England and Wales Family Court Decisions (other Judges)

IN THE FAMILY COURT

		25 April 2017

His Honour Judge Moradifar:

Introduction

1. At 9.33 am on 13 June 2016 BR called the emergency services having found his two and half year old child L unresponsive. L was taken to a local hospital where he was found to be in a coma. L was provided with emergency treatment whilst the cause of his condition was unknown and under investigation by the medical professionals.
2. At 15.04 on the same day, the results of the toxicology screen revealed the presence of carbamazepine in his blood. At 18.10 L was transferred to a specialist unit at the John Radcliff Hospital. At 18.30 further samples of his blood revealed a very large quantity of carbamazepine.
3. None of the adults who had care of L were able to give an account as to how carbamazepine had come to be in L's system. Unsurprisingly the police and children's services became involved leading to the arrest and interview of BR and his then partner JP. L and his two siblings were removed and placed in foster care where they continue to reside.
4. On 6 December 2016 JP gave birth to MG who shares the same father (BR) as the other children. Following a brief separation, JP and MG have been living together in a residential unit.
5. The local authority's allegations against the parents share a great deal of common ground between all three parents. Consequently the two cases have been listed before me to make a determination on the local authority's allegations.

Issues

6. It is accepted by all parties and the intervener that L was in a coma due to the very high levels of carbamazepine that were found in his blood. The issues that need determinations are:

a. When and in whose care did L ingest a high level of carbamazepine?

b. Has L ingested lower doses of carbamazepine on any other occasion?

c. Did L ingest carbamazepine accidentally or as a consequence of a deliberate or reckless act?

d. The extent to which if any of the adults who had care of L are culpable?

e. What is the extent and nature of domestic abuse in BR's relationship with CT and/or JP?

f. To what extent, if any, have any of the children been exposed to;

(i) Domestic abuse in the relationship between BR and CT, and

(ii) Domestic abuse in the relationship between BR and JP, and

(iii) The adults taking illicit drugs.

The law

7. The parties have each set out the applicable law and there are no issues between the parties in this regard. For the sake of brevity I will not set out those submission in my judgment and adopt the detailed submissions that have been made in this regard. In particular I am guided by the helpful summary that is set out by Baker J in Re JS [2012] EWHC 1370 (Fam). Following this decision Jackson J in Lancashire County Council v C, M and F (Children: Fact finding Hearing) [2014] EWFC 3 added a further item to this invaluable list of important considerations.
8. Furthermore, I have applied the observations of the President of the Family Division in Re A (A child) [2016] 1 FLR 1 and the decision of the Supreme Court in Re S-B (Children) [2010] 1 FLR 1161.
9. I am not bound by the schedule of findings that the local authority seeks and can make such relevant findings as are appropriate based on the evidence. Finally each of the respondents and the intervener has a right to a fair trial pursuant to Article 6 of the European Convention for the Protection of Human Rights and Fundamental Freedoms (1950) and this right cannot be interfered with unless it is pursuant to a legitimate aim, necessary, proportionate and in accordance with the law.

Background

10. BR and CT commenced their relationship in 2009. They have three children. P who is six, R who is four (five in May) and L who is three years old. The children lived with their parents until the summer of 2015 when the parents separated. The children remained living with CT until 5 January 2016. CT moved to her mother's address. BR moved into CT's address where he lived with the children. They saw CT once during the week and spent alternate weekends with her at the maternal grandmother's home from Friday until Sunday. These arrangements continued until June 2016 when the children were placed in local authority foster care.
11. In 2014, R was diagnosed as suffering with epilepsy. There are a number of individuals in CT's family who suffer with epilepsy, most notably CT's brother ST. He suffers significantly and has had many seizures, some of which have been life threatening requiring his hospitalisation. Consequently R was prescribed Tegretol which is an oral suspension containing carbamazepine. R takes her medicine once in the morning and once in the evening. By June 2016 the volume of prescribed medicine had increased and administered at the same frequency.
12. During BR and CT's relationship, BR began having a casual relationship with JP. She lived next door with her parents. For short periods, BR and CT would separate and BR stayed with JP. The relationship between CT and JP was very strained. After the final separation in the summer of 2015, JP and BR continued their relationship. After January 2016 JP regularly stayed at BR's new address. It is common ground that she played a significant part in looking after the three children, in particular L during the day when BR spent a lot of time out of the home.
13. A shared feature of these parents' lives was the use of and the culture of illicit drugs. At some point they have each taken and been involved with illicit drugs, particularly cannabis. This has included times where they have partaken in cannabis with others or together.
14. Another shared feature of BR's relationship with CT and JP is complaints of domestic abuse. This is illustrated in the case papers by the number of police call outs and the complaints that each of the two women made over a significant period of time. Both CT and JP accept that there have been times that their respective behaviour has abusive and volatile. JP who is a teenager, suffered with an increasing sense of frustration at being left to look after the three older children whilst BR spent time away from the home.
15. In April 2016 JP fell pregnant with MG. She continued to visit the father next door and spend significant periods of time there. This included staying a number of evenings per week, although she also stayed at her mother's address. JP has a difficult relationship with her parents. Her father is a regular drug user and her mother drinks to excess. She found the first half of her pregnancy difficult and continued to care for the older children, particularly L who did not attend nursery.
16. Pursuant to the existing arrangements, the three older children visited and stayed with their mother at the maternal grandmother's then address during the weekend of 10 June to 12 June 2016. The children were collected at 17.30. CT was working that evening and did not return until 23.00. The children and the mother spent Saturday together and they were returned to the father's care at around 13.26 on 12 June 2016.
17. At around 8 am the father first took R to nursery, returned home before taking P to school. L had remained sleeping. Around 9.05 to 9.10 BR returned home. Children Services were due to attend the property and meet with BR and JP at around 10 am that morning. Shortly before the ambulance was called, the father had tried to wake L up but he was unresponsive.
18. None of the adults who had care of L could explain why he had fallen into a coma. None of the adults reported witnessing or being aware of any incident that is capable of explaining L's condition. However by the time the toxicology report had been made known to the father and L had been transferred to the John Radcliff Hospital, the father had begun to blame the mother and her family for L's condition.
19. Pursuant to agreements under s. 20 Children Act (1989), on 16 June 2016 P and R were paced in local authority foster placements. On 17 June 2016 L was discharged from hospital and joined his siblings in the same placement. On 15 July 2016 the local authority applied for care and supervision orders in respect of all three children. The case came before me on 20 July 2016 when the children were made the subject of interim care orders that have continued to date. Following the birth of MG in December 2016 the local authority applied for care and supervision orders in respect of MG. Given the common factual matters between the two sets of proceedings, the two cases are listed before me to determine the local authority's allegations. These are contained in the local authority's schedule of findings that state:

"At the relevant date (i.e. 16 June 2016) P, R and L were suffering and were likely to suffer significant harm attributable to the care given to them or likely to be given to them if an order were not made, not being what it would be reasonable to expect a parent to give to them for the following reasons:

Intoxication of L:

12-13 June 2016: acute ingestion

On 13 June 2016 L was taken by Ambulance to the Accident and Emergency Department of the Royal Berkshire Hospital and upon examination was unresponsive. He suffered two seizures which required medication, was intubated and ventilated. He had a further seizure following transfer to the John Radcliffe Hospital.

Blood tests taken at the Royal Berkshire Hospital at 13.30 on 13 June 2016 revealed that L had a high level of Carbamazepine (more than 20mg/L) in his blood. This was well above the therapeutic range of 4-12 mg/L and had directly caused his coma. L is not prescribed Carbamazepine – an anti-convulsant given to his sister to treat her epilepsy.

L had been fed more than 642 mg of Carbamazepine, This is a toxic dose for a child of L's age (age 2), and causes intense sedation, up to the point of coma and potential respiratory depression.

BR and/or JP gave L the Carbamazepine that caused his coma, either in syrup form or as a tablet on 12^th or 13^th June 2016. In the alternative CT gave it to L on 12^th June 2016.

BR and/or JP and/or CT have not provided any plausible explanation that could account for L ingesting Carbamazepine on 12 and/or 13 June 2016. In particular, there is no revealed accident that could account for L ingesting Carbamazepine.

Whoever administered the Carbamazepine would have been aware that L was not prescribed this medication and that it was likely to result in serious harm.

If the Carbamazepine was administered to L by BR and/or JP, the other adult knew that it was being administered to L and failed to protect him. If administered by either, both BR and JP knew that L required urgent medical attention but allowed him to lie comatose in bed until the ambulance was called.

If the medication was administered by CT, or L ingested it when in her care and this was known to her, she failed to notify BR so that timely medical treatment could be sought, and CT thereby exposed L to significant harm and failed to protect him.

Course of Conduct: previous ingestion:

A hairstrand test subsequently carried out in relation to L by Thames Valley Police has tested positive for Carbamazepine during the three sequential months from mid-April 2016 to mid-July 2016. The levels of Carbamazepine detected, namely:

1379 pg/ml – segment 0-1cm;

1980 pg/ml - segment 1-2 cm; and

2519 pg/mg - segment 2-3 cm

are consistent with L having ingested Carbamazepine on multiple occasions.

The hairstrand test results and L's admission to hospital on 13^th June 2016 with a Carbamazepine overdose amount to a deliberate course of conduct on the part of an adult carer or carers.

The Carbamazepine detected in L's hair was deliberately administered, either in syrup form or as a tablet, by BR and/or JP, alternatively CT, from at least April 2016 until 12-13 June 2016.

Whoever administered the Carbamazepine detected in L's hair would have been aware that L was not prescribed this medication and that it was likely to result in serious harm.

In the alternative CT and/or BR and/or JP were negligent in that they failed properly to supervise L, thereby enabling him to gain access to the medication on an unknown number of occasions, from at least mid-April 2016 until 12 or 13 June 2016 inclusive.

P and R:

The Local Authority reserves its position on any findings it may seek in respect of P and R pending further expert evidence on the issue of Carbamazepine.

Exposure to Domestic Conflict and Dysfunctional Behaviour by the Parents and JP:

P, R and L were exposed to conflict and aggression between BR and CT, including shouting and arguments; for example:

(i) BR has behaved in a controlling and aggressive way towards CT over the course of their relationship, including hitting her, punching her in the face and on one occasion strangling her to the point that she was fearful for her life [C22/4.1 1; G21-23];

(ii) 20.12.2011: the parents had an argument in respect of the care arrangements for P which resulted in the police being called [C18]; and

(iii) 14.6.2013: there was a significant argument between the parents which resulted in a neighbour calling the police [C19]

P, R and L were exposed to conflict and aggression between BR and JP:

(i)Between late 2015 and mid-2016 there were up to 10 referrals/call-outs to Thames Valley Police as a result of incidents between BR and JP; in particular:

(a) In or around early 2016 BR put his hands around JP's neck and grabbed her [C9-10; G16];

(b) On another occasion in 2016 BR tried to hit JP: he swung his arm and stopped near to her face [C9; G16];

(c) On 13 February 2016 JP and BR had a significant argument which resulted in JP being found semi-conscious in BR's home, when the children were present, having had a panic attack. JP alleged that the children had woken her up in the early hours, after she had been out drinking, and that she was stressed and wanted to sleep [C20; L112-115];

(d) At or around 2 am on 14 February 2016 the police were called to BR's home (for the second time in 2 days) after an argument he had with JP: JP alleged that BR was controlling towards her and would not let her out of his sight or associate with other people [G8-9];

(e) On 1 March 2016 the police were called to the family home after a significant argument between JP and BR, during which he screamed at her. The incident led to JP leaving BR home and going to her mother's home next door, following which she refused to engage with the police [C21; G12];

(f) On 12 March 2016 the police were called following an incident between BR and JP during which she told him that she was fed up with looking after his children and accused him of having stolen her dog [C21; G13-14]; and

(g) On 17 May 2016 an argument took place between BR and JP (then pregnant with BR's child) during which he became angry and made threats that he would get someone to rape her younger sister and called JP a "little girl" [C9; G15-17].

(ii) CT was aware of the conflict in the relationship between BR and JP. She failed to protect the children from the conflict.

17. The children were exposed to the dysfunctional relationships between BR and CT and BR and JP, both of which were characterised by instability, separations and reconciliations (eg: C16/3.1 16-17).

