England and Wales Family Court Decisions (other Judges)

IN THE FAMILY COURT
Sitting at Medway

IN THE MATTER OF THE CHILDREN ACT 1989
& THE ADOPTION AND CHILDREN ACT 2002
AND IN THE MATTER OF A (dob 25.7.14)

		2 June 2015

1. SUMMARY
2. At the outset of this hearing there were two applications relating to baby A: both by Medway Council, for a final care order (issued 18.9.14) and for a placement order (issued 13.3.15), the plan being for his adoption. During the course of this hearing an application for further assessment under s38(6) Children Act 1989 was issued by the Mother that both parents should be fully assessed at Symbol residential centre, but where the Father will be taking the lead as A's primary carer.
3. Part-way through this hearing, having had an opportunity to consider the import of central aspects of the evidence heard and the relevant law, Medway Council, rightly and inevitably in my view, altered its stance so that it no longer pursued final orders at this hearing and agreed that it should fund a further assessment of the parents as outlined in the Mother's application. The reasons for this will become apparent during the course of this judgment.
4. I have made directions necessary to facilitate this assessment and to bring the matter back before me at an IRH soon after its completion in 6 weeks time. It is quite evident that such an assessment is absolutely necessary, and by Symbol who are a well-recognised centre of excellence in terms of assessment of families with issues of learning disability; going as it does to the heart of the case, namely: whether this Father can parent A (and his unborn child) as primary carer to a good enough standard and also support and assist the Mother to involve herself in the parenting of A as appropriate bearing in mind her learning disability, and also to analyse Mother's difficulties and thus the type of support she and the family require.
5. I have been obliged to consider and make very serious criticisms of the social work, the social worker, the record-keeping, the supervision/management of the social worker and the attitude towards working with this family, and of the foster carer and the investigation of complaints against the foster carer, and of the approach of the local authority to the key issues and evidence in this case. I have also been obliged to consider aspects of the case management and the non-compliance with directions that almost derailed a two week final hearing.
6. But for the assiduous commitment by the advocates appearing before me to carry out their roles with tenacity and helpfulness, and the court's attempts to encompass and accommodate the difficulties posed to the proceedings and to carry out its investigative role while preserving fairness and avoiding delay, there is a very strong possibility that this case may have resulted in gross delay, injustice, further prolonged and possibly permanent separation of the parents and their son or some unacceptable combination of the above.
7. CASE OUTLINE
8. A was born on 25.7.14 to RP and MK. He was born 6 weeks early and remained in Medway Hospital until 8.8.14 with his Mother until they moved to a mother and baby foster placement, under a section 20 agreement that had been signed by the parents on 6.8.14. He remained there with his Mother until she left it on 17.9.14 in circumstances which will be discussed further, and he then moved on to a second foster placement on 19.9.14 and at which placement he has remained to date following the grant of an EPO on that date and ICOs since 25.9.14. He has developed healthily and has regular positive contact with his parents with whom he has bonded well. He is a British child of mixed Indian and Pakistani heritage.
9. RP is a young woman of 26, born in England to a Muslim family of Indian origin. She is a British national and speaks fluent English and Urdu. She has been assessed within these proceedings as having a learning disability and has an overall IQ score of 54. She is married to MK, a young Muslim man of 27 who was born and brought up in Pakistan and who arrived in this country in October 2010 on a student visa. His visa was revoked after two terms due to his studies ending and he is seeking leave to remain in the UK. MK is a native Urdu speaker, but speaks some English. He has needed assistance from an interpreter at court. Due to his immigration status MK has no access to welfare benefits and is reliant on RP and their relatives, and any work he can obtain.
10. They met in the Ilford area where they both have relatives, and married in July 2013 at the Ilford mosque about two months after meeting. RP's family did not attend the wedding due to their then disapproval of the situation. The parents describe their relationship as a 'love marriage', and it is clear that they are very close. They are expecting their second child in August. They currently live together in a room in shared accommodation in Ilford with two other families. The maternal family have rallied in their support for this young family in recent months, and the parents have been supported during these proceedings by the daily attendance of Mr S (Mother's step-father) and by a maternal cousin, notwithstanding the former's full-time work as a taxi driver. Their plan, backed fully by Mr S, is for Father to give up his traditional role of provider in order to care for the family's children as their primary carer, incorporating Mother's role into the family as possible and appropriate, and for Mr S to provide and share their accommodation with them and to provide for the family financially.
11. Originally, Medway's stance had been to cite a wide range of concerns against the parents. These covered Mother's capabilities and behaviour, Father's attitude to Mother's abilities and to allegations of her poor behaviour, Father's allegedly controlling or abusive behaviour towards Mother, and the state of the parents' home in 2014. The criticisms of Mother's behaviour included significant allegations of abusive behaviour by Mother towards A and the foster carer which included: shaking A during the early hours of 17.9.14; slapping the foster carer on 16.9.14; and shouting abuse at A and the foster carer, including racist abuse. Additionally, Medway claimed that the Father's approach and the wider family's ability to assist were insufficient to meet A's needs. These allegations were set out in the initial threshold document and then in a Scott schedule that I requested be prepared at the outset of the hearing, and were further elaborated in the first SW Ms Anyimiah's and the current SW Ms Stewart's statements.
12. The parents claim that Medway had not considered them fairly, that the foster carer herself had been abusive to Mother with consequent impact upon the Mother, that their complaints had been ignored, and that the type of support necessary to this family had not been properly considered or provided, including the potential contribution from the extended family despite the Family Group Conference held in early January 2015.
13. The Children's Guardian Lynn Magson has been involved since the first ICO was granted. Her final report concluded, reluctantly, that the orders sought by Medway should be granted in the event that the allegations made by Medway were established. However, she too, on hearing the evidence and issues develop during the course of the hearing, now supports the assessment of this family by Symbol, and expressed a number of concerns and criticisms of Medway's handling of the case.
14. PROCEDURAL ISSUES
15. Thus at the outset of this hearing there were significant contested findings and the most serious of final orders sought against the parents. However, it became apparent that the preparation for such a hearing had been a mess, and there were a number of evidential and procedural issues that almost forced the adjournment of an entire final hearing that would have caused significant delay and extended further the separation of parents and child. I will discuss aspects of this case management as a separate final section of this judgment.
16. In short, it quickly emerged that the documents included in the 350 page PD27A compliant bundle prepared by Medway had been 'culled' (to use the term coined by counsel for Medway) from all the documents relating to the case. That cull had been undertaken unilaterally by Medway at the last minute and without agreement of the other parties, and they unsurprisingly considered it to be partial and incomplete. Last minute attempts were made by A's advocate to prepare a more comprehensive bundle. Given the wide-ranging and serious counter-factual issues it was necessary to further expand the bundle during this hearing to include key missing documents. These have included the medical notes and social work case recordings for the key period of August to September 2014, but the bundle was also even missing the Mother's statement and the Father's first statement.
17. Additionally, the evidence has now included the statements and notes of the Safeguarding Midwife Mrs Rose and the Health Visitor Ms Gibson. These were directed by DJ Gill at the IRH held on 5.2.15 to be filed by Medway by 12.2.15 and they were named in the IRH order as witnesses to be heard at the final hearing, but their evidence and notes were still outstanding at the outset of this hearing (mid-April). I made peremptory directions to ensure, in A's interests, that this evidence was available by day 3 of this hearing. Such directions were among those that should and could have been sought and made since the IRH but long prior to the final hearing. I was also obliged to direct that missing foster carer's notes and social work recordings from the crucial period in August and September 2014 should be provided. I did not permit Medway to file a further statement by Ms Down, supervising SW from ISP (the agency providing the foster placement), as to what she had seen, heard or done regarding the foster placement. This application was made over a week after the final hearing had begun and on the morning that the foster carer was due to give evidence. Ms Down had not been one of the named witnesses in the IRH order, and I considered it was unfair for the local authority to be attempting to add further evidence and witnesses at this very late stage in the proceedings, and would risk an unnecessary and disproportionate adjournment.
18. I have read all the documents and evidence filed in this case and all the documents additionally prepared by the advocates (whom, I must add, have been of great assistance to the court in the challenging circumstances in which this final hearing came to court). I have heard evidence from Mrs Rose, Ms Gibson, Ms Anyimiah, Ms Barton, the foster carer Ms McG, Ms Stewart, the parents and the Children's Guardian; and I have heard and read the parties' submissions.
19. I have also listened to and read the transcripts of four brief audio recordings taken in or near the foster home in mid-September 2014. These, it appears, were provided by the Father to his solicitor less than a week before this hearing, in a format that could not be readily opened or listened to, albeit that the ISW Ms Barton was able to listen to one of the recordings during her assessment of the parents in January 2015 and requests had been made since then for the provision of this material, albeit it appears that no directions were made at any stage.
20. It was clear that this material was, and has been proved to be, central to the parents' concerns and counter-allegations relating to the mother and baby foster placement. I will come on to consider the nature of these recordings in more detail, but in short the foster carer accepted during her oral evidence that two of the three recordings said to have been recorded in the foster placement were indeed conversations she participated in with the Mother. The third (a few words without context) she denied as being her voice. However, her concessions have meant that investigations of the provenance of those two recordings have not had to arise.
21. Following two of the recordings being transcribed overnight by A's advocate, I directed that the remaining two recordings be transcribed and that the parents' statements, the audio recordings and transcriptions should be provided to the foster carer before day 3 of this hearing, with additional directions that she respond in writing, attend court the following week to give evidence and may attend then with a legal representative. In the event, Ms McG did file a further statement in response, and attended court as directed, did not attend with a legal representative, but had not listened to the recordings until the morning she attended court. This was facilitated by using the Children's Guardian's laptop to do so at court. Thereafter, Ms McG asked for the opportunity to bring a legal representative to court. She clarified that this was simply as a result of having listened to the sound of what she had already read in the transcripts, and she also clarified that she accepted that it was her voice in the two principal recordings. The nature of the allegations against her were clarified, and she accepted my decision that the opportunity to bring a legal representative had been given her 6 days earlier and that as it was simply due to having heard the sound of the recordings (the text of which had been in her possession for 6 days and which she accepted were her words in conversation with the M), it would cause disproportionate and unacceptable delay to A for there to be an adjournment on the morning she was due to give evidence to permit her to instruct and bring a legal representative.
22. I have, as an additional step to observe and facilitate the Article 6 rights of those affected, provided this judgment in draft form to all parties and to those against whom I proposed to make findings (including Ms McG the foster carer), with permission that they could then provide such further written submissions to the court as they wished the court to consider, and of course could do so with legal advice and representation if they wished. I gave the parties 7 days to so respond, and Ms McG 14 days in order to permit time for her to take legal advice if she chose to do so. I have read and taken into account all such further submissions, received from Ms McG and on behalf of the Children's Guardian. Ms McG's submissions are dated 29.5.15 and are more in the form of a statement than submissions. I am satisfied, bearing in mind the over-riding objective and the need to avoid delay, that an appropriate balance was struck while still ensuring proper observation of the Article 6 rights of those involved.
23. On the first day of this hearing I also granted an application that the Mother should be assisted by an intermediary during the course of the hearing. Having read the report dated 10.4.15 that was prepared by Clare Jones, a full-time intermediary employed by Communicourt with qualifications in speech and language therapy and experience of working with those suffering communication disorders, it was absolutely clear that in order to ensure that the Mother had the opportunity to be properly and fully involved and represented at this crucial hearing, that she would need the help of an intermediary. There was clear scope, without such help, for Mother misunderstanding what she heard and for her instructions being inaccurate or misunderstood. There were additional concerns about her ability to answer questions, particularly of the sort often used during cross-examination. A 'ground rules' hearing took place on the morning of day 2 of the hearing with the assistance of the intermediary, and modes of appropriate questions were discussed and the need to take regular breaks of 15-20 minutes every 40-45 minutes to ensure that the proceedings were being followed by Mother, to take her instructions and give her advice and to provide her with a break so that her concentration could be maintained in the following hearing period. Additionally, due to the travelling time that required the parents to leave home at around 5.30am, and due to Mother's pregnancy and her learning disability, it was also advised that it was appropriate to avoid sitting late. This was achieved on all but one day when it was important to conclude the ISW's evidence.
24. I echo Mr Justice Cobb's recent commendation of Communicourt's service to the Mother and the court (Newcastle City Council v WM & Ors [2015] EWFC 42), save that the intermediary had to change half-way through the hearing due to prior hearing commitments of the first intermediary assisting the Mother. This problem undoubtedly arose due to approval for an intermediary only being given on day 1 of the final hearing, but it would have been preferable for Communicourt to have ensured there was a single intermediary available for the whole of the listed hearing dates. However, I am entirely satisfied that the Mother's was able to participate as fully and effectively as possible and that her Article 6 rights were well met in the circumstances.
25. By mid-way through the second week of this hearing, and in particular following the evidence of the ISW, the foster carer Ms McG, and of the SW Ms Anyiamiah, and before the parents gave their evidence, Medway necessarily reviewed its position. The most serious findings of abusive and aggressive behaviour by Mother against A and the foster carer, for which Ms McG was the sole witness, were no longer sought; and Medway acknowledged that it could not pursue final care and placement orders in the current circumstances. Those circumstances being: where the couple were united, the Father was offering to become A's and his unborn child's primary carer and to support the Mother's parenting to the extent that she is able, and where he does not suffer from a disability, and where his and Mother's capacity to meet A's needs in those circumstances had not been assessed, and in addition where the local authority faces serious criticisms as to their management of the case in its initial and later stages. Medway concurred that the family should be properly assessed on that basis, and indeed agreed to pay for that assessment at Symbol, and I have seen an amended care plan to that effect dated 30.4.15.
26. LEGAL FRAMEWORK
27. These applications are governed by the Children Act 1989 and by the Adoption and Children Act 2002. The welfare of the child is paramount and no order should be made unless it is in their interests. In coming to my decisions in this case I have borne in mind the paramountcy principle, the no order principle and the need to avoid delay set out at s1 Children Act 1989.
28. Each family member's ECHR Article 8 rights to family life are engaged, and any intervention of the court must be to promote those rights, to balance competing rights, and in doing so to give appropriate precedence to the welfare of the children and ensure that any intervention is necessary and proportionate. It is essential to bear in mind the principle that it is preferable, while also considering the child's needs, for them to be brought up within their own family.
29. I have not, due to the changed stance of Medway, had to consider the application of the relevant welfare checklist (dependent upon the order sought) nor, for the same reasons, have I had to consider the dispensation with the parents' consent under s52 Adoption and Children Act 2002 in the course of this judgment, but I have invited Medway from time to time during the course of this hearing to consider the adoption welfare checklist and the relevant case law.
30. Of particular assistance is the guidance provided in the leading cases of Re B [2013] UKSC 33, Re BS [2013] EWCA Civ 1146, Re G [2013] and most recently the helpful analysis of the President of the Family Division in Re R [2014] EWCA Civ 1625: a 'global' 'holistic' approach, based upon a sound and thorough evidential basis, looking at the pros and cons of the realistic options equally in terms of A's welfare interests, must all be considered. Those cases, and Re BS in particular, reflected on the case of YC v UK (2012) 55 EHRR 33 which stated that family relationships should be preserved, families rebuilt and family ties only severed in exceptional circumstances, and that it is not enough to say that a child could have a more beneficial environment for their upbringing elsewhere. If A's parents are able to provide good enough parenting then A's upbringing ought to be undertaken by them.
31. Medway was originally requesting the 'last resort' of adoption, and in relation to applications for adoption we derive the following important principles from the cases I have referred to: that the child's interests are of course paramount, but we must not forget that those interests include being brought up within their own family; and that intervention by the family courts must be proportionate and not become social engineering by turning away from leaving or reuniting children with their imperfect but adequate birth parents in favour of idealised alternatives.
32. In Re BS, Munby P also firmly comments at paragraphs 28-29 about the necessary consideration of what support should be provided to enable a parent to meet their child's needs and that local authorities should then take steps to ensure that they do what is necessary.
33. A requirement before any section 31 orders may be made, is that the court must be satisfied that the threshold test set out in section 31(2) Children Act 1989 is met, either by agreement or by findings, namely: at the time protective measures were put in place, 17.9.14, when A was separated from his parents', he had suffered and/or was likely to suffer significant harm and that harm or likelihood of harm was attributable to the care given to him or likely to be given to him, if an order was not made, not being what it would be reasonable to expect a parent to give him.
34. In relation to any findings: the standard of proof is the civil standard i.e. the simple balance of probabilities; and where I describe events or make findings, I have applied the balance of probabilities, the burden of proof being on the party seeking the finding. In making any findings I have considered all the evidence and submissions, even if every potentially relevant factor may not be specifically cited.
35. In the decision of the President in Re A 2015 [2015] EWFC 11 and as neatly summarised by Lord Justice Nicholls' in paragraphs 55-56 of Re J 2015 [2015] EWCA Civ 222, there will be particular, and even 'insuperable' difficulties for a local authority if it is seeking to base a case for permanent removal of a child from their family on important findings that are only based on hearsay and that are contested by that parent.
36. I also remind myself of the 'Lucas direction', namely that just because a witness lies about one thing, it does not mean that they are dishonest in all things, and the reasons for their lying need to be borne in mind. Additionally, I bear in mind the recent guidance of Lady Justice Macur in Re S 2014 EWCJ Civ (135), which makes the further point that non-disclosure or lying does not necessarily mean parenting or ability to co-operate is impaired:

