B e f o r e :
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IN RE P (A CHILD) |
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Crown Copyright ©
The original Schedule of Proposed Findings14. (i) In March 2014 P sustained a fracture of her right humerus, and fractures to her left tibia and fibula.
(ii) The two sets of fractures may or may not have occurred at the same time. If they occurred as part of the same incident, they arise from two separate and distinct applications of force to the child – one to cause the arm fracture and the other to cause a leg fracture.
(iii) The fractures would have been caused by considerable and excessive applications of force.
(iv) Any carer present at the time of the fracture(s) would have known that excessive force would have been applied to the child, and that the child had sustained injuries sufficient to warrant immediate medical attention being sought.
(v) The fractures were caused by the acts or omissions of the mother and/or the father. The Local Authority does not seek any finding that the fractures may have been caused by a third party.
(vi) The parents failed to seek medical attention or prompt medical attention for the injury.
(vii) A fracture to a baby of this age would usually be accompanied by a present carer giving an account to a notable event that caused the fracture(s). The parents have to date failed to give an account of any such notable event or events.
(viii) Following the arm fracture and/or the leg fractures the child is likely to have cried in pain and would be inconsolable for a period. For the first 72 hours or so following the injury the child would have not moved or would have been reluctant to move the fractured limb(s). The child would have been distressed when the fractured limb(s) were moved or manipulated in an out of clothing. There may well have been associated swelling around the fracture site(s).
(ix) According to Dr Watt (consultant paediatric radiologist) the arm fracture would have occurred in the window from 13th to 19th March 2014. The leg fractures happened within the time window 4th to 20th March 2014.
(x) In accounts given by the mother, upon the child's return to her care at around 5pm on Sunday 16th March following contact with the father the child was whingey the arm was not swollen.
(xi) At times the mother has indicated that on Monday 17th March 2014 the child was in a distressed state and would make no effort to crawl.
(xii) According to the mother on Tuesday 18th March 2014 the child was making no effort to crawl. She was grisly and clinging and did not want to be put down.
(xiii) By Wednesday 19th March 2014 the mother said that the arm was noticeably swollen and that the child cried when the arm was touched. The mother further reported that the child was not moving her arm at all and great care had to be taken when changing her.
(xiv) At 5.30pm on the evening of Wednesday 19th March the mother took the child to the A & E Department of the Royal Bournemouth Hospital.
(xv) Whether or not the mother caused the fractures, the Local Authority seeks findings that:
(a) The mother's account is incomplete.(b) At times her account has varied in detail significantly when given.(c) The mother unreasonably delayed in seeking medical attention for the child given the child's presenting symptoms.(xvi) The mother, or the father, or both parents know more about the injuries and the circumstances of the injuries than they have so far been willing to admit.
(xvii) Whether or not there was an incident of domestic violence between the parents in late 2013.
(xviii) Whether or not there was domestic violence or aggression from the mother towards Hayden (her partner at the time) during their relationship.
(xix) Whether or not the mother asked Hayden to lie about his whereabouts in the period in which P could have sustained injury.
Law
"(a) that the child concerned is suffering or is likely to suffer, significant harm; and
(b) that the harm, or likelihood of harm, is attributable to –
(i) the care given to the child, or likely to be given to him if the order were not made, not being what would be reasonable to expect a parent to give to him …"
"Harm" is defined in Section 31(9) as ill-treatment or the impairment of health or development, including impairments from seeing or hearing ill-treatment of another.
Whether the harm was attributable to the care given to her not being what would be reasonable to expect a person to give i.e. whether the injuries were inflicted non-accidentally by the mother, the father or by some third party.
(i) The burden of proof lies with the Local Authority.(ii) The standard of proof is the balance of probabilities.
(iii) Findings of fact in these cases must be based on evidence, including inferences that can be properly drawn from the evidence and not on suspicion or speculation.
(iv) When considering cases of suspected child abuse 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 conduct an overview of the totality of evidence (the evidential jigsaw) in order to come to a conclusion whether the case put forward by the Local Authority has been made out to the appropriate standard of proof.
(v) Amongst the evidence received in this case there is expert evidence from a variety of specialists. This is important evidence but these opinions need to be considered in the context of all the other evidence. The court must remember that its role and that of the experts is distinct.
(vi) The court must be careful to ensure that each expert keeps within the bounds of his own expertise and defers, where appropriate, to the expertise of others.
