oral evidence in the event no further questions were asked and Dr Douse was not invited to give oral evidence and bar some limited submissions as to how precise his conclusions were as to the timing of the consumption of thallium, his conclusions were not disputed and Ms King's summary contained in her written closing submissions was accepted by Mr Tyler albeit with some additional observations as to timing in particular.

That summary (with some additional observations) is set out below.

a) Thallium is a rare element, usually isolated commercially from the flue dusts of various high temperature metal sulphide or roasting operations. It may also be present in the environment from old mine or metal extraction operations or from flue dust from metal sulphide or roasting operations, power stations and cement works. In its natural state it is safely chemically bonded with other elements.

b) Environmental exposure to thallium might possibly occur through consumption of certain hyper accumulator vegetables grown in such areas but unless exposures were extreme with vegetables grown on areas of very highly contaminated soil the resulting levels of thallium would usually be expected to be significantly lower than those resulting from acute exposure to thallium (e.g. by ingestion).

c) Thallium poisoning is a rare phenomenon; chronic and environmental exposure would usually be expected to result in significantly lower levels of thallium in body fluids when compared to acute poisoning.

d) Thallium and its salts are extremely toxic to humans and exhibit a combination of complicating factors such as difficulty in the diagnosis of intoxication by observation of symptoms and also a delay in the appearance of adverse symptoms; many of which can be readily confused with those of a range of other more commonly encountered diseases, thus delaying or preventing timely and critical lifesaving and injury preventing therapy.

e) Features of acute thallium poisoning vary according to how it was administered but include

a. Gastrointestinal symptoms which usually predominates early within the first 3 to 4 hours, but they may be mild or non-existent even in acute cases.

b. Neurological symptoms usually appear within the first 2 to 5 days although may appear between 12 and 48 hours. These involve painful, rapidly progressive, ascending peripheral neuropathies (weakness, numbness and pain usually in the hands and feet). Distal motor weakness occurs with the lower limbs affected more than the upper. Ataxia and tremors are possible, athetosis, nerve palsies, headaches, insomnia, possible coma possible death. Anxiety, agitation personality changes may also occur.

c. Ocular symptoms

d. Dermatological symptoms. During weeks 2 to 3 (10-21 days) a sudden onset of hair loss quickly progresses to diffuse alopecia, primarily affecting the scalp, temporal parts of the eyebrows, the eyelashes and the limbs.

e. Other; cardiovascular symptoms, tachycardia, pleuritic chest pain autonomic neuropathy predisposing patients to cardiac arrhythmias and sudden death for many weeks after the initial exposure

f. without treatment death from thallium poisoning has been reported to have the potential to follow in about 10 to 12 days however death as soon as 8 to 10 hours has also been documented.

f) Chronic toxicity in general has milder symptoms than in acute toxicity peripheral sensory disturbance, mental aberrations, loss of weight and sleeplessness are the most common features.

g) Prompt application of aggressive and unusually invasive medical therapies that are very specific to thallium poisoning immediately following exposure within a hospital has been shown to have the potential to prevent death and minimise adverse sequelae. Antidotes and treatment methods have yet to be fully approved and thus the antidote Prussian blue does not appear in the British national formulary. Prompt treatment with Prussian blue reduces the exposure of organs and tissues to prolonged elevated levels of thallium thus minimising damage.

h) The only definitive method for detecting and confirming thallium toxicity at the time of the incident was by analysis of body fluids such as urine and blood using sophisticated analytical methods.

i) On the rare occasions it occurs, thallium poisoning is often misdiagnosed and/or the diagnosis is delayed. Its qualities result in multiorgan system toxic involvement and a diverse plethora of non-specific and diverse symptoms capable of resembling a range of other ailments. Guillain Barré syndrome resembles the ascending paralysis of thallium poisoning. A number of other conditions have been reported to be capable of exhibiting symptoms that could be misattributed.

j) Thallium sulphate is colourless and largely odourless and almost tasteless and dissolves in liquid. Its solubility increases with temperature so a greater amount would dissolve in hotter black coffee than white coffee. The presence of milk as a soluble protein might precipitate thallium from solution. It is dense and a small amount (a finger pinch) might deliver a fatal dose. It may be absorbed through skin as its salts are soluble. It is extremely toxic by ingestion and very toxic by absorption. Most cases of thallium poisoning are reported to occur as a result of ingestion. Thus, thallium sulphate features in many of the reported poisoning cases and is recognised as an 'ideal' clandestine poison.

k) The reported levels capable of causing fatality in most adult humans have been described as usually within the range 10-15 mg per kilogram bodyweight. A level of 5.7mg/kg bodyweight is estimated to be the minimum dose in a healthy adult that would lead to significant symptoms. The minimum possible lethal dose for the mother is 0.65grammes, for the maternal grandmother 0.68g and the maternal grandfather 0.91g. The minimum level of thallium to cause significant symptoms for the mother is 0.37g and for the maternal grandmother 0.38 g.

l) Thallium exposure can be either chronic (repeated multiple doses over a prolonged period of time) or acute exposure (exposure to a single dose). The vast majority of reported cases are ones of ingestion. Occupational exposure and consumption of contaminated vegetables has been found usually (unless extreme) to result in significantly lower levels of thallium in blood and urine and that are clearly different from those resulting from acute ingestion of thallium salts. The evidence points to the most likely source being acute exposure as a result of ingestion of a compound of thallium

m) The work carried out by the laboratories in the UK and Bulgaria together with the observed symptoms of toxicity provide sufficient evidence to confirm that the substance responsible for the intoxication of the mother, the maternal grandmother and maternal grandfather was likely to have been thallium. The maternal grandfather died from Thallium poisoning.

n) The severity of the symptoms and speed of the maternal grandfather's death may be attributed to his age and physical vulnerability and/or the high dose of thallium he ingested. His death was more rapid than that commonly described. Ingestion of lower than usual levels may cause fatality in unusually vulnerable individuals. The maternal grandfather may possibly have been unusually vulnerable

o) In cases of thallium poisoning death can follow as soon as 8 hours after ingestion. (This is also what is said in the presentation on the SD card D2 365).

p) The timings of the symptoms experienced by the respondent and the maternal grandmother were found to appear to approximately correspond to those described to commonly appear in many cases of thallium poisoning by ingestion. They are consistent with them having drunk the coffee in the morning of 11^th September 2012;

q) It is not possible to estimate the amount of thallium absorbed from the levels measured in urine and blood because of the complexities of how the body deals with thallium.

r) Tests show that the maternal grandfather orally ingested thallium with food or liquid. The toxic effects of thallium are generally considered to be most likely experienced as a result of the ingestion of contaminated food or drink. Other routes of exposure such as inhalation and skin absorption are usually likely to be confined to workplace type incidents

s) The symptoms experienced are characteristic of acute exposure to thallium/thallium poisoning (E64, E116 and E124-E128 and regarding the absorption process D2 14) not chronic ingestion (E134).

t) Food contaminated by thallium in the soil was unlikely to be the source of the poisoning given the levels of the toxin found in the bloodstream of both the mother and the maternal grandmother and the likelihood is that it resulted from acute contamination (See the case studies at E77-85).

u) The amount of thallium the maternal grandfather ingested cannot be identified. It must have been more than the lethal dose (E109-E111).

v) The amount of thallium ingested by the mother and the maternal grandmother is difficult to estimate (E109 and E142). Any dosage can only be estimated on the basis of reported lethal doses of thallium for adults (E109). The estimated total amount of thallium ingested by the mother and maternal grandmother is in the range 0.75g – 1.3g. The combined dose ingested by the two women would have been lethal to either of them.

w) From the blood samples taken from the respondent and the maternal grandmother, it is possible to determine that they ingested similar amounts of thallium (D2 78 and 80 and D2 166 and E121). This is consistent with both surviving victims ingesting a lesser quantity of the poison and with the postulation that the poison was administered in the coffees in the morning of 11^th September.2012 (E111).

x) Extrapolating from minimum lethal doses and the levels at which serious symptoms are consequent upon ingestion of thallium, if the poison was in the shared cup of coffee, the combined dosage would be sufficient to be lethal and may be almost twice the lethal dose (E112 and E122).

y) The most likely method of ingestion of Thallium by the maternal grandparents and the mother was orally and, through consumption in food or drink (E65-66 regarding the general proposition and regarding this case E116)

z) Thallium was available from sources outside hospitals over the internet and in rodenticide. The only household product that might be expected to contain thallium would be a rodenticide. Its use (thallium sulphate) in rodenticide was banned in countries such as the USA and UK due to the problem of the ease of accidental poisoning and its use as a human poison. Old forgotten supplies still cause accidental poisonings. In 2012 its use as a rodenticide continued round the world both as a restricted use rodenticide in Europe and also as a more freely available product in underdeveloped countries.

Other aspects of the scientific evidence in particular the results of the tests carried out on the mother, maternal grandmother and maternal grandfather are contained within the chronology. In particular, I note the conclusions of those reporting that the levels detected were consistent with acute exposure and with ingestion rather than chronic exposure or inhalation or absorption. The hair analysis of both the mother and the maternal grandmother showed thallium was ingested in a timeframe consistent with the visit to Town A and that it is likely that the poison was ingested at the same time given the relatively parallel occurrence of the clinical signs,

Evaluation and Discussion

I draw upon my observations or conclusions on the evidence contained within the detailed chronology. They must be read as a whole together with this.

In considering various aspects of the argument and testing propositions I am acutely conscious of the need to place any single issue into the overall landscape within which a non-compartmentalised approach must take place. A point that might seem irrefutably to point to the probability or improbability of a fact or a conclusion must be set in the context of all other matters which bear upon the ultimate answer to the ultimate question; matters of direct evidence, inference, improbability or probability, credibility, motive

I remind myself that to approach the determination of the facts by a process of seeking to exclude possible causes would be wrong. As with pool of perpetrators cases the proposition that the most likely of a number of possible causes is more probably than not the cause would be wrong. Something maybe the most likely of the identified causes but that does not allow for unidentified or unknown causes nor does it mean that the most likely crosses the threshold of the balance of probability. Thus, it is wrong to simply rule out as unlikely or less likely or even fantastical some of the possibilities and leave only deliberate poisoning by the father as the most likely and thus probable cause. The mother must demonstrate that the totality of the evidence makes it more probable than not that the father did it. As Lord Brandon noted in the Popi M it is only possible to rule out possible causes as 'impossible' if all the facts are known which is certainly not so in this case and even if one could rule out all other possibilities as either impossible, improbable or less likely one would still be left with another (as a base proposition) unlikely or improbable event, namely a 'son-in-law' poisoning his 'parents in law'. Ms King did not seek to persuade me that the mother could meet the burden and standard of proof and thus establish that the father was the perpetrator merely by a process of elimination. Her position was that adopting a holistic approach the combined effect of a host of matters, which included the unlikelihood of other possible causes, would lead to the conclusion that the father was the perpetrator. Mr Tyler placed significant emphasis on the fact that a number of other possible causes could not be ruled out; the rodenticide on a grocer's shelf contaminating food, the isolated contamination of water used to wash food eaten, etc. However the fact that a possible cause remains 'live' because it cannot be ruled out, does not prevent the court determining that another possible cause was on balance of probabilities the actual cause because the court must stand back and survey the broad landscape and seek to incorporate the totality of the evidence and, inevitably, the combined effect of that overarching perspective may persuade the court that on balance of probability one of a number of possible causes was the actual cause.

This seems to me to be a case which requires very considerable caution when it comes to reliance on the recollection of witnesses whether contained in witness statements or within their evidence given many years after the events, in relation to events which are of the utmost emotional intensity, where the stakes are so high, where events have been relived and pieced together time and again and where evidence has been given in court and tested once already. There is plainly an obvious and real risk that the witnesses' memories have been subjected to the sort of influences identified by Leggatt J and which might have shaped the testimony that they now give. The tendency to interpret events in the light of all that has occurred and the belief systems that have developed was evident in both the mothers and the father's evidence. The mother's assertion that the father intended to generate a viral illness in A in order to give him a 'base' illness in the mother on which to build the Guillain Barré syndrome possibility was put forward but rapidly withdrawn when it was pointed out that her case was that her poisoning was inadvertent and so the father would have had no need to expose her to a viral illness as a foundation for Gillain Barré Syndrome. However, this did illustrate powerfully how the mother now is capable of interpreting most events consistently with the father's deliberate poisoning of the family. Given the intensity of her belief that the father did poison the family it is perhaps not surprising that she interprets events in a way which is consistent with this belief, but it was a stark illustration of the need for the court to apply the most careful scrutiny and objectivity to assertions of inference that can be drawn from established facts. Likewise, the father sought to say he had not done more in September/October 2012 because he was criticised whether he was inactive or proactive albeit he also seemed then to accept that the criticism arose after the event rather than at the time. In relation to the witnesses' memories of the events of autumn 2012 it seems to me that it is, in this case more than almost any other, near essential to look for corroboration from contemporaneous documents or inferences that can be drawn from them or to look for reliable corroboration from other witnesses. In relation to corroboration of one person's memory by another person's memory there is of course a danger that both of their memories have been shaped and have come to converge as a result of the processes identified by Leggatt J.

Indeed, the possibility of memory creep was graphically illustrated when the mother sought to be recalled following the conclusion of the father's evidence. She did so because she said that after she concluded her testimony and reflected on it, she realised that her evidence about the state of the curtains in the bedroom when she looked out onto the veranda was speculation rather than something that she actually remembered. She told me that she felt compelled to bring this to my attention as she did not wish to put anything before the court that she was not confident was actually her recollection. As far as I can tell the question of the state of the curtains was first raised by me and thus was a new area of enquiry which she had not thought about before and thus, the evidence which she gave, which I think she believed at the time she was in the witness box to be her memory, was she later realised, only after the event speculation. As it happens her evidence in relation to the curtains was as Mr Tyler noted in his submissions all over the place and I would not have felt I could rely on it in any event. The contrast between the inconsistency of the curtain evidence and the consistency of some other aspects of her account of 12 September was quite marked albeit I do not automatically draw the inference that her other evidence is thus reliable given that her other evidence has been the subject of much deliberation down the years. Another issue of possible memory creep arises out of the mother's evidence that she first saw the father through the bedroom window and then again a few seconds later when she went out onto the veranda; her statement of May 2018 does not refer to her seeing him through the bedroom window but that comes out during her account to HHJ Jacklin QC [T54] However, being cautious in relation to memories of historic events and being cautious in evaluating the evidence which emanates from those memories and in seeking documentary or other corroboration does not mean that the evidence cannot be relied upon. Caution does not equate to excision or exclusion.

In relation to the evaluation of the mother's testimony Mr Tyler submits that the risk of it being moulded over the years is particularly acute given the intensity with which she believes that the father is the poisoner of the family. He submits that this causes her to believe wild or extraordinarily speculative propositions examples being the deliberate development of a viral illness in A or the absence of documents from Bulgaria being due to the father or his agents having bribed the authorities there. Mr Tyler submitted that the mother had developed the belief and a strongly held belief of the father's guilt by late September or early October; in this he relied upon the mother's assertion that that was so during her cross-examination. I have to say that the chronology, recollections of her friends but also the other evidence of the mother and the maternal grandmother together with common sense and a legitimate inference from the totality of the evidence is that the mother did not come to a firm view as to the father's responsibility until later in October. High stakes and the intensity of the emotions engaged are relevant to the possibility of memory being moulded subconsciously to support that belief. I am satisfied from the evidence that the mother has given, corroborated by that of her mother and friends that neither she nor her mother jumped to a conclusion that the father was the perpetrator and that both of them reached that view albeit in different ways by a process of elimination and of having regard to the advice they had received from doctors as to the levels of poison being consistent with deliberate poisoning rather than accidental consumption.

I acknowledge Mr Tyler's point as to who has conducted the investigation and put the evidence before the court. Whilst the mother has been responsible for laying the evidence before the court, in fact much of it emanates from the Bulgarian police investigation and indeed that comprises material generated by the father more than the mother. In other respects, the material is the product of scientific investigation in Bulgaria or independent expert evidence adduced here. Prior to the inception of these proceedings the father adopted an approach, legitimate but by choice, of not investigating alternative causes in order to put forward a positive case to clear his name. Whilst the mother is the prosecutor, she has not been the sole investigator and hence the sources of evidence are varied.

Mr Tyler also rightly cautions me against the risk of circular reasoning. This was illustrated by the reliance the mother and Miss King placed on the father having raised the possibility of Guillain Barré syndrome which mimics the symptoms of thallium poisoning and which it was asserted was an attempt to mislead the mother and any treating doctors away from the possibility of thallium poisoning. The father's case was that the mother's description of her symptoms was consistent with Guillain Barré syndrome which was why he raised it. It is immediately apparent that the mother's submission that the court should rely on the father having raised Guillain Barré syndrome as an indicator of his guilt is in fact reliant on the assumption that he was aware of the thallium poisoning which is of course circular if approached in that way. However to be fair to Ms King I think on reflection her submission on GBS was that the rapidity with which F raised it and its rarity and its being outside his field together with the fact that it mimics thallium and its being raised would divert the mother and doctors placed in the overall landscape was what was potentially relevant.