"23. It has become de rigueur for a trial judge expressly to articulate their self direction in accordance with R v Lucas [1981] QB 720 in fact finding hearings. That is, the significance that may or may not attach to the lies told by a party in relation to the injury/behaviour in question. There is none such in this judgment which deals with outcome. A specific reference to the same is unnecessary but I do consider that it was unrealistic for the judge, and the professionals, not to have appraised the same exercise in the context of the non disclosure and/or deceit in question. The fact of a parent's non disclosure or deceit is not necessarily determinative of parenting capacity or, depending on the circumstances, an ability to co-operate with the authorities."

37. I have also considered the Working Together to Safeguard Children Guidance (March 2015) and the Good Practice Guidance on working with parents with a learning disability issued by the DoH and DES in 2007, and the cases of Re X Y X (Minors) [2011] EWHC 402 (Fam) and P v. Nottingham City Council and the Official Solicitor [2008] EWCA Civ 462.
38. OUTSTANDING ISSUES
39. Due to the contraction of the number and types of findings sought by Medway against the parents, the threshold criteria were partly agreed, but certain issues remain contested and are considered later in this judgment.
40. A further contested factual issue arises that does not fall within the threshold criteria, it having occurred during the currency of the proceedings and while A was living apart from his parents in foster care: whether the Father locked the Mother into their accommodation in Chatham while he travelled to London. This is set out by the ISW in her report. It is an issue which it will be necessary to determine so that Symbol can consider the history of the parents' interactions within their forthcoming assessment. I am also asked to consider the parents' housing, co-operation and sharing of information generally.
41. The remaining issues, while no longer central to the trajectory of the case and the plans for the child from this point, are highly relevant to the management of the case this far and therefore to the approach to this family and their reaction to that approach:

a) The propriety of the section 20 procedure and reliance on it;

b) The foster placement –

i) its appropriateness, and the failure to provide a specialist foster placement;

ii) monitoring of the placement;

iii) foster carer's record-keeping;

iv) verbal, racial or physical abuse by the foster carer;

v) complaints by the parents and the investigation of any complaints;

vi) the continuation of the foster placement on 16.9.14;

c) Further social work practice concerns in this case –

i) The adequacy of the social work record-keeping;

ii) The fairness of procedures up to and including the strategy meeting on 17.9.14;

iii) The exploration of alternative approaches to supporting A remaining with his family.

42. LOCAL AUTHORITY WITNESSES
43. MS ANYIAMIAH was the first social worker and allocated to the case for the key period from A's birth until November 2014. She gave evidence over two days, the second day being due to the failure by Medway to provide a set of social work recordings for the relevant period until days 5 and 6 of the hearing. Ms Anyiamiah did her best to recall the events that took place late last summer, but it was frequently the case that she asserted that something should be in her case recordings only for it not to be the case. Ms Anyiamiah began in a more resistant mode than she ended her evidence. By the end of her evidence she was quiet, abashed and readily admitting to several obvious deficiencies in her and Medway's management of the case. She struck me as hampered by her own poor record keeping, and increasingly aware of the inadequacies of her and Medway's handling of the case. Where she was inaccurate or inconsistent I did not consider that she was intentionally misleading, but was in genuine difficulties due to poor records and poor recall.
44. MRS ROSE was the safeguarding midwife at Medway Hospital and made the initial referral to social services by telephone on 1.8.14 following concerns expressed by her midwife colleagues, but which she had not witnessed herself save for occasions observing Mother's care of A when she had to reiterate the same things to Mother regarding basic care of A. She described Mother as very timid and quiet, that she cried and said she felt sad sometimes, and that she came across as quite vulnerable. She said she looked a bit frightened but that could be because of the circumstances of a tiny premature baby with not a lot of support. She confirmed that Mother said she was 'used to' Father shouting at her. She confirmed that she and not social services arranged for Mother to have a capacity assessment done by the learning disability nurse Ms Onaiyekan on 7.8.14 (M250), and that she definitely raised this at the meeting held before the section 20 agreement was signed on 6.8.14 (M99) due to her concerns about Mother's vulnerability and abilities. Mrs Rose struck me as a helpful, straightforward and honest witness who had taken her safeguarding role seriously in relation to both Mother and baby A.
45. MS GIBSON was the health visitor who was allocated to baby A following their discharge from the midwifery team, and she visited the family on 21.8.14, 2.9.14, at the LAC review on 4.9.14 and on 12.9.14. She was quite clear about the difficulties in achieving change in the Mother's habit of feeding A only 90ml of milk per feed during early September until she very strongly reiterated this on 12.9.14, and the importance of this due to his being unsettled and not making progress, and the need to increase feeds as the baby grew. She accepted that the drop in his weight at this time could be due to a number of factors. She confirmed her observations of Mother needing prompting and support in her basic care of A, and that at one point neither parent could accurately describe how to prepare bottle feeds. She said she had the impression from Ms McG that the foster carer genuinely wanted to help the Mother and had no reason to think she was putting on a show, and heard no negative comments from her. The foster carer did not strike her as the type of person who would tell Mother to piss off and slam the door on her. She too was a helpful, straightforward and honest witness.
46. MS JANICE BARTON is an experienced independent social worker who conducted a PAMS assessment of the parents in January 2015. Her report and conclusions set out her discussions with the parents and her views that she did not recommend rehabilitation due to the extent of Mother's needs, the time it would take to achieve any change and the lack of insight and resistance shown by the parents to such suggestions. She was a fair witness and eventually acknowledged that her approach had inevitably, despite the care she had taken to acknowledge the unproven nature of Medway's assertions against the parents, been affected by the repeated negative allegations against them. This was particularly apparent, for example in paragraph 134 of her report, where she confirmed that she thought the court would only have separated the Mother from baby A for a good reason by making findings at that interim stage last September. Hence she expressed herself in terms of it being justified to accuse Father of failing to accept those allegations against Mother made by the foster carer. However, they were not established findings. She accepted it would be fair for Father not to accept those allegations if Mother was denying them and there were no findings by the court, and in addition he was telling her about recordings made by them of the foster carer's behaviour towards the Mother. She reported that Father had tried to play her the recordings but that she could only hear the recording in which she could hear the Mother being told repeatedly to 'piss off'. She had never met the foster carer and so could not confirm who it was on the recording, but she set out the details in her report. She described the Father as bemused by the degree of intervention by social services. She confirmed that Father should have been sat down and had a proper explanation of the implications of Mother's cognitive assessment from the SW, and that when she herself did so in clear terms to him he was visibly shaken and changed his stance from asserting there was no need to help to proposing to care for A himself. She observed Mother's real difficulty simply changing a nappy during contact. She gave clear evidence, under pressing cross-examination, of her recollection of the episode when the parents were discussing with her the occasions when Mother had been locked into their property by the Father. I will consider this in more detail later in this judgment. She concluded her evidence by stating that if Father was sincerely willing to put himself forward as A's carer, and arguably also the unborn baby's and possibly also the Mother's carer, then there should be further assessment and preferably by Symbol. She added that, having now seen the Family Group Conference report, that their support should be considered as its content bodes well if the family were able to offer that help. My overall impression was of an experienced, empathetic and helpful professional witness, whose accounts of her observations were sound and honest. However, it was notable that she acknowledged that her assessment had been influenced by a misunderstanding of the weight to be given to the allegations in the case. This, in my view, had led her to misinterpret certain of the background issues and hence undermines her original recommendations that no rehabilitation should be attempted, albeit her accounts of her own direct observations were clear, cogent, consistent and reliable.
47. MS WINSPEAR gave brief evidence of the search for an adoptive placement for A, prior to Medway conceding that it would no longer be seeking final orders. She clarified that in the initial search for families prepared to take a Muslim boy born in 2014 and with some background of learning disability in the family about 20 families were listed nation-wide on the relevant register. This was prior to any further analysis of those results and would not indicate if they were still available placements, or would be actually suitable for A, and nor was she able to say how many other Muslim boys made up the pool of those for whom such placements were sought. Her evidence was too general to be of much help to the court if the placement order application were proceeded with.
48. MS STEWART is the current SW and has been since near the end of 2014. She gave evidence after the point at which Medway had agreed it would fund an assessment at Symbol. She highlighted difficulties with attempts to see the parents' accommodation or gaining an understanding from Father of their address despite several efforts to clarify. Four ante-natal appointments in Redbridge have been missed despite four messages left on Father's telephone for Mother. Mother does not have a telephone of her own. It became clear that Mother is still registered in Chatham for her benefits. She expressed concerns that Father was not simply being protective of Mother, but was being obstructive and not sharing information about Mother's family for the genogram. She was taking an appropriately fair approach to the question of further assessment of this family, given the highly unsatisfactory earlier stages of Medway's family, but she was also fair in highlighting ongoing areas of concern that must be the proper remit of the further assessment.
49. MS McG is an experienced foster carer, having fostered since 1998. She currently fosters two teenage boys, one of whom is of a Muslim background. She is a Seventh Day Adventist and of Afro-Caribbean ethnicity; the relevance of this being the contrast that the parents experienced with their own background. Her overall demeanour was striking, in that her tone was confident and assertive, to the point of frequently presenting as combative, abrupt and harsh. When challenged her voice rose quickly and her tone and vocabulary noticeably hardened. She was quick to answer, often speaking loudly and repetitively over those questioning her, and had to be requested on several occasions to calm her answers and refrain from arguing. She was quick to resist, resent, argue and disparage. I have taken into account that this was the first occasion that she has appeared and been questioned in court, and that she faced some robust questions but which were not inappropriate or hostile. Even bearing in mind that context her responses were remarkable as I have described and cannot, as she has submitted, simply be explained as discomfort or a natural reaction to difficult questioning. She gave inconsistent answers that did not always fit with her statements and other recordings. There was however a single area in which her answers had a slightly different tone and when she comparatively softened, and her voice dropped and she used a gentler and more straightforward mode of speech: when she was describing simple matters of the baby's needs and her observations or interactions with him. This was in the main quite a marked departure from the rest of her answers that were otherwise almost entirely antagonistic, and I found this to be a revealing factor that demonstrated perhaps some limited empathy for the baby that was noticeably lacking from the rest of her evidence. She did, in this more sympathetic mode, confirm that the Mother had indeed developed a good bond with A from a shakier start, and that she had seen the Father demonstrating hands-on competent care and a good bond with A. These less contentious and gentler aspects of her evidence centring on A, including those of Mother's repeated need for prompting and assistance in his basic care, chimed convincingly with the observations of Mrs Rose, Ms Gibson and Ms Barton, and I find those were therefore likely to have been genuine reports of observations of A's needs. I go on to consider her evidence in more detail later in this judgment, but in general I otherwise found her to be an aggressive and unhelpful witness who demonstrated significant and sometimes shocking antipathy towards the parents.
50. MOTHER

a) The Mother was assessed by Mr Crimes an Occupational Psychologist on 5.9.14 and by Dr Conning a Consultant Clinical Psychologist on 10.9.14. She scored 'extremely low' in all fields in Mr Crimes' assessment and in the 0.1^st percentile due to her full IQ score of 54, and he concluded she would have 'minimal capability' across key abilities such as communication, judgment, negotiation, planning, memory, comprehension, attention to detail, and would require significant support and guidance to make effective decisions. Dr Conning considered that notwithstanding the very low scores shown by Mother and their compatibility with a diagnosis of learning disability that she had capacity to conduct litigation, and she considered this may be due to the extensive support from Father and her legal advisers. Mother did not recall to Dr Conning that she had been to a special school and was surprised at her low results. She did in fact attend a special school and her family informed Medway and the hospital of her history of learning difficulties.

b) The further report from Communicourt dated 10.4.15 is not an expert's report, but was nonetheless most informative in its appendices, setting out specific examples of where the Mother had demonstrated failures to comprehend or respond accurately when given simple scenarios and tested by questions upon them. Of note was that Mother can show a good understanding of conversational language within a familiar context and would appear more able in that context, but her language and communication disability emerged more strongly in unfamiliar contexts requiring more detailed information. This was reflected during her brief period of giving evidence in court, and I do find that the Father's explanation that, as a non-fluent English speaker he had not fully noticed the degree of difficulty experienced by Mother who does speak English fluently, is borne out by her superficially more competent ability to chat in familiar contexts.

c) I do not propose to make any detailed findings at this stage as to her functioning, given the forthcoming assessment of Symbol, but I do find that it should have been clear from at least the date of Mr Crimes' report in early September that a specialist assessment would be required and that the foster placement would not be meeting her needs.

d) As a result of her difficulties and the advice set out in the various reports, but Communicourt in particular, attempts were made to limit cross-examination to essential matters and to certain types of questioning. It quickly became clear that it was difficult to achieve meaningful cross-examination due to her limitations and the necessary approach to them. As a result few matters were put to her and then only minimally. Due to her difficulties with memory and suggestibility, as amply and skilfully demonstrated in the Communicourt and psychologist's reports, I have very serious reservations about being able to rely on any of her recollections regarding contested facts.

e) She said she had lived at an address in Ilford for the last month or two with the Father, and where two other Bengali families also live, and until then lived in Chatham. She said Father had not raised his voice or hand to her, and that it was to Mr S her step-father that she had been on the telephone while at the foster placement. She explained that she recorded the conversations on the mobile 'because people won't believe me so I recorded it'. She claimed to have a key for the back door when Father locked her in their property in Chatham and that she told Father to make sure he locked the door so she was safe. She said she had not felt good in the foster placement without the Father because she wanted that support, and that she was happy that both of them were to be assessed at Symbol.

f) The Mother came across as quiet, shy, very happy and comfortable in her relationship with the Father, and it was clear that she loves her son 'with all my heart' and wants to be 'a proper family'. I accept the evidence set out in the foster carer's records, the contact records and observations of the ISW and the Children's Guardian that Mother has developed a good bond with A, but can show anxiety and confusion handling him and meeting his needs and requires support in doing so.

