England and Wales Family Court Decisions (other Judges)

IN THE EAST LONDON FAMILY COURT SITTING AT CROYDON

		THE CROYDON LAW COURTS
		9th October 2017

This Transcript is Crown Copyright. It may not be reproduced in whole or in part, other than in accordance with relevant licence or with the express consent of the Authority. All rights are reserved.

If this Transcript is to be reported or published, there is a requirement to ensure that no reporting restriction will be breached. This is particularly important in relation to any case involving a sexual offence, where the victim is guaranteed lifetime anonymity (Sexual Offences (Amendment) Act 1992), or where an order has been made in relation to a young person.

HHJ PROBYN:

1. At 40 minutes past midnight on 3 January 2017, A, a new-born baby of some 12 days of age was admitted to the Accident and Emergency Department at Croydon University Hospital with severe respiratory depression. In brief, A had consumed a large amount of the drug Tramadol from his feed. He was described by the treating physician as being some 30 minutes away from death. Thankfully, he was successfully resuscitated and has not suffered any long-term medical consequences as a result.
2. A was placed under Police Protection in the early hours of 3 January 2017 and a referral was made to the Local Authority, the London Borough of Croydon ("LBC"). His parents signed a Section 20 agreement with LBC. A was discharged on 5 January. He was initially placed by LBC with his paternal Uncle, LM, and family. On 9 January, he was moved overnight to a foster placement and the following day placed with his maternal great-grandparents, Mr and Mrs ST, where he remains. His parents moved to their home on 13 March 2017 and have cared for A under their supervision since that time.
3. LBC issued an application for a public law order on 21 February 2017 and the matter was allocated to me. The police closed the case on 8 March 2017 having determined that, in their view, there was no realistic prospect of identifying who had contaminated A's feed.
4. I dealt with an application for an interim care order on 13 March 2017 as the parents had withdrawn their consent. I refused to make an order and approved the arrangements for A's care as I have described. I made further directions on 16 March 2017 for a fact-finding hearing listed on 15 May with a time estimate of three days. I joined five intervenors to the hearing, all family members and people who allegedly had the opportunity to contaminate A's feed. I made detailed directions for an effective fact-finding hearing, not least of which being full disclosure from the police of their investigation.
5. The police did not comply in any proper way with my order. On 15 May 2017, I had to renew the order for disclosure against the police, which was directed to be produced to the LBC by 17 May 2017. They again failed to comply with that order. In the meantime, at the hearing on 15 May 2017 the Intervenors were discharged as at that stage no party sought to retain them in the pool of potential perpetrators. This decision was re-visited as it had become clear by 17 May 2017, on closer scrutiny of the disclosure which had, at that stage, been obtained from the police, that the contamination of A's feed was far greater than originally thought to be the case. In light of the outstanding issues the matter was adjourned to 1 June 2017 for further consideration of the evidence and re-joining the intervenors.
6. In the interim, I discussed these developments with my Designated Family Judge, HHJ Atkinson, who on consultation with our then Family Division Liaison Judge, Mrs Justice Pauffley DBE, decided that the case should remain allocated to me.
7. By 1 June 2017, the police had complied with my order. The Local Authority applied for the intervenors to be re-joined which was unopposed. A fact-finding hearing was listed to commence on 15 September 2017 with a time estimate of eight days. The lengthy adjournment was to accommodate, amongst other matters, the birth of the third child of two of the intervenors. Evidence and submissions concluded by 28 September but unfortunately due to the pressure of other work commitments, delivery of this judgment was delayed to today, 9 October 2017.
8. A's parents are CD and EF. They are the 1^st and 2^nd Respondents. In relation to the fact finding, CD and EF, along with 5 family members are in the pool of potential perpetrators as persons who had the opportunity to contaminate A's feed. In addition to the mother and father, the potential perpetrators are the paternal grandparents, JK and GH, paternal uncles, LM and NP along with LM's partner, QR. The allocated social worker is Miss Sarah Stow. The Children's Guardian is Miss Nayar Hanif.
9. The Local Authority is represented by counsel, Mr Buck. CD is represented by leading and junior counsel, Mr Goodwin QC and Miss Adams. EF is represented by leading and junior counsel, Mr Twomey QC and Miss Dixon. The Guardian's counsel is Mr Littlewood and A's solicitor is Mr Gavin Blackman. JK is unrepresented. LM is unrepresented. NP is unrepresented. GH instructs counsel through the direct access scheme, Mr Butler. QR is represented by counsel, Mr O'Brien. At this juncture, I extend my gratitude to all counsel for their assistance in this difficult and complex case.
10. I will expand upon the history and factual issues in due course but in outline, the Local Authority seeks findings as follows:

(a) A's milk formula was contaminated with approximately 12 fragmented 50mg tablets of zamadol melt;

(b) A's presentation at hospital was a result of a single administration of tramadol rather than a series of either low or high dosages;

(c) The timing of ingestion was from 9.00pm onwards on the evening of 2 January 2017;

(d) The tablets were placed there deliberately;

(e) The individual responsible did so with the intention of causing A very serious harm or was reckless in regard to the same;

(f) Contamination did not take place within the manufacturing process;

(g) Contamination by parties unknown outside of the home can be excluded;

(h) There is a realistic possibility that any one of the seven adults above was responsible;

(i) On the civil standard of proof, the court is invited to find that the perpetrator was QR.

All of the adults involved robustly deny responsibility for the same.

11. If I can exclude external contamination, Mr Goodwin QC argues on behalf of the mother that two options remain: a ruling that the evidence is insufficiently cogent to permit a finding against any of the adults as a perpetrator or upon close scrutiny of the evidence the court may find against QR as sole perpetrator. In relation to the mother, he says that there is no evidential basis for a finding against her other than opportunity. He says that the evidence clearly points in the opposite direction and should lead to a positive finding that she did not contaminate A's milk formula. The mother equally supports the father in his case and similarly argues that the evidence against the grandparents and NP falls far short of a realistic possibility that any one of them was responsible.
12. Mr Twomey QC, on behalf of father argues that if the court is satisfied that contamination was by a family member, the court should not only exclude the father and the mother but also make a positive finding that it was as a result of QR placing the drug in A's formula at some point between 8.00pm to 9.00pm on 2 January 2017.
13. GH cannot contemplate that any member of her family would have done such a thing and it is argued on her behalf that in the event I exclude external contamination the cause remains unknown. It is said that whilst this is a remote possibility it is less so than causation by any member of her family, including QR. Her husband and their youngest son, NP, share her view.
14. LM adopts the submissions advanced on behalf of his partner, QR. It is argued on her behalf that the perpetrator is more likely to be the work of a malevolent third party rather than any member of the family. She seeks exoneration as does LM.
15. As far as the evidence is concerned the case papers are considerable with witness statements, expert reports, police and Local Authority disclosure and the parties' medical records. The expert scientific evidence is a follows:

(i) Dr Skeet and Dr Sharp; Dr Skeet is a Senior Forensic Pharmacologist and an Honorary Senior Lecturer in Pharmacology at the College of Medicine, Veterinary Medicine and Life Sciences at the University of Glasgow, specialising specifically in the clearance of drugs from the body and the adverse effect of drugs. Dr Sharp, his colleague, is a Forensic Pharmacologist, she specialises in drugs of abuse and the clearance of drugs from the body

(ii) Dr Coulson has provided a substantive report and an addendum report. He is a Senior Lecturer in Clinical Pharmacology, Therapeutics and Toxicology at Cardiff University. He is an Honorary Consultant Physician, Clinical Pharmacologist and Toxicologist at Cardiff and Vale University Health Board where he practices in general internal medicine, clinical pharmacology and clinical toxicology. His clinical duties include work with the National Poisons Information Service where he is responsible for advising healthcare professionals on the diagnosis and management of cases of suspected poisoning in neonates, infants and children;

(iii) Professor Atholl Johnson is a Clinical Pharmacologist and Toxicologist with over 40 years' experience in the assessment of the action of drugs in man and the measurement of drugs and biological fluids. He is a Professor of Clinical Pharmacology at Barts and the London School of Medicine and Dentistry, Queen Mary University College, London and Visiting Professor of Forensic Pharmacology and Toxicology at St George's University, London. He is also the Science Director of the Laboratory of Analytical Services International.