In order to determine whether any particular combination of facts is in fact supportive of the mother's case one approach or cross check may be to test the combination of facts from the perspective of the mother's theory but also from the perspective of the father's theory. If the facts are equally consistent with both it would not be possible to say they support the conclusion that the mother's case is established. However, adopting that approach rarely leads to that outcome in my experience, particularly in a fact and evidence rich case such as this. Logically, in order to prove the mother's case, she must identify a combination of facts which taken together establish her case; in that process inevitably either actively or passively she must establish that no other explanation of that combination or indeed another combination is equally or more probable. Given that I am evaluating the mother's case on the balance of probabilities rather than to say that I am sure, the court is not looking for absolutes or certainties but rather whether facts or rather the combination of facts and inferences lead logically to the conclusion that the mother's case is more probable than not. The nature of the standard of proof in a civil case being the balance of probabilities self-evidently recognises that there remain other possible but ultimately improbable alternative explanations. In adopting a non-compartmentalised and holistic approach the court surveys the broad landscape and accepts there may on that landscape be features which are inconsistent with one or other of the cases contended for. But if what the court sees in its over-arching survey is a landscape populated by oaks, beeches, and chestnut trees, roamed by rabbits, roe deer and foxes the presence of a teak tree and a jaguar is not likely to deflect the court from the conclusion that it is looking at a deciduous woodland rather than a tropical rainforest. It may well question why they are there and look for explanations for their presence but unless on closer examination the landscape actually appears to be equally or more populated by tropical rainforest varieties and creatures the court is likely to conclude; deciduous woodland it is. To focus on the presence of the jaguar and say that means this cannot be a deciduous woodland would be to adopt a compartmentalised and linear approach which would be wrong and so focusing on any single fact in this case and to say – to be fair to Mr Tyler I am not sure he ever put his case quite so starkly in this way – that it excludes a conclusion of the father being the perpetrator would be wrong. Of course, in some cases a single fact – alibi for instance - might be so significant that it would be a dominant feature on the landscape which would potentially dictates the outcome. I do not see any of the facts in this case as being so significant. There are some aspects of the mother's case such as her reliance on travelling to Bulgaria by car which do not seem to add anything to the picture either way. There are other matters which in combination are inconsistent with a particular outcome.

In a case such as this where not only is the evidence historic in terms of the witness testimony but where the contemporaneous documentary evidence is incomplete, that being particularly so in relation to the Bulgarian police investigation (the record of what the mother told the police in October 2012 and the record of what took place during the visit to the Villa on 10 December 2012 being particularly significant omissions) the court must be alive to what was the third possibility identified by Lord Brandon in the Popi M case which is that the case alleged is simply incapable of being determined on the balance of probabilities because the evidence does not enable the court to find that the mother's case is established on the balance of probabilities. In contrast to the underwriters in the Popi M case the father has not, as he is entitled, put forward an alternative case for the court to adjudicate upon on the balance of probabilities and it is therefore part and parcel of the father's submission that the state of the evidence in this case is not such as to enable the court to determine on the balance of probabilities that the mother's case is established.

Motive is not an integral part of proof of the facts. An obvious motive may make something more probable. The absence of any motive might make something less probable, but it is far from determinative. The character of a person and their relationships with others might add or subtract weight from the inherent probability or in this case improbability. A person of good character like the father is inherently less likely to perpetrate a murder than a person who has a track record of serious violence, but it is not a bar. The father's colleague Dr X speaks highly of him as a workaholic dedicated doctor. Experience in the courts tells us that sometimes people do dreadful things for negligible or no reasons and in some cases, it is simply impossible to identify a motive. It is not necessary to prove a motive in order to establish the mother's case. Nor does the absence of a proven motive mean the mother cannot prove her case. However, it is a factor to be taken into account in the weighing of the totality of the evidence. The presence of an obvious motive for the commission of any act may lend support to the inherent probability of that person having perpetrated the act. The absence of any obvious motive may lend support to the inherent improbability of that person having perpetrated the act. The father is a man of good character and a member of the medical profession and these facts can legitimately be relied upon by him in support of the contention that he is an individual who is unlikely to have committed a heinous act such as the deliberate poisoning of anybody still less a relative. However, inherent improbability is far from an absolute. We know that people of good character and members of the medical professions are capable of committing serious criminal acts. We also know individuals are capable of committing serious criminal acts for no obvious or determinable reason. The evidence of the state of the relationship between the father and the maternal grandmother would not suggest that it would give rise to such intensity of hostility in the father that he would wish to kill her still less the maternal grandfather. Nor does the evidence as to the possible financial benefit to the father establish any real basis to see that as a motive. The possibility that the mother might inherit their wealth which would benefit the father would not seem to be of such magnitude or direct benefit to him as to amount to any sort of obvious motive. The question of whether the father wished to remove the maternal grandparents from the relationship dynamic in order to remove a source of support for the mother or a source of interference into the mother and father's relationship cannot be so easily ruled out but the nature of the evidence has not enabled me to reach a conclusion on this potential motive.

The father's attitude to the relationship and his apparent lack of emotion about and empathy for the mother leads me to place less weight on the unlikelihood of the father being capable of having committed the poisoning. A father and partner who demonstrably deeply loved their partner and mother of their child and who was empathetic and emotionally supportive would be far less likely to commit such an act than an individual who placed little value in the relationship or their partner and who was neither empathetic or emotionally supportive but self-centred and preoccupied with himself, as I conclude the father was. Likewise, an emotionally intelligent and empathetic individual who takes ownership or responsibility for events in their life would be far less likely to be the perpetrator of such an act than an individual lacking in emotional intelligence and empathy and who is able to displace responsibility for their own actions and to blame others.

The absence of an obvious motive or even one which could be said to have some real substance might in some circumstances be of very considerable weight. Were this a case where the father's character and personality and the dynamic between the parents were such that any motive or acting upon it was simply incomprehensible that might be of very considerable weight in the evaluation of the probability of the father acting as alleged. The evidence in this case establishes that the relationship between the parents was troubled. Although they had been through counselling and had decided to continue the relationship the father's portrayal of it as a normal or loving relationship does not in my view accurately depict its reality. The mother had identified what she regarded as fundamental differences in their characters and outlook which had caused her to consider that the relationship had no future albeit she had at the end of the counselling process decided to continue to try. The father's evidence as to what were the problems underpinning their relationship and what he had learned from the counselling demonstrated no insight into any difficulty. Although he maintained that he had insight into himself this did not seem borne out by his evidence which did not show him to be reflective in any way or demonstrate any aspect in which he had compromised or changed in order to pursue the relationship. Although minor examples, the insistence on driving to and from Bulgaria and his refusal to defer A's return illustrate him overriding the mother's legitimate concerns. Even the issue of the unpacking of the warning triangle and jackets caused a significant argument between them when the mother's request that it be positioned in the car (as required by law) was not something that the father could readily agree to. The father's evidence demonstrated that he is a man who seeks to place responsibility for events away from himself and on others. This was obvious throughout his evidence ranging from the minor issue where responsibility for A staying in the sea to long was A's rather than his, through to the mother being responsible for him to assisting in his efforts to obtain Prussian blue, through to his solicitor being responsible for the final approval of his statement to the Bulgarian police and for the advice which caused him to defer issuing proceedings. It seems to me that an individual who obviously finds reasons to place responsibility for events at another's door is likely to be more capable of behaving in unpredictable ways than somebody who obviously takes responsibility for their actions. In addition, an individual who is obviously empathetic and values how others feel is less likely to act in a way which will cause harm than somebody who is not empathetic. The father's evidence in particular as to the period between 13 September and mid-October demonstrated in a quite stark way how he was unable to empathise with the mother's position. His failure to move heaven and earth to understand what was wrong with the mother and to deploy the knowledge that he as a medical professional had to secure information about her condition or to seek to open doors which he as a medical professional might have had the key to was worrying. He himself now accepts that he should have done more and his statement that he did not do more because he had been accused of being the cause and was insulted or aggrieved by this demonstrated a most unattractive focus on his own interests and emotions at a time when one would expect an individual with any real empathy to be focused on the mother's needs; she having lost her father and she and her mother both being seriously unwell. These facts therefore lead me to conclude that the absence of an obvious motive is of less significance than might be the case with another individual. The issue of the father's failure to act may be of more significance as I shall address later.

Mr Tyler is right that there are gaps in the evidence in particular the record of the mother's and grandmother's interviews in hospital in October 2012 and also the notes of the visit to the villa. Plainly, it would be beneficial to have them, but I do not consider the absence to be so significant that it prevents me reaching any conclusions. The combination of the other sources of evidence seem to me to be sufficient to discern the picture. The lack of direct evidence makes the task harder but again does not in my view, on the totality of the evidence in this case, prevent me reaching a conclusion.

Given the Bulgarian criminal prosecution decisions were set aside by courts on the basis of inadequate process or reasoning I do not think any real inference can be drawn about the leaning over incident from its absence of reference in those prosecutors' documents.

In submissions, Mr Tyler addressed the relevance of the existence of other possible causes which cannot be excluded. I acknowledge that there are many other possible causes which one can imagine as Mr Tyler demonstrated during submissions. It is of course possible that old rat poison was on a shelf in a grocers which fell onto foodstuff purchased by the maternal grandmother and which was then consumed by those affected. It is conceivable that some source of thallium had somehow got into the mineral water drunk by those affected. The range is in effect as limitless as the imagination. However, one must look at the totality of the evidence to look at whether in the context of everything else, a possible explanation is of sufficient weight to counteract the weight of other matters pointing in a different direction. The maternal grandmother said they never had problems with rats and had as far as she knew never used rat poison in the house or the garden and there is evidence as to both the use of water, likely acute poisoning, no known rodent problem which tend to undermine the weight that should be given to other possible causes. That is not to rule them out entirely but to place them in the context of the entirety of the evidence that exists in relation to them, the entirety of the other evidence and bearing in mind we know that in some areas the evidence is incomplete. Ultimately, it seems to me it is a matter of weight. Other possible explanations include:

i) Ground Water: whilst it remains a possible source of thallium poisoning, I consider it to be highly unlikely for the following reasons:

a) The medical evidence points to the conclusion that the thallium poisoning was acute and not chronic and so it is not associated with the consumption of fruit or vegetables which have absorbed thallium which has then been ingested.

b) The water from the pump which was installed 15 + years before and which had been used for irrigation purposes for that period of time without any previous difficulties.

c) There were no known mining or smelting operations in the region which might have been responsible for the presence of thallium in groundwater.

d) No one suggested that water from the pump was used as drinking water; drinking water came either from the Town J spring collected in large containers or from the tap.

e) The water was used to water vegetables in the garden which were then consumed by the maternal grandparents, A for the four months he was with them and the mother and father during the time they were with them. None of the five experienced any illness which might be associated with thallium poisoning earlier in the summer.

f) If it was the source of thallium its presence in food would have been from residual water left on washed fruit or vegetables which were offered to all of the family and I conclude it is unlikely that the mother, maternal grandmother and maternal grandfather consumed sufficient fruit and vegetable to sustain the levels of poisoning that they did whilst the father and A would appear to have escaped without consuming any.

g) Neighbour B; the neighbour uses water from a well drilled to a similar depth to the MGF both for irrigation and for drinking and he is unaware of any quality issues;

h) Neighbour A also has a well, next but one away from the maternal grandparents' home and he had experienced no difficulties with his water supply in terms of any contamination. He was also unaware through his work which involves environmental issues of any contamination problems with water sources in that area;

i) If it was contamination it would seem to be a one-off contamination of a particular pouring of water as no contamination is suggested before or subsequently.

ii) Mineral water. This was collected from a communal spa in 10 L containers and drunk over a period of time, used for cooking and washing fruit and vegetables. There is no suggestion that the communal spa was contaminated or that anybody had experienced illness from consuming the mineral water in this household in the days, weeks and months before the incident. The absence of definitive testing of the water is not necessary to prescribe weight to the likelihood of this possibility.

iii) Contaminated food. In terms of fruit and vegetables, the scientific evidence does not support chronic thallium poisoning from the consumption of fruit and vegetables grown in contaminated soil or with contaminated water. The shared lunchtime meal makes it most unlikely albeit not impossible that the three affected individuals eight something which was contaminated sufficiently to poison them but was not eaten by the father or A.

Mr Tyler submitted that the emergence of symptoms in the late afternoon was potentially more consistent with the thallium being ingested or otherwise administered later than 7:30 AM and perhaps more consistent with the consumption of lunch from 11.30 AM. It is certainly true that the evidence from the mother and the maternal grandmother that symptoms began to be experienced in the late afternoon or early evening-particularly if gastrointestinal might be more consistent with lunchtime consumption if they arose within 3 to 4 hours, but the symptoms described in the maternal grandfather - slurred speech might be neurological in origin, in which case onset in the early evening would be consistent with thallium entering his body sometime after 7.00 AM in the morning. In any event given that both the maternal grandmother and the maternal grandfather appear to have consume their coffees over a period of 3 to 4 hours or more I do not conclude that this element of the timing assists much in determining when the thallium came to be present. The evidence would suggest that the mother consumed her half of the coffee in a more concentrated period of time from 7.30 AM. However the report of Dr Douse does not support a rigid timeframe in the emergence of symptoms and the differing physiological conditions of the mother, maternal grandmother and maternal grandfather are also likely (on the basis of Dr Douse's report) to have played some role in how their bodies responded to the presence of thallium. The evidence as to timing supports the conclusion that on the balance of probabilities the three sustained thallium poisoning on 11 September 2012 between getting up and around lunchtime. It is in other evidence that the answer to the source of the thallium poisoning is more likely to be found.

Overall, I do not think that determinative weight can be ascribed to the leaning over the coffee incident which the amount of time dedicated during the hearing might suggest it warranted. Ultimately the father accepted that he was up before the mother, that he encountered the maternal grandmother in the inside kitchen making coffee for herself and the grandfather, that he may then himself have been on the veranda in the vicinity of the table with the grandparents' coffee on it. He may have been looking out over the garden or lighting a cigarette. The mother's recollection of seeing him in the vicinity of the table where the grandparents' coffee was placed is therefore far from ruled out by the father's evidence. The evidence of the mother's witnesses that she mentioned the matter to them in October/November 2012 following her discharge from hospital and later to the neighbour when they returned to the villa is evidence that I accept as I have said above. I also consider that the nature of the investigation itself appears to identify coffee as the primary potential vehicle for the delivery of the poison. The forensic examination of the villa focused very heavily on coffee related items including the coffee pot. It seems to me that the only logical inference that can be drawn from that is that the information the police had received up to that point from the mother and from the maternal grandmother had identified the morning coffee and the differential between the consumers of the pot brewed coffee and the instant coffee drunk by the father as being central to how the thallium had been consumed. Whilst the analysis of some food leftovers points to some openness to certain other sources the analysis of food related items seems to be very much subsidiary. As the maternal grandmother's evidence confirmed the range and sorts of food and drink contained in the house there must have been many, many other food items that could have been collected and taken for analysis. I have also concluded that the visit to the villa on 10 December was more in the nature of a reconstruction as described by the mother and maternal grandmother. If they had, as I have concluded they did, told friends and neighbours of their theory as to the delivery of the poison being in the father administering it whilst on the veranda to the two pot brewed coffees and if the police focus of the investigation was on coffee (as it seems to have been from the forensic examination) it seems that this is what the mother and grandmother told the police. The level of detail that may have been given when they were spoken to whilst at hospital may not have been great, but it must have been sufficient to alert the police to the morning coffee as a central focus. It also seems to me that the mother was not motivated by any animus to the father to identify him as the perpetrator and the evidence of her friends as to her creeping identification of him as her prime suspect, overcoming her psychological inertia against that possibility, ruling out other causes and then identifying him in itself tends to corroborate her having seen him by the table and the coffee being the source of administration. If she had not seen him and thus identified an opportunity who knows where she would have ended up; if there was a complete absence of opportunity it seems improbable, she would have identified him. The parties' account of the reconstruction is consistent with the trajectory of the police investigation up to that point and, as I have concluded in the chronology, I accept that their broad recollection and indeed description of the visit as a reconstruction rather than a confrontation is accurate. I am therefore satisfied that some re-enactment of the father being next to the coffee table and leaning over it was undertaken then. Thus, overall, I'm satisfied that the combination of those sources of evidence establishes that the mother's recollection of seeing the father on the veranda leaning over table on which the grandparents' coffee was placed is reliable.

Precisely what she saw and over what period I do not consider to be of critical importance. Her evidence is not that she saw the father do anything in relation to the coffee it is in effect that he had an opportunity to interfere with the coffee. On analysis of the father's own evidence, it does not seem to me to rule out him having that opportunity. If he was alone on the veranda with the grandparents' coffee for any length of time that constitutes an opportunity and his evidence does not rule this out. However, having an opportunity to put thallium in the two coffees is no more than that. If the evidence established that he had not been alone with the coffees at any stage that could be a very significant, perhaps dominant, feature on the landscape and would probably rule him out as the administrator of the poison, if indeed it was contained in those coffees. Given it is the mother's case (Scott Schedule) that it was the coffee which contained the poison an absence of opportunity would point strongly to the conclusion that the mother could not establish on balance of probability that he was responsible. The converse of course is not true. An opportunity to administer the thallium does not mean that he did administer thallium. The maternal grandmother had an opportunity to administer thallium to the two coffees as much as the father did. The answer to who introduced thallium and how must therefore be determined by the non-compartmentalised overarching survey of the landscape. So, what other features do emerge from the landscape and, putting them all together, what picture emerges? Is it a clear picture or are there so many pieces missing or damaged or so many pieces of other jigsaws present that one simply cannot put what is there together and emerge with a sufficiently complete jigsaw to determine what it shows on balance of probability?