18. JP is a young woman with little if any experience of caring for children prior to beginning her relationship with BR. When caring for the subject children JP has on occasions not been able to manage her anxiety levels, resulting in her behaviour becoming volatile and dysfunctional.

19. BR was aware of JP'S difficulties in caring for the children: he failed to protect the children from being exposed to her anxiety and dysfunctional behaviour.

20. BR has a history of aggressive behaviour towards both the children and towards professionals working with the family. In particular:

(i) in March 2014, when R was admitted to the Royal Berkshire Hospital following seizures, BR was refused access to the ward as a result of his confrontational behaviour towards staff;

(ii) in 2014 BR was aggressive towards the children's health visitor, resulting in her requesting to be removed as she was fearful of BR [C22/4.1 5];

(iii) JP lost her job as a result of BR behaving in an aggressive and volatile manner at her workplace [C16/3.1 16];

(iv) On 19 May 2016 BR shouted aggressively at the children: this was audible to the children's social worker who was outside the family home at the time [C10];

(v) On 13-16 June 2016 BR was un co-operative, obstructive and on occasions aggressive towards the children's social worker and medical staff treating L in hospital [C14/3.1 10]; and

(vi) Following her move to foster care in June 2016 R said she did not want to live with R because he hit her [C26/4.2 2].

Parental Drug Use

21. Both parents have used cannabis and allowed other adults to use cannabis when the children have been in their care. Both parents tested positive for a constituent of cannabis over the period April 2016-October 2016 [C8 30.12.2015; 9.1.2016].

Neglect:

22. The children have experienced chaotic and neglectful care when living with the parents, with CT alone and with BR and JP. In particular, the parents have failed to meet R's medical needs consistently by not taking her to review appointments for her epilepsy: she failed to attend appointments on 3 appointments (including a rescheduled appointment) in 2014 (including 9 July 2014 and 10 September 2014) [L135] and her appointments were cancelled on 1 April 2015 and she failed to attend on 1 July 2015 [L126]."

Evidence

I have read the case papers, listened to the 999 call by BR at 09.33 on 13 June 2016. Additionally I have heard the oral evidence of twelve witnesses who have included two very highly regarded experts in their respective fields, the consultant paediatrician who cared for L during his admission in the morning of 13 June 2016 and importantly each of the three parents. I will turn to the medical evidence before I set out the remainder of the oral evidence.

Medical evidence

20. Dr Gordon was the Consultant Paediatrician who was in charge of L's care when he was first admitted to hospital on 13 June 2016. She confirmed her statement and notes that were identified as accurate. Dr Gordon explained that she attended on L at around 10.30 am on that day. L was very unwell. He was deeply unconscious and had two seizures whilst in hospital. At 11.45 he had been unconscious for at least two hours and a decision was made to insert a breathing tube. The cause of his condition was unknown. She explained that BR and JP who were in attendance had described L as well and "normal" during the previous day. They did not disclose any trauma or any event that would explain L's condition. In the circumstances, Dr Gordon found L's case to be challenging. She explained that there were three possible main causes for his condition. These included difficulties in the brain such as bleeding or tumour, infection or ingestion of a drug or poison. She further explained this is why she was careful to take an accurate account of the events of the previous day and hours leading to L's admission to hospital. By the time L's blood screen result that identified the presence of a high quantity of carbamazepine was known, Dr Gordon had left L. Later he was transferred to the John Radcliff Hospital.
21. Dr Pascal Kintz is an expert in "chemistry, toxicology and blood alcohol determination" as appointed by the French Supreme Court. Dr Kintz is particularly concerned with the interpretation of hair testing. He was the first of the two jointly instructed experts in the case that I heard from. He confirmed that his four reports are accurate and that he stood by his opinion as expressed in the said reports. Dr Kintz explained that hair in children grows very differently to those of adults and that they are generally finer. He was cautious to compare results between P's and L's hair test as they are different ages and their hair may behave differently. With that in mind, he explained that the readings in the results for P's hair are low and on balance, consistent with environmental exposure. Those in L's are higher and are on balance consistent with a combination of administration of carbamazepine and environmental exposure. The rate of hair growth is variable in children of L's age and 3 centimetres could represent a time frame ranging between one to six months. As to the issue of L's hospitalisation, Dr Kintz stated that the hair results must be looked at together with the blood results. In doing so, he was without doubt that L had ingested a single overdose of carbamazepine. Depending on the form in which the drug was ingested, this being liquid, tablet or a slow release form, L ingested the overdose of carbamazepine sometime between one and half to twelve hours prior to the time that the ambulance was called.
22. Dr George Rylance was the second of the two jointly instructed experts that I heard from. He is a retired Consultant Paediatrician with many years' experience as a clinician and a court-appointed expert. He has written eight papers concerning carbamazepine. Subject to two important amendments to his written reports, he confirmed those two reports as being accurate and that his opinion as expressed in those reports have not altered. Dr Rylance remained of the opinion that it is "extremely likely" that L received a large dose of carbamazepine on the morning of 13 June 2016.
23. Dr Rylance told me that he has treated hundreds of children who were taking carbamazepine. A smaller proportion of those children would have been around L or R's ages. In a therapeutic dosage, carbamazepine can cause drowsiness and dizziness. This normally subsides after about two weeks. In a therapeutic setting the dosage usually increases over time as the child grows and there is a build-up of tolerance. Dr Rylance has experience of about twenty cases of carbamazepine poisoning in children of L's age group. He told me that the intervention at hospital did not treat the carbamazepine issue and this would have been dealt with and processed by L's own body. L could have ingested this drug in many forms, including tablet, oral suspension or a slow release form. Regardless of the form, he ingested a very large quantity. The form is relevant to the issue of timing. In Dr Rylance's opinion taking a liquid or tablet form as compared with a modified or slow release form would give a time frame of no more than eight hours prior to the ambulance being called. That is to say not before 13 June 2016.
24. He further explained that for ethical reasons there is no reliable research concerning carbamazepine and its behaviour in children, particularly concerning the issues of absorption and the peak of the drug in the child's blood. However he stated that this would be over a relatively short period of time and to alter the time by one hour would equate to a "huge change in percentage terms". He denied that the drugs that L was given in hospital would have interacted with the carbamazepine in his system. Whilst this may be a factor with other types of drugs, it is not the case with carbamazepine. He further denied that digestive factors would impact on the rate of absorption given that this particular drug is absorbed through the stomach. Similarly he denied that absorption may be affected by body weight with this particular drug although this may be a factor for other drugs. He explained the mechanism by which drugs may be processed through the liver via the portal vein and with each passage the absorption of that drug may be affected. However this does not apply to carbamazepine. Dr Rylance discounted the possibility of L taking a small amount of medicine accidentally. He commented that the concentrations discovered in L's blood were four or five times more than what would be expected and the effects would be seen well within the eight hours of ingestion and more likely within no more than two or three hours. Dr Rylance concluded by confirming that his opinion as summarised in paragraph 3 of his report remains unchanged. When pressed as to how confident he was in his opinion by reference to civil and the criminal standards of proof, he stated that he was "close to one hundred percent" sure.