16. The police disclosure includes interviews with the parents, grandparents, NP and QR. The parents were interviewed under caution on 3 January 2017. GH, JK and NP were interviewed on 6 January 2017. GH was interviewed again on 25 February 2017 and QR was interviewed on 1 March 2017. LM and QR initially gave statements to the police on 20 January 2017, those statements being taken by Rtd Inspector, Alan Warwick. He went to Streatham Police Station which is where LM, who is a police officer, is based. LM gave his statement by himself but he sat in on QR's statement. The police obtained evidence from the manufacturer of A's milk powder, Danone and have provided details of the manufacturing processes, security of the product both within the factory and thereafter to the point of purchase. Hair strand testing was undertaken of the parents and intervenors for Tramadol.
17. I have heard from Dr Coulson, Inspector Warwick, the Officer in Charge of the police investigation, PC Colenut, the allocated social worker, Miss Stow and from the mother, father, GH, JK, LM, NP and QR.

The Law

18. The legal framework is set out in an agreed document prepared by Mr Littlewood, undertaken not only to assist me but also the unrepresented parties. It is a concise explanation of the law and I incorporate it and annex it to this judgment but for the avoidance of doubt I make the following points:

(i) throughout the burden of proof remains with the Local Authority, no party has to prove their innocence;

(ii) the standard is the civil standard of proof, namely the balance of probabilities;

(iii) I remind myself of the Lucas direction, namely that it is common for witnesses in these cases to tell lies in the course of the investigation and the hearing and the court must be careful to bear in mind that a witness may lie for many reasons, such as shame, misplaced loyalty, panic, fear and distress and the fact that a witness has lied about some matters does not mean that he or she has lied about everything.

(iv) In terms of identification of a perpetrator I apply the guidance from Baker J in the case of Re J S [2012] EWHC 1370 in which he stated:

'When seeking to identify the perpetrators of non-accidental injuries, the test of whether a particular person is in the pool of possible perpetrators is whether there is a likelihood or real possibility that he or she was the perpetrator, see North Yorkshire County Council and SA [2003] 2 FLR 849. In order to make a finding that a particular person was the perpetrator of non-accidental injury, the court must be satisfied on a balance of probabilities. It is always desirable where possible for the perpetrator of non-accidental injury to be identified both in the public interest and the interest of the child although where it is impossible for a judge to find on the balance of probabilities, for example, that parent A rather than parent B caused the injury, then neither can be excluded from the pool and the judge should not strain to do so, see Re D (Children) [2009] 2 FLR 668 and Re SB (Children) [2010] 1 FLR 1161'.

19. I have received two emails from Mr Twomey QC and Mr Goodwin QC. Mr Twomey helpfully referred me to the case of Graves v Brouwer [2015] EWCA Civ 595 and the Judgment of Tomlinson LJ. He pointed out the relevant paragraphs at 24, 27 and 30 of his judgment. I have had particular regard to the discussion on causation and note in particular at paragraph 24,