51. FATHER

a) The Father is a personable, charming young man of what appears to be at least average intelligence. He has some ability to speak English but expressly preferred the help of an Urdu interpreter while giving evidence. I heard his spoken English in the recording of his conversation with the SW outside the foster home, which then continued on to his conversation with the emergency services operator which immediately followed. His vocabulary and expression are understandably limited, but he was largely able to make himself understood to them. I can appreciate that he would not always be able to follow the jargon and nuance of court proceedings, and I have taken these difficulties into account when considering his evidence.

b) He confirmed that he was happy to go to Symbol and to take full 24 hour responsibility for A and his unborn child. I found his comments to sound entirely sincere. His ability to follow through with actions will be assessed in the forthcoming work at Symbol.

c) Equally, I am wholly convinced that the ISW was correct in finding that the Father was physically shaken by his realisation of the extent of Mother's difficulties when it was properly explained to him in January 2015. He was able to talk about this in convincing terms in that he had not had a proper explanation before and it was then that he realised and now understands that 'she will not change'. He explained how before that he had noticed her forgetfulness or picking a wrong word, and he thought it meant she had to learn things to keep them in mind. He said he had not been sure about her learning disability when other people said it. Bearing in mind his frequent attendance at the foster placement where he contributed actively to A's care and is said to have been the one who bathed A, and his 'protectiveness' of Mother at meetings and his locking Mother into their flat while he was away in London, I find that he was indeed aware that Mother was vulnerable and suffered some difficulties in her functioning albeit he may not have grasped the full extent and permanence of her learning disability. I accept that he did not understand it fully and thought it could be addressed by 'learning things'.

d) There were key moments during his evidence where he actively changed his answers in ways that could not properly be explained away as interpretation difficulties, for example where he explained in some detail in evidence in chief and cross-examination that he had only seen the kitchen and sitting area of Mr S's home in Ilford, but when challenged that he had told the Children's Guardian he had lived there, he then 'just remembered' that he had stayed at Mr S's home for a few days; and similarly he changed his account of what happened in relation to the flat keys when Mother was locked in to the property. I deal with this in more detail below.

e) I consider that the Father is a prime example of a parent involved in care proceedings whose evidence is not always truthful, but where the Lucas direction and the points made in Re S 2014 are highly relevant. I have borne in mind that English is not his first language and that he is unfamiliar with the way social services work in this country and with how matters might affect his immigration status. I consider that where I find that he has lied, for example in obfuscating details of his and the Mother's accommodation to the SW, the Children's Guardian and the court, or where he lied about locking the Mother into their home in Chatham, that these examples fall within the ambit of his eagerness not to be doing something thought wrong (locking Mother in) or his anxiety not to get something wrong due to misunderstanding what child protection professionals need to know or will find significant (his accommodation); and I emphatically do not find at this stage that any of this dishonesty or poor co-operation can be equated to an inability to parent A. The extent to which his co-operation or his relationship with the Mother may impinge on his parenting skills may yet be commented on by Symbol.

f) The Father clearly loves A very dearly, and I note that no witness who has observed him with A has failed to comment on the positive bond between them and his good efforts at hands-on parenting.

52. CHILDREN'S GUARDIAN, MS LYNN MAGSON – Due to the more limited nature of the proceedings by the time she gave her evidence, and the agreed proposals for the case to progress by way of the assessment at Symbol, the Children's Guardian did not need to give extensive evidence. She confirmed wholehearted support for that assessment as it was essential, in her view, to have a full understanding of Mother's difficulties and the impact on her parenting so that the Father's input could be assessed with that understanding and his commitment to the necessary responsibilities could be assessed. She too raised the difficulties that she had experienced trying to clarify the nature of the parents' present and future accommodation in Ilford, and that she had been given a number of different explanations and information. With regard to the foster carer, she emphasised how struck she had been by the exceptional nature of the foster carer's presentation and that in all her experience she would never have expected such evidence. She considered that other professionals, like her, may have found it hard to believe that a foster carer could be like this. She considered that the impact on Mother of her experience in that foster placement would have been highly stressful and would have caused her great anxiety; and I entirely accept this analysis. She was shocked that the foster carer was invited to the strategy meeting on 17.9.14, and at the extreme views expressed by the chair of that meeting against the parents; further commenting that once such views are expressed it can be difficult to change from that view. She was disappointed to discover that the hospital, and not social services, had taken the lead in initiating a capacity assessment of Mother and that she had signed the section 20 agreement beforehand without such an assessment. She considered, looking back with hindsight, that nobody (including herself) had ensured that Father had a proper understanding of Mother's learning disability or challenged him with sufficient information to ensure he was properly informed until he met the ISW in January 2015.
53. COURSE OF SIGNIFICANT EVENTS

53.1 A was born 6 weeks early on 25.7.14 and it was a difficult birth, requiring that the Mother receive blood transfusions. Mrs Rose made a referral from Medway Hospital to social services on 1.8.14. A number of concerns were expressed relating to Mother's ability to care for A unaided, the parents' relationship and that Mother was heard to say 'shut the fuck up' to A. Mrs Rose confirmed in her evidence that she did not hear this but believes she read this somewhere. She conceded that the only note that could be found of such a comment was of Mother saying this about another new mother in a neighbouring bed who was snoring.

53.2 While Medway chose to cite and rely on several entries in the hospital records relating to these concerns, they were all accepted to be second or third-hand hearsay and it was also pointed out that there were equally several examples of Mother being described as doing better and accepting help.

53.3 Following Mrs Rose's referral on 1.8.14, Mother was assessed for post-natal depression and none was noted. Given her difficulties I accept that it was unsafe for Medway to assert that this was a firm indication of no such issue at the time.

53.4 On 5.8.14 the SW met with the parents and noted Mother's vulnerability and struggle to understand and contribute to discussions. I note that the Learning Disability nurse advised the SW to make a referral to the Lordswood Learning Disability team. I have found no such referral in the notes. A strategy meeting was fixed for 7.8.14.

53.5 Later on 5.8.14 the SW visited the home in Chatham with Father and I accept her evidence that it was unsafe and unsuitable for a premature baby to return to, and was far from ideal even for two adults. It was an unfurnished and dilapidated flat above a former pub which was being converted into an off-licence. It lacked lighting in places and heating and hot water. The floors were unfinished boards. Although the parents' 'bedroom' was clean, the bathroom and lavatory were cold and mouldy. I accept that A was born 6 weeks early, but it is clear that it would have required a great deal of work in a remarkably short period of time to be brought up to an acceptable standard, and I note that there were still difficulties with basic facilities at the time that the Children's Guardian was visiting later in the year. I find that the parents' accommodation was seriously inadequate on a number of fronts.

53.6 On 6.8.14 the SW claims she contacted the Maternal Grandmother and Mr S to see if alternative arrangements could be made within the family to support them. Issues have been raised about her manner of doing so, and whether appropriate support was offered. I make no finding as it has not been possible to explore this fully, but I note that there were several meetings that took place on this date and the SW will have wanted that information beforehand and so may have sounded abrupt and left little time for matters to be considered.

53.7 By the end of that day the parents had signed a section 20 agreement which they and Mr S thought simply covered a two week period in a mother and baby foster placement. It is clear from the notes in the medical records, and the SW accepts, that the issue of Mother's vulnerability was raised by Mrs Rose before Mother signed the section 20 agreement. The SW also accepted that in addition to the hospital's concerns, Mr S and the Maternal Grandmother had confirmed that Mother had a learning difficulty. The SW accepted that it was not appropriate to have obtained Mother's signature to an agreement under s20 in such circumstances where her cognitive abilities had been questioned by other professionals and no assessment had taken place. I also note that it was obtained prior to the strategy meeting taking place on 7.8.14.

53.8 The following day on 7.8.14 the Mother was assessed by the Learning Disability nurse. I consider this to have been an entirely appropriate step taken by the staff at Medway hospital. It concluded that Mother had capacity, but understandably may have missed the more nuanced difficulties with Mother's failure to comprehend and to convey her lack of comprehension due to her superficial abilities to chat.

53.9 Mother was assessed again at the hospital before discharge by Ms Ashton, specialist midwife for mental health, who concluded Mother did not show signs of post-natal depression, but expressed further concerns about Mother's ability to process information. Mother then moved to the placement on 8.8.14 and remained there under section 20 for 40 days until the placement came to an end on 17.9.14.

53.10 On arriving at the placement the SW accepts that the parents were disappointed that it was so far from Father's home in Chatham and that it was not a Muslim placement.

53.11 On 19.8.14 the Access to Resources Panel met and highlighted concern that Mother's ability to consent to s20 should be established, clarified that the foster placement would not be carrying out an assessment but that it would be done by the SW and by a cognitive assessment of Mother by a clinical psychologist. The panel approved the continuation of the foster placement for a maximum of 12 weeks.

53.12 A cognitive assessment of the Mother did not proceed on 21.8.14. The Father accepts that he discouraged this from taking place.

53.13 On 27.8.14 Dr Tsang paediatrician who examined A on 26.8.14 emailed to the SW a confirmation of a discussion with the SW in which she had highlighted conflict and tension between Mother and the foster carer during her examination, in the context of Mother requiring clear and step by step verbal instruction. The foster carer is described as a quiet spoken lady and that Mother raised her voice and accused her of trying to separate the family. In the light of my own impression of the foster carer, it is clear that, and I note, that Ms McG certainly had the capacity to present to both the HV and Dr Tsang in this positive calm way in the early stages of the placement. However, I find that this should, in the context of a non-specialist placement about which the parents were already complaining, have set alarm bells ringing for the SW who should have immediately investigated the extent of Mother's vulnerability in the placement. There is no record of any such step having been taken.

53.14 On 2.9.14 Mother missed a further cognitive assessment appointment due to having a bad back.

53.15 On 3.9.14 there was a pre-proceedings meeting held at the foster placement at which the parents were informed that Medway intended to issue proceedings and the parents agreed an extension of the s20 agreement. In the minutes of the LAC review meeting held on 4.9.14 it is suggested that it was only on 3.9.14 that the parents first raised their complaints about the foster placement. However, the SW Ms Anyiamiah accepts that they had been raising concerns throughout the placement. On 3.9.14 the parents were told that their complaints would be considered at the LAC review.

53.16 At the LAC review on 4.9.14 it was noted that the plan for permanence was for Mother to attend a specialist mother and baby placement once the cognitive assessment was carried out and if the assessment indicated it was appropriate 'so that a thorough assessment can be undertaken', and if there were no concerns then Sunlight would carry out a joint parenting assessment. Neither specialist placement nor assessment took place. The LAC review reveals no detailed minute or discussion of the complaints or concerns held by the parents about the foster placement save that it is reported that the parents raised that the room is cold, the two foster children play loud music and swear and that the foster carer used inappropriate language; and that the placement is not a cultural match and the parents wanted to be placed with Muslim carers as they feel their needs are not understood, and want to live in Redbridge where they have family support. The recommendations of the LAC review include reference to a written agreement about the language to be expected in the home, hygiene, respecting one another in relation to being adults and cultural differences. The SW claimed that this was to address the parents' grievances, however it clearly makes reference to hygiene which, as will be seen later in this judgment, was an issue of particular concern to the foster carer. I have not been referred to any such written agreement and I find that it was never followed through.

53.17 Until this point there had been limited emails and occasional more formal notes kept by the foster carer, but from this date it is noted in the LAC review minutes that she would be writing notes of progress and concerns. At these two meetings it was also decided that Father's contact at the foster home should be reduced to 3 hours 4 days per week. The rationale given by the SW was that this was done in order to see Mother's capabilities. I find that this was unusually unhelpful given that this was not a specialist placement, would isolate and expose her vulnerability unnecessarily, and that Father was willingly attending more often in order to try to support Mother's care of A.

53.18 On 5.9.14 the Mother was assessed by cognitive psychologist Mr Crimes, and this was sent to the SW on 8.9.14.

53.19 On 10.9.14 the SW emailed her Team Manager Jayne Morrell and Service Manager Jayne Grice and drew their attention to the mention of a specialist placement at the meetings with the parents earlier in September, to the assessment of Mr Crimes and the strategies he recommended to work with Mother which she rightly pointed out 'can be best achieved with a specialist placement setting'. She mentions Mother's struggle to care for A and that she is 'beginning to demonstrate increased levels of frustration/aggression at her son', and points out that they have complained about the placement. She asks if these managers want the forthcoming care plan to include consideration of a 'specialist MB placement'. No reply to this email appears on the social work records and the SW was unable to recall any response she had been given to this email, save to claim that it was possible it had been informally discussed.

53.20 On 10.9.14 Caroline Down the foster carer's supervising SW from ISP, the independent agency providing the placement, emailed the SW following a visit to the placement at which she put Mother's concerns to the two boys at the placement. They both vehemently denied playing music loudly as they use headphones; or swearing or making lots of noise as they said the foster carer is very strict about swearing and Ms Down avers that she has observed them to be quiet; and that Ms McG has no pork in the house. They also said they had not heard Ms McG shouting and swearing but pointed out that they could not say what happens when they are not at home. Nor, I observe, would they hear anything if they were wearing their headphones. Ms Down reports the boys' concerns that Mother was shouting at, about and in front of A. Other than this enquiry by SW from the ISP agency itself there is no other investigation of the parents' complaints.

53.21 The health visitor last visited on 12.9.14, resulting in an email to the SW about her strong advice to the Mother to ensure A is fed 120ml per feed.

53.22 It is from 13.9.14 that the foster carer's notes include references to abuse from Mother to the foster carer. Until this point from the start of the placement on 8.8.14 there have been mixed reports in the notes, including improved bonding between Mother and A, good bonding between Father and A and his competent hands-on care of A; but also concerns expressed by Ms McG about Mother's care of A including the need for repeated advice, prompting and support, her ability to cope and respond to advice, and her manner of speaking to A where she becomes upset and blames A for her predicament. On 13.9.14 Ms McG alleges in her note that Mother told her to 'fuck off out of my room', 'go to hell' and 'fuck off you black bitch get out of my room'.