Other evidence

25. I next heard the evidence of SW who is the first social worker in this case and has written one statement in support of the local authority's applications which she confirmed as accurate. SW stated that she had a clear recollection of a conversation with BR in which she advised him not to take JP to the hospital. BR denied this conversation ever happened and called her a "liar". She further confirmed that in a separate conversation BR had told her that he had instructed someone to watch the hospital when L was in hospital. She further stated that R had said that her father had "hit her" and that P stopped her immediately. BR had told her that he was "keeping tabs on" CT and he knew that she had been on holiday. Whilst he reported that he and JP were separated and he questioned the paternity of their child, they then presented as a couple.
26. I next heard from DC Harris who is the investigating officer in charge. He confirmed the accuracy of his statement. DC Harris explained that when visiting P and R on 15 June 2016, the social worker who accompanied him spoke to the children and he made the notes (J184). P and R were seen separately and confirmed that R had stated that she takes the medicine as it makes her go to sleep. Neither child had stated anything that merited a formal interview. He stated that he wrote his note (J271 to 273) on the day he spoke to the father and prior to this, he could not remember if BR had mentioned anything about the medicine spilling in the bag, although he does remember it being mentioned. He did seize a bag from the father's address on 17 June 2016. BR had told him that the bag had been thrown out but he had found it. He also stated that BR showed him a plastic tub in which the syringe was kept.
27. MG is the three children's foster father and he was the next witness to give evidence. He has been a foster carer for eight and a half years, during which time he has cared for twenty six children. He confirmed his two statements and his foster care logs as being accurate. He stated that he keeps notes on pieces of paper and he types them either on the same evening or next evening. When the children were first placed with him, he found P and R very hostile to each other. They were "argumentative and physical with each other". L was more timid. He was scared and would jump at any sudden movement. L needed a lot of reassurance that was not going to be "told off" or punished. He told me that when the children were first placed, the girls were "bickering". At first he could not say what about. He heard P stating that L had picked up a medicine bottle and drank it. R corrected her by stating that their mother had given this to him. R then stated that it was JP who gave it to R, then paused and said she had made a mistake. By reference to his note of 20 July 2016 where it is reported that R told him that her father "smacks her", MG confirmed that he wrote his notes immediately. He also stated at first P reminded him about when R needed to take her medicine.
28. In answer to further questions, MG gave further detail of the experiment in which he had invited his children and the three children to try and open a bottle of R's medicine. He said that he was concerned about safety if indeed any of the children could open the bottle. He offered money as a prize and despite the children's best effort they could not open the bottle. He used an identical bottle. P was particularly determined as she competed hard with his son. P tried very hard but was unable to open the bottle. She was very upset by this.