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

20. I also note Mr Goodwin QC's email in which he referred me to the decision of Keehan J in Re DB [2013] EWHC 4066. He reminds me that an individual cannot be found to be responsible for an injury by a process of elimination. This was the subject of some discussion in the course of submissions, Mr Goodwin submits that this clearly supports the proposition that a single individual can only be held culpable if a finding is made on the balance of probability. Culpability cannot be established by reduction firstly to two members and then to one on the application of the "real possibility" test. I observe that this forms part of Mr O'Brien's submissions to me on behalf of QR, namely that the court must be vigilant to avoid a finding by default. I agree.
21. Turning to the history, this family was unknown to the Local Authority before this event. CD was born on 9 November 1995 and is 21 years of age. She grew up in Orpington with her mother and her older brother, her parents having separated when she was aged eight years. I understand she had little contact with her father but she has a close, positive relationship with her mother and with her maternal grandparents who she says played a large part in her upbringing.
22. It is evident from the special guardianship assessment of Mr and Mrs ST that they are family orientated and have provided great support to the mother and father and A throughout these proceedings. This, of course, does not diminish the support provided by other family members but simply a recognition of their involvement and love for their family.
23. CD is a hairdresser, she told me she did well in her GCSEs and did a hairdressing course. She completed it and has worked for the last four years as a hairdresser and in due course would love to return to the job. It was evident she derived great satisfaction from it.
24. The father was born on 4 June 1991 and is aged 25 years. He grew up in Shirley in Croydon with his immediate family. He also described having a close relationship with his extended family and his maternal grandparents who are close neighbours. When EF was 18 he moved into their home in order to have his own bedroom as until then he shared with his older brother, LM. He lived with his grandparents until he and the mother moved back to his parents' home in preparation for A's birth.
25. EF told me that he is a plumber and he has worked for his current employer since he left school at the age of 16. He was initially apprenticed to the firm and he has stayed with them since then. He clearly holds them in high regard and they appear to have the same view of him. He has been able to confide in them about these events and they have stood by him. They have given him time off when he has needed it, initially for contact with A and when the proceedings commenced, for court hearings.
26. The parents have been in a relationship since June 2012. They knew from an early stage that they wanted to be together. They have been engaged for about five years and decided to start a family in 2014. It took about a year and a half for A to be conceived. They were overjoyed when this happened. It was a straightforward pregnancy and birth with the father present.
27. The paternal grandparents have also been the subject of a special guardianship assessment. GH is aged 51 years and JK is aged 57 years. They met in 1984 and married in 1988. They own their home in Shirley where they bought up their children. The mother's parents, as I have already noted, live quite close by. They describe the family as close and loving.
28. Living at the home at the time of the incident were JK, GH and NP along with the parents and A. The kitchen is separate to the living room on the ground floor. The three bedrooms are upstairs along with the bathroom. JK is self-employed as a sound engineer in the music business. GH is a qualified nursery worker and has worked with pre-school children for over 24 years. She has a diagnosis of pseudo-epilepsy which is treated with Lamotrigine. GH has not had a seizure for some considerable time.
29. LM is aged 28 years and is a full-time police officer based at Streatham Police Station. He has three children with his partner, QR , who is aged 26 years. Their children are X, Y and Z. X is 3 years of age. He was born on 4 August 2014 and accordingly conceived in late 2013. Y is approximately 15 months. She was born on 24 July 2016 and would have been conceived around October 2015. Z was born on 18 August 2017 and was conceived in late November 2016.
30. LM and QR have been in a relationship since January 2012. I do not know when they started to live together but they told me that they were trying to have children for two years before X was conceived and presumably decided to have children fairly soon after their relationship started. They live at QR's family home in Mitcham with her parents. They share a bedroom with their children. QR is a nurse but has been on sick leave from December 2015 and thereafter on maternity leave, initially for Y and then for Z. From the papers, I believe she qualified in 2011 and has been employed at the University College Hospital on the Haematology and Oncology ward, the Royal Marsden Hospital as a theatre nurse and then moved to St Helier Hospital in Epsom in September 2015.
31. The parties' medical notes have been disclosed. There is nothing of relevance to the issues in the parents' records or those of JK, LM and NP.
32. QR has extensive medical records in respect of her psychological and/or mental health and her physical health. In respect of her mental health I note the following entries:

(i) 27 April 2010 she attended the GP with what was described as psychiatric issues with low mood, eating disorder, concerns about her weight, suggestion that she was cutting her wrists but no suicidal intent and citalopram was prescribed;

(ii) 19 May 2010 the dosage of citalopram was increased;

(iii) 4 June 2010 she felt much better;

(iv) 20 December 2010 her GP wrote a letter to her university about depression;

(v) July 2011 she stopped taking citalopram;

(vi) 17 February 2012 she attended the GP once again in a low mood, she felt stressed at the end of her nursing degree but denied any suicidal ideation and was prescribed citalopram once again;

(vii) 15 June 2012 she attended her GP with anxiety and depression. She felt affected by her body-image and her weight and sought a referral for cosmetic or plastic surgery in the form of breast-reduction. She described having had Bulimia but had stopped vomiting about a month prior to the appointment. A further psychiatric referral was made;

(viii) 21 June 2012 her GP wrote a letter to her college about depression;

(ix) 26 June 2012 she was seen at St George's mental health clinic in relation to her suitability for plastic surgery as previously described;

(x) 17 March 2015 she again saw her GP as she felt psychologically affected by, what she described as, asymmetrical breasts;

(xi) 26 August 2015 she had an appointment with Dr Iyab plastic surgeon in relation to the proposed breast surgery, there having been an application for funding;

(xii) 24 March 2017 she suffered an anxiety attack.