53.23 On 14.9.14 Ms McG claimed that Mother told her to fuck off and raised her hand towards her in the kitchen while saying 'don't you dare touch my son', and during a disagreement about time out of the placement to see the Father, Ms McG claims Mother said 'I don't give a shit about the baby, my husband comes first and half an hour isn't long enough you fucking cow'.

53.24 On 15.9.14, although this is nowhere included in Ms McG's carer's note of this date, Ms McG claims in a separate document entitled 'My Personal Statement' that Mother slapped her in the kitchen and called her a 'fucking black bitch' following Ms McG refusing to give Mother money and telling her to ask her husband for it. She follows this with the suggestion that Mother immediately accused Ms McG of slapping her instead. At the end of this document she sets out that in the evening when she was on the telephone with her daughter Mother came downstairs saying 'why can't you shut your mouth, there's a baby upstairs trying to sleep and who are you talking to anyway?' Ms McG's document then claims that she responded 'Who I'm talking to is none of your business' whereupon Mother left the room and went upstairs.

53.25 It is clear that the recording made by the Mother at the foster placement entitled 'Piss off and get lost and bad language' (transcript G41) is, by the admission of Ms McG, a recording of the conversation that took place that evening to which she briefly refers in My Personal Statement as I have described above. It is far from the encounter described by Ms McG in My Personal Statement. In it, Ms McG grossly over-reacts to calm requests by the Mother to 'just keep your voice down please' with an astonishingly vicious barrage of repeated words of abuse at Mother followed by the door being slammed on her. I return to this later.

53.26 The second recording is likely to have been recorded on 16.9.14, and before the arrival of the ambulance called by Mother, as there is no mention of the pushing incident nor of the ambulance being called, whereas there is mention of Mother coming down the night before and asking Ms McG to keep her voice down, being sworn at and having the door slammed on her. It is a recording that is again accepted by Ms McG of a conversation that took place between herself, her adult son and the Mother (transcript G42 'New Recording 10'). It is notable for its insensitive discussions with Mother by Ms McG and her son, for the Mother asserting that she is being disrespected by Ms McG in response to being told by the son that she is disrespecting Ms McG, for Mother reporting what happened the night before, and of Mother denying allegations that she swears or racially insults Ms McG or slapped her.

53.27 On 16.9.14 Ms Down again emailed the SW at 09:01 and 13:34. The first email (G45) attaches a document called 'My Personal Statement' and sets out Ms Down's concerns about the alleged slap of the foster carer by Mother and that she may have to give notice on the placement. It is not clear but it is likely that this is the same document that the court has seen dated 15.9.14 and headed My Personal Statement.

53.28 The second email (G57) sets out the observations of Ms Down that she heard Mother shouting while she was at the placement in the morning of 16.9.14, taking details from the foster carer of her claim that she was slapped by Mother the day before. She cites concerns about the racist and physically abusive behaviour to the foster carer and the 'continual allegations' by the parents. She criticises the amount of 'babysitting' the foster carer is said to be doing of at least 4 hours per day, and that she believes this family has 'massive issues with working with Black Caribbean/Black African individuals' and that this needs to be challenged and addressed immediately. I note that I did not hear direct evidence from Ms Down, for reasons already mentioned, and so I make no findings about her enquiries or the shouting she or the boys claim to have heard. I note that the foster carer's notes never mention any excessive babysitting, and the only mentions are of the parents going out for appointments such as for the cognitive assessment on 5.9.14 or for 45 minute walks together (17.8.14) and the disagreement on 14.9.14 when the parents were out for just under two hours. This begs the question as to whether Ms Down was familiar with the content of the foster carer's notes at the time she sent this email or was simply repeating the foster carer's allegations, and I find that the latter is the more likely.

53.29 Shortly after, at 14:47 on 16.9.14 the SW emails Mr Jacob of the Medway legal department about the increasing concerns as to Mother's behaviour becoming increasingly worrying and 'dangerous', and that the Team Manager Ms Morrell thinks that the plan should be altered to safeguard A and to issue proceedings without further delay. She confirms that the carer's daily logs can be filed later in the proceedings. The SW confirmed that she had not seen all the carer's notes at this point, and that the parents' concerns had not been set out in the social work records, nor investigated by anyone other than Ms Down.

53.30 Meanwhile, at around 2pm according to Ms McG's note, the Father arrived at the foster home and Ms McG claims in her note that he told her to 'leave my wife alone or I'm going to sort you out', and the parents then left for a walk for about an hour. At 15:54 according to the ambulance records the Mother called the police and ambulance to the foster home, claiming that Ms McG has pushed her. Ms McG sets out in her note that Mother would not tell her why she had called the emergency services, but also reports that the paramedics informed Ms McG of the accusation made by Mother that she had pushed Mother hurting her back. The paramedics treated Mother for muscular skeletal soft tissue injury and give advice on pain relief as set out in their record of attendance. The foster carer claims the police then called her to tell her they will attend within 4 hours, but they did not in fact attend. Mother is noted by the paramedics as having reported to them that she was pushed and fell over that morning resulting in back pain. In her statement the Mother states she was pushed by Ms McG into a table. It is notable that despite their attendance and treatment of the Mother, this episode is subsequently dismissed by the SW and foster carer, and by an ISP manager, as their 'finding nothing wrong', with the implication that the Mother has fabricated or at least exaggerated this incident and that they are therefore entitled to disregard it.

53.31 Later that afternoon the SW visits the foster home and on her way there is met by the Father outside on the street a few houses away. The third recording is of the conversation between them in which the Father shares his concerns and is urged by the SW to speak to his solicitor or to make a formal complaint. Her tone is patient but becomes slightly more anxious and short when it is clear that she can hear the Mother's cries and shouts from the foster placement. These can be heard on the recording and I find that these were loud cries of anguish and distress by the Mother calling for her husband that could be heard several houses away, and are as reported by the SW and the foster carer. She is reported as holding A while in this distress, and I find that it is likely that she was holding him at the time the SW arrived. Once the SW leaves the Father he then continues recording a new conversation he has started with the emergency services due to his concern about the Mother in the placement. His anxiety and distress become apparent and he occasionally sounds tearful, but at no time does he behave or speak inappropriately or lose his temper.

53.32 Notwithstanding the Mother's complaint of an assault by the foster carer and her calling the ambulance and police, the SW calmed her down and encouraged the Mother to return to the foster placement. There has never been any investigation into this complaint of assault made by the Mother against Ms McG, and I find it astonishing that the SW should have sanctioned, let alone encouraged, a continuation of this placement leaving such a vulnerable new mother with the foster carer who she is said to have slapped the day before and whom she claims pushed her earlier on this day.

53.33 It is at around this time that the Father is said to have raised a hand towards the SW during further conversation on the street between the parents and the SW, and during which she claims she was trying to encourage the Mother to visit her GP due to her distress the SW had witnessed earlier. I consider this incident later in this judgment, but in the highly stressful circumstances of 16.9.14 I do not find it to have been an inappropriate action by the Father nor indicative of abusive or controlling behaviour.

53.34 So Mother returned to the placement that afternoon once the SW had left. Ms McG alleges in her note of 16.9.14 that ten minutes after the SW left, the Mother re-entered the house and immediately slapped her across the face screaming 'put down my son'. Ms McG claims she then called the police, and goes on to state that Mother again told her to 'fuck off, fuck off, fuck off you black bitch' when offered help that evening. I have seen a social work case recording said to have been made at 03:39 on 17.9.14 (G1) detailing a call from Kent Police at 22:37 (on 16.9.14) as Mother had called them due to not getting on with the foster carer. This is followed by a call to Kent Police by social services to update them and referring to Mother apparently slapping Ms McG. A further call is made at 03:08 by social services to the police who had not yet attended the foster home. I have seen no record of the foster carer telephoning the police as she claims about being slapped by the Mother.

53.35 In the early hours of 17.9.14, the foster carer claims she went unannounced into the Mother's room due to continued crying by A which changed in pitch, and saw Mother shaking A. She called the ISP out of hours service and the police and was advised to take A to hospital. Entries in a social work case note (G2) suggest that these calls were made at about 4am and that at least by soon after 4am the police were at the foster placement. There were significant discrepancies in the foster carer's evidence regarding this very serious allegation against the Mother, and also regarding the other serious accusations by her against Mother, covering the timings, the movements, and the reporting and consistency of the allegations. I address these later in this judgment, but note here that these are the allegations originally sought against the Mother by Medway, but which after the conclusion of the foster carer's evidence were unsurprisingly discarded. In particular, I note here that I find the timing of this shaking allegation, coming as it did straight after the foster carer knew the police and ambulance had been called on 16.9.14 due to an accusation that she had assaulted the Mother, to be significant; and in combination with other key features of the foster carer's evidence, drive me to conclude on the balance of probabilities that this assertion that Mother shook A cannot be relied on as a truthful account.

53.36 A was then taken to hospital with the foster carer and Mother was sent home to the Father and has been separated from A ever since. A strategy meeting then took place at 2pm on 17.9.14 on the paediatric ward at Medway Hospital at which both Ms McG and a Ms Hannett from the ISP agency were present, and contributed to the discussion of the risks said to be posed to A by Mother. There were no concerns raised about Mother's allegations which were described at the meeting as 'claiming various misdemeanours and that Ms McG pushed her and she hurt her back' but were immediately dismissed by Ms Hannett due to the ambulance crew finding 'there was nothing wrong', and no strategy meeting nor any subsequent investigation were undertaken to consider Mother's claims of abuse and assault by Ms McG. The acting team manager Ms Willis, chairing the meeting, described both parents as 'clearly not suitable to care for [A]', that both are 'very aggressive and it is a miracle that [A] has not been seriously injured mentally and physically'.

53.37 Proceedings were issued on 17.9.14 and an EPO was granted on 19.9.14. A remained with Ms McG until moving to his current foster carers on 19.9.14. A contested ICO hearing took place on 25.9.14, where no opposition was mounted to the ICO and no evidence was heard. Directions were made. Mother was then assessed by Dr Conning in early October 2014.

53.38 The second CMH took place on 31.10.14, and a timetable was created. Reference is made to the Father providing information sought in an email from the Child's Solicitor dated 6.10.14. It is unclear from the order if this relates to the recordings.

53.39 There was no progress made on suggestions that the family should be assessed by Medway's in-house service Sunlight, despite the Children's Guardian chasing for it through late 2014. The SW was reallocated in November 2014. The parents were then assessed by the ISW Janice Barton in January 2015 following further delay and subsequent to further directions made on 5.12.14.

53.40 Eventually, despite it being set out in numerous sets of directions in 2014 the Family Group Conference took place on 4.1.15. Mr S attended with 9 other friends and relatives. There was a great deal of support for the parents discussed, and in particular that the family could be supported by moving in with Mr S, with additional support and help from female friends and relatives in caring for and learning how to care for A. The new SW Ms Stewart attended and confirmed that these were all positive leads. She also confirmed that her concerns are set out at the end of the FGC report (G21) which primarily relate to a timetable, and the provision of details so that feasibility can be considered. A further FGC is suggested to clarify those issues, but none has ever taken place and Ms Carmit accepted that no further action was taken thereafter in any respect to explore this support available to the family.

53.41 The ISW's report was completed on 18.1.15. She interviewed the Father on dates in December and January, and the January dates all post-dated the FGC. My understanding of her evidence was that the discussion with Father when he finally better understood Mother's difficulties and was shaken by that understanding came towards the end of their interviews, and thus was likely to have also post-dated the FGC meeting.

53.42 Directions were given on 15.1.15 to permit instruction of Communicourt. The IRH took place on 5.2.15. No further directions were made at that point as to any special measures Mother required or in relation to the recordings that were played to the ISW. Extensions of time were given to Medway for the provision of statements and source documents that had already been directed on several previous occasions, including: midwifery and health visiting notes, and a statement from the foster carer. The case was timetabled to a 10 day final hearing on 13.4.15 and allocated to an unknown circuit judge.

54. THRESHOLD CRITERIA
55. The following are agreed by the parties as constituting and meeting the threshold criteria as at 17.9.14:

a) For a limited period, up to 12.9.14, the mother for whatever reason was unable to follow the new advice of the recommended 120 ml milk feed for A with the risk that he might be underfed.

b) Over time, Mother was observed by a number of professionals to struggle to maintain the provision of basic care needs of A without prompting and guidance.

c) Father had shown that he was unable to engage with professionals and put all guidance given on parenting into practice. Father had indicated that there was no need for professional involvement because at that time he thought that the extended family in Redbridge would be sufficient help.

d) The family home in Chatham was observed to be unsafe and not habitable for a young baby to live in. For example, there was no running hot water and no heating. In spite of the obvious hazards and the unsuitability of the home condition at the time, there was no other property that the parents could provide as a home fit for their newborn son.

e) Father failed to acknowledge and lacked insight into Mother's cognitive difficulties until carefully explained by the ISW Janice Barton in January 2015.

56. These items are contested and are taken from the final draft of Medway's proposed threshold findings document:

f) When asked about the report of Father being heard shouting at Mother, Mother reported to the Safeguarding Midwife Mrs Rose that she was "used to" Father shouting at her.

In the light of the expert evidence as to Mother's capabilities, and in particular the high risk that she may misunderstand, misreport or be suggestible, I do not consider it safe to take from her comment to Mrs Rose that there was shouting from Father of a significant sort to justify any inference of domestic violence. I do not doubt that Mrs Rose accurately and fairly reported her recollection of this conversation, but its relevance to threshold issues cannot safely be established. This is particularly the case where the parents have raised the possibility of their being a cultural difference that has been misunderstood, namely that an Urdu-speaking couple will be louder and more assertive in their speech patterns than a couple speaking English and that this may have been misinterpreted. Additionally, I note that this finding is sought in the context of there being no direct evidence of any actual shouting or other inappropriate behaviour by the Father towards the Mother, and Medway are not seeking such a finding given that comments of this nature in the hospital notes are second or third-hand hearsay and thus all the more susceptible to such misunderstandings and are unable to be tested, and therefore unsuitable to provide the basis for such significant findings. Mrs Rose confirmed that she had seen or heard no such behaviour herself.

g) At times Mother was prepared to say that she had learned enough to care for A without support. At other times Mother said that she did require support to help care for A.