Evidence from the family and friends

29. I next heard from the family members and a friend of the family. The first of these was the mother of the three children, CT. She confirmed that her four statements and the document in which she replies to the local authority's allegations as being true and accurate. She proceeded to tell me that she is twenty five years old. In June 2016 she had two cleaning jobs and another at weekends working in a warehouse. She lived with her mother ("MP") and her two brothers at MP's address. She believed that the children were collected on Friday 11 June 2016 by her mother at around 16.00. She did not return home until 23.00 that evening. L woke up at around 5.30am to 6.00 am and woke everybody up. She told me that this was usual for L as he wakes early and is very active. The children had their breakfast downstairs in the kitchen. CT gave R her medicine down stairs. The medicine is locked in a cabinet in the kitchen and only her brother and her mother have keys for this. When R stays with her, she borrows the key from her mother.
30. Later that morning she took the children to a local park and produced some photographs showing the children in the park and at home. After returning from the park they watched DVDs and played games. CT told me in some detail about the DVDs and the games. Later that day she proceeded to cook a roast dinner as the children were returning to the father on Sunday. The children were involved in helping with the cooking. After dinner there was more play before the children went to bed. Up to this point the children were with their mother at all times. She put P and R to bed whilst MP looked after L for a short time. She gave R her medicine upstairs and then locked the medicine in a safe situated on top of her wardrobe. She then put L to bed.
31. On Sunday morning they had breakfast downstairs, CT did some laundry and played with the children in the garden. She prepared the children for leaving that included packing their clothes. She placed what was left of R's medicine in a sealable plastic bag and put it in another bag. This was the usual practice. She asked MP's partner, TR to put the bag in the boot of the car. She was able to see TR with the bag and saw him place it in the car. She told me that there was medicine left in the bottle which was not damaged and demonstrated by reference to an identical bottle that the level of medicine left was just under the label. She estimated that this would last until Monday or Tuesday.
32. She accepted that she was upset with her family as they did not appear to be helping her with getting the children ready to leave. She referred to them in an extremely derogatory manner in a text to BR in which she informed him that they were on their way. She described the children as entirely "normal". On arrival at 13.26 she checked the bottle again and it was intact. BR came to the door and did not seem "chatty". She observed that there was an atmosphere in his house. In cross-examination CT gave varying accounts as to where the medicine bottle was stored from Saturday evening through to Sunday lunch time. However she was adamant that given the family's familiarity with this drug and epilepsy, they are very careful as to where and how the medicine is safely stored. She further denied that she has ever seen any Tegretol bottles damaged, broken or Tegretol being spilled. When P was two and half years old, she managed to climb onto the kitchen top, access the refrigerator and take a bottle of "Calpol". She tried to open it but did not succeed. She denied seeing any of the children ever opening any bottles of medicine. CT removed the medicine from the refrigerator. CT further stated that R can get drowsy when she takes her medicine at night. In her opinion it would be very obvious if a child had taken the medicine accidentally and it would be dangerous for a child to take it in this way.
33. CT stated that she was seventeen years old when she started her relationship with BR and it lasted for six and a half years. The relationship was characterised with much violence. She confirmed a number of incidents that are detailed in her statements including being punched in the "stomach" and BR stating that he will "punch the baby out of" her, another where he grabbed her around the throat, being "head-butted" and bitten on the nose. She called the police on many occasions but not on every occasion. She explained that much of his behaviour was related to drugs. He smoked cannabis on a daily basis. He took other drugs such as MDMA. He also dealt in drugs. He was a different person when he did not take drugs. He was also controlling of her. CT accepted that there were times when both she and BR argued and were violent towards each other. She told me that she was only frightened of BR when he "hit" her and later stated that "he'd be seriously hurt if he hurts me".
34. She stated that after their separation, if he argued with JP, he would come to her house. Normally he would let himself into the house. He would try and have sex with her. On two occasions they did have sex. CT accepted that JP was correct to have concerns about BR having sex with her. She also stated that she too was correct to be concerned about JP when CT and BR were in a relationship. On reflection she agreed that she and JP had been manipulated by BR. He enjoyed having two women fighting over him. She readily accepted that the children were exposed to the domestic abuse in her relationship with BR. In the second half of 2015, she was struggling with the children and getting P to school. She accepted BR's suggestion of him looking after the children. She explained that this was supposed to be a temporary arrangement. P's behaviour in particular deteriorated. BR told her to misbehave. Before she read the case papers, CT was unaware as to how much JP was involved in looking after her children.
35. The children have been living with BR since January 2016. CT continued to deal with the R's prescription however from about March 2016 she passed the responsibility for this to BR. From that point CT did not collect any more medicine for R. Her medicine always travelled with her. It was always placed in a sealable plastic bag. CT strongly denied anything untoward happening to the children over that weekend in June 2016. She was equally strong in her assertion that her brother's medicine was tightly controlled and that she was "one hundred percent sure" that the children would not be able to access his medicine. CT struggled to follow some of the questions about the number of bottles of Tegretol that may have been within her house hold, these having been based on a calculation of how many would have been prescribed. She clearly stated that she has never collected more than two bottles and never seen three bottles at the same time containing Tegretol.
36. CT accepted that she had wrongly asserted that there was no communication with her about L being in hospital. She accepted that the telephone records illustrated this. She told me that she was advised by JP and BR not to go to the hospital although she wanted to. She accepted that once the blood screen results were available BR was very angry and was blaming her for L's condition. CT denied that there was a conversation between ST and family friend SS in which he is alleged to have said that L had "got hold of" his medicine.
37. I next heard the evidence of the children's father, BR. He confirmed his six statements and the contents of his replies to the local authority's schedule of findings as accurate. He then updated his responses to the said allegations. These have been detailed in writing. I will not set these out in detail save to observe that these included his acceptance of calling SW a liar but denying that she had ever told her that JP should not be at the hospital, denying that he had ever punched CT, stating that he will "punch the baby out of her", "head butted" her or biting her on the nose by stating that he didn't want to know what she tasted like. He denied putting his hands around CT's throat or attempting to strangle her. He also denied putting his hands around JP's throat but accepted that he held her by her collar which may have resulted in her finding it difficult to breathe. He confirmed that the photographs of a cannabis leaf and plant were taken by him at CT's address and that they belonged to her then partner. He was gathering evidence against CT. He told me that the text messages are a complete record. He maintained that he has always stated openly that he used to take cannabis but not any other drugs. He denied hiding cannabis in R's pram and that he ever dealt in drugs.