(vii) Evidence of parents and any other carers is of the utmost importance. Added to the evidence of the parents in this case is that of the paternal relatives. It is essential that the court forms a clear assessment of their credibility and reliability.
(viii) 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 that a witness may lie for many reasons, such as shame, misplaced loyalty, panic, fear and distress and the fact that a witness has lied about some matters does not mean that he or she has lied about everything – see R v Lucas [1981] QB 720.
(ix) The judge in care proceedings must never forget that today's medical certainty may be discarded by the next generation of experts or that scientific research may throw a light into corners that 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".
"Finally, when seeking to identify the perpetrators were non-accidental injuries the test of whether a particular person is in the pool of possible perpetrators is whether there is a likelihood of a real possibility that he or she was a perpetrator. Nor did I make a finding that a particular person was the perpetrator of non-accidental injury the court must be satisfied on balance of probabilities. It is always desirable where possible, for the perpetrator of non-accidental injury to be identified both in the public interest and in the interests of the child, although where it is impossible for a judge to find on the balance of probabilities, for example that parent A rather than parent B caused the injury, then neither can be excluded from the pool and the judge should not strain to do so."
"The term non-accidental injury may be a term of art used by clinicians as a shorthand and I make no criticism of its use but it is a catch-of everything which is not an accident. … A true distinction is between an accident which is unexpected and unintentional and an injury which involves the element of wrong. The element of wrong may involve a lack of care and/or an intent of a greater or lesser degree that may amount to a negligence, recklessness or deliberate infliction."
Evidence
Medical Evidence
"P is reported to have been crawling for approximately three weeks although has not crawled in the previous week in relation to her arm injury. P is able to pull to her knees but not to stand. She is able to sit unsupported for two or three months".
Later in the letter:
"On examination P had decreased mobility of her right arm with some swelling evident. Otherwise she was well appearing with no significant abnormality … P was moving her other extremities well aside from the right arm.
She is recorded as having some bruising in the dimples of her right elbow joint and a two centimetre by one centimetre area of bruising on her right forearm about two thirds of the way down on the ulnar aspect. This appeared to be separate from any bruising which occurred in conjunction with her arm fracture and had linear patterning within it. No additional external injuries were visible on P".
"The presence of soft tissue swelling and absence of periosteal new bone formation in relation to the supracondyler fracture of the right humerus fracture between 12th March 2014 and 24th March 2014 indicates that this fracture was probably less than ten days old on these dates. This fracture is therefore most likely to have occurred between 14th and 19th March 2014. Provided, as I believe, radiographs dated 19th March 2014 were obtained prior to manipulation then the fracture was already present before any manipulation was undertaken".
"In children under the age of 18 months fractures of the tibia and fibula are highly indicative of a non-accidental injury and in the absence of a clear history of a significant traumatic event, non-accidental injury must certainly be suspected. In conclusion, the finding of multiple fractures of different ages without plausible explanation in an infant of this age is highly indicative of non-accidental injury".
"At 6 months of age an arm injury is usually associated with a credible history of an event and its aftermath (e.g.: infant fell, grabbed her arm, she cried etc.). No history is available. There was both HV and GP follow-up although no examination details are available.
The above injury indicated carers presented P for medical care and took advice appropriately. The cause and nature of her arm injury on 19th November 2013 cannot be determined on information provided".
"Rob, P isnt moving her arm at all. Did she do something when she was at yours?"
Father replied:
"Really, no, she fine. She was with you all of yesterday."
Later the father sent a message to the father:
"Is P ok now? Sorry, I missed your call. Just finished work late".
Mother replied:
"Yes, she's alright now. I just got a bit worried, ha, ha. She's fine, thanks for asking".
Later text from mother:
"P's top tooth has come through."
Father replied:
"O, that's good."
"You don't see P from now on! You can go through the courts! It's getting too much and I'm not happy!"
"The following day, Sunday 16th March, P had a big long sleep in the morning (which should read afternoon) which was unusual but I didn't really think about it. I just assumed that she might be under the weather. I took P for a long walk on the Sunday afternoon and (the mother) came to collect her at about 5pm. Again, I had no concerns at that time".
Stocktaking
Submissions
"Acute swelling of the limb was likely to have occurred close in time to the injury (within a few hours): the swelling would last for up to 72 hours during which time it would decrease, not increase; and the swelling would not suddenly have appeared three days later when it was first noticed … If injury had occurred on 8th January, the swelling and inability to use the limb if was seen on 10th January would have been noticed on 8th and 9th January …"
"On Monday 17th March 2014 P was crying/no efforts to crawl. This suggests an injury is likely to have occurred by this time (distress/reluctance to use the arm)".