It is pointed out on Mother's behalf that Mother at times is recorded as having acknowledged that she needed support (for example on 6.8.14 in hospital at page M100), while perhaps she understandably resisted such suggestions in more formal and adversarial settings such as the LAC review meeting on 3.9.14. And it is pointed out on Father's behalf that given Mother's learning disability it is unwise to place too much weight so soon after the arrival of her premature baby on her differing comments about her perception of the support she might need. However, in the context of it being conceded that Mother was observed by a number of different professionals at different stages to be unable to carry out basic tasks correctly without prompting and guidance, and where the Father himself was unable to comprehend the nature and degree of support that Mother would require until he had it properly explained to him by the ISW in January 2015, it is clear that she did need considerable support and that as a family they lacked an adequate insight into that factor in order to guard against its consequences. These are not criticisms of either parent, but are simply the facts of the state of affairs that existed at the time of the issue of proceedings, and which inevitably placed A at risk. It is also suggested on Mother's behalf that, but for Medway's failure to work with the Mother and Father appropriately, this state of affairs may not have arisen in that the Father would have had proper advice and Mother would have had proper assessment and support and therefore there would have been no consequent risk to A. This may be a fair assertion as to what Medway ought to have done (and which omissions I comment on later in this judgment), but it does not remove that state of affairs as it existed at the point that Medway issued proceedings on 17.9.14, and as such must fall to be considered under section 31(2) Children Act 1989.

h) A cognitive assessment of Mother was completed with the finding that her cognitive functioning was "extremely low". Mother's scores across the four indexes [sic] of Verbal Comprehension, Perceptual Reasoning, Working Memory, and Processing Speed were all extremely low with an IQ of 54 (less than 99.9% of her normal age group). The risk to A being that without the necessary support and without fully being assessed by the Local authority [sic] Mother was unable to meet A's needs.

This is resisted on Mother's behalf as an element of the threshold criteria, on the basis that it thereby somehow suggests that all those experiencing a learning disability and with an IQ of 54 are automatically unable to parent their child to a good enough standard. However, it is the case that the Mother was assessed by Mr Crimes and that he describes these findings in relation to her cognitive functioning scores in his report dated 5.9.14, and as summarised in the first sentence set out above. It is also the nub of this case that Mother has a learning disability, without which disability the Father would not have struggled with understanding its implications for their parenting of A, and without which the various professionals would not have made their observations as to Mother's repeated need for prompting and guidance when providing basic care for A. Again, in the context where Mother accepts that she was observed by a number of professionals to struggle to meet A's needs without prompting and guidance and where the Father accepts that he did not fully understand the implications for her parenting of A until January 2015, it can be seen in this particular case with these particular circumstances and as at the date of 17.9.14 when proceedings were issued, that without assessment of the difficulties posed for Mother's parenting of A and the provision of consequent necessary support and without Father's insight into these problems, A was likely to be at risk of significant harm in her care. This is by no means a blanket finding that all those with such a cognitive assessment are therefore unable to parent (which would be an unfair and inaccurate generalisation, and I acknowledge that the bare diagnostic result from psychometric testing is not correlative in itself with parental adequacy: paragraph 1.2.6. DoH Good Practice Guidance), but is driven by the acknowledged facts of this particular case.

i) In his protective role Father accepts that his behaviour towards Mother could be seen by others as controlling and domineering. He did not understand at the time that such behaviour may not have a positive effect on a child's emotional well-being.

This 'acceptance' by the Father does not extend to his agreeing this concern is a threshold criteria factor (a position also held by the Children's Guardian), but that he may have been perceived, wrongly, as controlling and domineering while trying to guide and protect the Mother in their interactions with the local authority. The Mother's position is that it is simply not accepted that the evidence establishes that he behaved in this way. Medway asserts that the evidence is there from the SW's account of the Father answering for Mother during meetings and barring her from attending the first cognitive assessment appointment in August 2014. They also cite the later occurrence of the Father locking Mother in their property in Chatham as evidence that can be seen to vindicate this as a threshold finding. While I acknowledge that the Father accepted that he resisted the Mother attending the first cognitive assessment appointment, and there was some caviling about her attendance at the 5.9.14 appointment, I note that Father does not speak very good English and was at the time in the throes of finding himself deeply at odds with a social work team in a child protection system that he did not fully understand, and where he felt that no-one was listening to his concerns about his wife's experiences in the foster placement. He may well have spoken protectively and taken over discussions given the Mother's communication difficulties. Other observations that allege controlling behaviour, such as at the hospital, have been discussed already and hearsay does not suffice to establish such a finding. I note that the SW Ms Anyiamiah herself did not want too much emphasis on or for it 'to be overplayed' that she had stated that Father had raised his hand towards her during a conversation outside the foster home when he was discouraging her from speaking to Mother after she left the foster home on 16.9.14. She agreed that it was a highly stressful occasion for all concerned, and she was not concerned that Father was being deliberately threatening, but that he was concerned that Mother should not say anything more at all. She said she did think it was controlling and a domestically abusive relationship. In the circumstances that I have considered in the round, I find it unsurprising on 16.9.14 that the Father should have abruptly raised a hand to prevent further discussions with the Mother. She had been very significantly distressed only a short while previously, screaming for him from the foster home, and having been treated by ambulance staff following her claim of being pushed and hurt by the foster carer. I do not find that Father was being controlling or domineering on this particular occasion, but was understandably highly anxious. I deal later in this judgment with the allegation that he locked Mother into their property in Chatham, and I have found that it is more likely than not that this occurred, and that he is likely to have done so in part because he did worry about the Mother's abilities on her own. The question of the nature of the relationship between the parents and how the Father manages the Mother's vulnerability is one of the matters that must be assessed by Symbol, and I do not consider that the evidence before me at this point assists me to be able to make any clear finding as to whether it was protective, mistakenly so, or controlling. It does not in any event necessarily equate to a pattern of abusive behaviour that would pose a risk of significant harm to A.

j) Father failed fully to co-operate with professionals and acknowledge all of the local authority's concerns, especially after he perceived [the foster placement as being] an unsuitable placement for Mother and his son and the apparent failure of the Local authority to acknowledge or deal with his complaints about the placement.

In the light of the findings I make in this judgment, I find it unsurprising that the Father has conceded that he felt unable to demonstrate complete co-operation with the social workers in the case and acknowledge Medway's concerns in the period immediately leading up to the issue of proceedings in mid-September. He was instrumental in his wife not attending the first cognitive assessment appointment in August, and I have discussed this in the paragraph above, however he was assiduous at attending other meetings, attending the foster placement to help with caring for his son, and attempting to put forward his own concerns about the placement and Medway's approach. I do not consider that this is a true threshold issue, but it shows the understandable effect of this local authority's actions and omissions upon the Father, and is also likely to be reflective of his limited understanding of the child protection system in this country; and I consider that the observations in Re S 2014, that problems of this sort do not equate to or imply an inability to parent are significantly applicable to this issue of Father's approach in 2014. What was unhelpful, and that I have not fully understood the reasons for, was the failure to ensure that the recordings that have proved so crucial in this case were promptly provided once they had been made and certainly once they had been played to the ISW and were being requested by the Children's Guardian and Medway. Again, this is not a threshold issue, but the parents' co-operation and the Father's ability to demonstrate insight will undoubtedly be central to the future assessments in this case.

57. LOCKING MOTHER INTO THE FLAT
58. This issue came to light in the ISW's assessment when she learnt from the Mother that Father went about twice per week to London from about 5-10pm, leaving her locked into their accommodation on her own. She said she had no key and agreed she would have to try to escape through a window in an emergency. She also said she did not like it, but she was not worried about it being unsafe as the Father would check everything before he left. The ISW reports that Father confirmed that he did lock Mother in the property but assured her it was not frequent. When Ms Barton identified safety risks the Father gave her an assurance he would ensure a key was cut for Mother.
59. In her oral evidence Ms Barton was just as clear. She described exploring it in some detail with the Father and her own visit to the property. It had a roll-down shutter to the front of the shop covering the shop door, stairs at the back leading up to the flat above. It was fully double-glazed and she checked that there was no key available for Mother for the back door. She was quite clear she had been shown no keys for either front or back door and there was no key hanging by the back door. She explained that the Father had told her that there were only two keys and that he had one and the landlord had the other and that he would get a key cut for the Mother.
60. At first, during the Father's oral evidence, he said that he had one key and the Mother had the spare key, and that it was hung in a box in the kitchen. Later in his oral evidence he said that someone else had cut a key for the Mother the day before, and this was clarified as being the day before he went to London. He asserted that he only went on one occasion. He claimed that he did not tell Ms Barton about the key, but then said he did tell Ms Barton about there being a back door key but that she did not go close enough to the door to check. When I attempted to clarify what he was telling me, the Father then said he got a key cut the next day, and could not answer properly when I asked why there was any need to cut her one the day after Ms Barton had visited if in fact the Mother had a key. His answers were puzzling and inconsistent, and attempted to distract from Ms Barton's clear account. His response to the Mother's account to Ms Barton was that she often forgets things under pressure, but this does not explain his own confusion as to getting a key cut.
61. I have taken into account that during her brief oral evidence the Mother reported that she had a key to the back door and that she told the Father to lock her in so she would be safe. I note that this is entirely different to her account detailed by Ms Barton, and I have already mentioned my concern about reliance on Mother's ability to recount accurately. Due to her cognitive difficulties, she was not challenged in cross-examination with her account set out in Ms Barton's report. I therefore do not place great weight on these comments during her oral evidence.
62. I firmly prefer the evidence of Ms Barton and I find that Father was not telling the truth to the court, but had been more truthful in the first place to Ms Barton, i.e. the Mother's account of being locked in and of not having a key. Ms Barton was able to report conversations and details of the arrangements in the flat with consistent recall and cogency. She gave a consistent and firm account of her conversations with the Mother and with Father at the time; Father confirming the situation and that Mother had no key as he and the landlord had one each and he would get a key cut for the Mother. This is consistent with Mother's discussion with Ms Barton of how it made her feel and that she would have to use a window in an emergency. I take into account Mother's difficulties with memory and suggestibility at that time, but this was a concrete situation. The discussion was taking place at the flat itself and related to recent events and to the Mother's feelings provoked by being shut in, plus the Father confirmed Mother's account then to Ms Barton so corroborating Mother's account to her.
63. I feel less able to find whether this took place twice per week as Mother told Ms Barton, or much less often as the Father relates. Timings are clearly something that the Mother finds particularly difficult to relate clearly and accurately. For the same reason I am unable to find that Mother's account to Ms Barton that she had not seen her family in Ilford since before A was born is accurate.
64. Medway seeks this finding against the Father that he locked Mother into the flat in order to assert that the Father is controlling and domineering towards the Mother and that this is a dangerously abusive relationship. It is not clear what the Father's motivations were, and this will be further assessed in the coming weeks at Symbol, and I do not consider that this episode and the finding that I have made permits the court to extend so far as the assertion by Medway. But, given the nature of Mother's difficulties and her forgetfulness that the Father was prepared to acknowledge, I consider it is likely that at least in part the Father was locking her in due to his anxiety about her vulnerabilities if she were on her own. The fact that she did not like this and that she also told Ms Barton how it made her remember the upsetting time when her own mother locked her in to their home when she was younger demonstrates a lack of insight by the Father into how to manage the Mother's vulnerabilities. Whether this was mistakenly protective and paternalistic, or controlling and/or abusive is not clear. What is clear is that this was unsafe and inappropriate, and I consider that the Father became aware to some extent of the inappropriateness of his actions once he had seen the ISW's report and this has led to his attempts to deflect the court from this finding.
65. Again, it remains to be seen in the forthcoming assessment how the dynamic of their relationship functions and is affected by any increased knowledge and understanding and by their altered roles, and in particular how his management of this challenging and unfamiliar full-time role of parenting can be combined with appropriate handling of the Mother's weaknesses and vulnerability.
66. FAMILY'S CO-OPERATION & ACCOMMODATION ISSUES
67. I have set out difficulties experienced by Ms Carmit and the Children's Guardian in relation to identifying and visiting the parents' accommodation. This must be remedied. Housing and benefits difficulties should not be concealed and appropriate assistance should be provided. And there remains complete lack of clarity as to why the recordings made last September were not promptly provided by the Father to his solicitor
68. I acknowledge the context of distrust and suspicion that the course of events and the Father's evidence revealed, but it is clear that there has been unhelpful obfuscation by the Father in relation to accommodation in particular. There is now an opportunity for a fresh start and for open and honest working together in A's interests.
69. SECTION 20
70. The guidance of Hedley J in Coventry City Council v C, B, CA and CH [2012] COPLR 658 is as follows, at paragraph 46: "i) every social worker obtaining consent to accommodation of a child from a parent (with parental responsibility) is under a personal duty to be satisfied that the person giving consent does not lack the required capacity; ii) the social worker must actively address the issue of capacity, take into account all the prevailing circumstances and must consider the questions raised by Mental Capacity Act 2005, section 3 and in particular the mother's capacity to use and weigh all the relevant information; iii) if the social worker has doubts about capacity, no further attempt should be made to obtain consent on that occasion. Advice should be sought from the social work team leader or management."
71. I acknowledge that the Father signed the section 20 agreement, but this is not good enough (cf s.20(7) Children Act). I have been appalled at the reliance placed by Medway on a section 20 agreement signed by the Mother. She was encouraged to sign it on 6.8.14 without any assessment of her learning difficulty or her capacity. This is wholly unacceptable when the SW knew from the hospital staff and family members that Mother had a learning difficulty and appeared to have problems with her understanding.
72. Medway should not have waited to rely on assessments prompted and undertaken by another agency. Given the anxieties expressed by Mrs Rose at the meetings on 6.8.14, I consider that a section 20 agreement should never have been pursued that day.
73. While I accept that subsequent assessments, by the Learning Disability nurse and by Dr Conning, have suggested that she has capacity, these should not vindicate this practice of relying on a section 20 agreement that was obtained beforehand. In any event I do not consider that an Learning Disability nurse's assessment on the ward should have been relied upon in relation to the import of a section 20 agreement by which a parent agrees to major interferences with the family's life. And I further note that Dr Conning's assessment of the Mother's capacity in October 2014 was couched in terms of having capacity in the context of her being supported by her legal team and her husband (also legally advised by then).
74. It is likely that the cognitive assessment appointment two weeks after the section 20 agreement was signed, on 21.8.14, followed from the Resource Panel's concerns expressed at the meeting on 19.8.14, and there appears to have been no attempt by the SW or her team manager to arrange one before then. Although I acknowledge that efforts were then made to obtain a cognitive assessment of Mother on 21.8.14 and 2.9.14 that were not successful due to the Mother's non-attendance, nonetheless it meant that the section 20 agreement that was extended on 3.9.14 was equally flawed.
75. Mr Crimes' assessment was sent on 8.9.14. He assessed Mother as having a full IQ score of 54, and as he noted in the accompanying email to the SW this was about the lowest level of functioning he had ever assessed. This was not an assessment of her capacity but set out a grave picture of impairment of her ability to comprehend and make decisions about complex information. Mother was not then assessed as to her capacity until 10.10.14 which was within the care proceedings and with the benefit of legal advice and representation – an important difference. Given the information from Mr Crimes on 5.9.14, Medway should immediately have taken steps in early September and not continued to rely on a section 20 agreement obtained from a vulnerable new mother with this degree of learning disability.
76. Several difficulties arise for vulnerable adults in these circumstances. They are unlikely to want to appear to be difficult or obstructive and so they may well agree to section 20 arrangements that are not necessarily appropriate. Once they have agreed to such arrangements, and are in a mother and baby foster placement as in this case for example, there is a natural impetus to remain with the child and so be locked into a continued agreement to the arrangement. Most significantly, the use of section 20 agreements results in vulnerable adults coping with such circumstances without legal advice or representation.
77. This was compounded here by there being no referral to adult services and no input from social workers experienced in working with vulnerable adults and who are not focussing simply on child protection issues, but are able to bring their knowledge and experience to bear on the case.
78. Just over 40 days passed between the section 20 agreement and the issue of proceedings. It was in this period that the Mother was placed in an inappropriate placement, isolated from her family and increasingly deprived of the support of her husband, and moving towards the breakdown of the placement. I acknowledge that this is not the length of time experienced by the families in the recently reported cases of Re P (A child: Use of section 20) [2014] EWFC 775 and Northamptonshire and DS [2014] EWHC 199 (Fam), but the real significance is this: if it had been properly recognised that section 20 should not be used in these circumstances and proceedings had been issued at an earlier stage, it is likely that arguments about appropriate placements and assessments would have been raised by the parents' legal representatives, and an inappropriate placement and lack of assessment and ultimately early separation of baby A from his parents may well have all been avoided.
79. FOSTER PLACEMENT
80. I find, and the SW accepted, that this was not an appropriate placement. I accept that Ms McG is an experienced foster carer and has successfully cared for children including her current charges for many years. I also accept that in the first couple of weeks she described getting on very well with the parents. However, Ms McG was not a specialist foster carer with specific training and/or expertise in working in partnership with parents with learning disability, as is recommended in the DoH Guidance (at 2.2.15). This placed A and the Mother, and indeed Ms McG, at a disadvantage which it was Medway's responsibility to avoid. Ms McG explained that she underwent two days training a year as a foster carer, and that this contained elements relevant to learning disability such as having to speak slowly and make sure that parents understood. It was absolutely clear from her oral evidence that any comprehension she had of Mother's difficulties was extremely limited. She described her as 'unwell' or that 'she wasn't well'. And she also, at the strategy meeting described the Mother as trying to 'turn the tables on me'. She repeated this in her oral evidence, saying that Mother was 'devious', and 'building [a case] up so that she would be removed from the house' and that her actions had been 'calculated to provoke me'. This implies a degree of cleverness, cunning and forethought that it is clearly beyond the Mother's abilities, and thoroughly demonstrates Ms McG's lack of understanding of learning disability. It is clear to me that Ms Mc G's lack of experience and understanding in this area, and the attitude to Mother's learning disability that she betrayed in her evidence, must have meant that her interactions with Mother were unlikely to have been sympathetic to Mother's needs and therefore unlikely to have been successful in supporting Mother.
81. I also accept that it was not ideal to place Mother in a non-Muslim household. While Ms McG had a Muslim teenager placed with her, this is vastly different to living in a Muslim household and being in an environment geared to and familiar with the practices and expectations of a very different culture. Ms McG was asked about her accommodation of Mother's needs as a Muslim and gave three practical examples in that she had provided a mat for prayer and had bought halal food and not cooked pork, and had provided separate eating utensils which were not used after the first occasion. These were appropriate steps and I do not criticise the foster carer for doing her best in this respect. Parents cannot always expect to be placed in culturally matched placements, and it should not necessarily have determined whether this placement should be used, but it was an additional difficulty for an already vulnerable mother to cope with in an otherwise ill-suited placement in terms of meeting her and A's primary need for an environment skilled in supporting parents with a learning disability.
82. The SW acknowledged that a specialist foster placement or a 'specialist placement setting' (as in her email of 10.9.14 to her managers) should have been provided. She asked for a specialist foster placement and was offered this placement. I appreciate that Mother and Baby placements are a scarce resource, but if it was not suitable it was not suitable and an alternative resource should have been pressed for. The success of Mother and Baby placements often relies heavily on the direct relationship forged between a mother and the foster carer. This will become all the more crucial and potentially fragile where the mother suffers from a difficulty such as a learning disability. I find that Medway fundamentally let down A, his Mother and indeed Ms McG, by placing them together in what should have been evident at the time was an unsuitable arrangement.
83. It is notable that a period of two weeks was mentioned at the meeting in hospital when the s20 agreement was signed on 6.8.14, and a specialist placement of some sort should have been found in that limited period. It may then have been simply pragmatic to support Mother and A in an otherwise unsuitable foster placement for that limited period. As it was, an extension was approved by the Resources panel on 19.8.14, but even they acknowledged that the foster carer would not be carrying out an assessment. Over three weeks later the SW pursues this point with her managers in her email of 10.9.14, but no further action is taken.
84. The SW also accepted that given the concerns in this case combined with the unsuitability of the placement, that she should have monitored the placement very closely. She pointed out that she made about weekly visits, and certainly far more than was statutorily required. She did accept however: that she had not read all the foster carer's notes; that she was unaware that some notes were missing; and that her social work records do contain a referral from Dr Tsang that highlighted possible difficulties and vulnerabilities in the placement that should have resulted in closer monitoring. There is no record of any response to that referral about Dr Tsang's observations of an unhealthily difficult interaction between Mother and Ms McG during the visit to her clinic in late August.
85. The foster carer's records and statements gave me great concern. Her initial recordings are in the form of brief and informal emails. These recordings progress in late August/early September to more formal notes using a set form. The first set of her records filed by Medway in these proceedings was missing all her notes from 8.8.14 to 3.9.14 and the note of 14.9.14 and the document entitled My Personal Statement dated 15.9.14. By day 3 of this hearing most of those missing documents had been provided, at my direction, but notes for 11, 12, 19, 26, 27, 28, 30 and 31 August, and 3 and 8 September were still missing.
86. When the foster carer attended to give her evidence, I directed her to email and bring on the following day any of those remaining missing notes that had been emailed at the time in August and September. I stipulated that these should only be the original emails bearing the original notes to ISP, so that we could be quite clear that they had been sent at the time and what they had said at the time. I also clearly explained that they should not be newly written up, but that I was directing the provision of only the original recordings sent at the time in August and September. This was not done by Ms McG. Instead she chose to bring newly written notes of most of those dates, unconnected to any emails. She confirmed that they had not been sent at the time, but she had written them up that night before returning to court with them, and had done so from her handwritten notes that she had found for the purpose.
87. This was concerning in a number of respects. Firstly, they had not been written up at the time and thus were not sent, but neither ISP nor the SW noticed that these dates were missing. This is indicative of poor management and supervision of this placement by ISP and Medway. Secondly, she had claimed the day before that she had shredded all the hand-written notes that she had made, but was now claiming that she had found some notes. She had also claimed that she used a 'diary' to record her observations. This then became a 'notebook', the pages of which she tore out and shredded, and so she said she was unable to bring any original notes to court. I have taken into account her submissions that this was all a misunderstanding, and that she meant that she had only shredded the notes she had written up and sent. This was not what she told me during her oral evidence, and I find that Ms McG was dishonest and actively misleading about her note-keeping practice. I find that I cannot rely on her assertion that none of her original notes could be inspected, as she clearly then found some in order to cover up her gaps in recording. I also find that she did not regularly write up her notes each evening as she claimed, or there would have been no such gaps.
88. The document My Personal Statement dated 15.9.14 (N45-46) differs from the placement recording note she completed bearing that date (N21-22). It appears to have been sent to Ms Down at ISP either late that night or the next morning as Ms Down attaches it to her email to the SW at 09:01 on 16.9.14. Ms McG claimed in her oral evidence that she thinks she wrote it several days later over the following weekend (20-21.9.14) and that is why it was not in her foster placement recording of that date. I do not believe that it was written so long afterward given Ms Down's email. I note that My Personal Statement contains an inaccurate reference to the conversation in which Ms McG viciously shouts 'piss off' repeatedly at the Mother before slamming the door on her, characterising it instead in both the note recording and My Personal Statement as a rude attack by Mother to which Ms McG claims she mildly responded.
89. We know however, having listened to the recording and read its transcript, that in fact the Mother was calmly and fairly meekly pointing out that the conversation was noisy for the baby and that Ms McG was 'shouting so loud' and that she did not ask who Ms McG was talking to as Ms McG claims. After a few exchanges of this nature Ms McG explodes against the Mother, shouting and using a remarkably vicious, loud and nasty tone:

"R….. piss off out I'm getting it on the phone piss off out R….. piss off out I'm on the phone when you on the phone chatting loud in your in your Pakistani language I don't say anything I just grin and bear it yeah I don't (indistinct) so piss off out and leave me on the phone piss off. Piss off when (indistinct) your Pakistani language I not saying anything I leave you (indistinct) but get with I don't say anything to you right, so get lost"

This is then followed by the sound of steps walking away and a door loudly slammed.

Ms McG accepted that this is her voice and this was how she behaved to Mother on this occasion. She was unrepentant during her oral evidence, but in her submissions indicates she has now reflected on this and accepts that she behaved inappropriately, for which she now apologises and will be seeking support from her fostering agency. She claims that this inappropriate behaviour was as a result of repeated provocation and the breakdown of the placement. I shall return to that assertion later.

90. I find it is significant that My Personal Document is written after this incident and is then sent to Ms Down, and contains an allegation against the Mother that she had slapped Ms McG that is not in the recording note covering that period; and that it also contains an inaccurately anodyne account of this wholly inappropriate loss of temper and swearing at Mother. I do not understand why its content about Mother slapping her was not included in the recording note of 15.9.14, unless it simply had not happened and so had not been written up into it earlier that evening.
91. If we consider the account of a slap in My Personal Statement on 15.9.14 and the further slap alleged on the evening of 16.9.14 in the recording note of that date, there would appear to be two incidents when Mother slapped Ms McG. However, I note that only one is mentioned in the foster carer's first statement and not at all in her second statement. In her first there is no mention at all of the alleged slap on the afternoon of 16.9.14, which I consider would have been a significant and memorable occurrence, coming as it did straight after the ambulance and SW visits. I also note that at the strategy meeting the next day Ms McG only cited a single slap by Mother. Ms McG's oral evidence failed to clear up any of this confusion, and I found her accounts consistently inconsistent and unsatisfactory, although she did maintain that Mother had slapped her. The local authority no longer seeks a finding against the Mother that she slapped Ms McG, and the Mother denies having done so. In considering the totality of the evidence, I do not find that the complaint of a slap on 15.9.14 is reliable and I consider that the inconsistency of the accounts also casts doubt on the reliability of the alleged second slap on 16.9.14. I am driven to find that it is likely that Ms McG feared a complaint about her abusive outburst to Mother on the night of 15.9.14 and tried to pre-empt this by making a complaint about Mother slapping her and playing down her own abuse of Mother and playing up Mother's alleged abuse of her. She did not, of course, know at the time that she had been recorded and so that the significance of this would be picked up and any denial of her behaviour towards Mother that evening of 15.9.14 could not therefore be maintained.
92. Ms McG tried to claim in cross-examination that her tirade against the Mother on 15.9.14 that I have set out above did not use swearing, and that it was not 'abuse'. This is obviously an absurd minimisation in the face of wholly inappropriate behaviour. She was thoroughly and vehemently unrepentant, claiming she would do 'absolutely nothing' differently. She also tried to claim that this was the only occasion she spoke this way to the Mother, and that the Mother had deliberately provoked her by coming down and asking her to be quiet. In her submissions she further claims that the parents began a campaign to complain about her and repeatedly provoke her in order to bring about the end of the placement so that they could live together and thereby preserve the Father's immigration status. I do not accept these assertions. A good point well made by the Children's Guardian's advocate was how unlikely it was that on the occasion that Mother tries to record the foster carer it happens to be the only occasion the foster carer swears loudly and viciously at her. The Mother's case is that she was recording her as she was not being believed about being treated abusively and that this was a regular occurrence. I find that it is highly unlikely that this was the only occasion, and that the Mother was indeed trying to record her following a series of such occasions of verbal abuse and mistreatment that she had tried to complain about. I also consider that it is highly unlikely that the parents could have planned such a campaign, hoping to get such a response from the foster carer, or could have predicted what outcome would arise from highlighting the problems they were experiencing.
93. Ms McG also submits that her allegations against the Mother that the Mother was abusing and slapping her were not properly investigated and so she could not present her explanation fully. Ms McG attended a strategy meeting on 17.9.14 at which she repeated at least some of those claims, and was assisted by Medway's legal department to prepare her first statement filed in these proceedings. Her agency ISP has supported her in making her statements and by attending court to support her attendance. Until a point in this hearing after Ms McG had completed her evidence, Medway itself was pursuing these findings against the parents. Ms McG was the source of these allegations and has been able to set them out in statements and repeat them to me and be questioned about them, and therefore I do not follow and reject this submission.
94. There is no contemporaneous written note by the foster carer of her allegation that she saw Mother shaking the baby. It only appears via the recordings of professionals involved at the time and in the foster carer's first statement dated 11.3.15 which provides little clarifying detail. The foster carer's oral evidence was inconsistent with accounts recorded by those professionals. She said it took place soon after midnight and she demonstrated two slow shakes by Mother while saying 'shush shush' to A. The records suggest she claimed there were three shakes to the SW and paediatrician, and she subsequently accepted she may have said three shakes to them. ISP worker Ms Hannett's account of what Ms McG told her was noted by the duty SW in the early hours of 17.9.14 and state that Ms McG told her she saw Mother holding A under the arms but with her hands behind his head. The call from a PC French also set out in the duty SW recording at 04:51 states that 'the actual shaking incident did not involve the baby's head moving separately from its body'. I conclude from these recordings made very soon after these professionals had spoken with the foster carer that they are recounting a description given by her of a limited kind of shake involving some protection of the head from moving, although it is difficult to imagine someone both holding a baby under the arms and holding their hands behind his head. This contrasts with the 'vigorous shaking' described by the foster carer to the paediatrician and repeated in the strategy meeting notes. Finally, Ms McG's submissions refer to seeing Mother "jolt the baby whilst trying to shush him", and this is a slightly different version again, and certainly not one shared at the time with the child protection and medical professionals. These descriptions were not greatly assisted by Ms McG's oral evidence where she demonstrated two limited forward and backward movements. She was unclear when pressed about the position of Mother's hands. She said she had not seen Mother's face as Mother's back was to her. She described Mother as holding A out in front of her, in which case I am not convinced that she could have had the clear view of what was happening in front of Mother's body as she claims. For these reasons, and as outlined already in conjunction with the timing of her extremely abusive reaction to Mother on the night of 15.9.14 and the timing of Mother's complaint against her on 16.9.14 of being pushed and hurt, I do not consider that this can be seen as a reliable account by the foster carer of having witnessed Mother shaking A. I was unsurprised when Medway chose not to pursue these allegations against Mother further.
95. The second conversation, in which her adult son can be heard speaking, I also find to have been wholly inappropriate. The foster carer claims that some disrespectful comment by the Mother precedes the start of the recording and led to her son's reaction challenging the Mother not to disrespect his mother. I acknowledge that her son does not raise his voice and I accept that on one level they do simply point out that she is not prevented from leaving but if she were to do so they would have to inform social services, but the foster carer does not intervene to control or limit the conversation which repeatedly challenges the Mother and in which she is accused of being attention-seeking. She joins in the conversation with a number of challenges and some sarcastic laughter. However, it is all conducted with a level of inconsideration bordering on scorn for her predicament and her learning disability. Ms McG claimed that there was nothing wrong with this conversation and that the Mother was attention-seeking. She should not have permitted or conducted such a conversation with the Mother, and (until receipt of her submissions) has clearly failed or refused to see why. As I have already discussed, this conversation is likely to have taken place some time on the morning of 16.9.14 before the situation escalated further.
96. I am asked to consider whether the foster carer was racially abusive to the parents. She denies it, claiming that as she is black she is aware of how inappropriate it would be, and countering with her own accusations that the Mother called her a 'black bitch'. In her oral evidence she added that the Mother had called her a 'black bastard' and said that she had never wanted to live in a black home. Being called a 'black bastard' has not featured previously in any account given by the foster carer. I am aware that the parents were indeed very unhappy at not being in a Muslim household, but given the manifest difficulties with the foster carer's evidence and that Medway do not seek such a finding, I do not consider making such a finding against the parents.
97. In her oral evidence the foster carer made some notable remarks. She repeated several times, and with almost as much venom and resentment as in the recording I have quoted above, that she had to 'grin and bear it' while the Mother was talking on the telephone 'in her Pakistani language'. Mother speaks Urdu and is British of Indian origin. She never once in her recordings or her evidence correctly used A's name, but dismissed this due to the name having been changed. She denied using the terms 'Indian dog' or 'Pakistani dog'. She described the parents as 'reeking' of body odour that permeated her home, and in her emailed note of 15.8.14 wrote that they 'absolutely stink', a phrase she repeated more than once and with emphasis in her oral evidence. While I accept that she needed to draw attention to examples of poor hygiene, I find that the manner in which she did so was vindictive and pointed, and not simply a straightforward observation. Overall I find that there was an ongoing vigorous antipathy to the very physical presence of the parents in her home, that she resented listening to Mother speaking in Urdu, and I do find that she demonstrated in court gross racial insensitivity and a visceral dislike of the parents, nastily expressed. The evidence is however insufficiently clear to make any finding of racial abuse and I do not make such a finding against the foster carer.
98. Ms McG denies that the few words of the final recording of "dog you shithouse you dirty dog" are her voice. There is no context for these words and the Father, who says he recorded them during a disagreement with her, says his telephone ran out of power almost immediately after he switched it on to record. While the voices appear similar, the circumstances of this recording are too uncertain to reach any finding.
99. I am invited to find that Ms McG pushed the Mother on 16.9.14 resulting in a minor injury to her back. This is strongly denied by Ms McG, and she submits that this was the apex of increasingly serious lies made up against her, and she seeks a positive finding that she did not push the Mother. She cites that there was no physical sign of injury found by the ambulance crew, and that she has never been investigated or charged with any offence at any time before or since. I have rehearsed the main points of the evidence earlier in this judgment, and the context and timing of this allegation in the process of the breakdown of this placement and the conclusions I have so far drawn in relation to the foster carer. I note the Mother's account varies slightly between that reported to the paramedics and in her statement. I have no detail as to the exact circumstances of the push, the moments leading up to it, its timing, its whereabouts, and the actions and movements involved. I take note of the surrounding circumstances which include the Father being said to warn the foster carer to leave his wife alone, the ambulance being called, and the degree of the Mother's distress that afternoon, and which are relied upon by Mother's counsel as circumstantial evidence indicative of the push having occurred. I include in my consideration that Mother could not be cross-examined in detail on this point, and I conclude that in all these circumstances that it is not possible, given the lack of detail and the quality of the evidence before me, for me to reach a finding against the foster carer, nor for the same reasons is it possible to make a positive finding that the Mother was not pushed. In doing so, I note that this matter has not been investigated by the local authority nor any other agency, and that other bodies have other duties they may wish to perform in relation to such an allegation.
100. It will be evident from what I have set out so far, that Medway did not adequately investigate these complaints by the parents. It is unclear whether Ms Down of ISP was requested to look into the earliest set of complaints, which included verbal abuse by the foster carer, or whether she was simply informed of these complaints and looked into them automatically as part of her role as supervising SW at ISP. It can immediately be seen that the SW of the agency being paid by Medway to provide this foster carer is in a compromised position with an obvious conflict of interest in doing so. The brief discussion of the complaints at the pre-proceedings meeting and LAC review meeting on 3 and 4.9.14 were not adequate: full details were never sought from the parents, nor their complaints properly noted in the social work records; the only forum for exploring the issues was at formal child protection meetings primarily concerned with other matters; no complaints process was offered or explained to the parents; and even the 'agreement' referred to at the end of the LAC review minutes was never pursued. This forms part of my concern that the parents' complaints were never properly attended to or taken seriously by the professionals, but were dismissed as insignificant or unworthy of proper attention. This was a serious corporate failing by all concerned.
101. It beggars belief that after the events of 16.9.14, when the foster carer was claiming that she had been slapped by Mother and Mother was claiming she had been pushed and hurt by the foster carer, that the SW encouraged Mother to return to the placement and her management sanctioned its continuation. Notwithstanding where the truth of those allegations lay, this was clearly not an appropriate environment for A, nor his vulnerable Mother. As I have already mentioned in considering the Children's Guardian's evidence, I find that this environment would undoubtedly have had an extremely negative effect on Mother, depriving her of the support of the Father, exposing her to unskilled and unsympathetic foster care, and in a hostile environment about which she complained but where her complaints were dismissed. It is unsurprising that she became anxious, upset and distressed and that the placement broke down.
102. SOCIAL WORK PRACTICE
103. I have set out in Appendix A and B to this judgment respective links to the 2007 DoH Good Practice Guidance on working with parents with disabilities which is cited as a relevant resource in the 2015 Working Together Guidance, together with limited extracts from those documents (while of course recommending that these documents should be properly considered by those involved in this case in their entirety).
104. I also quote here from Mr Justice Baker's analysis in Re X Y X (Minors) [2011] EWHC 402 (Fam):