38. He told me that the children lived with him from January 2016. P was riddled with nits and all of the children were a "handful". They didn't eat well having become accustomed to eating crisps and noodles when they lived with their mother. He also told me that his relationship with JP is now at an end. He accepted that there had been violence in both of his relationships with CT and JP but that this was to a lesser extent in his relationship with JP. He accepted calling them names and referring to them in derogatory ways including "sket" and "skank" but denied knowing what the former meant. He stated that JP did not lie about being covered in bruises when texting her cousin, but that this was through "rough and tumble". He accepted that he had lost his temper on accessions. On one such occasion he proceeded to punch JP but stopped just before making contact with her. He told me that he would strike women as he had been out of control and in self-defence. During the course of his evidence he referred to CT as that "thing". He denied fault on his part and blamed the arguments on CT including those arguments with JP. BR denied being controlling or manipulative. At first he denied telling P to misbehave when she was with her mother. When pressed he accepted that on one occasion he told P to misbehave as she did not want to go to contact with her mother. BR denied that he was manipulating P.
39. BR told me that JP was involved in the care of the children and at times she found it difficult and frustrating. He "guessed" that she resented this. Usually she looked after L during the day as P was at school and R was at nursery but sometimes R and L. After being pressed on the issue, he accepted that he went out during the day to work or go fishing with his friends. He denied smoking cannabis after the children started living with him and denied dealing in drugs.
40. By reference to a number of text messages, BR told me that on 8 June 2016 he and JP had a significant argument in the presence of the children concerning take away food. JP left for next door and he followed her. She shut the door behind her and he was struck on the head by the door. The disagreement had continued and on 11 June 2016 JP stated that she would be moving out. However they talked it through and were back together by 12 June 2016. He stated that it was his fault as he would go out fishing with his friends all the time. JP stayed with him on 11 to 12 June 2016. The children returned at 13.26 and BR went out shortly after and returned about 16.30 to 17.00. JP was unhappy and gave him the "cold shoulder". There was an atmosphere for about an hour. BR was unable to explain why he or JP had never mentioned him being out of the house on 12 June 2016. He was taken to text messages relating to this that had been deleted and recovered by the police. He denied deleting the messages and could not explain why they were deleted. BR had forgotten that JP's mother had visited that evening and told me that JP went home sometime between 21.30 and 22.30. He was unable to explain the discrepancies in his account of how JP came to be in his home on the morning of 13 June 2016. He denied that there was any attempt by him to conceal JP staying with him that evening.
41. BR stated that on 13 June 2016 he woke up at around 6.30 am and put his head into the children's room at around 6.30 to 6.45 am. P and R were waking and later JP arrived. By the time JP arrived, the girls were up. L can be the first to wake up but this depends on what he has done the previous day. He took R to nursery and then returned to take P to school. He stated that that this was an important day as he was expecting children's services to visit at around 10 or 10.30 am. He was busy dealing with the girls and getting them ready. It was about three hours before he noticed there was something wrong with L and called for an ambulance. He confirmed that his observations of L as recorded by Dr Gordon as accurate in which he described L as "normal" during the course of the previous day and evening. He denied that after being told about the presence of carbamazepine that he tried to blame CT. Later in his evidence he accepted that L would normally wake up around 6.30 am and he would be very active.
42. BR was questioned about an incident in February in which he states that P was trying to give R her medicine. He explained that he did not mention this to anyone as he didn't want to get P into trouble. He first sought legal advice and then told the police later. He had spoken to JP about it but could not say why JP had not mentioned it. When taken through his statements, he stated that he "probably" did not tell JP about it but mentioned it to her before he went for his police interview in August 2016. Later in his evidence when it was put to him that JP didn't know about the February incident, he stated that the only person he told was his "nan". BR was questioned in detail about how L came to ingest carbamazepine. He was clear that he was blaming CT's household. He stressed that the expert opinion was "their opinion". Later in his evidence, BR was taken carefully through the medical evidence and accepted that L had carbamazepine in his blood, he was in a coma and nearly died. He accepted this on the basis of the opinion of the medical professionals. He was unable to explain why he rejected the opinion of the experts on the issue of timing and stated that "I can do so if I want to".
43. He accepted that it would have been impossible for L to ingest the carbamazepine accidentally at his home. BR denied that he had any knowledge that carbamazepine causes drowsiness. He did so despite his daughter being on this drug for two years and the warning that is printed on the label on the bottles of Tegretol. BR was taken to paragraph 19 of his statement at C43. There he states that from around March 2016 he started collecting R's prescription. This was in contradiction to his oral evidence in the course of which he clarified he may have done this "once or twice" when he was with CT. He further stated that he never had more than one bottle of medicine in his possession. BR told me that when the medicine returned with R on 12 June 2016 there was about three days' worth of medicine left in the bottle. He first noticed the spill that evening. He washed the bottle and placed it back in the cupboard but didn't wash the bag. He put the bag in the bin outside his address. He accepted that this was first mentioned on 16 June 2016.
44. BR's evidence continued with his criticism of CT. He confirmed that he has nothing "decent" to say about her and stated "I'm telling the truth about her being an unfit mother". He explained that his grandmother had become aware of CT's holiday, who in turn informed BR. By reference to CT, he denied keeping "tabs on that thing". He told me that he followed JP to work on one occasion. This did not result in her losing her job and she left her work voluntarily. BR accepted that JP cared for the children particularly L during the day. She was eighteen years old and was frustrated. He denied she would do this in the evenings. He continued to assert CT was causing the arguments between him and JP. He further accepted that his behaviour can be intimidating towards JP. BR confirmed the nature of the conversation he had with SS and explained that this happened when he was outside of the hospital and SS approached him.