The father's evidence was to the effect that he undertook no research himself in relation to thallium poisoning and, other than taking the mother to hospitals and being present with her, did not deploy his medical knowledge, contacts or any other skill or advantage he might have had as a doctor to further the mother's cause. He accepted that he was at fault in not doing so. However, he sought to explain his failure in two ways. Firstly, he said he was attacked for being either inactive or taking control and so in effect decided to leave the mother to do things for herself but subsequently accepted that this was an ex post facto rationalisation of his actions.

His second explanation was given in connection with his answer to a question I asked him. He accepted that he had been telling the mother in England that her condition was not as bad as she believed and that the tests which had been carried out indicated that her internal organs were functioning properly. He also accepted that he had told Friend A that the mother was better than she appeared as her organs had not been damaged and she was stressed. I queried how he could be so confident with the results of the tests which had been carried out given that thallium poisoning could be fatal and he had no knowledge of how it operated on the body and the timescales over which it could lead to severe injury or death. After a certain amount of contemplation the father told me that he felt insulted and hurt by the mother's accusation that he might be the source of their poisoning and that as a result he had not undertaken the research into thallium that he might have done and that he had told the mother and Friend A that she was fine on the basis of the UK hospital tests without really knowing whether she was or not. He said perhaps he should not say that as it was probably unprofessional to have done that. He gave the same reason in effect for not seeking answers to the question of where the thallium had come from which had killed his would-be father-in-law, and which had made his would-be mother-in-law and his partner so very ill. For a period of time the mother certainly feared that she would die which, until thallium poisoning was confirmed, and she was through the worst of it and reassured both by her treatment and the fact of her beginning to recover, must have been a genuine fear. His answer to his not having sought to identify where the thallium might have come from was, as I say, that he felt aggrieved by the accusation that had been made against him.

The absence of any application to the court to see A prior to 2018 is unusual and I do not accept the father's explanation for it. The mother in effect invited him to make his application and to see the evidence that she had which pointed to him as the perpetrator. The father did not make that application. His explanation that he was advised to await the outcome of the police investigation might have been understandable for a relatively short period of time, but it does not explain the prolonged failure over several years. The father sought to attribute responsibility to this on his lawyers; he was following their advice. However, as weeks turned into months and months turned into years, I do not accept that that is an adequate explanation. Nor do I accept it is likely that that advice endured over the years. I cannot conceive of any lawyer particularly a family lawyer giving the sort of absolute advice that the father suggested he was given. Had the matter been put before the court a fact-finding would no doubt have been considered and, in the meantime, it may have been that interim supervised contact would have been considered. The explanation the father gives is even less credible when one considers that the police investigation concluded at various times and at the latest by September 2016 the father had a certificate to that effect. However, he did not issue proceedings for well in excess of another year. I do not think the father was putting A's interests first in any sense, it may have been said that he was seeking to avoid causing the mother any additional distress and thus held back for her sake. However, the contents of the communications in 2013 and indeed the father's attitude to the mother generally would not support this at all. The most likely explanation is that the father was putting his own interests first which may have been mixed perhaps having elements of finance, emotional stress but also it seems to me probable that avoiding a court determination was part of his reasoning. That does not mean he did not want a court determination because he was guilty because of course the risk of an adverse court determination would have profound consequences for his ability to practice in medicine, his reputation and otherwise. However, he undoubtedly put his own self-interests before those of A.

Conclusion

I have given this case the most anxious and protracted consideration. The length of the judgment perhaps indicates this. Notwithstanding its length it cannot of course incorporate all that I have read, all that I have heard from the witnesses and from the advocates or the entirety of my thinking processes as the tides have flowed one way and then the other. The law mandates that decisions in this context are made on the balance of probabilities rather than the court being satisfied so that it is sure (or beyond reasonable doubt). Given the profound consequences of the decision it seems to me that the time given has been proportionate to the issues concerned. It has not been an easy evaluation to undertake both in seeking to determine facts but more importantly, what conclusions are ultimately to be drawn from the host of facts present.

Ultimately, I have reached my conclusion on the basis of I hope a very broad survey of the landscape. Pieces of the jigsaw have been put together or have been discarded. The eventual picture which emerged from that process is not a complete picture, but it is in my view more than clear enough to reach a conclusion on the balance of probabilities. I do not conclude that this is a case which falls into the Popi M category three. A combination of pieces of evidence together with the ruling out of other possible causes has created sufficient strands to form a rope which will bear the weight that a finding of this nature requires on the balance of probability. I have not and cannot ascribe any numerical factor to any one strand nor can I say that there is a steel core to the rope without which it would not bear that weight. It is the constellation of matters which appear in the landscape perhaps through a degree of mist, or the many pieces of the jigsaw which create an incomplete but discernible picture which have led me to my conclusion.

The pieces of evidence and matters which have perhaps formed the most important strands of the rope include:

i) the mother, maternal grandmother and maternal grandfather sustained thallium poisoning;

ii) The levels of thallium and the symptoms experienced point to the thallium poisoning being acute rather than chronic and so consumption from contaminated vegetables (deriving the thallium either from the soil or from pumped water) is unlikely;

iii) The evidence from the post-mortem and the other scientific including expert evidence support the conclusion that the thallium was ingested with food or drink rather than being inhaled or absorbed by the skin;

iv) The mineral water present at the property was drawn from a well-known communal source, had been drunk by members of the family over several days or used in cooking and on that day was on balance of probabilities consumed not only by the family members affected by thallium poisoning but also by A and at least indirectly by the father through the consumption of foods washed in it. It can be ruled out as an unlikely source of the thallium that was ingested;

v) Pumped water from the garden was used to water the vegetables and could only have contaminated them in a way which would have led to chronic thallium poisoning which is not indicated;

vi) The food that was consumed in the evening was consumed after the emergence of some symptoms in the maternal grandfather and the mother in the late afternoon and early evening. By the time of the evening meal the maternal grandfather was clearly beginning to exhibit symptoms which I am satisfied were linked to the thallium poisoning;

vii) At lunchtime a shared meal was eaten which all of those present partook of. Although the father and A may have eaten less there is nothing to suggest that something was eaten only by the mother, maternal grandmother and maternal grandfather. In any event whilst accepting that one cannot rule out the possibility not only that they were the sole consumers of some foodstuff or drink, but that that foodstuff had accidentally become contaminated with sufficient thallium from an unknown source, leads me to conclude this is an unlikely source of poisoning. The timing of symptoms in the afternoon/evening is probably less consistent with poisoning at lunchtime although it is not out of the timeframe;

viii) Although the father and A were not tested for the presence of thallium neither demonstrated any symptoms which were consistent with them having consumed thallium. I am therefore satisfied on balance of probabilities that neither of them consumed thallium;

ix) An obvious distinction between the parties in what they consumed that day is in the coffee where all agree that the father only drank instant coffee whereas the mother, maternal grandmother and maternal grandfather drank brewed coffee. Whilst the water used may have been different (although I do not accept that this has been established) I do not consider it probable that mineral water could be the source of the thallium. I do not think it is a necessary part of that conclusion to have scientific testing of the mineral water that was present at the property on that day;

x) The scientific and other evidence points to the brewed coffee consumed by the mother, maternal grandfather and maternal grandmother as the likely source of the ingestion of thallium. The fact that the mother and maternal grandmother shared a cup of coffee which made them both seriously ill but did not kill them is consistent with that having contained a sufficient amount of thallium to kill one individual. The fact that the maternal grandfather consumed a whole cup of coffee and died relatively rapidly of thallium poisoning is consistent with that having contained a sufficient dose of poison to kill an individual. His underlying health probably contributed to his rapid deterioration and death. His hotter black coffee could have held more thallium than the cooler white cup of coffee shared by the mother and maternal grandmother. That provides a rational explanation of the distinction between the outcome for those three individuals;

xi) The father as a qualified medical doctor would have the intellectual capacity to determine the amounts of thallium that would be required to deliver a sufficient dose to kill an individual without delivering such a significant dose as to make it obvious to the consumer of the drink that it had been contaminated with something or to lead to far swifter emergence of gastrointestinal or other symptoms;

xii) The father's reference to GBS as a possible cause given he had never come across it in his clinical practice but had learned about it in his medical training many years before leads me to conclude that it is more probable than not that he had some more recent knowledge of it than he says;

xiii) The mother was plainly very seriously ill by at the latest 27^th September when she began to suffer from hair loss. Even assuming the father was prepared to accept the results of the investigations by his medical colleagues prior to that, his behaviour thereafter is far more consistent with his having prior knowledge of the underlying cause. By that stage she had lost a stone in weight and was losing her hair and yet he did nothing more than drive her around to the hospitals. He put his medical knowledge to no use at all whether in conducting research or seeking to open doors in terms of medical treatment. At a time when the mother was frantic and had come to believe that she was poisoned his failure to do anything of substance on the medical front is almost inexplicable save by prior knowledge of the causes;

xiv) His failure to look into any other possible sources of the thallium poisoning at any stage cannot be reconciled with his assertions as to the state of the relationship with the mother. If he loved her and they had a normal relationship it is inconceivable that he would not have sought an explanation for her condition in particular when thallium poisoning emerged as a possible and then confirmed cause. Apart from anything else if thallium was present on the property the possibility of the family resuming occupation and most importantly A resuming occupation would have been a compelling reason to enquire into the possible sources of thallium. He had the financial means and contacts in Bulgaria to enable him to be proactive in this regard if he had so wished. The failure to do so is far more consistent with his knowledge that the property did not pose a risk;

xv) The father's behaviour subsequent to the return to England and most significantly the fact that he reassured the mother and Friend A that the mother was not as sick as she seemed, without him having conducted any research into the effects of thallium on the body and the development of symptoms leads me to conclude that he was able to provide this reassurance because he already knew what the effects of thallium were and its progression. He could only have provided that reassurance at that stage if he knew that death was unlikely by that stage given the symptoms that the mother was demonstrating. I do not think that the list of chemical compounds adds anything to the case. The presence of the thallium PowerPoint I do not think is likely to be the complete source of the father's knowledge of thallium and I felt unable to reach any conclusions on the relevance of the material on the SD card. The length of the document and the lack of any obvious connection between the father and those who attended the session lead me to conclude that I cannot place any reliance on the presence of the documents on the SD card. Although I am satisfied that the SD card is the father's and that his non-acceptance of it can be rejected, the presence of those documents and his non-acceptance of the card or their presence does not seem to me to satisfy the modified Lucas test. By this stage, findings having been made against him, his attitude to it can clearly be explained by his desire to minimise the weight of the case against him rather than simply by guilt.

xvi) The circumstances in which the father's account was given to the Bulgarian police on the seventh and 10^th of December 2012 satisfy me that the written statement which emerged from that process and which was signed by the father on every page was the account that he intended to give to the police at that stage. It was not given in error. His account as to the time he arose and who was already up was a lie. I'm satisfied that it meets the modified Lucas test in that it is (a) deliberate, (b) relates to a material issue, and (c) is motivated by a realisation of guilt and a fear of the truth. I am satisfied he did not give the account to the police that he was up before the mother and was on the veranda with the coffee and that he did not do so because in the circumstances which existed at the time it would have created a direct link between him and the central focus of the enquiry. I am satisfied that the mother had identified coffee as the possible source of the administration of thallium by the time they spoke to the police. The focus of the forensic examination of items from the property confirms that coffee was the central focus. That could not have been the case unless the mother and perhaps the maternal grandmother had identified that as the possible route for the administration. I am also satisfied that the evidence establishes that the mother had spoken of seeing the father leaning over the table by October 2012. This had been mentioned to her friends and probably to the police. The visit to the property I am satisfied was more in the nature of a reconstruction than a confrontation over who had eaten what and when although the two are not irreconcilable in any event. I am satisfied that the father's account of the reconstruction is not accurate, and that the mother's and the maternal grandmother's account is more accurate. Having told her friends of seeing the father in the vicinity of the coffee leaning over it seems inconceivable that she would not have mentioned it to the police either before or subsequently and thus by the time the visit to the villa took place on 10th December 2012, I am satisfied on balance that the evidence establishes that the issue of the father leaning over the coffee and the coffee being the source of the thallium were known to the police and at the father's statement was a lie intended to distance himself from those central components of the investigation. I do not accept that it was inadvertent or an oversight, but it was deliberate, and I am satisfied that the explanation is distancing himself arising from his knowledge of the truth.

xvii) The improbability of a man of the father's character carrying out such an act weighs against the conclusion that the father perpetrated the act but that improbability carries less weight than it might otherwise do given my conclusions as to the nature of the father's character in particular his lack of empathy, the apparent lack of emotional connection with the mother and his propensity to absolve himself of responsibility.

xviii) The absence of a motive also weighs against these conclusions. None of the possible motives articulated by the mother seem to have firm roots in the evidence. The nature of the relationship between the father and the maternal grandparents far from explains it. Financial motives do not explain it. I am unable to get to the bottom of the issue of control, but I do not consider that the absence of an identified motive carries very much weight on the other side of the scales or in the overall interpretation of the landscape.

My reference to those matters as being the principal features on the landscape does not mean that there are not features which are inconsistent with that conclusion; there are as I have referred to at xvii and xviii above. The lack of any noted response of the father to the mother consuming the coffee containing the poison is also another outlier but, as Ms King noted, is understandable if the father froze or was unable to act without drawing attention to himself. It does not require to be explained in my view in the overall evidential context. However, the picture which emerges from the overall survey even if one seeks to give the outliers more weight than they seem to me to bear or to focus on other matters does not create a picture which is as consistent overall as that which I have outlined. In my process of cross checking my conclusions and piecing together the jigsaw in different ways or focusing more heavily on other issues, the end result in my reasoning processes has been that there are more 'outliers' which if one draws them back into the picture alters the perception of the picture back to my conclusion on balance of probabilities. It is an incomplete picture which emerges, and it is a picture which emerges in which some parts of it are not consistent with the whole but overall, it is sufficiently clear and complete to meet the standard and burden of proof that lies upon the mother.

That conclusion is that mother has proved that it is more likely than not that the father was responsible for the introduction of thallium into the coffees that were on the table on the veranda on the morning of 11 September 2012 and that he introduced sufficient thallium (a finger pinch in each may have been enough) into each which caused the death of MGF and which but for fate would probably have killed MGM and which in the event caused serious thallium poisoning to the mother and to the maternal grandmother. Thereafter I'm satisfied that the father failed to take any step to assist in the treatment of those three individuals and in particular sought to divert attention from himself and thallium poisoning as the cause of their illness. Why the father did this I have no idea; only he can know.

That is my judgment.

CHRONOLOGY

Early 1970s Applicant father born ("F" or "the father").

Mid 1970s Respondent mother born ("M" or "the mother").

Late 2000s Parties met on a dating website.

Late 2000s Parties met physically for the first time in Bulgaria.

Late 2000s The Father arrived in the UK and moved in to live with the Mother. [C13]

Early 2010s Parties moved into their new flat in London. [C14]

Early 2010s Mother's parents ("MGM" and "MGF") arrived in the UK to help refurbish the new property.

Early 2010s Mother's parents left the UK following arguments with the Father.

2011 Child A was born.

03.06.2011 'Reagents' file date on SD card. A Bulgarian price list for various chemicals.

M submits this points to F's awareness of Thallium as a poison and its qualities and antidotes.

F says (a) he cannot recall having this SD card and it contains files which pre-date any likely purchase of such card (b) his financial records do not disclose any such purchase prior to June 2012 (c)he does not recall downloading this and was unaware of its contents.

The file appears to be a list containing several hundred chemical reagents and their prices. It contains three entries relating to thallium nitrate, thallium sulphate and thallium chloride and their prices. Contains no other information about thallium.

17.10.2011 Maternal Grandmother arrived in London. [C14], [D1 41 §43]

23.11.2011 The Mother started a new part time job. [D2 247]

12.12.2011 The Father started a permanent job at Hospital K. [C23]

The Father raised concerns about Maternal Grandmother staying with their family and wanted her to leave. [D1 57 §20]

The Mother told the Father that she did not want to live with him anymore. [C 14]

Jan 2012 F Statement of 15 Dec 2018

"In January 2012 I have spoken to M and have told her that the best thing for us as a family was for her mother to return to her home, so that we can build our own life with our son, in the way we considered appropriate."

2012 Child A's first birthday.

M alleges MGM scolded F for allowing A to burn himself on a candle.

13.02.2012 'Heavy Metals and Radioactive Substances' Powerpoint

Date of file recorded in SD card.

The document appears to be a paper presented to a group as some part of a training programme. The father does not appear on the list of those involved. The reference to thallium covers some 14 pages out of 129. It contains information about the lethal dose, symptoms and treatment.