"132. The last thirty years have seen a radical reappraisal of the way in which people with a learning disability are treated in society. It is now recognised that they need to be supported and enabled to lead their lives as full members of the community, free from discrimination and prejudice. This policy is right, not only for the individual, since it gives due respect to his or her personal autonomy and human rights, but also for society at large, since it is to the benefit of the whole community that all people are included and respected as equal members of society. One consequence of this change in attitudes has been a wider acceptance that people with learning disability may, in many cases, with assistance, be able to bring up children successfully. Another consequence has been the realisation that learning disability often goes undetected, with the result that persons with such disabilities are not afforded the help that they need to meet the challenges that modern life poses, particularly in certain areas of life, notably education, the workplace and the family.

133. To meet the particular difficulties encountered in identifying and helping those with a learning disability in the family, the government published in 2007 "Good Practice Guidance on Working with Parents with a Learning Disability". In their closing submissions, Miss Ball and Miss Boye contended that such good practice guidance is required because there is little evidence of effective joint working between adult and children's services and practitioners in each area rarely have a good working knowledge of the policy and legislative framework within which the other is working. They submitted that local authorities frequently do not take account of the fact that, if children are to be enabled to remain in their own families, a specialist approach to a parent with a learning disability is absolutely central to any work that is done, any protection which is offered and any hope of keeping the family together. The 2007 guidance points out, inter alia, that a specialised response is often required when working with families where the parent has a learning disability; that key features of good practice in working with parents with a learning disability include (a) accessible and clear information, (b) clear and co-ordinated referral and assessment procedures, (c) support designed to meet the parent's needs and strengths, (d) long-term support where necessary, and (e) access to independent advocacy; that people may misunderstand or misinterpret what a professional is telling them so that it is important to check what someone understands, and to avoid blaming them for getting the wrong message; that adult and children's services and health and social care should jointly agree local protocols for referrals, assessments and care pathways in order to respond appropriately and promptly to the needs of both parents and children; and that, if a referral is made to children's services and then it becomes apparent that a parent has a learning disability, a referral should also be made to adult learning disability services. The guidance also stresses that close attention should be paid to the parent's access needs, which may include putting written material into an accessible format, avoiding the use of jargon, taking more time to explain things, and being prepared to tell parents things more than once."

105. And Wall LJ makes a relevant comments in P v. Nottingham City Council and the Official Solicitor [2008] EWCA Civ 462:

"175. It is, I think, inevitable that in its pre-proceedings work with a child's family, the local authority will gain information about the capacity of the child's parents. The critical question is what it does with that information, particularly in a case where the social workers form the view that the parent in question may have learning difficulties.'

176. At this point, in many cases, the local authority will be working with the child's parents in an attempt to keep the family together. In my judgment, the practical answer in these circumstances is likely to be that the parent in question should be referred to the local authority's adult learning disability team (or its equivalent) for help and advice. If that team thinks that further investigations are required, it can undertake them: it should, moreover, have the necessary contacts and resources to commission a report so that as soon as the pre-proceedings letter is written, and proceedings are issued, the legal advisers for the parent can be in a position, with public funding, to address the question of a litigation friend. It is, I think, important that judgments on capacity are not made by the social workers from the child protection team.'

181. In the pre-proceedings phase local authorities should feel free to do whatever is necessary in social work terms to assist parents who may become protected parties. My view, however, is that this is best achieved by members of the adult learning disabilities team who do not have responsibility for the children concerned."

106. It is clear that the purpose of the 2007 DoH Good Practice Guidance, namely to ensure that appropriate steps are taken to ensure services and training are in place to meet the needs of parents with disabilities, has yet to be met in Medway; and there appears to have been little if any awareness of the DoH Good Practice Guidance's recommendations shown by Medway's practice in this case.
107. In order to comply with their duties under s17 Children Act 1989 and in accordance with the good practice set out in the Guidance, this SW, her managers and this local authority should have:

Immediately made a referral to the adult services Learning Disability team and worked together with them to benefit from their advice, training, experience and resources;

Triggered an assessment of Mother's abilities via the Learning Disability team;

Ensured the appointment of an adult care SW for Mother:

Identified and provided a specialist resource within a short period of time, in order to assess the Mother, and her and the family's needs for support;

As soon as the parents expressed complaints about the placement, if not before, provided her with details of how to complain;

Investigated more fully the support options available from Father, friends and family.

108. I have already dealt with their inappropriate obtaining and reliance on a section 20 agreement, and consider that the case should have been dealt with either by way of intensive Learning Disability support that would then been unlikely to have required section 20 to be employed and/or by the issue of proceedings to ensure that proper legal advice and representation was available to the family.
109. Whether or not this Mother had a learning disability the parents' complaints about the foster carer should have been respected and investigated. I find it shocking that there is no adequate record of the parents' complaints, that no investigation took place save for the wholly inadequate enquiry made by the ISP agency SW Ms Down earlier in September, that no further investigation was triggered by Mother's claim of being assaulted on 16.9.14, and that the alleged perpetrator of that assault was herself a participant and contributor to the strategy meeting on 17.9.14. This was fundamentally flawed. Equally, the comments made at that meeting by the Acting Team Manager Ms Willis are themselves shocking and indicative of an extreme and negative position taken up at an unjustifiably early stage by Medway, and revelatory of the wholesale dismissal of the parents' version of events and lack of insight into Medway's own flawed management of the case.
110. I note that at such strategy meetings a member of the 'fostering service' should be present if the child is in foster care. That must refer to the local authority's own fostering service that commissions and manages foster placements. I do not believe the fostering service was involved and have seen no record of their being informed of the parents' complaints. If this had been done they may have identified the difficulties with continuing with the placement on 16.9.14 and with inviting Ms McG and the ISP manager to contribute to the strategy meeting.
111. Equally, there is a remarkable lack of insight into the almost inevitable impact on a vulnerable Mother with significant learning disability of being placed for weeks in an unsuitable mother and baby placement. The involvement of an adult services Learning Disability team is likely to have assisted with this insight, and also with support, advice and information for the Father.
112. Ms Anyiamiah, I have found, was not dishonest in her approach, but I do find that her approach was slapdash, her notes incomplete, with steps not followed through, and her practice betrayed a significant unawareness of the issues set out in the DoH Good Practice Guidance. Her managers must share this blame as it should have been immediately apparent that a referral to adult Learning Disability services ought to have been made, a specialist assessment/placement identified, and the parents' complaints considered and investigated even-handedly. I find to be sound the Children's Guardian's reflection that once such a hardened attitude is taken up and indeed publicly expressed by members of a social work team, it will undoubtedly be hard to move away from that approach, as here.
113. I commend Ms Carmit for her fair approach to the situation as it unfolded during this hearing, but I note that she too failed to spot the need for any input from adult services since her involvement in November 2014. She also admitted to failing to follow up the numerous positive expressions of support from Mr S and family and friends at the Family Group Conference in January 2015. This is now being appropriately remedied, both by the assessment at Symbol to identify the parents' abilities to meet A's needs and any areas of support that may be required, and by further work with the family involving Mr S and the wider group of friends and family.
114. CASE MANAGEMENT

a) PD27A COMPLIANT BUNDLE – There is little point in Medway having created a bundle a few days before a final hearing by unilaterally selecting documents to fit the 350 page limit. Needless to say it was not considered fit for purpose by the other parties and I have already identified that it lacked crucial documents. This, and the various acts of non-compliance discussed elsewhere, betray an unacceptable failure by Medway to adequately prepare the case, to consider properly which documents would be required, to focus on the issues and the evidence, and to apply itself with care and a sense of the necessarily heavy responsibilities borne by applicant local authorities when applying for care and placement orders which have life-changing consequences for families.

b) In order to achieve a meaningful compliance with PD27A, the local authority should liaise with the other parties at an advocates' meeting prior to the IRH to agree a provisional core bundle index. This will not only assist with the proper analysis of the issues and evidence in readiness for an IRH, and permit a proper resolution of issues at that hearing, but will also identify any further documents that may need to be the subject of an application to depart from PD27A and form a supplemental bundle, and which can be addressed and resolved at that IRH. I will be implementing directions to facilitate this approach at CMHs, but even absent such directions it is evident that a local authority applicant should be taking on this responsibility in any event.

c) INTERMEDIARY - I commend A's solicitor for raising the question of an intermediary with those representing Mother in mid-November. A consent order was not circulated until mid-December and was ordered in mid-January. This was knocked back by two refusals of prior authority prior to the IRH in early February. No directions were made then and I consider that this was a missed opportunity. A further refusal of prior authority was made at the end of March leading to an urgent application to DJ Gill and the DFJ. This led to the report of Communicourt being provided on the last working day before the start of the final hearing and my direction that Mother should be provided with an intermediary, funded by the court service. This issue should have been considered and grappled with from the very first hearing, given Mr Crimes' report, and a more robust approach taken at the IRH, so that this issue too did not jeopardise the final hearing. This would also have avoided a change of intermediary half-way through the hearing, which was a direct consequence of not having an intermediary booked in from an earlier date.