45. I heard briefly from SS who used to be a friend of MP but has lost contact with her. She was highly reluctant to attend court and gave her evidence with special measures in place. She told me that she saw BR outside the hospital. He approached her and they had a general conversation about their children. She was aware that one of BR's children was in hospital. She agreed that this was probably around 21 November 2016. She couldn't recall much of what was discussed. At first she could not recall an earlier conversation with ST. In the course of questioning she recalled a conversation with ST outside of a shop. She stated that ST was upset but was not swearing. He had some court papers but he did not try to show them to her or ask her to look at them. ST told her that a child "might have got his medication". She further stated that she thought ST said this in anger and with sarcasm.
46. ST is CT's brother and the three children's maternal uncle. He has very reluctantly intervened in these proceedings as BR has raised the real possibility of L ingesting ST's medication. He was the next witness to give evidence. He suffers badly with epilepsy and has had many seizures and hospital admissions. He confirmed that the contents of his three statements are true. From the beginning it was clear that he was struggling with giving evidence and being involved in these proceedings. He stated that he and BR used to be best friends. He was surprised at BR's assertions and his medication is always kept safely in a lockable cupboard and never left unattended. His doctor has told him that a single dose of his medication would kill L within ten minutes of it being ingested. He was clear that in June 2016 he spent much of his time staying with his then girlfriend. At first he stated that the medicine cupboard at his mother's then address had one key and he had another cut for his mother. CT would borrow the key if the children were staying. Later this version changed although I note that by now he had become tired, agitated and impatient. He denied having a conversation with SS. Despite very proper and careful questions on behalf of BR, a significant part of ST's evidence was punctuated with profanities that were directed at the lawyers and the court. At the conclusion of his evidence, much of what he said was confused and unclear.
47. I also heard the evidence of MP who is CT's mother and the maternal grandmother to her children. She confirmed the accuracy of her two statements. She stated that on Friday 10 June 2016 she collected the children at around four o'clock. She looked after them as CT was at work. MP administered R's drug at eight o'clock in the evening after which she placed her medicine in the lockable cabinet in her kitchen. She further stated that there were two keys for the cabinet, she kept one and ST had the other. In the morning CT administered R's medication. MP recalled L waking up, telling me that he usually wakes up at 6 am and starts running around waking everybody up. She told me that on Saturday 11 June 2016 she was present at her home together with CT and LT her son. ST was moving between her address and his then girlfriend and he was not at MP's address on Saturday. She recalled the children being happy and their normal selves. L was "jolly" and played with his sisters and in the garden.
48. When questioned further, MP thought that she may have administered R's medicine on Saturday night and that CT was at work. She did not recall ST being there. She further clarified that she was very particular about making sure that the medicine was locked up and was adamant that there was no chance that any of the children could access the medicine in her home. She confirmed that the mother has a safe above her wardrobe. MP gave some detail about the violence between CT and BR. She stated that they are each responsible for their behaviour. She recalled an occasion when the parents were arguing and she found BR with his hands around CT's throat. MP screamed at him stating to "get the fuck off my daughter". She recalled another occasion that she heard BR threaten to "punch or kick the baby out of her". CT was pregnant with R at the time. Finally she told me that ST has told her that he never spoke to SS.
49. The final witness that I heard from was JP. She confirmed that her three statements are true. She told me that she has a younger sibling who is placed in foster care. She has a difficult relationship with her father who regularly takes cannabis and heroine. Her mother has issues with alcohol and currently has little to do with her. She took some delight in telling me about MG and how well she is doing. She also told me that she has now separated from BR. She suffered violence at his hands and he made her feel worthless. She recognised that they have a child together and they need to get on with each other. She and BR separated in March. It took a long time to come to that decision as she loved him and they have a child together.
50. JP told me that BR has a temper and accepted that she has a temper too. This was feature of her relationship with BR and the children were exposed to this. She gave some detail about the incident during which BR is alleged to have put his hands around her throat. When it was put to her that BR's version is a lie, she replied by stating that perhaps that's how he recalls it. She further confirmed that the contents of her text messages to her cousin were true and that she did have marks and bruises on her body. JP was asked about her text messages to BR concerning his alleged violence towards R. She told me that she could hear her screaming and crying. BR was shouting and swearing at her. It sounded like he was hitting her. She then distanced herself from that last comment by stating that she did not see the incident and it may be that they were just going up the stairs as described by BR. However she maintained that BR was angry and aggressive. She stated that BR was aggressive and controlling. He was smoking cannabis until June 2016. She was aware that he dealt in drugs and this involved her obtaining drugs from him for her father.
51. JP accepted that she has not always been truthful about the events that she has or has not reported to professionals including the independent social worker. She confirmed that BR would telephone her before and after meetings with the independent social worker but then stated that he would call her on a daily basis "anyway". She also told me that she was manipulated by BR. She was scared of him but not anymore. JP also accepted that this contributed to her difficulties with CT. She readily accepted that she had an affair with BR whilst he was in a relationship with CT and that CT was right to be suspicious. BR took full advantage of them both. She accepted that BR enjoyed "two girls fighting over him".
52. JP denied ever seeing two bottles of R's medicine at BR's address unless one was nearly finished and CT had dropped off a fresh bottle. She stated that she looked after the children a great deal but that BR would be home in the evenings. She stated that she had given R her medication on a fairly regular basis. She was pressed and she estimated this to be about one or two times per week. She accepted that this was inconsistent with the information that she and BR had previously given to the professionals. Later she stated that she did not give R her medicine all the time but "every now and then". She did not know about the February incident involving P and R. She thought it was "strange" that BR told the police and had not mentioned it to her.
53. She stated that she had forgotten that BR was out in the afternoon of 12 June 2016. She denied deleting specific messages and stated that she deleted all her messages. She was taken through the telephone records to show that there are messages that are not deleted. She accepted this but could not explain why those specific messages were deleted. She denied deleting any messages on BR's telephone. She told me that she went home to her mother's address that evening. She did not contact BR as she was "pissed off with him". She returned home at just after 21.00 hours. She returned to BR's address the next morning after he knocked on her door. P and R were up. She "did their hair" and made breakfast for them. She checked on L once. She agreed that when the children returned from their mother on Sunday 12 June 2016 they were all "normal".
54. JP explained that she used to protect BR. She knew that BR would not get his children back. She denied knowing anything about how L ingested carbamazepine. She explained that she always has the option to leave and go next door. She had no reason to give L any drugs.