(i) that the delay by the mother in taking P to hospital on 19th March was due to her inexperience, naivety and her isolation at that time from her grandmother;(ii) that the paternal family have been less than frank with the detail of the events over the period 15th 16th March;
(iii) that the humeral fracture had occurred by 17th March;
(iv) that the incidents giving rise to P's injuries occurred at the same time albeit by different mechanisms;
(v) that the mother can be excluded as a perpetrator of either of P's injuries;
(vi) alternatively the cause of the injuries was unknown.
(i) forensically speaking the first time the swelling is seen is likely to be close in time to the injury;(ii) swelling starts within hours and goes down within 72 hours;
(iii) if there was no swelling on either Monday or Tuesday (17th/18th March) this points away from P's arm being injured on the Sunday;
(iv) on a balance of probabilities it is submitted no injury had occurred by that time;
(v) a fractured arm is more painful than a fractured ankle. It would be very painful for the first 72 hours;
(vi) in respect of the ankle, 72 hours post injury the fibrous tissue would be sufficiently stable for the fracture not to be noticed unless direct pressure is applied to the site of the fracture. This happens, for example, during a nappy change when a carer would be likely to notice a pain response.
(vii) being "whingey" at 9 months is not a helpful indicator in this context because such whingeyness can arise for a number of different reasons. An observed reluctance to crawl without more is of little assistance to the court in coming to a determination.
(a) In March 2014, P sustained a fracture of her right humerus, and also fractures to her left tibia and fibula.The existence of these injuries is confirmed by the medical evidence and there has been no challenge.(b) Two sets of fractures may or may not have occurred at the same time. If they occurred as part of the same incident then they arise from two separate and distinct applications of force to the child – one to cause the arm fracture and the other to cause the leg fracture.
Following a consideration of the medical evidence I find that it is likely that there were indeed two separate applications of force. It seems unlikely that one mechanism could account for both fractures. Dr Robinson did proffer the possibility that if P had fallen from a height with outstretched limbs, one mechanism might account for both fractures. There is no history of such a fall.(c) The fractures would have been caused by considerable and excessive applications of force.
This has not been challenged.(d) Any carer present at the time of fracture(s) would have known that excessive force would have been applied to the child, and that the child had sustained injury sufficient to warrant immediate medical attention being sought.
I accept the submission that this is confirmed by the medical evidence. Also it is clear to me that these injuries amounted to significant harm.(e) The fractures were caused by the acts or omissions of the mother and/or the father. The Local Authority does not seek any finding that the fractures may have been caused by a third party.
In the support of the Local Authority's contention that a specific finding can be made that the mother was the perpetrator of P's injuries Mr Hand submits the following(i) That the evidence from the paternal family clearly shows that P was well over the course of the weekend 14th-16th March. Mr Ward-Prowse has suggested that the paternal family may have put their heads together and organised a cover up of an incident that occurred in the paternal home. I reject that. Such a scheme would have required the cooperation of C, the three aunts, Helen Scott and the father. I accept the point made by Mr Ward-Prowse that it is at first sight, strange that K and E did not mention the visit to Helen Scott when first seen by the police and social worker on 27th March. Such inconsistencies as have emerged in their evidence does not in my judgment establish Mr Ward-Prowse's point. I accept the paternal evidence about the events of that weekend.(ii) Mr Hand further submits that the effect of the evidence of Dr Robinson, and the mother's assertion that it was noticeable that P had stopped using her arm on the morning of Tuesday 18th March is consistent with an injury in the mother's care. I agree that the medical evidence was to the effect that following a fracture a swelling would emerge in hours rather than days and that generally by the end of 72 hours after the injury the swelling will have gone. In this case the swelling is noted by the mother for the first time on the morning of Wednesday 19th March. This was when the mother said she realised something was seriously amiss.(iii) It is curious that on the morning of Tuesday 18th March the mother sent a text to the father suggesting that P's arm had stopped working but then sent a further text on the morning of 19th March saying that the arm was better. This does not fit with the injury as seen on Wednesday morning.(iv) When considering the mother's evidence which, in some respects, was untruthful, I remind myself that this does not mean that everything she said cannot be relied upon R v Lucas (Above). This mother was young. She had shown herself in some ways to have been a good mother. Having said that, however, the mother's various assertions and the long gap between Wednesday morning and the visit to the hospital in the afternoon strongly suggest that she knew that she had something serious to hide in respect of her conduct towards P.(v) When considering the question of the perpetrators I do not think that there were two, one causing the elbow injury and one causing injury to the ankle.(vi) I find that the mother, while alone with a whingey child, lost her self control and a fit of temper or exasperation caused the injuries to P. No one else was responsible for the two fractures.(f) The parents failed to seek medical attention or prompt medical attention for the injuries.