d) NON-COMPLIANCE WITH DIRECTIONS – Medway repeatedly flouted numerous directions to file key source documents and witness statements following initial directions in September, CMOs in October and December 2014, and finally the IRH in February 2015. This was completely unacceptable and placed the parties and the court at a gross disadvantage and almost led to the abandonment of this hearing with consequent delay and injustice. It is clear that this case is unfortunately far from an isolated example of such practice by Medway, and is an habitual problem that local practitioners and the court struggle with. I am raising with Kent's DFJ and FDLJ practical measures to solve such problems and prevent them recurring.

e) However, I am also disappointed that the parties (including Medway) did not pursue an urgent hearing to address these failures. There should have been a swift and comprehensive response to the local authority's failures following the IRH by obtaining a prompt listing. Such requests are frequently received and action promptly taken by this court, albeit that in this case there was no allocated circuit judge from the date of the IRH. I understand that timetabling failures were raised with DJ Gill at the IRH which led to further re-timetabling, but when further breaches continued after the IRH the court was not requested to reconsider the timetable and no hearing was sought, whereas these issues should have been pursued and an urgent listing obtained.

f) ALLOCATION – I acknowledge that it may have disadvantaged the case management of this case that it was allocated to an 'unknown' Circuit Judge by DJ Gill at the IRH. This was not DJ Gill's fault, but because a new Circuit Judge was in the process of being appointed to a vacant post and this problem was a function of the process whereby the identity of a new Circuit Judge remains unknown until their royal warrant is signed, and therefore there was no allocated Circuit Judge to address case management issues in the period between the IRH in January and the final hearing in April. While it is of course preferable for any matters raised by the parties to be dealt with by an allocated judge who would be conducting the final hearing in order to maintain continuity and focus, I note that DJ Gill was able to refer the intermediary issue to the DFJ.

g) LATE PROVISION OF RECORDINGS – As I have mentioned, it is unclear whether a direction made in late 2014 related to the recordings made by the parents, but it was highly unsatisfactory that they were not provided by the Father in an accessible format to his solicitor until the week before the hearing. I have not been able to clarify why this problem arose. What is clear is that these recordings were central to a proper understanding of the case. If there had been an earlier order debarring the parents from relying upon them unless they were provided by a certain date, this may have triggered their provision, but I note that if I had taken that stance at the outset of a final hearing it would have resulted in a serious misunderstanding of the case. I remain puzzled as to why these recordings were not the subject of directions at the IRH.

h) BEST EVIDENCE – It is salutary and sobering to consider that there are many children in foster care, and many parents in parent and baby foster placements, and there will be occasions when parents complain about their treatment in those placements, but that it is the frequent practice in care proceedings not to require the foster carer to attend court, but to rely upon their notes and the social worker's evidence. In the light of Re A 2015 and Re J 2015, and an example such as this case, it will be all the more important to consider with a sharp focus the nature of the evidence that the court needs to consider, and best evidence in particular. In this case, the parents' allegations were frankly treated dismissively from the outset. But for this court's willingness to permit the consideration and transcription of the recordings, despite the extreme lateness that they were provided, in combination with the requirement that the foster carer attend to give evidence (which was correctly anticipated at the IRH), it would have been impossible to gain a just and proper understanding of this case.

HHJ Lazarus

2.6.15

APPENDIX A

Department of Health: Good practice guidance on working with parents with a learning disability

http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_075118.pdf

Why is this good practice guidance needed?

As the research summarised in Appendix A illustrates, practitioners often experience some difficulties supporting families are affected by parental learning disability:

• Children whose parents have learning disabilities and who are in contact with children's social care services have high levels of needs;

• There is little evidence of effective joint working between adult and children's services. Children's

services practitioners, and adult learning disability workers, rarely have a good working knowledge

of the policy and legislative framework within which each other are working. Appendix B therefore

sets out the respective policy and legislative framework with the aim of increasing understanding

of both the responsibilities of children's and adult social care, and of parents' entitlements.

Whilst the same values about safeguarding and promoting the welfare of children should be applied to the children of learning disabled parents as to the children of non-learning disabled parents, such families have specific needs which require particular knowledge and skills if the professionals working with them are to provide an equitable service to these children and their parents. A specialized response is often required when working with families where the parent(s) has a learning disability but many children and family social workers do not feel adequately equipped to work effectively with them. At the same time, many adult learning disability services struggle to effectively support parents with learning disabilities.

There are five key features of good practice in working with parents with learning disabilities:

1. Accessible information and communication

2. Clear and co-ordinated referral and assessment procedures and processes, eligibility criteria and care pathways

3. Support designed to meet the needs of parents and children based on assessments of their

needs and strengths

4. Long-term support where necessary

5. Access to independent advocacy.

1.2.3 Identification of needs should start when a pregnancy is confirmed.

Procedures, criteria and pathways therefore need to be agreed between maternity services and

children's and adult social care. Such agreements could relate to parents with learning disabilities in particular or to all groups of parents and their children who may be identified as vulnerable. An

important starting point will be to recognise:

• Pregnant women with learning disabilities are entitled to universal services

• Universal services are required to make "reasonable adjustments" to make their services

accessible and suitable for people with learning disabilities

• Early assessments of support needed to look after a new baby will help to prevent avoidable

difficulties arising.

1.2.4 Adult and children's social care services should jointly agree referral procedures to prevent

parents and children falling between the two services.

It is good practice that, as a general rule, referrals relating to the needs of parents with learning

disabilities should be directed to Learning Disability services, unless there are concerns about

children's welfare, in which case a referral should also be made to children's social care. If a referral is made directly to children's services, and it then becomes apparent that a parent has a learning disability, a referral should then also be made to adult Learning Disability services.

1.2.6 Services in contact with parents with learning disabilities should promote good practice in

assessment by using appropriate assessment materials and resources and/or access specialist

expertise.

Needs relating to learning disability should be considered whatever the level of assessment, whether it is an assessment of additional needs being carried out by a universal service using the Common Assessment Framework, or a child in need assessment using the Framework for the Assessment of Children in Need and their Families, or a section 47 enquiry to establish whether a child may be suffering harm. This means that a range of professionals who are in contact with children may need to consider, using the Common Assessment Framework, the possibility of parental learning disability and its impact on children. Children's social care will also need to consider the impact and needs associated with learning disability when assessing children in need, and in safeguarding children.

Where a parent has a learning disability it will be important not to make assumptions about their

parental capacity. Having a learning disability does not mean that a person cannot learn new skills.

Learning disabled parents may need support to develop the understanding, resources, skills,

experience and confidence to meet the needs of their children. Such support is particularly needed

where they experience additional stressors such as having a disabled child, domestic violence, poor physical and mental health, substance misuse, social isolation, poor housing, poverty or a history of growing up in care.

…

Diagnostic psychometric assessments can provide information about whether a parent has a learning disability and about their skills and abilities. However, "Although such information is useful, it must be stressed that there is no direct correlation between the results of these tests and parental adequacy"(McGaw and Newman, 2005, p.27). A list of such assessment tools is given in the Resources section.

Assessments should cover family and environmental factors, as well as parental capacity. Research tells us that family and community support networks are particularly important for parents with learning disabilities and their children. We also know that parents with learning disabilities are

particularly likely to experience difficult housing situations and poverty. Both the Common

Assessment Framework and the Framework for the Assessment of Children in Need and their

Families require that family and environmental factors are covered.

Adult learning disability services should ensure that Person Centred Planning is made available to

parents with learning disabilities as part of both the assessment of their needs and the planned

response to these needs. Person Centred Planning is a process of life planning which enables the

identification of a person's strengths, needs, relationships and the barriers they face. It is a

particularly appropriate method to use where people with learning disabilities are parents (see

Resources).

1.4.1 A need for long-term support does not mean that parents cannot look after their children.

Some parents with learning disabilities will only need short-term support, such as help with looking

after a new baby or learning about child development and childcare tasks. Others, however, will

need on-going support. Most may need support at various different points of their family's life cycle

for two main reasons. Firstly, although a parent with learning disabilities can learn how to do things, their cognitive impairment will not go away. Just as someone with a physical impairment may need personal assistance for the rest of their life so a person with learning disabilities may need assistance with daily living, particularly as new situations arise. Secondly, children and their needs change. A parent may have learnt to look after a baby and young child and be coping well. However, as the child enters adolescence other support needs may arise.

1.4.2 Where a need for long-term support with parenting tasks is identified, it should form part of

the community care and/or child in need plan.

Early identification of support needs will help prevent unnecessary difficulties arising but it should be recognised that some support needs may be on-going and this should be reflected in care planning.

2.1.4 When a key worker is appointed for a child whose parent has a learning disability, it is

important that the worker has some understanding of learning disability or, if not, that the worker has access to such expertise.

2.2.4 Core assessments involving families affected by parental learning disability should

always include specialist input concerning the impact of learning disability.

Core assessments should also include seeking information from others who may know the parent(s) well, providing the parent gives their consent.

It should be recognised that, in many cases where there are risks of significant harm to children of

learning disabled parents, parents usually face other difficulties in addition to learning disability.

These may include mental health and/or physical health problems, domestic violence, substance

abuse. Assessments should therefore also include, where appropriate, specialist input on these

issues.

2.2.8 Where children are subject to a child protection plan, it is good practice to appoint a key

worker for the parent(s) with learning disabilities (as well as a key worker for the child/ren).

Both key workers should be part of the core group and should have expertise, or access to

expertise, in supporting families affected by parental learning disability.

2.2.14 Placement with extended family members should always be considered.

Support from the extended family can work well and can take the form of 'shared care' or of permanent placement. On the other hand, there are some circumstances where extended family members would not provide suitable support, and there are other circumstances where extended family members attempt to 'take over' care of children without appropriate involvement of parents. Assessments which take into account the wider context of the parents' and children's circumstances and needs will ensure that care planning is fully informed by both the possibilities, and the limitations, of extended family involvement.

2.2.15 Where possible, foster care placements should be made with carers who have experience and/or training in working in partnership with parents with learning disabilities.

2.2.16 Parents should be informed of the complaints procedure and it will be important that such

procedures are conducted in ways which ensure people with learning disabilities equal access to all stages of the complaints process. This should include information in easy to understand formats and any support required to use the complaints procedure.

APPENDIX B

Working Together to Safeguard Children

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/419595/Working_Together_to_Safeguard_Children.pdf

Statutory assessments under the Children Act 1989

• A child in need is defined under the Children Act 1989 as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled. Children in need may be assessed under section 17 of the Children Act 1989, in relation to their special educational needs, disabilities, as a carer, or because they have committed a crime. Where an assessment takes place, it will be carried out by a social worker. The process for assessment should also be used for children whose parents are in prison and for asylum seeking children. When assessing children in need and providing services, specialist assessments may be required and, where possible, should be coordinated so that the child and family experience a coherent process and a single plan of action.

The purpose of assessment

29. Whatever legislation the child is assessed under, the purpose of the assessment is always:

• to gather important information about a child and family;

• to analyse their needs and/or the nature and level of any risk and harm being suffered by the child;

• to decide whether the child is a child in need (section 17) and/or is suffering, or likely to suffer, significant harm (section 47); and

• to provide support to address those needs to improve the child's outcomes to make them safe.

30. Assessment should be a dynamic process, which analyses and responds to the changing nature and level of need and/or risk faced by the child. Any provision identified as being necessary through the assessment process should, if the local authority decides to provide such services, be provided without delay. A good assessment will monitor and record the impact of any services delivered to the child and family and review the help being delivered. Whilst services may be delivered to a parent or carer, the assessment should be focused on the needs of the child and on the impact any services are having on the child.

Focusing on outcomes

52. Every assessment should be focused on outcomes, deciding which services and support to provide to deliver improved welfare for the child.

53. Where the outcome of the assessment is continued local authority children's social care involvement, the social worker and their manager should agree a plan of action with other professionals and discuss this with the child and their family. The plan should set out what services are to be delivered, and what actions are to be undertaken, by whom and for what purpose.

54. Many services provided will be for parents or carers (and may include services identified in a parent carer's or non-parent carer's needs assessment).18 The plan should reflect this and set clear measurable outcomes for the child and expectations for the parents, with measurable, reviewable actions for them.

Timeliness

57. The timeliness of an assessment is a critical element of the quality of that assessment and the outcomes for the child. The speed with which an assessment is carried out after a child's case has been referred into local authority children's social care should be determined by the needs of the individual child and the nature and level of any risk of harm faced by the child. This will require judgements to be made by the social worker in discussion with their manager on each individual case. Adult assessments, i.e. parent carer or non-parent carer assessments, should also be carried out in a timely manner, consistent with the needs of the child.

58. Within one working day of a referral being received, a local authority social worker should make a decision about the type of response that is required and acknowledge receipt to the referrer.

59. For children who are in need of immediate protection, action must be taken by the social worker, or the police or NSPCC if removal is required, as soon as possible after the referral has been made to local authority children's social care (sections 44 and 46 of the Children Act 1989).

60. The maximum timeframe for the assessment to conclude, such that it is possible to reach a decision on next steps, should be no longer than 45 working days from the point of referral. If, in discussion with a child and their family and other professionals, an assessment exceeds 45 working days the social worker should record the reasons for exceeding the time limit.

61. Whatever the timescale for assessment, where particular needs are identified at any stage of the assessment, social workers should not wait until the assessment reaches a conclusion before commissioning services to support the child and their family. In some cases the needs of the child will mean that a quick assessment will be required.

Strategy discussion Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm there should be a strategy discussion involving local authority children's social care (including the fostering service, if the child is looked after), the police, health and other bodies such as the referring agency. This might take the form of a multi-agency meeting or phone calls and more than one discussion may be necessary. A strategy discussion can take place following a referral or at any other time, including during the assessment process.	Strategy discussion Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm there should be a strategy discussion involving local authority children's social care (including the fostering service, if the child is looked after), the police, health and other bodies such as the referring agency. This might take the form of a multi-agency meeting or phone calls and more than one discussion may be necessary. A strategy discussion can take place following a referral or at any other time, including during the assessment process.
Purpose:	Local authority children's social care should convene a strategy discussion to determine the child's welfare and plan rapid future action if there is reasonable cause to suspect the child is suffering, or is likely to suffer, significant harm.
Strategy discussion attendees:	A local authority social worker and their manager, health professionals and a police representative should, as a minimum, be involved in the strategy discussion. Other relevant professionals will depend on the nature of the individual case but may include: • the professional or agency which made the referral; • the child's school or nursery; and • any health services the child or family members are receiving. All attendees should be sufficiently senior to make decisions on behalf of their agencies.
Strategy discussion tasks:	The discussion should be used to: • share available information; • agree the conduct and timing of any criminal investigation; and • decide whether enquiries under section 47 of the Children Act 1989 should be undertaken. Where there are grounds to initiate an enquiry under section 47 of the Children Act 1989, decisions should be made as to: • what further information is needed if an assessment is already underway and how it will be obtained and recorded; • what immediate and short term action is required to support the child, and who will do what by when; and • whether legal action is required. The timescale for the assessment to reach a decision on next steps should

Provision of services for children in need, their families and others

Section 17(1) states that it shall be the general duty of every local authority:

(a) to safeguard and promote the welfare of children within their area who are in need; and

(b) so far as is consistent with that duty, to promote the upbringing of such children by their families.

by providing a range and level of services appropriate to those children's needs.