MAR 2012 Parties continued to argue, but agreed that the child goes to stay with the maternal grandparents in Town A for the summer, while they work on their relationship. [D1 57 §20]

Mar 2012 MGM tells F that she has said to M to separate. Described M as 'exceptionally subordinate' to MGM [C20]

09.04.2012 Maternal Grandmother returned to Bulgaria. [C14], [D1 41 §44]

11.04.2012 The Mother and A travelled to Bulgaria and stayed with the Maternal Grandparents in Town A. [D1 5 19], [D1 41 §44], [D1 57 §20]

Mid-April 2012 The Father travelled to Bulgaria to stay with the Paternal Grandmother for Easter without informing the Mother. [C14]

the father said he wished to spend some time with his family and did not wish the mother to know he was there otherwise she would have wanted him to visit her.

28.04.2012 The Mother returned to London. A remains in Bulgaria.

01.05.2012 The Mother found out about the Father's secret travel to Bulgaria and asked for a separation. After a week the parties reconciled "for A's sake" and engaged a local counsellor. [D1 4], [D1 22 §88]

16.05.2012 parties attend first of 6 counselling sessions.

17.06.2012 F buys SD card [Z56]

June Parties go to Paris

19.07.2012 Parties attend last counselling session.

Counsellor: It appeared to me that the counselling had been a beneficial experience for both of them[.C25]

Aug 2012 MGPs do shop in anticipation of visit and bulk buy coffee beans amongst other things and instant coffee

20.08.2012 Parties travelled to Bulgaria by car. [C15]

23.08.2012 Parties arrived in Town A and on the next day travelled with A to stay with the Paternal Grandmother in Town B.

Parties went to beach, visited parks, had meals, met colleagues. We had a normal time. I didn't get on well with his mother and I was stressed.

08.09.2012 Parties left Town B after lunch and returned to Maternal Grandparents' villa in Town A.

Parties arrive in Town A in evening

09.09.2012 A had fallen ill with a cold and high temperature.

11.09.2012 Alleged poisoning is said to have taken place.

Mother's Account:

Statement: Nov 2018 I changed my mind about lying in bed, and I got up five minutes later. I immediately went out on the veranda, still in my pyjamas. F was there, with his back to me. I could see that he was leaning over the table where there were two cups of coffee. One was white coffee and one was black coffee. I believe that this was when F put thallium in the two cups of coffee, because neither of my parents were present. My mother had gone back to the kitchen, and my father was somewhere in the garden. F did not greet me for a few seconds but then turned to me and lit a cigarette. I lit a cigarette with him and we sat down together on the swing seat.

Evidence 2019: The first thing I saw because the bedroom there is a window that faces the veranda and the table, so when I raised from the bed I saw F was there, I didn't say anything to him then, I just went to the ... to the corridor, to the front door of the villa and I said, "Oh F, good morning, you're here, you woke up earlier today'-

Evidence: 2021:

My mother shouted if I wanted a coffee and I said no..Then I got up. The first thing I saw was F with his back to me. ..You enter the house through the veranda. The bed faced the window – I got up – his back was to me and by the table I got up – the room wasn't in darkness as the curtains were part open I went to the window and opened the curtain and net curtain, The table was where it is [in the photo taken on 12.11.20] I remember seeing F there – I don't know what he was doing. I have sieved and selected what I need to remember – once I fit all the pieces of the puzzle – that is what I remember. A was still sleeping – he was about to wake up at some point. I saw F at the table – I opened the curtains first – I opened the curtains – and I saw F standing by the table A didn't wake up –The window was open – the curtain didn't cover the whole of the window – When I got up I can't remember where the net curtain was The left hand curtain was covering the first panel. You are asking me to remember things I can't possibly remember. They can be partially drawn – we only use the curtain on the left – we never use the one on the right. I pulled the curtain back. The fact is I saw him there. I was looking through the mosquito net. I saw him in the middle of that table. Facing towards the garden and back towards me. He was upright I couldn't see his hands I don't remember seeing his hands I didn't see any movement. From the bedroom – I acknowledge to my mind he had got up before me. I didn't say anything. I turned around – went out of the bedroom – I was in pyjamas and barefoot – I then said good morning darling , you're up before me and he didn't respond and this was when he didn't turn I put something on my feet and approached him – at the back and the turned suddenly with his cigarette in his mouth and we kissed and I got a cigarette – and I got my mother's coffee and we went and sat on the swing seat. I saw him as I came to the front door onto the veranda, I don't remember his hands – I couldn't see his hands – I could only see his body (hesitates) I couldn't see movement. He turned round. He had one hand to his mouth with a cigarette- he was smiling and he had a coffee in the other hand. I wouldn't say there was anything suspicious. [The mother went on to say that he wasn't bending over the table but was lent forward, and that he took his mug of coffee and they went and sat in the swing seat where they both had a coffee and a cigarette. The mother said she did not see him do anything to the coffee and did not think there was anything suspicious at the time. She said she did wonder why it took so long to turn around. She also went on to say that the father did nothing to distract her from drinking her coffee and nor was there anything else about his behaviour which was unusual.

MGM Statement to Bulgarian Police: 24 July 2014: On 11 September I and my husband got up as early as 6:00 in the morning. As in every morning after getting up, I made our coffee in a stovetop expresso maker. I asked M, who was still in her bed, if she would want me to prepare more coffee and leave some of it for her. She flatly refused. I poured the prepared coffee into two cups of about 300 ml each, for me and my husband, the way as it was done every other morning. I added milk to my coffee, and not to my husband's coffee. My husband liked to drink black coffee. Minutes later, at about the same time, F appeared at the front door of the house, right from where the veranda is accessible. I exclaimed, "Ah, F, why are you getting up so early?", to which he didn't answer. I was very surprised at his early appearance, as already said, he liked to sleep and rest until later. When F appeared, me and my husband were staying on the veranda, I was pouring the coffee in the two cups that were on the table. We sipped some coffee and went out into the garden. In general, we used to drink our morning coffee until noontime, because I prepared it in large quantities and we would sip while smoking cigarettes until about noon. F knew this very well. Going out into the garden, our coffee cups remained on the veranda table. We started doing different things in the garden such as picking fruits and vegetables - peaches, grapes, tomatoes, peppers, etc. for their travel. As we worked in the garden, F was constantly walking around the yard and inside the house, passing through the veranda where our coffee was left. Not long after, I cannot say exactly when, M appeared on the veranda. She was also surprised by the early rising of F, and that he had woken up before her. As I learned later from her, when she came out of the house she saw F with her back to her and facing the table just opposite the entrance of the house. He had been directly bent over the table. On her greeting he didn't turn to her immediately and didn't answer her, but stayed for a few seconds with his back to her, while at the same time posing as if lighting up a cigarette over the table and facing the coffee cups…

Seeing my daughter was already up, I went to the veranda. She asked me, "Is there any coffee for me?", to which I said, "No, you did refuse any coffer a little ago, make your coffee yourself." But she felt too lazy to make it herself and knowing that I would not be angry with her, she took a sip of my coffee. She drinks her coffee prepared in the same way as me, with a lot of milk, so she decided she could share my coffee instead of making for herself. Meanwhile, F had prepared in the kitchen instant coffee separately for himself (as was normal), the coffee being stored in the kitchen. He and M sat down in the cradle on the veranda and he saw that she was drinking from my coffee. Meanwhile, my husband was working in the garden, coming to the veranda periodically, sipping from his coffee and smoking cigarettes…..M indeed drank about half of my coffee cup and I did the other half. She told me, "Mum, I felt sorry for you and that's why I have not drunk all your coffee, and there's some left for you." I remember that from my cup of milk coffee we both drank approximately equal amounts. MGF, at that time, undisturbed that no one was going to drink his bitter black coffee without milk and sugar, he sipped it all calmly by noon.

MGM Statement: On 11th September 2012 MGF and I woke up very early as usual. As I do every morning after waking up, I made coffee in a stove-top coffee maker. I realised at this moment that M was also awake, but apparently had the intention of sleeping longer because S was also asleep. I asked her if she wanted coffee in advance, but she refused as she wanted to go back to sleep. I poured the ready in to two large cups for my husband and myself. I added milk to my coffee whereas I left my husband's coffee black as that was the way he liked it. I took the coffee out to the veranda. Not long after F appeared and I exclaimed "Oh F, why are you up so early? There's nothing for you to do." He simply shrugged his shoulders and said nothing, after which he made his own Nescafe instant coffee. I recall that is the only type of coffee he would drink. I was very surprised by his early wake up, because F usually liked to sleep until the late morning. 8. MGF and I used to drink our morning coffee slowly until noon, because the caffeine dosage was very high. We used to drink it in between smoking breaks on the veranda. This is what happened on 11 September 2012. The cups of coffee remained outside on the veranda while MGF and I were working in the garden. I noticed that F kept walking around the yard, the villa and the garage, constantly passing through the veranda, where our coffees were left. Apparently, he did this with no reason and without having anything to do. Not long after, M had woken up as I overheard her talking to F. They were seated on the veranda swing, smoking and sipping from their coffees. I saw that M had taken my cup of coffee, which did not bother me. By the time they finished their cigarettes, M had drank half of my coffee.

MGM Statement 15.11.2018 [D1 -34]: At that time, I was washing some grapes at the veranda sink for them to take home. M gave me the emainder of the coffee and then returned back inside as A had woken up. At this point I lit my own cigarette and sipped a few times from my coffee continuously until I finished it. No one appeared to have drunk out of MGF's coffee, presumably because no one would drink from his bitter black coffee. He then continuously sipped from it alongside a few cigarettes until it was all finished.

Father's account

Bulgarian Police: 10.12.12

In the morning on 11 September 2012 I got up around 8:00, I do not remember exactly plus or minus half an hour. When I woke up, everyone was already up, we with M and the child slept in a bedroom on the first floor. Normally, I am the last one to get up. I think that the three of them were up before me. Surely, MGF and MGM were up before me. After my getting up I went from the bedroom to the living room to make my coffee. I do not remember if any of the others were in the living room, I took a cup from a cupboard installed above the sink, then I took coffee from the adjacent cupboard - instant coffee in a glass jar, I poured some water, I do not remember from the storage water heater or the teapot. I always drink only instant coffee, while the others boil it in a coffee machine. I put some sugar from a glass jar in the cupboard with the coffee and went outside. I cannot remember where everyone was at that time.

Met Police:C22 – 21.10.2013

In August 2012 M and I travelled to her parent's house in order to collect our son A and to spend time at her parents and my mother's houses. Prior to leaving M's parents house and return to the UK, our son A had been unwell for a few days. He had flu like symptoms and on the evening we were leaving to travel back M complained that she was feeling unwell and had a blocked nose I assumed that she had picked up a virus from A.

Evidence:

Maybe I remember the details some of them. There was an issue about this a long time about what time I got up. I woke up early – I can't fix particular time 6 or 6.30 it was really early – I think it was our last day and that was the reason I woke up early I knew it was going to be (how you say) (it was going to be a rough day, prepare the car, pack the luggage and A's stuff.

And then we have to travel 2 days back to the UK so I was more or less, don't get me wrong, a bit nervous and so I didn't sleep very well – a bit shallow sleep so maybe I heard MGM and MGF I heard noise and it woke me up but I can't confirm if this was the reason I think she [M] was asleep and I remember leaving her in the bedroom. MGF and MGM They were in the kitchen as I just described. There are outside units I am talking about the main kitchen. They were – I found them in the kitchen – for a very short time – we met in the kitchen

I was just up and my eyes were still a bit closed and they said what are you doing and I was like a bit struggle (mmmmm) let me have a coffee and I speak to you later

There is a boiler which heats the water from the mains and I use this for the coffee. I think they had already made their coffee. They drank normal grain coffee. They as far as I am aware they use the mineral water from the bottles If I am not wrong they went out of the house as they had to do some stuff – pick some fruits in the garden and they have a cigarette. I did my coffee – I make my coffee and I think I joined them outside or whether they were still on the veranda I can't remember. I followed them out. I am not sure if I went into the garden or stayed on the veranda I can't remember everything minute by minute – I guess I lit up a cigarette and had it with coffee – if the GP's were in the garden maybe I went and asked if they needed help and they said no there is nothing we need help with so I don't think I had other choice to walk around or sit on the veranda to have my coffee and have a cigarette. I can't recall how long it was – maybe 5 mins or maybe ½ hour. I am not sure exactly what I was doing between her getting up I think she came on the veranda but what the situation was I am not sure. My mind cannot remember where I was. Possibly I would … if I was there .. maybe I was next to the bench or the table facing the garden, maybe I was I cannot recollect whether I had fresh cigarette – I am a smoker and you light up on a regular basis and it is a habit and 9 years later on when talking about habits it is very possible, I am not sure, I don't remember leaning over the table

In general the table would have anything on it – plates, cups, glasses, ashtray, if some drink something grape or fruit might be left on the table.

I can't remember what was on the table that morning

I think there was an ashtray in the veranda on the table or the work top

All the adults smoked

I had a habit of keeping cigarettes and lighter in my pocket.

If I had lit up I might leave it on the table

Meanwhile the MGP's – my recollection is they smoked cigarettes they made from cylinder with filter with special small machines made up with tobacco made from the market.

I am not sure if their coffees were on the table – very likely they were.

No I didn't no I didn't [put poison in]

We did have a coffee and cigarette – I can't remember if I was sitting and standing or sitting on the bench

I don't recall where she got her coffee from

I think she had coffee from her mother's cup

Conclusions:

Given the father's evidence (other than his police statement on 10.12.12) it is safe to conclude that he was up before the mother and that he was on the veranda. I am also satisfied that the totality of the evidence supports a conclusion that the mother saw him through the window and then a few seconds later when she emerged onto the veranda. Other than that it is very difficult to be sure of anything other than he was there. The mothers evidence as to who she told about her seeing the father near the coffee and when or why it was not referred to in particular conversations or documents was difficult to follow and at times inconsistent. However given the passage of time and the extent to which she was tested in evidence I'm not sure that either much reliance can be placed on her evidence in this regard or that it can be said that it supports a conclusion that her evidence is generally unreliable. Evidence as to conversations and their contents are in my experience peculiarly susceptible to errors of recall particularly when circumstances suggest multiple conversations which might have borne upon that subject have taken place.

8am – 10pm

Parties loaded the car, had lunch, picked fruit and vegetables, had dinner and the father had a sleep. The parties had an argument about the travel pack with the yellow vests and warning triangle which the father had stowed with the spare tyre and the mother insisted on having them in the car.

Mother: Statement: A woke up at about 8:30am. F seemed agitated all morning and was constantly walking in and out of the house and onto the veranda. We were due to leave Bulgaria by car the following morning so we spent the majority of that day packing. The atmosphere was tense. F and I argued frequently that day. In particular, when I found out that F placed the car's roadside survival kit at the bottom of the boot. I thought it would be wiser to have it more readily accessible in case the car broke down on the motorway. I had told him this, but he had ignored me. He eventually conceded, but it seemed to me that F was being deliberately difficult. That evening, we had dinner at around 19:00 by which time I could see that my father's face had become unusually red. He complained of having dry lips and I noticed that he had started lisping when he spoke. By this time, I was also feeling unwell. I felt feverish, I had a headache and I was feeling weak. I presumed at the time that I must have caught a viral infection from A. I now know that the symptoms that my father and I were experiencing were those of thallium poisoning. Although we were planning on leaving on 12 September, F insisted that we left at 10.00 pm that evening to allow extra time because the car was overloaded. My father had told me previously that he worried about me and child A when we were in the car for long periods of time. He preferred for us to fly. I presumed that his apparent illness was due to worry. F then absented himself for a nap and my mother quickly prepared some food for us to take on our journey. We left the house by car at 22:00 that evening. In hindsight, I believe that F wanted to leave earlier than planned, because he saw that my father's health was deteriorating.

Evidence: the mother's oral evidence confirmed that they spent the day getting ready to depart with the maternal grandmother and father picking fruit and vegetables with the mother helping at one stage. A was still not well and didn't help and wasn't eating much. They ate lunch at around 1130 eating leftover drob sarma, salads cheeses and fried courgettes. The father preferred drinking carbonated drinks to water and the mother said he had only one or two bottles from the shop and she thought he drank water as well. In the course of the afternoon the decision was taken to leave that evening rather than early the next morning. Mother said the father wanted to leave earlier because the car was so heavily loaded and he was concerned about the progress they would make. She said she had not noticed any symptoms in her father at the point the decision to leave early was taken. At some point in the evening between seven and eight she noticed her father was a bit tired and a bit red in the face (there was an issue about whether this was 9 o'clock) and she herself felt fluey that evening.

MGM: St Bulg: MGF's face began to flush strongly in the afternoon. Later his mouth dried up and he began to lisp. M also complained that she didn't feel well exactly at about 19:00 - 20:00 and that she was starting to get sick. She complained of a temperature and chills. She thought she had caught the cold from A because the child had a fever last night, restless sleep, and almost did not get out of her hands. At 22:00 we saw them off at the entrance gate in front of the house with wishes for a nice and safe journey.

The mother and the MGM gave a statement setting out what Food & Drink that had been consumed.