Analysis

55. I have read the detailed and helpful written submissions on behalf of each of the parties. I have carefully considered this together with the oral submissions on behalf of each of the parties. It is beyond argument that on 13 June 2016 L was discovered to have a large quantity of carbamazepine in his system. This caused him to become very unwell and to go into a coma. L required immediate medical attention. He suffered two seizures in the local hospital to which he was first admitted and required ventilation. The medical evidence and in particular, the expert medical evidence is not challenged by any party save for BR. This evidence is relied upon by all of the parties except BR and JP. There are two types of ingestion of carbamazepine by L that have been identified. Firstly the large quantity of carbamazepine that was discovered on 13 June 2016 and is evidenced by the blood screening results and hair strand testing. Secondly the discovery of periodical ingestion. The latter is evidenced by the results of hair strand testing that in Dr Kintz's opinion are a combination of ingestion and environmental exposure. All of the parties agree that it is inherently improbable that L was administered carbamazepine in both CT's and BR's home and this must have happened in one house hold.
56. In respect of the ingestion on or about 13 or 12 June 2016, both experts are strong in their opinion. I note that each of the experts has separately set out a number of caveats to each of their respective conclusions in this regard. These are important caveats and were further developed in cross examination of the experts with great skill on behalf of BR. They were detailed in the submissions on behalf of BR. I have carefully considered and taken into account those submissions. Furthermore, I particularly note the strength of opinion that each of the experts holds on these issues and approach this evidence cautiously.
57. Dr Rylance was careful not to comment on the results of the hair strand testing that go to the issue of multiple episodes of ingestion. Dr Kintz is the appropriately qualified expert to comment on this issue. He has approached these test results with a great deal of caution. His opinion in this regard is much less certain and he reaches his opinion on a balance of probabilities that it is more likely than not that L ingested carbamazepine on several occasions. There are serious limitations in reliable data that would inform his opinion. As a result he cannot say with any precision over what time period the ingestion occurred or on how many occasions. He was careful to state that this occurred on several occasions and not regularly. Thus there would be no tolerance by L to carbamazepine that would be capable of altering his overall opinion. He further stated that given the recorded quantities, there can be no other explanation for the hair strand test results. It is submitted on behalf of the guardian that the anomaly that L's test results which showed ingestion of carbamazepine whilst in foster care, are capable of being explained by the variation in the rate of hair growth. The lower growth rate would place L in the care of his parents.
58. Having considered all of the evidence, I have paid particular regard to the evidence of each of the parents. I note that they each spent a great deal of time in the witness box. I note that they are young parents and in particular JP is still a teenager. There has been a significant passage of time since June 2016. Finally I take into account as I am invited to do so on behalf of CT, that she is intellectually less able than BR. The evidence of these parents, particularly BR and JP is riddled with inconsistencies and inaccuracies.
59. CT began giving her evidence with confidence. She gave a great deal of appropriate detail and context when describing her relationship with BR. Initially she was clear about the arrangements about R's and ST's medication. However this did not last very long. Her recollection became hazy and confused. Her responses to questions about the events of 11 and 12 June 2016 became less than clear. She was not helped by the evidence of her family members. On a number of key issues, such as who administered R's drug on the 11 and 12 June 2016, she was contradicted by her mother. My impression of CT was that of a lady who was trying her best to answer the questions. She had tried her best to get on with BR given that her children lived with him. This goal was not always achieved by her. She faced a great many challenges living in her mother's property and sharing it with her brothers who appear to be regular cannabis users. I found her evidence about the prescriptions and the collection of R's medicine convincing. Despite his later evidence, this was in part corroborated by BR and the text messages that she attached to her earlier statement. Notwithstanding the apparent busy and potentially chaotic household, I am satisfied that CT and her family were vigilant about the storage of drugs within her home.
60. BR was in the main composed and controlled when giving his evidence. His attempts at proving his intelligence by refusing to look at the pages in the bundle was less than impressive. His attitude towards CT, the mother of his three children was uncaring, callous and at times designed to cause hurt. This was in direct contrast to his responses to the complaints made by JP. In the main he tried to shift any blame from her and tried to take responsibility. This was particularly illuminating given that JP told me that she knew "he would never get his children back". However, I note that in respect of important issues, he also blamed JP. For example, he suggested that JP had deleted his text messages, an assertion that she strongly denied.
61. I was concerned to note the change in the description of the children following their return from their mother's home. L was described as "normal". This changed once L's blood results confirmed the cause of his condition. BR's reluctance to agree that L would routinely wake up early was concerning. This is in direct contrast to CT, MP and JP who described L as waking early and being active. He would normally wake others in the household. BR's attempts at explaining the February incident involving P and R had no basis in reality. His explanation as to who he told and when lacked any credibly. Similarly his explanation that CT mainly collected the medicine until June 2016 was incredible and in my judgment an attempt to shift any blame onto CT or her household. BR's evidence in respect of the spilt medicine and the explanation as to why this was not mentioned to the police until 16 June 2016 also lacked credibility.
62. Both CT and JP, described him as controlling, manipulative and aggressive. One of the most concerning example of this was his reported attempts to control what JP was discussing with the independent social worker. In my assessment of JP' evidence, she appeared to be influenced by a sense of dread and fear when giving her oral evidence. On many occasions she sought to step back from her previous complaints against BR. On other occasions she sought to excuse BR's reported behaviour towards her. She shared a common distain for CT. She was united with BR in seeking to undermine CT and to place the blame on her. Her explanation of the deletion of crucial text messages lacked any credibility. In common with BR, her attempts at explaining why there was no mention of BR leaving his home during the afternoon of 12 June 2016 also lacked credibility. It was extremely concerning that she made no mention of the incident in which she believed BR was assaulting R. This was only apparent once the text messages were produced. Not only she did not mention this, her attempts at trying to minimise this event and to state that she did nothing as R is his child concerned me greatly. Most importantly both BR and JP have demonstrated serious inconsistencies about the events of 12 and 13 June 2016. I find it incredible that neither of these two adults have been able to give a remotely accurate account of the events covering these two dates. Where there has been any consistency or reliable information given, it has come about as result of other information such as text messages revealing the same.
63. It is a worrying feature of this case that the person or persons responsible for L's condition have chosen not to share the events that caused his admission to hospital. The evidence does not support an accidental ingestion of carbamazepine by L. There is no reliable evidence that would support a finding that L was given the medicine by another child. Therefore the only realistic explanation is that carbamazepine was administered to L during that weekend in June by one or more adults and that adult or adults would know how and when L ingested this drug. My findings have very serious ramifications for these four children and are capable of affecting the rest of their lives.

Conclusion

64. The adult respondents have each in their respective responses to the local authority's schedule of findings made a number of concessions. There were further concessions made during the course of the oral evidence. BR's most up to date concessions are detailed in a helpful updated document. In my judgment all of the concessions are entirely appropriate and without hesitation I make those findings.
65. Having regard to the totality of the evidence before me I make the following findings:

A. Events of 12 and 13 June 2016

i. From March 2016 BR was responsible for collecting R's prescribed medication in the form of Tegretol.

ii. Between 21.30 hours 12 June 2016 and 9.30 am 13 June 2016 L ingested a large quantity of carbamazepine that was potentially life-threatening.

iii. As a consequence L went into a coma and required immediate medical attention.

iv. He was admitted to hospital after an ambulance was called at 09.33 am on 13 June 2016 where he suffered two seizures and required ventilation.

v. The carbamazepine was administered to L by either BR and/or JP.

vi. If carbamazepine was administered to L by BR or JP and not both, the other was aware of it.

vii. BR and JP failed to seek appropriate medical attention for L in a timely manner thereby increased the risk of harm that he suffered.

viii. BR and JP concealed from the treating medical professionals, the police and social workers that L had ingested carbamazepine.

ix. By reason of the above findings CT and her household had no responsibility for the carbamazepine that was ingested by L.

x. P did not attempt to give R carbamazepine in February 2016 as described by BR.

B. Previous ingestion of carbamazepine

Whilst there is a sense of clarity about Dr Kintz's evidence in this regard, in particular when he stated that he cannot think of another explanation other than ingestion of carbamazepine, I am not satisfied that the evidence is sufficiently reliable. There are far too many variables and a distinct lack of reliable scientific research and consensus amongst the research scientists. The medical evidence is not corroborated by any other evidence. In the circumstances, I do not make the findings sought in this regard.

C. Domestic abuse

In addition to the concessions by the parties, I make the following general findings

i. The relationship between BR and CT was characterised with arguments and violence. They were violent to each other.

ii. On one occasion BR placed his hands around CT's throat and attempted to strangle her.

iii. On one occasion when CT was pregnant with R, BR punched her in the abdomen.

iv. The relationship between BR and JP was characterised with arguments and violence. BR was the perpetrator of violence and JP has sought to minimise this.

v. On one occasion when JP was pregnant with MG, BR placed his hands around her throat and attempted to strangle her.

vi. BR was controlling in his relationship with CT and JP.

vii. BR instructed R to misbehave when in the care of her mother.

viii. P, R and L have been exposed to C. i. and iv. above.

ix. The children have been exposed to illicit drugs and adults taking illicit drugs.