This allegation is now made only against the mother. While it may have been the case that P was indeed teething and as a result was clingy and whingeing on the Monday the evidence suggests that by Tuesday morning P had stopped using her arm and the mother so informed the father by text. The mother and P were at JB's home all day together on Tuesday but the mother informed no one of any difficulty until she called Hayden at about 1600/30 on the Tuesday afternoon. Until around 16.00 hours on Wednesday the mother sought no help for P from anybody. It is surprising that she did not try to contact JB. It is submitted and I agree that the delay in seeking medical attention is clear.(g) A fracture to a baby of this age would usually be accompanied by a present carer giving an account of a notable event that caused the fracture(s). The parents have to date failed to give an account of any such notable event or events.
No account has been given.(h) Following the arm fracture and/or the leg fractures the child is likely to have cried in pain and would be inconsolable for a period; for the first 72 hours or so following the injury the child would have not moved or would have been reluctant to move the fractured limb(s); the child would have been distressed when the fractured limb(s) when moved or manipulated in and out of clothing; there may well have been an associated swelling around the fracture site(s).
It is submitted on behalf of the Local Authority that this allegation is satisfied on the face of the evidence. I agree.(i) According to Dr Watt the arm fracture would have occurred in the window from 13th to 19th March 2014. The leg fractures happened within the time window of 4th to 20th March 2014.
The medical evidence as to this has not been challenged. It is submitted that the mother's text message to the father on the morning of Tuesday 18th March indicates that the arm fracture had probably occurred by that time. I think that is a correct analysis.(j) In accounts given by the mother, upon the child's return to her care at around 5pm on Sunday 16th March following contact with the father; the child was whingey but the arm was not swollen. Further at times, the mother has indicated that on Monday 17th March 2014 the child was in a distressed state and P would make no effort to crawl. According to the mother on Tuesday 18th March 2014 the child was still making no effort to crawl, and she was grisly and clingy and did not want to be put down. By Wednesday 19th March 2014, the mother said that the arm was noticeably swollen, and that the baby cried when the arm was touched. P was not really moving the arm at all, and great care had to be taken when changing the baby. At 5.30pm on the Wednesday 19th March the mother took P to the A & E Department at the Royal Bournemouth Hospital. Regardless of whether the mother caused the fractures, the Local Authority seeks a finding that
(i) the mother's account is incomplete;(ii) at times her account has varied in detail significantly when given, and(iii) the mother unreasonably delayed in seeking medical attention for her child given her presenting symptoms.The evidence as to these contentions is clear. I find them proved.(k) The mother, or the father, or both parents in truth know more about the injuries and the circumstances of the injuries then they have so far been willing to admit.
The Local Authority limits this allegation to one against the mother. It is submitted that the mother knows what happened to P but has chosen not to tell the truth. I am satisfied that that is the case.
(a) Was there a DV incident between mother and father in late 2013? It is said after separation that there was indeed such an incident, and it is alleged that the mother assaulted the father and the police were called.It is clear from the mother's own evidence that she accepted on occasions punching and pinching the father although she denied biting him. R further described two occasions when she says the mother had assaulted her. I find that allegation proved.(b) Was there DV or aggression from the mother towards (Hayden) during their relationship?
I have already commented that Hayden was not generally a reliable witness. His account of the attack in the bathroom, however, carried the ring of truth. Having learned from the mother's mobile phone that she was conducting an affair with another man, he locked himself in the bathroom to read the messages on the mother's phone. The mother broke into the bathroom carrying a knife. He pushed her into the bath tub. This account is consistent with the experiences relayed by the father and R.(c) Did the mother ask (Hayden) to lie about his whereabouts in the period in which P could have sustained injury?
The evidence is not clear on this point. I do not think that resolution of this issue one way or the other takes the main part of this case any further. I make no finding as to this.
Dated this 20th day of January 2015
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HIS HONOUR JUDGE BOND