Father; Bulgarian Police Statement. Throughout this day, 11 September, we were loading the luggage which was prepared to be taken to London. Loading was done mostly by me, while MGF helped me. At about 12:00 we sat down in the living room for our lunch. We had drob-sarma, fried courgettes with cheese, and as far as I remember, some vegetable salad. I ate very little of the drob-sarma, a couple of courgettes and salad. I was not hungry because I was sick to my journey. The rest of them had of all dishes normally. I think that at the lunch I had some carbonated apple soft drink, bought from X shop, I don't remember what brand. My son drank water, I don't remember what the other three drank. I know that MGF and MGM went to a neighbouring village to fill and take drinking water in plastic cans. All three of them - M, MGF and MGM drank from that water, but I have never done. I remember that I ate courgettes and salad because the drob-sarma had been left from the previous days and I didn't want to have the same dish. After lunch we continued with the loading of the car with the luggage. I do not remember after lunch whether we had coffee or any strong drink. In the evening we sat down to dine, I did not remember at what time, it was dark. MGM prepared fried pork steaks and we had a quick meal. Initially, I and M had decided to have a sleep for a few hours and early in the morning leave for London. However, while discussing things, we decided to leave in the evening of 11 September. After having our meals we loaded the car with the remaining items, took good-bye with MGF and MGM, and left for London at about 22:00. I don't remember anyone complaining about any health problems throughout 11 September, only M said in the evening that she had a stuffy nose. We supposed she was infected by the child who had a viral infection, but was already improving.

F's Evidence:

the father's evidence was to the effect that through the morning he was involved in preparing the luggage and loading the car. There was an argument over the safety kit and he had to unload the car and reload it. He said he had little to eat at lunch and only drank some soft drink. In particular he did not eat drob sarma. He agreed the mother raised the possibility of her and A staying because A was still ill but he said he wanted them all to go as she was to share the driving and A only had a cold. He said he decided he wanted to leave early as the car was heavily loaded and the roads through Bulgaria were not motorways and he thought it would take them a long time with the heavily loaded car to make progress. They had dinner some point after 6 o'clock it could have been 7 o'clock and he then had a nap as he was going to drive through the night. He said he did not notice that the maternal grandfather was unwell.

The father's evidence as to what he ate at lunchtime and what he drank was difficult to reconcile with his evidence as to how busy he had been loading and unloading the car on a hot day but otherwise there was little difference between the evidence of the parties. His reasons for not unloading the car and proceeding with what he seemed to be saying was an overloaded car seemed inadequate.

10.00pm Parties depart.

The mother said the MGM and MGF were both there to wave them off. That was the last time she saw her father.

12.09.2012 Parties travelling.

04.30am MGF feels unwell and ambulance called.

MGM: St Bul: After seeing M, F and the child off, my husband said, "I'm very sick, I don't know what's going on with me, I'm going to bed." I said, "Okay, tomorrow we'll see what we're going to do." At 02:00 in the morning he wanted to get up and fell from the bed. He repeated again: "I'm dying, I'm very sick." I called an ambulance and he was taken to the Emergency Centre at 4:00 - 5:00 in the morning.

M's Statement During our journey, I texted my parents at regular intervals to update them of our progress. For example, I texted my father at 1:21am to say that we had crossed the border into Serbia, and again at 06:27 to say that we were in Montenegro. I texted my mother at 14:22 to tell her that we had crossed the border from Hungary into Austria. I did not receive a response from either of them, but I was not especially concerned because I knew that they were planning to travel to Town D that day to mend a water leak in one of their flats. M St: By the morning of the 12th September, on our journey home from Bulgaria I had developed a headache, pins and needles in my feet and my lower legs were numb up to my knees. My muscles ached in my upper limbs as if I had been strenuously exercising. F told me that he thought my symptoms reminded him of a syndrome called Guillain-Barre ("GBS"). He told me that this syndrome might have been triggered by the viral infection I had caught from A the previous day. At that point, I had no reason to believe that my condition was serious. By late afternoon on the 12th September, by muscle aches had become stronger and I could not stay in a sitting position in the car for a long period of time. During the evening of the 13th September I read an article on F's laptop that said GBS is associated with numbness that started in the feet and expanded up the body. It said that should it reach the vital organs of a patient, they must be hospitalised immediately. F commented that he was not a neurologist. I then decided that I should check in to a hospital as soon as we reached London the next day.

M's Evidence: GBS was mentioned at 7am on 12.9 when I commented to F that my legs felt very tired and my calves felt like I had run a marathon – I hadn't exercised or run and hadn't loaded anything – it seems strange to experience muscle ache – he said "you may have a viral infection from A and he said you must tell me – he said GBS is a very serious illness – I thought he was over-reacting at 7am in the morning but as our journey progressed – I was becoming aware that the pain was climbing from my calf muscles to my knees and I could touch my leg and part was numb and part wasn't

Then I was thinking maybe I have GBS – prior to that I was perfectly healthy – I was becoming more and more worried – he was a doctor – I asked what GBS was

All the sensations were climbing up my legs – when we reached Vienna I asked to look at the lap-top to look at GBS – I also found out that day my father was ill later that day

MGM: Bul St: The next day my condition grew worse - pains in the stomach, muscles of the legs and hands accompanied by headache, which I naively linked to the stress from the sudden illness and later to my husband's death. I called my daughter on the phone and without giving me much explanation she said she was unable to return for her father's funeral. She later told me that she did not want to make me worried unnecessarily by telling me that at that time she was in a hospital dying from burning pains in her legs and head.

Father: Bul St: During the trip on 12 September, at daytime, I do not remember what time, M complained that she felt weakness. We did not pay much attention to her condition. We arrived in Vienna in the late afternoon. We had a hotel booked and stayed there for the night. In the evening at the hotel M talked with her mother on the phone and told her that we had arrived. After the call ended, M said her mother did not sound good on the phone and told me there was something, but she did not know what. I told M to call her again if she thought so. I went out to smoke and when I came back I understood that M had called MGM again and was told her father, MGF, was admitted to the hospital in Town J because he felt sick and started to stumble. M said that according to MGM the likely cause for MGF's condition was his worry about our journey

Father: Met Police Statement: We travelled back to the UK and during this journey her condition deteriorated. I had no idea that her mother was also unwell. Whilst we were travelling back to the UK we stopped off at a hotel in Vienna and I remember being told by M that her father had been admitted to hospital. M had been talking to her mother and she told me that she felt her mother was hiding something from her as her mother was not talking as she normally would. I went outside for a short while and when I returned to the hotel room M told me that her father had been admitted to hospital. At this point I was unaware of what was going on and why he was in hospital. The following day M had a conversation with her uncle and she told me that her father had been diagnosed as having a stroke. In the meantime M began complaining about aches and pains in her legs and body but the symptoms she was describing initially I believed she had flu. However, she began to explain to me the symptoms in more detail and because her muscle pain was worsening and travelling up her body I believed she may have some sort of neurological complications from the viral infection.

18.36 M calls MGM:

I called my mother at 18:36 (Austrian time) on 12 September, while we were on our way to Vienna. I anticipated that by this time, my mother and father would have returned home. My mother told me that they were on their way back to Town A, but she was not very talkative, and the conversation was unusually short. I was worried that there was something my mother wasn't telling me.

19.30 M calls MGM

M: One hour later, I called my mother again, to check that everything was ok. She told me that my father had been admitted to hospital at 4:30 am that morning, 6 hours after we left their villa. She told me that my father had complained during the night of total body numbness including his head, body and legs and was unable to walk on his own when the ambulance arrived.

Parties stay in hotel in Vienna overnight

the medical records shed some light on what was said at the time about the development of symptoms. They tend to support the conclusion that the more serious emergence of the symptoms was later on the 12^th and into the 13^th rather than first thing in the morning on the 12^th. That suggests that the first reference to GBS is more likely to have been later on the 12^th and that might be consistent with the mother's account that she looked at it on the father's laptop in Vienna.

13.09.2012 Parties travelling

F Bul St: Early in the morning at about 8:00 on 13 September we continued further to London. On the same day, no later than midday, M complained that she felt pain in the muscles of her legs. I told her it was probably due to the virus and I offered her to take anti-inflammatory drugs. She took Ibuprofen from the first aid kit in the car and we continued with our travel. On that day, late at night we arrived at the hotel in France we had booked. On the same day, 13 September, during the trip, M talked on the phone with her uncle who went to the hospital and learned that her father suffered an ischemic stroke. In the meantime, her mother went to Town D as she had an arrangement with construction workers because of water leakage in one of their flats in Town D. M received information about her father's condition from her uncle. We continued further with our travel and arrived in France at about 22:00 and stayed at a hotel we had booked before leaving for Bulgaria. I remember that M complained again several times that the pains in her legs were getting stronger and gradually "going" upward to the gluteal muscles, reaching the navel at her front side. I suggested that she might have a Guillain-Barre syndrome because her symptoms, among some others, were typical.

14.43

M calls MGM. No news about MGF but MGM told me that she felt very tired, her feet were burning and she was uncomfortable sitting on the bus seat.

F evidence says he called his mother from Calais and they discussed GBS. [C27]

PGM makes no reference to this but discusses telephone calls.

Parties stay in hotel in Calais overnight

21.15 Maternal Grandfather died, Initially diagnosed as a stroke.

Final diagnosis: hypertensive disease grade III; ischemic brain stem stroke. Complications: acute respiratory failure; acute heart failure ...

14.09.2012

06:32 F phones PGM

Father: Bul St: We were for the night in the hotel and at 6:00 in the morning we quickly packed, left the hotel and were in a hurry to arrive in time for the ferry. M and the child were sitting in the backseat. On our way M's phone rang, I have no memory who called her and to whom she talked, and I heard her say only: "How so?", "When?", "Why?". I turned my head to her for a second or two and she then explained that her father had died. Such was her reaction to this news. She neither burst into sobs, nor had a fit of hysterics, and she did not even visibly accept the news as the worst thing that could happen to a parent. In my opinion, her reaction was not normal for a person who had just been told he or she had lost a parent. I myself, hearing what happened to MGF, had my eyes filled with tears and memories flooded my head. He was a good man and we had never exchanged a bad word.

13.34 M attend Hospital A. [D2-16]

Severe Pain in Legs Going Upwards. She experience since 3 days ago numbness of the legs and now is traveling since below her breast area.

Returned from Bulgaria today - coryzal illness 3 days ago - muscle soreness in inner thigh area 2 days ago - burning and paraesthesia in lower limb area - gradually ascending towards upper body and now up to the level just below the breast. Feels generally weak, no localised weakness of limbs. No SOB. Husband is a medical doctor, worried about GBS. Also just found out that father passed away. Examination Details T 37.1, BP 130/85, HR reg at 100. chest dear - HS normal - subjective paraesthesia throughout lower limbs up to about T5/"T6 level. power L=R. normal power & sensation both upper and lower limbs. Diagnosis ascending paraesthesia ?GBS

15.05 Examination

developed coryzal symptoms on Tuesday (mild) – Wednesday (12^th) developed medial thigh aches - by Thursday (13^th) this hypersensitivity and pain had spread to include all of both legs. Today has spread from top of legs up trunk to now be at breast level. ….Imp Guillain Barre Syndrome

16.30 Examination

38 year old female started with coryzal symptoms three days ago. Wednesday (12^th) complaining of central chest discomfort worse with coughing and deep breaths. In the evening started to have muscle aches in medial thighs bilaterally. Spread to whole of both legs up and abdomen stopping at breasts initially tender but now painful all the time. 59.1kg

M speaks to MGM who informs her that she had severe stomach aches, pain in her legs and restlessness which had started the day after they left. M does not tell MGM that she is experiencing similar symptoms or that she is in hospital that she did not want to worry her ahead of the MGF's funeral.

15.09.2012 M in Hospital A

16.09.2012 MGF's funeral.

Afterwards family attended the house. Brother and wife and his sister and husband ate food at our house. They stayed with her eating and drinking the food that was there prior to 11^th September

Comment: No illness experienced by these family members

15.30 M remains in Hospital A. F asks for morphine for her as she is in pain. Nurse suggests 5mg – F suggests 10mg.

17.09.2012 M speaks to MGM who says she has ongoing symptoms with the pain worsening. M tells MGM that she also has similar symptoms and had been admitted to hospital. M says MGM suggests to M that they had been poisoned and they discussed food poisoning. M says her mother's suggestion that it was F seemed crazy but it planted a seed in her mind

F thinks it may have been around then but was only visiting M in hospital.

18.09.2012 M remains in Hospital A.

19.09.2012

M speaks to Friend A.

Friend A: After that I talked with M on the phone when she had returned to London. She called me from a London hospital and told me she was very sick. She called me one morning and told me that she had terrible pains all over the body which occurred as early as they travelled from Bulgaria to England. She said she felt very strange and thought her mother-in-law had poisoned her with something…..She didn't say a word about F. M had told me that she had very intense pains all over her body, which started from the legs and moved up, and she was very sick in general. I searched into Google for poisoning and relevance of symptoms involving strong pains all over the body.

Friend A texts Mother: "My dear, the symptoms may be poisoning by heavy metals, arsenic, thallium, while for the polonium poisoning of Litvinenko there is no detailed description of the symptoms, except that his hair loss indicated a radioactive source. .......... I will keep searching and I'll ask Friend D about the various isotopes".

20.09.2012 M discharged from Hospital A:

impression likely myalgia, secondary to viral illness. Neurological examination normal, bloods normal, scans no abnormalities detected. D2 -32

M suggests to F that they have been poisoned.,

I asked him what he poisoned us with and that I suspected his mother may also have been involved. He remained very calm and simply asked me to stop upsetting him with my crazy thoughts. He said "how dare you make such accusations? I can't be responsible for my mother's actions". I then asked him to explain my deteriorating illness and I said to him that if I did not have GBS as he initially suggested, what else could it be? I said to him, "you are a doctor after all". His reply was that he was not a neurologist and my symptoms seemed to be neurological. He suggested that I go to bed and try to have some rest.

F thought the accusation came later and that it was only once she accused him or perhaps possibly twice she accused him of poisoning before she went to Bulgaria.

21.09.2012 Friend A and M speak.

Friend A Bul St: Two days later I sent a message to M and asked her what had happened with her tests. She called me back on the phone and said she had already been discharged from the hospital and the hospital staff declined further testing because all her other results were normal. I and M discussed that this might be due to the stress she experienced at her father's death, as all her test results were normal.

23.09.2012 The Mother was admitted to the Hospital B, discharged on 26^th September 2012. [D2 37-38]

25.09.2012 Hospital B: D2-35 Husband has been at Hospital B this morning, seen by me briefly and expressed opinion to medical team that he feels there must be an organic cause. He was unfortunately at home at of our assessment. Hospital suggest psychological origin. M diagnosed with mild depression following MGF's death.

Neither the mother nor the father appears to have mentioned that the MGM was also suffering from similar symptoms.

26.09.2012 M discharged from Hospital B.

27.09.2012 The Mother and the Maternal Grandmother noticed they had intensive hair loss. The Mother returned to Hospital B to report this new symptom. [D2 40-42]

19.03 M attends Hospital B. Complaining of two-week history of ascending pain from feet to chest. In CMH for 4/7 was Guillain Barre/meningitis/MS et cetera all no abnormality detected. Patient came here admitted for four days diagnosis of acute stress reaction. Hair started falling out today, worsening all over body pain. Thinks may be poisoned [D2-40]….. Patient states her father passed away two days after onset of symptoms. Interestingly her mother in Bulgaria has also had similar symptoms but has since resolved after taking clonazepam. Patient has tried taking some clonazepam to no good effect. Impression polydipsia as part of grief/anxiety reaction resulting in hyponatraemia. Self discharged.

F St Bul: I think she stayed one day at home and at that time began to complain of intensive hair loss. M said she talked with her mother on the phone and told her about the pains she had, and her mother told her she had the same symptoms. On that same day she talked with her mother by Skype and I heard saying she had very intensive hair loss. Then I heard her mother saying that she also had a hair loss. MGM's words were, "Ah, dear daughter, we're poisoned, that's some poison for sure". She obviously saw me in the camera and asked me, "F, what do you think, what is this, what can it be, you doctor?". I said I did not know it, and that I was not a poison specialist, and if it was poisoning they had to undergo tests to confirm it.

Around this time MGM's neighbour (a gynaecologist) wonders if she has been poisoned, speaks to a colleague and then advises MGM to go to Town D to get tested at a particular hospital in that city, Hospital C.

M and MGM speak with F present. MGM tells M she has been advised to go to Town D and Hospital C who could test for serious poisoning.

28.09.2012

29.09.2012 M speaks to her employer, Friend E, about her illness and says she suspected she and her family had been poisoned and suspected F may be responsible. Friend E searches "hair loss, pain in legs, poison" and finds article on Thallium poisoning. [D1 27-29]

The Mother researched and printed out an article on Prussian Blue antidote, identifying quantities of the drug needed for treatment. [D2 260-261]

M said in evidence that it was on this day that she began to believe the father had poisoned them.

M Statement: Friend E called me back that afternoon and he told me that the internet had indicated I may have been poisoned by thallium, which is found in rat poison. His research showed that thallium-based rat poison is banned in the UK, but might still be available in Bulgaria. I was shocked. Friend E said I should look it up on the internet myself, so I did. I saw that an antidote for thallium was Prussian blue. 57. F sat next to me on the sofa while I was researching Friend E's findings. When I finished I said to F "so you have poisoned us with thallium. Did your mum give you the rat poison so you poisoned us as one would usually kill a rat?" In response, he was very quiet and continued to work on his laptop. He responded to me by saying that I should stop hallucinating and he went on the balcony to smoke. When F came back in the room I asked him to help me research which hospitals in London had a toxicology lab that would be able to test for thallium. It was, of course, horrific for me to have to ask F to help me with this, given my suspicions, although I simply could not do it by myself. F told me that Hospital D had a toxicology lab. I attended A&E at Hospital D that afternoon, driven there by F. While we were in the waiting area, I asked F why he did not seem to be worried about my condition, despite the fact that it was obviously very serious. He was constantly telling me that I looked better than I said I was feeling. I felt as if he was treating me like a terminally ill patient, looking after me pretending that everything is normal. I asked whether F or his mother, knew a toxicologist in Bulgaria who he could call. Following my insistence, F called a former colleague of his in Bulgaria called Dr X who he had remembered was a toxicologist. F described my symptoms to him and Dr X suggested that thallium poisoning was the most likely diagnosis. He also said that I should go to Town D.

F ST BulG: The next day, 28 or 29 September, I don't remember the exact date, M said she had talked on the phone with her former employer named E (Friend E) who told her it was a thallium poisoning. I don't know this man and I have never seen him, I know from M that he is a trader . And then suddenly without rhyme or reason M asked, "F, did you poison us?". Later on, she asked me several times this question. I was shocked by this question and replied to her that it was not me and how she could think of me poisoning my child's mother. M began urging me to find a hospital where she could undergo toxicology testing, and to this end she also sought assistance from her friends. We found such hospital on the Internet and that night we went there, and we took the child as the babysitter was off duty. It made an impression on me that while we were waiting for the admittance of M for treatment, she kept demanding from the doctors treatment with a Prussian blue antidote and asked whether they had this antidote available. They told her that the first thing was to confirm if it was a poisoning and what poison, however they were not able to treat her with this preparation. Although I am a medical doctor, it was at that time I heard from M about this antidote and that Prussian blue is a thallium poisoning antidote. I don't know she learnt about this antidote, she told me she found about it on the Internet.

17.16: Mother attends Hospital D accompanied by the father.

[D2-49] 17.16 Symptoms: "pt thinks she might have been poisoned ? pain in body and hair loss in 2 days".

17.45: Initial Assessment:

Came back from Bulgaria with family on 11/09 on car trip the following day cramp in muscles of inner upper thigh Pain spread to the whole legs the following days Admitted to Hospital A ex MRI & LP & CT. CXT all clear Discharged 20/09 now has pain all over the body seen in RFH last Sunday (had Blood test and admitted for 4 days) last 3 days the hair is falling down The husband who is a medic suggested ?Thallium poisoning

19.46: History:

Has come today says is "poisoned" 3rd hospital she has come to. Has come here today as says this hospital has a toxicology unit 11th September left Bulgaria from her 10 day holiday. Drove the whole journey 12th September c/o muscles aches in her inner thighs as if had been exercising a lot 12th September in Vienna ok 13th September says muscle ache to the legs getting worse and going up the leg in the morning. In the evening on reaching Calais c/o increased pain in the legs Husband who is a medical doctor suggested she might have Gullian Barre 14th September went to Hospital A > was admitted > had MRI spine, LP, CT head, CXR, blood tests > ALL NORMAL. Discharged on the 20th September and prescribed ibuprofen and paracetamol. Says during admission unable to sleep due to the pain. Says BP high Following 2 days at home. However says leg pain worse and unable to sleep due to the pain 23rd September went to Hospital B A&E for another opinion. Admitted for 3 days. Was given a psychiatry consult at Hospital B as results normal and thought pain psychogenic. 27th September says noted her hair falling 28th September > states has lost 2/3rd of her hair from her head. Also c/o numbness symptom to the scalp > can see currently hair falling very easily. Says unable to stand for long periods. Also currently constipated. Has lost 7kg over the last 2 weeks. Says her mother in Bulgaria is experiencing the exact same symptoms. Says has palpitation symptoms. Examination:n/a Diagnosis:? Poisoning Treatment: Red stream.

20:30 [D2- 47] Records:

20:30 Patient received into T7 from Triage with ? toxic poisoning. Pt recently returned from Bulgaria where became ill. Pt has 2/52 HX of weight loss approx. 7kg. Pt has some hair loss, ???? obs.

10.30

20:04 The Father spoke to his colleague toxicologist, Dr. X, [D2-432 and D1 63-64]

F St Bulg: Meanwhile, I contacted Dr. X, a toxicologist with the General District Hospital of Town B, Bulgaria. I explained the situation with M and asked for his. opinion. He suspected that most probably it was poisoning by heavy metals. And he asked me a specific question, "Does anyone take lithium based preparations?". His opinion was that it was poisoning by lithium or thallium. I asked him if such tests are made in Bulgaria and which clinic. He replied that the best clinics are those in Hospital E in Town D and Hospital C, and also the best laboratories.

Dr X: St 27.12.2018 in the last days of September 2012 F sought me for comment and professional advice as a toxicologist…. Accordingly to the description I received from [F] the two women suffer had begun on 11/12 September 2012, with symptoms varying in type and intensity, but in broad terms they included: upward going, burning pain and numbness in the locomotor apparatus stomach pain accompanied by nausea but without vomiting, headache, tachycardia, dysrhythmia, hypertension……The newly emerging during the last 24 hours (at the time of the conversation) was the intense hair loss. As far as I realized then, the least symptom had become the cause of everybody's anxiety, as well as the reason, in combination with the above-mentioned inexplicable constellation, F to seek for my professional opinion of a toxicologist in search of treatment for his relatives. Based only and exclusively on the medical history (clinical picture) described by F on the phone and the negative laboratory results, I expressed the view that this was probably a heavy metal poisoning…..I remember that, in turn, F insisted on advising him to which particular hospital and which laboratory to direct his relatives for further research and treatment.

22.30 (delayed notes) Quereshi: P/C alopecia

…..7kg weight loss in 2 weeks loss of appetite ++ roots dead.

The patient's mother has had identical symptoms and signs in Bulgaria following the same timeframe

cause of death for father uncertain. Husband and son are both entirely well…. On examination thin; marked alopecia: ImpL DD: thallium toxicity /radiation exposure

phoned National poisoning centre. Advised i) not classical for thallium poisoning but quite possible…… ii) Need to broaden differential…. ii) Admit and manage supportive measures no need for Prussian blue iv) … v) … vi) thallium levels can be performed through Cardiff but will not change overnight management.

No weekend service available

samples sent for testing

23.00 Further examination;

no consistent anatomical deficit but some inconsistent area?? Decreased loss of..?? /pain; Imp: likely poisoning? Thallium

M confronted him for the second time about the poisoning

30.09.2012

06.55 nursing notes. Patient reports she is continuing to feel numbness sensation in her face. Vital signs remain stable.

08:10 Exam

14:30 Note

call to poisons information service. Blood and urine sent for thallium testing. These can be analysed on Monday. Hair sample also sent off.

20:00 Patient remained stable

23:20 Chest pain started tonight

Imp: atypical pain… Unlikely to be cardiac

MGM examined at Hospital E for suspected exogenous intoxication …. To look for heavy metals and in particular thallium.

M phones Friend A She was very worried and afraid, and said that her condition was getting worse, that much of her hair had fallen and hair loss continued. Then she said that her mother had the same symptoms - the pains all over the body and hair loss, and she was thinking of coming to Town D in Bulgaria for testing. After that call I immediately contacted M's mother, MGM. We had a discussion and it was decided that MGM would come immediately to Town D in Bulgaria and I would take her to one or other hospital.

01.10.2012 The maternal Grandmother was admitted to Hospital F in Town D. [C2/D2 165-167] Samples of hair, blood and urine taken.

09:50 M examined. Hx: Hair loss (scalp, pubic and now c/o leg hair) and leg muscle ache… CNS grossly intact.

10:40 No argon for testing for thallium. Testing to be done on 3.10.12 latest.

11:50 Dermatology advice. Spoke to Hospital B who had Diagnosed functional leg pain following post grief stress and psychogenic polydipsia leading to hyponatraemia.

19:00 observations checked stable. Patient is verbally aggressive on occasions. Gets upset when she has to wait. Apologised. Seen by team, was informed she would stay in hospital but also informed that she will be discharged today.

M discharged from Hospital D.

F St Bulg: M stayed in this hospital for about two or three days. When I went to take her from the hospital, she told me that blood samples were taken from her for toxicology testing, but that could not be done right at that time as the test machine was not in working order. On 1 October we went home. ….In fact, I knew from M that on 1 October her mother was admitted in the hospital, test samples were taken

02.10.2020 The maternal Grandmother tested positive for Thallium poisoning early in the morning and immediately informed the Mother. The hospital called the police.[D1 38 §30], [D1 16 §61], [C1 –2]

Evidence: the mother says that the MGM called her on the morning of 2 October and told her that the results showed thallium. And M spoke with MGMs doctor, Dr Y, who told her MGM had been severely poisoned and needed immediate treatment. Dr Y suggests to M if she can't get treatment in London that she come to Bulgaria. MGM says police coming to see her. M books flight to Bulgaria. She says that the father was in the flat getting ready to go to work and she asked him where the poison could have from come from and he said how how could he know. F goes to work. MGM said she told the mother that the police were going to visit her and that she would share her suspicion that the father was responsible. The maternal grandmother said that by this stage she had come to the view that it was the father who had poisoned her because she had gone through the process of trying to think where the poison could have come from and because they had not been visited by anybody and had received no deliveries and they had eaten and drunk the same by process of exclusion it seems she reached this view. She said she also thought the father's response over Skype when her hair and that of the mother was falling out was distant

F St Bulg: the results obtained after two days indicated thallium in the blood.

13:00 M calls Hospital D.

M tells hospital her mother has tested +ve for thallium. Hospital were attempting (since 30 Sept) to get testing for thallium done but the lab. Had no argon as needed and so the tests were not carried out. Unsure when it would be delivered. Contact with toxicology consultants at Hospital G. M experiencing hand numbness. [D2-70]

16.40: Notes

Sample to be sent to a Trace Elements Lab for thallium analysis tomorrow morning. If patient worsens she should present to Hospital G's A & E where there is a toxicology medical team.

Have informed patient of above (patient is also concerned re Prussian blue availability and I cannot answer her).

Discharge Note: The impression of M's presentation was that of likely poisoning. Discussion with Service was that this may be due to Thallium toxicity, Urine and blood samples were sent for Thallium concentration and trace elements. A hair sample was also collected. Discussion with the Dermatology team also resulted in a hair loss screen being carried out. Whilst in hospital, M experienced an episode of chest pain. ECG and troponin were negative for a cardiac event. This was deemed likely to be the result of an anxiety attack. She remained stable otherwise and was discharged. She will be followed up as an outpatient in Dermatology, Rheumatology and Toxicology clinic, where the results of outstanding tests will be made available.

03.10.2012 Medical Notes: 05:39 a.m. as M claims on going problems with being poisoned with a heavy metal, ?seen at Hospital A and had various tests which were all NAD, has recently lost her father and become obsessed with poisoning. O/e pressured speech with LAS, no vomiting, no diarrhoea, has had hair loss since father died. PMHx nil

The Mother attended the A&E at Hospital H, accompanied by the Father, in an attempt to get treatment and obtain Prussian Blue, known to be the only drug to treat Thallium poisoning with. Her request was denied because she had not been diagnosed with Thallium poisoning at the time [D2 76], [D2 409-427].

Extract Notes: this was a rational conversation with a frustrated lady who feels that she has been badly managed in past three weeks by NHS in UK. She threatened to sue hospital on return from Bulgaria. I reiterated that she would be discharged against medical advice. Her partner (who is a medical doctor) witnessed conversation.

The Mother decided to seek treatment in Bulgaria. Parties and A travelled to Town D in Bulgaria. The Mother was immediately admitted to the same hospital where the Maternal Grandmother was treated. [D2 78-79]

D2 -414

Father Bulg St: After midnight on 3 October, at M's insistence we went to another hospital which I found on the Internet at M's insistence, and where she could be treated with a Prussian blue. As I was parking the car, she headed for the building and there she was told they didn't have such toxicology ward and they called an ambulance car to take her to another hospital. So we found ourselves in another hospital where M persistently asked and wanted treatment with a Prussian blue agent, and they kept answering her they could not do it. We went home and she decided that she would return to Bulgaria together with the child for testing and treatment. On 3 October, on my insistence, I accompanied them in our travel by air to Town D in Bulgaria. At the airport we were met by M's cousin and her spouse, M's girlfriend and a man, a friend of M, whom I have never seen and don't know. M got into his car and said they were going to Hospital F in Town D. I asked why there, as Hospital E and Hospital C in Town D were the best, and she said her mother was treated there and she wanted to go there….I stayed for the night with her girlfriend, a lawyer, and the next day I returned in London with the first flight.

F's Evidence:

F's St Met Police. At no time was I aware that M, her mother or her father had been poisoned with thallium. Even to date I have not seen any documentation confirming that they had been poisoned. I can only assume that they have been poisoned by the fact that the matter is being investigated. About 2 weeks after we had returned to the UK and M had been discharged her mother told us via skype that she believed she had been poisoned but no mention of thallium. As far as I can remember M began to search the internet for the symptoms and the first person who mentioned thallium was one of M's ex-employees whose name I cannot remember.

The father's evidence as to his state of knowledge by this time was hard to piece together. He appeared to be saying that he did not know that the grandmother had tested positive with thallium.

FRIEND A: M had lost a lot of hair and the skin of her skull was visible, and she had severe pains. We also saw M's mother. She was in a similar condition. M complained of a headache that didn't go away with the drugs taken. During our talks M expressed strong conviction that her partner F was the perpetrator, because for the short time they spent in Town A with him and her family no outsiders had visited their house. M's mother said that no outsider had come to their house throughout the last month……When F stayed in my home for the night, without even asking him, he began to explain that he had never heard nor known about this substance, the thallium, and even he didn't know what it was all about. He supposed it was the heavy metal group, but he didn't even have time to read about it. In my opinion, he did not have an adequate response to the whole situation. He was explaining to me that M was much better than it looked like. He was pointing out that once she had no vital organs injured, her condition could not be that bad, and she was overstressed. I asked him if he had ever wondered from where such a substance could come and how he could explain that he himself had not been harmed at all, given they all were together. And he replied that the meals were entirely prepared by M's mother and they took the meals together. What they only consumed differently were the beverages, and that her whole family were drinking water from a certain spring, while he was drinking only soft drinks. He even drank his coffee with water from the storage water heater, while all of the M's family used water heated in an electric kettle.

Friend A's account given in October 2012 is consistent in its account of hospital attendances of MGM and in its account of what M told her with M's hospital attendances in the UK. That would suggest that Friend A's account is likely to be fairly reliable in its recall.

4.10.2012 M admitted to Hospital F. Samples taken.

04.10.2012 Medical Report on MGM: STATUS AT DISCHARGE, OUTCOME OF THE DISEASE AND OPINION FOR THE COLLEGIUMS FOR PROFESSIONAL DISEASES: The patient was accepted with manifestations of acute thallium intoxication (probably after intake of food, contaminated with the poison) with toxic levels of thallium in blood and urine, electromyography evidences of polyneuritis syndrome in the lower limbs from axon type and diffuse alopecia. After the conducted infusion therapy with water - salt solutions and potassium chloride (as competitive antidote), vitamins of the B group, spasmolytic and nootropic substances the pain symptoms were reduced and the patient is discharged in improved condition with the above diagnosis.

The police speak to MGM. The interview was "interrupted" due to her severe health condition. [D2 108].

M interviewed by police at hospital. No record exists of this interview.

The mother's evidence is that at this time she was extremely anxious and was convinced that she would die and asked the hospital to help her make a will. She said that she was concerned as to what would happen to A if she was to die particularly as she had suspicions that the father was the source of the thallium poison which her mother had tested positive for and which she believed she was suffering from and subsequently was confirmed as suffering from. She said she feared she would die notwithstanding the hospital told her she had not suffered internal organ damage and she was desperate to secure Prussian blue as the antidote. Friend A's evidence confirmed the level of the mother's anxiety and her preoccupation with what would happen to A and her mother if she died.

05.10.2012 The Father found a source for Prussian Blue, seemingly in Germany. [D2 174].

He states that he was informed he could not get Prussian Blue in the UK without the Mother being present in the UK and without her being diagnosed with Thallium poisoning.

The Mother informed the Father of her test results.

Although I cannot find a contemporaneous document which records the date the mother received the results of tests confirming she also had sustained thallium poisoning I accept that it is likely to have been on or about 5 October given that she gave samples on 4 October and the maternal grandmother's results appear to have come through within 24 to 36 hours. The continuing search for Prussian blue would also appear to be consistent with that. It is inconceivable that the mother did not tell the father of the confirmation of her statement that he did not know they had suffered thallium poisoning is hard to understand.

The Mother continued to search for a means of obtaining Prussian Blue.

Friend A: After that I visited M in the hospital. It was Friday or Saturday. M had lost a lot of hair and the skin of her skull was visible, and she had severe pains. We also saw M's mother. She was in a similar condition. M complained of a headache that didn't go away with the drugs taken. During our talks M expressed strong conviction that her partner F was the perpetrator, because for the short time they spent in Town A with him and her family no outsiders had visited their house. M's mother said that no outsider had come to their house throughout the last month. On the other hand, M's doubts, and in particular, her beliefs were based on the fact that F was not harmed at all.

08.10.2012 Having ascertained that Prussian Blue could not be sourced in Bulgaria, after a number of calls the Mother was able to find a means of filling a prescription from Bulgaria in Germany. [D2 183-184].

F St Bulg: On 8 October M told me on the phone that her test results were obtained and that there was thallium in her blood. I would add that on about 8 October M told me that the police would inspect the house in the village of Town A and exhume her father's body because he had the same symptoms as they did. Meanwhile, I understood that M called my friends and relatives, telling them that my mother and I had poisoned them, and was trying to convince them of it.

ITEMS SEIZED FROM VILLA [C8] pursuant to police order.

MATERIAL EVIDENCE (ME) OF SIGNIFICANCE TO EXAMINATION The following material evidence was provided for analysis as listed in the Order: 1. Substance of used coffee closed in 2 glass jars - ME I 1 and ME No. 2. 2. Three glass cups, one of which contains dark liquid, a jar of honey and a jar of Nescafe Cold instant coffee - ME No. 3 ,4, 5, 6, 7. 3. A stovetop expresso maker - ME No. 1 and 1 small plastic bottle with white cap, containing liquid - ME No. 9. 4. Two jars containing dark brown substance (coffee-like) and one jar marked "Salt of lemon" - ME No. 10, 11,12. 5. One empty jar marked "Sugar" - ME No. 13. 6. One jar marked "Nescafe Cold" - ME No. 14. 7. One jar containing substance which is granulated sugar-like - ME No. 15. 8. Hair of different lengths, of white and chestnut colour - ME No. 16. 9. Food leftovers - red peppers - ME No. 17.

10.10.2012 M and MGM discharged from Hospital F.

Admitted subsequently to Hospital E.

.. The mother and maternal grandmother were visited by psychologist and it was following these visits that the MGM said the mother began to talk about what had happened to them. She said that psychologist tried to persuade them to start talking about what had happened as they weren't communicating between themselves about it. The maternal grandmother says that it was during their stay in hospital that the mother first mentioned having seen the father leaning over the coffee cups. She said she couldn't remember exactly what had been said that they were discussing what they had eaten and what they had drunk and trying to remember where everybody was. Discussing what they had each done that day and it was during this conversation she recalled the mother saying something about the father's position. She said they discussed accidental poisoning on a number of occasions but the doctors view that the dose was a large one seems to have led them to rule it out. The maternal grandmother's recall of what the mother said movements about the father's was very much I thought impressionistic rather than detailed. (I'm not sure if these were hospital psychologists or part of the criminal investigation as the father referred to psychologists attending his interview on 7 December) Friend A said that during her short visits to see the mother that some reference was made to the suspicion that the father was responsible for their poisoning but these were not lengthy or detailed conversations.

11.10.2012 Bulgarian Toxicology result

Conclusion: 1. In both tested patients the presence of thallium, and respective intoxication with thallium compounds, was detected and confirmed. 2. MGM ingested higher concentrations than M. This may be due to a higher dose for a short period of time or prolonged intake of the poison, or a combination of both. 3. From the hair analysis it can be concluded that in both patients tested the entry of the poison occurred within more than 3-6 weeks before date of testing. Considering the relatively parallel occurrence of the clinical signs, a common time of the onset of entry of the poison into the body of both patients can be assumed.

16.10.2012 Prussian Blue was imported from Germany and delivered to the Mother, who was still in hospital with the Maternal Grandmother.

Bulgarian Police Statement from Friend A [C4]

After this therapy M shared to me that they would try to continue their family relation and strengthen their relationship, but they also realized they had to work consciously on their relationship. M also said that their characters were hard to fit together, but she didn't tell me of anything serious and striking,,,

18.10.2012 The Mother and the Maternal Grandmother were discharged from the Hospital E. [D1 17].

19.10.2012 The Mother was informed by Hospital D, that her blood test results (from blood sample taken on 30.09.2012) had arrived showing extremely high level of Thallium detected in her blood. [D2 82-84], [D1 17].

23.10.2012 M urine test: Thallium 93.6micrrgram/l [D2-262].

Hospital D notes: Call from Hospital D - thallium levels in samples very high. Patients needs contacted and told to go to Hospital G for Prussian Blue therapy if not already treated.

M contacted by Hospital D and told of test results. …she was angry because she wasn't guaranteed admission and would only return to UK if guaranteed admission [D2-82].

25.10.2012 Forensic Chemical Examination. [C8].

Toxic action in acute poisoning by thallium (thallium compounds) in humans is indicated by: abdominal pain; pain in the extremities; muscle pain and general muscle weakness; headache; changes in the mentality and a specific symptom - hair loss (alopecia). The human lethal concentration is 6-15 mg / kg thallium (for a 70 kg person 0.4 - 1.1 g, less than 1/2 teaspoonful). Without treatment, death occurs within 10-12 days after intake, but there are cases of fatal outcome 8 hours after ingestion. In the human body, at a single intake, thallium has a biological half-life period of about 10 days (maximum up to 30 days). With appropriate treatment, poisoned persons recover from acute poisoning after about a month.

The concentration of thallium detected in the bee honey (ME No. 4) can be attributed to the natural background, and the biological concentration of the element, respectively. The uniform content of thallium detected in the sample shows that the distribution was homogeneous, and thallium was not superficially introduced or surface layer contaminated. This concentration of thallium is not toxic to the human organism, especially given the amount of honey taken. Thallium was detected in the dark liquid (ME No. 3) which has the appearance and smell of coffee that has probably been sweetened with the honey bee submitted as a sample. The thallium concentration detected is not at a toxic level that can be associated with the induction of acute poisoning. The content of thallium in the food leftovers (ME No. 17) which contained soil admixture can be due both to introduction with the soil, and the natural biological content of this element in the vegetable. The detected amount of thallium cannot be determined as a cause of acute poisoning when one meal (300 g) with the detected thallium concentration is taken. The presence of thallium in the hair submitted for analysis clearly demonstrates that the person from whom they originate was in contact with a thallium preparation in a toxic concentration.

The items seized are clearly focused primarily on coffee related items whether coffee itself, items used to make coffee, coffee cups or sweeteners. The only non-coffee related items are the small plastic bottle with a liquid in it, sort of lemon (which may be citric acid) and food leftovers in the form of red peppers and hair samples. I consider it a legitimate inference that those seizing the items were therefore focusing on in particular with a subsidiary purpose in looking at food items or other unidentified items which might conceivably contain thallium (citric acid and the plastic bottle.) That would indicate that the police investigation was at that stage

M contacted by Hospital D and informed they will offer assessment and if thallium will admit. She seemed happy with this.

Oct/Nov M stays with Friend A.

Friend A said that after M was discharged from hospital she came to stay with her on a couple of occasions. She said that by then it was clear that she was going to survive and her focus had changed from what would happen to S were she to die to try to understand what had happened. She said that she was constantly going over all that had happened and they had long conversations about what had happened and that during this period of time she pieced together the events of the last morning including how after she got up she had seen the father leaning over the coffee cups on the last morning they were at her parents' villa. She said that during her piecing together of events the mother was considering all sorts of different options but the hospital had said the levels of thallium were so high it was a big dose. She described the thought of the father having done it as nagging her and her trying to work out what opportunity he could have had.

07.11.2012 The Bulgarian Ministry of Interior wrote to their representative in the UK (Mrs Rositsa Petrova) seeking assistance with their investigation. [D2 99-104].

08.11.2012 The Mother attended the toxicology clinic at Hospital G. [D2 86-90].

By late October these symptoms had essentially settled with little or no ongoing leg pain, much in proved mobility and improved appetite. She feels that her memory / concentration is perhaps slightly poorer than previously, at times she forgets names and events, but this is improving, although not back to her baseline. Her vision and hearing have been OK and she has no ongoing headaches. She has no problems with coordination, she previously had a tremor, but this has settled. Her gait is now normal, she has no paraesthesia. She has a general feeling of decreased sensation over her lower legs but can feel and distinguish hot and cold, and things touching her legs and distinguished different sensations in her legs.

These thallium results indicate that this lady has had an episode of excessive thallium exposure and many of the symptoms she has experienced are in keeping with this, in particular the alopecia, muscle pain and poor mobility. However, it also appears that there may be other issues here - I note the diagnosis of anxiety / depression at Hosptial B and also the suggestion of a cervical / lumbo-sacral radiculopatía Bulgaria, and also that a psychiatry review during her inpatient admission in Bulgaria concluded anxiety and hypochondria syndrome. Currently, she does not have clinical features of ongoing end organ thallium toxicity. Her hair is growing and she has no abnormal neurology on examination. Therefore I do not feel that there is the need for any ongoing therapy from the point of view of thallium toxicity.

9.11.2012 Prosecutor's Report [D2-99].

Shortly after their return to Bulgaria, arrived M together with F with whom MGM declared that she was in conflict. Such conflict has occurred on the occasion that F did not want to eat the food prepared by MGM, as well as that he has drunk coffee different from the coffee which the others have drunk. M and F stayed in the summer house three or four days, then they left for the town of Town B and after that - for Great Britain. Immediately after the departure of M and F, the husband of MGM felt bad (severe stomach pain, muscles and limbs stiffness). Emergency team was called and PGF was hospitalized in Hospital J in Town J, where he diseased on 13th September 2012…..On 4th October 2012 M Zlateva came from London to Bulgaria and she was promptly admitted in Hospital F in Town D, for medical treatment. A biological material was taken from M for examination. The result from the examination made showed that there was a poisoning with Thallium. The injured person M was interrogated by the Investigating Police Officer. During this interrogation, the latter confirmed what her mother had told, but with details…..On 8th September 2012 they came back to the village of Town A to take the preliminary prepared "winter supplies" and conflicts between MGM and F occurred again. In the morning of 11th September 2012 MGM has prepared coffee with milk for herself and black coffee for her husband MGF. M refused to drink coffee, but when lighting a cigarette she started to drink from her mother's cup without making additional coffee for herself. On 12th September 2012 at approximately 04:00 h. MGF felt bad and with the help of emergency team he was hospitalized in Hospital J in Town J where, after deterioration of his state, he diseased on 13th September 2012. On the same date, at about the same time, his daughter M had pain in stomach, muscles stiffness and later heavy hair loss.

The contents of the prosecutor's report would appear to be drawn from a variety of evidential sources including accounts given by the mother and MGM. The focus on the consumption of coffee would tend to suggest that the accounts given by the mother and MGM identified this as something significant in relation to their consumption of thallium. The further investigations to be carried out do not specifically identify the need for the father to be questioned about coffee but it is expressed in very general terms. The later order of May 2014 also identified coffee as the focus of the possible administration of thallium.

13.11.2012 The parties met at their London flat. [C19] M tells F to leave. The Mother returned to Bulgaria on the next day.

Pre- 15.11.12 M stays with Friend B and Friend C and discusses events in Bulgaria

Mr Neighbour A speaks to M and MGM.

05.12.2012 The body of the Maternal Grandfather was exhumed. [D2 8-14]. Post-mortem Report:

Specimens from the corpse of MGF. The drug diazepam detected in the liver screening is in a concentration range suggesting therapeutic intake of the drug. The toxic element thallium was detected in the specimens tested. The measured thallium concentrations exceed multiple times non-toxic levels of presence shown in the published literature, which is a categorical and unambiguous indication of exogenous introduction of the substance. Acute poisoning by thallium - detection of thallium in the internal organs in concentration repeatedly exceeding non-toxic levels of presence; acute erosive duodenitis - blood in the small intestine and in the first half of the colon; bilateral purulent bronchiolitis; The cause of the death of MGF is acute poisoning by thallium, which is evident from the detected concentrations of the substance in the internal organs of the corpse. The amount of thallium detected by the use of the described scheme and method of analysis is in toxic concentration and can lead to death at a single introduction into the body. The presence of higher levels of thallium in tissue specimens from the digestive tract indicates that it has entered the body through oral ingestion.

06.12.2012 The Father met the Mother in Town J, Bulgaria and collected his car. [C20]

07.12.2012 The Father was questioned by the Bulgarian police.

The father said that he attended the police station to be interviewed as a witness and on this occasion was not accompanied by a lawyer. He said he was therefore about 16 hours from 11 AM to 3 AM and was extensively questioned about the history of his relationship, events of the summer, what occurred on 12 September 2012, who ate and drank what and what had happened subsequently. He thought he had reviewed the notes that were made on the seventh but it was in the early hours of the morning and so perhaps he missed things.

10.12.2012 Police brought the Father to the villa of the maternal grandparents.

The mother:

Statement of 6.2.21. in the morning of 10th December 2012, the Police arrived at my parents' villa in Town A, where the poisoning occurred. F was with the police in their car. My mother, child A and I were in the villa. The three of us then gave very detailed verbal statements about what each one of us did, ate, saw and heard on the day of the poisoning. I am sure I then said that I saw F leaning over the table where my parents' coffees were. I am sure of this, because I remember explaining it to Officer N (who was in charge of the investigation), while the other policeman was taking notes,

Evidence: Mr N said we are coming tomorrow and we want to do a reconstruction of what happened on the 11^th;. They arrived at the villa, they came after 9am – it was finished by 12noon. Officer N and another policeman made notes and a driver. All of us were there – together. I have a recollection of us all on veranda and I was in the middle demonstrating how I saw him and how he turned back. Then we went into the villa and sat in the living room and he started asking what did you eat and drink and we each said what we recalled. Child A was there, F tied to cuddle him and my mum said don't. I can't remember anything he said. I can't remember if any photos were taken.

MGM: the investigator N called and said they would come so we could make a reconstruction of what we had eaten and drank on the 11^th. There were 2 or 3 police offices – or 2 police and 1 writer – two police vans – and F was brought in. so we went to the porch, the terrace and Mr N started asking us questions regarding who ate what, who drank what, so we answered what we could recall about the food and drink and the dinner. I remember N mentioned that he was leaning over the cups and she copied the exact movement of his back. I told Mr N that it didn't matter what we consumed as food or drinks as we all ate and drank the same as us. I remember that F's attitude was very disrespectful – he would stand up started playing with the ….. then he was on the phone and N had to warn him 'don't forget why you are here Then after a while N said take him back to the police station and they did. They were on the veranda – they entered the house – both places – but I can't recall if they were around the garden but they might have been……during the reconstruction – they went into M's bedroom and M showed him where exactly his position was when she woke up – where he was stood by the table – then she went on the balcony in her pyjamas but he didn't turn round straightaway. He had already been smoking a cigarette

Father: He said that he was asked to return on the Monday, 10 December which he did taking a lawyer with him. He observed that his interview on the 7^th had been conducted inappropriately. And at that point he realised that there was an issue with the timing of him getting up. The police wished to undertake a confrontation at the villa and they drove there and sat at the kitchen table where the police asked the grandmother to recall what happened on the morning of the 11^th which she then did. His account is that the police then asked him whether he agreed that he had been up early as he had told them he awoke at 8 AM and he says that he then told them that he agreed he had woken up quite early and that what he had told them was wrong. He says he cannot remember there being a reconstruction, or the mother saying that she had seen him standing over the coffee. He did remember A seeing him and smiling at him. He said that on their return to the police station he could see discrepancies in his statement but his evidence was that he did not read it fully and that his lawyer checked it. He now says that he has noted discrepancies in that it records that he said he got up at 8 AM and the statement suggests that he ate to drob-sarma whereas his evidence is that he accepts that he was up early that day and he did not eat drob sama.

14.20 C16 – Father's statement signed.

The father said that he and the investigating officer signed the original of the statement in Bulgarian and that he countersigned on each page.

This statement is the first and closest in time recorded account by any of the individuals who were present on 11 September 2012. The father identified what he called a discrepancy between the timing of his getting up that day recorded in his statement and what his account has been to this court. His evidence was that he had identified this discrepancy on 10 December. The discrepancy is not simply linked to the time that he got up which could be a relatively innocuous mistake but rather it places the mother, MGM and MGF as all being up before him and him making his coffee in isolation from them and without them being present. However the father and his lawyer considered the contents of the document that was produced by the police on 10 December following the visit to the villa and the father signed that statement and each page of it confirming that account. His account that he was up early first appears in his statement of December 2018 although that does not identify that he was up before the mother. That statement does not respond to the mothers detailed account given in her statement of 15 May 2018. In his evidence to me, he gave a much more detailed account and in particular accepted being up before the mother and leaving her in bed, making coffee in the kitchen with the MGM and MGF and being on the balcony. I find it impossible to accept that the father told the police on the 10^thDecember during the visit to the villa or otherwise that in fact he had been up before the mother, still less that he had made his coffee and had been on the veranda when the mother emerged. The statement was plainly the product of careful preparation, if there were amendments they were made prior to the production of the printed text as it contains no initialled corrections. The statement that he signed and which was approved by his lawyer was I am satisfied his evidence at that point and was produced by the police as they understood that to be his account which was given to them on the 7^th December and on the basis of all parties' recollections of the subjects covered on the 10^th it must have been what he maintained to the police at or after the visit. That was at least inaccurate and I am satisfied in the context of this case it was a deliberate inaccuracy- in other words a lie. I do not accept the father's case that it was a discrepancy that he somehow sought to correct but erroneously the final signed version continued to contain it. That flies in the face of the document itself and the context in which it was signed (the process took some 2 hours 20 mins on the 10^th in addition to the many hours on the 7^th December). On that day and in the context of the investigation what explanation is there for that lie?

15.12.2012 The Mother, the Maternal Grandmother and A returned to UK.

30.12.2012 Parties attended the bank to close their joint bank account.

03.01.2013 Med Note:

M is feeling very much better and is now back at work a couple of days a week. Her legs are very much improved with no ongoing pain or problems with her mobility. She has a general feeling of decreased sensation over her lower limbs as before, but she can differentiate light touch, sharp sensations and hot and cold. Her appetite has very much improved and her weight is back to normal. … From a legal investigation point of view, I understand from M that her father's body was exhumed in early December, but M is not aware of the results of this or of any of the other details of the police investigation in Bulgaria.

09.02.2013 M writes to F [D2- 445]

It is my problem how I will cope and live from now on with the pain and shame that I brought into my parents' home a man who dared to take their lives. Trying to keep me with you by eliminating my parents from your path was crazy! To say nothing of my worries about the genes our child inevitably carries! Know that if I wanted to, not only relatives and friends, but all of Town B, Hospital K, all of England and the whole world would have known what you have done to me. The only reason I decided not to make what happened publicly known, is to keep A's name intact as much as possible. It is entirely up to you whether this will continue to be so.

22.02.2013 F replies : D2-444

29.04.2013 Bulgarian Authorities sent a Letter of Request for Legal Assistance to the Home Office in UK, in connection with their investigation. [D2 223-226]

25.05.2013 The date when the Father last saw A.

F says he and mother sorted out some issues and M asked if he wanted to see A and they went to a park for 1 hour.

21.10.2013 Both parties gave statements at Scotland Yard. [C21 – F's]

Father: In 2012 as far as I was concerned M and I were still very much in love but M believed that we had different opinions and different points of view on many things. She suddenly said to me that she didn't believe that we could continue living together. As a result in April 2012, M took our son A to her parents' house in Bulgaria. When she returned we decided to seek the professional assistance of a couples counselling service. We went to a number of counselling sessions together and I believed that we had resolved our differences.

Prior to leaving M's parents house and return to the UK, our son A had been unwell for a few days. He had flu like symptoms and on the evening we were leaving to travel back M complained that she was feeling unwell and had a blocked nose I assumed that she had picked up a virus from A. We travelled back to the UK and during this journey her condition deteriorated. I had no idea that her mother was also unwell. Whilst we were travelling back to the UK we stopped off at a hotel remember being told by M that her father had been admitted to hospital…..The following day M had a conversation with her uncle and she told me that her father had been diagnosed as having a stroke. In the meantime M began complaining about aches and pains in her legs and body but the symptoms she was describing initially I believed she had flu. However, she began to explain to me the symptoms in more detail and because her muscle pain was worsening and travelling up her body I believed she may have some sort of neurological complications from the viral infection. Just prior to us leaving Calais to travel to Dover in the UK, M had been told that her father had died. She asked me not to mention to her mother that she had been unwell as she didn't want her mother worrying at that time when her father had died. Upon arrival in the UK the date I believe was 14/09/2012 I drove M straight to Hospital A ……At no time was I aware that M, her mother or her father had been poisoned with thallium. Even to date I have not seen any documentation confirming that they had been poisoned. I can only assume that they have been poisoned by the fact that the matter is being investigated. About 2 weeks after we had returned to the UK and M had been discharged her mother told us via skype that she believed she had been poisoned but no mention of thallium.

23.10.2013 Father's then solicitors wrote to the Mother for contact between their client and A [D2 169-171] and demand contact failing which he will approach the family court.

Mother states that she will disclose evidence to a judge and that F should approach the family court to seek his rights. [D2 172]

The Father did not pursue the request for contact, but denied the Mother's allegation in correspondence, asking to see the evidence. [D2 170-171].

7.11.2013 Communication over contact – [D2-169].

26.11.2013 Metropolitan Police took statement from Ms L (HR) at Hospital K. [C24].

29.01.2014 Metropolitan Police took statement from Ms P, with whom both parties attended couples counselling in summer of 2012. [C25].

07.02.2014 Paternal grandmother questioned by the Police in Town B, Bulgaria in relation to their investigation. [C26-27].

03.04.2014 Plaint: In her testimony of 3rd April 2014, the witness M declared that after waking up in the morning of 11th September 2012, she saw F bent over the table where the cups with coffee of MGM and MGF were.

14.04.2014 Prosecutor's Order to stop the criminal investigation in Bulgaria was issued at the District Prosecutor's Office in Town J. [D2 112-114]. Subsequently overturned on the basis of deficiencies in the investigation relating to the treatment of the M and MGM : D2-110. Records that M sought F undergo polygraph and that his computer be seized.

20.04.2014 The Mother appealed the above Order.

22.05.2014 Mother's appeal was successful. [D2 106-110]

"…Evidence was gathered that in the morning on 11.09.2012 three of the four adults staying in the house, with the exception of F, drank coffee. At about 4:00 on 12.09.2012 MGF felt bad and because of the rapid deterioration of his health was taken to hospital where he died on 13.09.2012 [D2-108].

The Court finds that the unreasonable and unjustified order to suspend the criminal proceeding rendered while making substantial procedural violations in the course of the pre-trial proceeding should be overruled and the case referred back to the Prosecutor for implementation of the instructions given in these reasons." [D2 109]

24.07.2014 Maternal Grandmother gave statement at Town J District Police Station. [C28-33]

As I learned later from her, when she came out of the house she saw F with her back to her and facing the table just opposite the entrance of the house. He had been directly bent over the table. On her greeting he didn't turn to her immediately and didn't answer her, but stayed for a few seconds with his back to her, while at the same time posing as if lighting up a cigarette over the table and facing the coffee cups. She had not been able to see immediately what he was doing at the table and why he had delayed his turning and his answer to her. In general, F is a man who keeps good control and at that time he had succeeded in hiding his embarrassment of the things he had been doing. When he turned his face to M, they exchanged some common words, and at that moment M didn't know what he had actually done..... By 19:00 - 20:00 that evening my husband's condition began to deteriorate. His tongue dried up and his tongue somehow thickened, and he begin to lisp slightly, and I said: "What about you, man? You will not travel, why are you so worried?"…… After seeing M, F and the child off, my husband said, "I'm very sick, I don't know what's going on with me, I'm going to bed." I said, "Okay, tomorrow we'll see what we're going to do." At 02:00 in the morning he wanted to get up and fell from the bed. He repeated again: "I'm dying, I'm very sick." I called an ambulance and he was taken to the Emergency Centre at 4:0 - 5:00 in the morning. After a day and night in the hospital he died with the diagnosis of a stroke….The next day my condition grew worse - pains in the stomach, muscles of the legs and hands accompanied by headache, which I naively linked to the stress from the sudden illness and later to my husband's death.

14.10.2014 Second Prosecutor's Order to stop the criminal investigation in Bulgaria was issued at the District Prosecutor's Office in Town J. [D2 116-122]

Extract: "On 11th September 2012 MGM and MGF drank coffee made in a coffee maker, and M drank from the cup of her mother. F did not drink from the same coffee; he prepared instant coffee for himself since he drank only instant coffee. On the same day M, F and the child A left with their own car to Great Britain."

It is certainly the case that none of the documents emanating from the Police/Prosecutor that they do not refer to F having been seen leaning over the table on the 11^th September. However the Reports all seem to refer to interviews of the MGM and M whilst they were in hospital and when it was accepted that the interviews were limited because of their illness. There is not a reference to the visit to the villa on 10 December 2012 or what might have been said or done then.

16.10.2014 The Mother appealed the above Order. The plaint is at [D2 124-131]

05.11.2014 Mother's appeal to carry on investigations was allowed. [D2 133-139]

Extract….."both witnesses claim that the intake of Thallium by the three injured persons is caused precisely by actions of F, i.e. he has poisoned them with Thallium, by expressing doubts that they have taken the Thallium with coffee which was drunk only by the three injured persons."

No reference to F having been seen in vicinity of coffee.

21.01.2015 The media report making public the plan to try and retrieve F's laptop from his mother's home. [D2 228-229]

Given the reference to the laptop in the April 2014 order it seems unlikely that the press reporting tipped the father off as the mother believes unless the order was not provided to the father.

15.05.2015 Police in Town B searched the paternal grandmother's flat, asking for the Father's old laptop. PGM told police an old laptop had been damaged and thrown away.

11.03.2016 Home Office UK responded by letter to the District Prosecutor's Office in Town J [D2 188-190]

26.04.2016 Third Prosecutor's Order to suspend the criminal investigation in Bulgaria was issued at the District Prosecutor's Office Town J. [D2 141-146]. The Mother did not appeal.

Order records:

'The investigation established that during the stay of F and M in the village of Town A from 8th September to 11th September 2012 the house has not been visited by persons outside the family'.

It is not clear why F did not apply for contact after that as he had said he was advised not to.

12.09.2016 Certificate stating no pending proceedings against the Father [D2-1].

07.02.2018 C100 application by the Father. [B 1-20]

Mother says F delayed his application in order to avoid any court scrutiny of his actions. The correspondence between their solicitors in 2013 invited the father to put the matter before the court if you wish to see A.

The father maintained that he was advised by his lawyers not to make any application whilst there was a pending police investigation.

The timing of the father's application and his explanation for the delay do not seem to match up. The April 2016 order and in particular the document from the Bulgarian authorities which he requested in September 2016 would seem to confirm that no ongoing proceedings were in place but proceedings were not issued for another 17 months. In any event even if court investigations had been under way in Bulgaria the English courts could both have made supervised contact orders and proceeded to a fact finding hearing. The father's stated reliance on solicitors' advice suggests either the advice was bad or his account of the advice is inaccurate. One would usually expect a father who was keen to re-establish a relationship with their child to press to get the matter before the court and to challenge advice not to. Whilst it may be understandable in the early days it becomes very hard indeed to understand as the months and subsequently years passed with no finality in the Bulgarian criminal investigation. I was unpersuaded by the father's evidence as to the application being issued when it was clear the Bulgarian investigation had concluded given the extensive delay. However I did not hear sufficient evidence on this issue to determine what actually was the true reason for the timing of this application. The father's oral evidence did not suggest that he had reached a stage of desperation to see A himself which was the driver of the application.

09.03.2018 C1A application by the Respondent mother. [B 21-29]

15.03.2018 FHDRA listed for 23.03.2018 was vacated and relisted for 27.03.2018. F files PS

19.03.2018 Safeguarding letter from Cafcass. [E 1-4] The Mother and Father are both interviewed. The Father reports that the Maternal Grandfather's death was recorded as a stroke and that the Mother was seen by various hospitals in the UK and was not diagnosed with poisoning and that the relationship had ended "a few months after the return to the UK". The Mother alleged that she and her parents had been poisoned by the use of Thallium by the Father.

The recommendation is that the central issue of the historic allegations needs to be addressed.

F's account to Cafcass was clearly tailored given his state of knowledge.

27.03.2018 F files PS [D1-1-2]

FHDRA – Deputy District Judge Gartland – Order No. 1. [B 30-33]

03.04.2018 Certificate: no charges against F in Bulgaria. [D2 156] and [D2 161].

01.06.2018 Mother's C2 Application to instruct an expert toxicologist. [B 34-45]

04.06.2018 Second DRA – HH Circuit Judge Jacklin Q.C. – Order No.2. [B 46-50]

21.08.2018 Food and Drinks List prepared by the Mother and the Maternal Grandmother upon request by Dr. Douse [D2 193-196]

17.09.2018 Order No.3 by consent – HH Circuit Judge Jacklin Q.C. [B 53-56]

15.10.2018 Third DRA listed for 16.01.2019.

16.01.2019 Third DRA - HH Circuit Judge Jacklin Q.C. – Order No. 4 [B 53-56]

Mar 2019 Father and partner conceive.

04.02.2019 Press release about purity of water in Town A [D2-256].

13-15 May 2019 Fact finding listed for 3 days hearing. Hearing relisted due to

Court's error.

7-10 October 2019 4-day Fact Finding hearing before HH Circuit Judge Jacklin QC [T 1-

280]

23.10.2019 The Father was approached via email by officer O of the National Investigative Service in Bulgaria. [D2 405]

24.10.2019 HHJ Jacklin QC notified the parties of Her findings by email to their respective counsel.

25.10.2019 The Father responded to officer O's email. [D2 406]

22.11.2019 Hearing held at West London Family Court

M says F represented to the court that he knew nothing about the continuation of the investigation.

F agrees and says this was a mistake

December 2019 Father and partners child born.

06.01.2020 Fact Finding Judgment delivered by HHJ Jacklin QC in writing

14.01.2020 Judgment on costs and disclosure delivered by HHJ Jacklin QC in writing.

Order for costs and disclosure also made by HHJ Jacklin QC. [B59-60].

28.01.2020 Appellant Father's Notice and Grounds of appeal filed at High Court.

06.02.2020 High Court Order made by the Honourable Mrs Justice Judd - parties to inform the GMC of the findings made against the Father. [B62]

07.02.2020 Hearing at The Family Court sitting at Barnet. Further Court Order No. 7 on costs made by HH Circuit Judge Jacklin QC. [B 63-64]

11.02.2020 Father's Skeleton Argument dated 09.02.2020 filed at RCJ.

April 2020 M alleges she discovered SD Memory card

M says she discovered it in a box of miscellaneous electronic items when she was looking for an SD card to put into a new camera she had bought for A. She checked the contents on her laptop before inserting it in the camera and realised that it contained files which appeared to be the father's.

The father says he does not recall purchasing this, that file dates are inconsistent with it being his and that he does not recognize various files on it. He accepts that many of the documents are his including photos he took in Paris and work documents.

Comment: the contents list is rather eclectic and has the appearance of something downloaded from a smartphone or other device. The random nature of the documents which are linked suggests that it is at least largely his. The presence of the two documents which refer to Thallium is either because F downloaded them or because M placed them on the card to bolster her case. F submits that this is plausible as the timing of the discovery was linked with the father's appeal and permission being granted and that her entrenched views about securing justice for her family are a sufficient motive for her to create evidence to bolster what she believed was a genuine case. The mother's evidence in general I have concluded to be essentially honest albeit potentially mistaken or erroneous in various ways. I do not believe she is capable of the and attempt to manipulate the court process that tampering with the SD card and placing before the court would involve. The evidence of her friend as to the timing of the discovery and her demeanour at that time and her provision of the downloads and card to the Bulgarian police and her offer of the card and downloads to the British police would seem to be inconsistent with her having manipulated the document. Such manipulation would carry with it a serious risk of the Bulgarian or UK police discovering the manipulation. Whilst her confession of having speculated in relation to the state of the curtains on 11 September 2012 can not be said to support the conclusion that she is entirely and transparently honest together with other aspects of her evidence when she in my view potently did not seek to elaborate when she might have done if she were dishonest support the conclusion that it is not probable that she manipulated that SD card. The presence of the files on the SD card seems more likely to be the result of the father's having downloaded them. However if they were there as a result of his action that does not necessarily amount to a building block in the case against him. The references to thallium within the documents are limited and in respect of the first it's dating is so far in advance of the poisoning events that seems unlikely to be linked. The second document is more closely associated in time with difficulties in the parties' relationship so might conceivably fall within a window of time more associated with the poisoning. The father's position in relation to the card seem to me to be consistent with other aspects of his evidence where he in effect requires conclusive proof rather than he making any admission based on common sense or probability. Given the serious consequences for him of a finding I do not think his stance of refusing to admit the SD card is his can properly be regarded as corroborative of his guilt. Ultimately the circumstances in which the PowerPoint was downloaded and the use to which it was put I do not find capable of determination on the evidence that is available to me.

21.04.2020 The Mother informed GMC of the Findings made by HHJ Jacklin QC to comply with Paragraph 2(b) of Order made by the Honourable Mrs Justice Judd dated 06.02.2020.

22.04.2020 High Court Order made by the Honourable Mrs Justice Judd. Appellant Father's application for permission to appeal granted. The case was transferred to the Court of Appeal.

13.05.2020 Order made by The Honourable Mrs Justice Judd in the High Court of Justice granting permission to the Appellant Father to appeal the cost orders of HHJ Jacklin QC dated 14.01.2020 and 07.02.2020.

15.06.2020 Court of Appeal Order – Appeal Hearing Listed for 08.07.2020. [B 67-69]

21.06.2020 Appeal Hearing adjourned to 28.07.2020.

28.07.2020. Appeal Hearing.

22.09.2020 Appeal Judgement delivered. [B 70-83] Court of Appeal Order. [B84-85]

26.10.2020 M to be allowed documents from Bulgarian Police.

04.11.2020 Father's C2 Application to withdraw from the proceedings. [B 87-99]

10.11.2020 Directions Hearing before The Hon Mr. Justice Keehan. High Court Order. [B 100-101]

10.12.2020 Directions Hearing before the Hon Mr. Justice Williams. High Court Order. [B 102-104]

06.01.2021 The Mother filed new draft Statement and evidence.

21.01.2021 Directions Hearing before the Hon Mr. Justice Williams. High Court Order. [B 105-108]

21.01.2021 Decision of the Bulgarian Prosecutor. [D2 490-491]

06.02.2021 The Mother filed Revised Statement No.4 and evidence. [D1 72-83]

11.03.2021 Letter of Request sent to the Bulgarian Authorities. [Z 8-11]

15.03.2021 Advocates meeting.

14-26.04.2021 Case listed before The Honourable Mr Justice Williams.