33. Her employment records have been disclosed and it is clear that on at least two occasions she underplayed her mental health history in relation to the disclosure required for employment health screening. The employment health form she completed in 2012 simply referred to having suffered anxiety in 2009. In 2015 she filled out a similar form when she said she admitted to anxiety aged 15 years. She told me that she did this to get an appointment when she would be able to explain her history on a face-to-face basis. She felt that if she had been honest she would not have had an interview. She made the point that they had access to her medical records in any event. It is notable however that whatever the risks of discovery arising out of the lie in 2009, it did not prevent her from repeating the lie in 2015.
34. QR is alleged to have had issues with CD and her relationship and position within the paternal family. When CD and EF met, he was living with his parents and she felt she got along with them straight away, likewise with the rest of his family, his brothers and QR. However, on CD's account there were tensions at times with QR. In September 2012 at a birthday party for GH, she said QR pulled her aside and said she felt she had been pushed out of the family since CD came on the scene. In 2014 CD said that QR told LM, in CD's presence, that he would want to be with somebody pretty and skinny like CD. Unsurprisingly, CD was embarrassed and she thought that LM's attitude changed towards her afterwards, that he did not kiss her hello or goodbye. In evidence QR accepted that she had said this and agreed that at that stage she still suffered from low self-esteem. LM challenged CD about not kissing her when they met, she accepted that when she saw him briefly in August he did so but that this was the first time for a long time.
35. QR's anxiety also appears to have extended to fears over her capacity to conceive. I note from the entry in her medical records on 20 September 2013 that she had been trying to conceive for over a year, coming up to 13 months. She had tried different things, such as keeping a diary and multivitamins. Her partner had got himself checked and everything was fine with him. Her periods were regular and normal. She told the doctor that she was currently under a lot of stress in looking after her grandmother and mother who were unwell and she was trying to do her masters at university. She needed a letter supporting her application for a time extension for her essay. She said her periods were regular and normal. This was not, in fact, consistent with other entries in relation to her menstruation. I note from a subsequent entry in June 2015 that her bleeding was described as irregular and they had never been regular.
36. X, as I have noted, was conceived in late 2013 but nevertheless QR subsequently sought assistance for infertility again. On 20 April 2015 she contacted the GP surgery requesting repeat clomiphene medication as she was off oral contraception and would like to try for a child. On 30 June 2015 she came into the clinic to discuss blood results. The doctor noted as follows,

"…waiting for a referral from physio and the infertility clinic and still no news. She is 10 months postpartum and is having investigation for lactorrhea and bloods, particularly prolactin. Normal so reassured."

37. The entry continues to note, "…bleeding not regular but never has been. She is trying to conceive for five months and stopped last method of contraception. Conceived through clonate last time that she bought in Spain, advised we did not advise self-prescribing in this way here."
38. QR told me that she had had two miscarriages, one in June 2015 and Z's twin on 26 and 27 December. I note there is no mention of the June 2015 miscarriage in the medical records. QR said that she had not sought medical attention as it was very early at two weeks. She and LM were on a weekend away and she did not want to upset it by seeking medical attention. I find this hard to reconcile with the entry on 30 June 2015 in respect of her request for fertility treatment, which makes no mention of the miscarriage. It seems to me that this would have been important and relevant information. In any event, Y was conceived presumably around October 2015 as she was born on 24 July 2017.
39. In the summer of 2016 once CD's pregnancy with A was confirmed it was agreed between the parents and paternal grandparents that they would move to their home. JK told me that it made sense for the young couple to move in with them so they could have the run of the house rather than be confined to a room as they were at the great grandparents' home. This meant that LM's old room had to be cleared. CD thought QR was upset and stressed by this, particularly as she was in the latter stage of her pregnancy with Y at the time.
40. Text exchanges between them have been produced. CD told QR not to stress about it, she did not want her or LM to be pushed out or feel ostracised because they were moving into their room. QR's response makes it clear that it came as a shock and that, at least in her view, it was a fait accompli. She went on to say:

'We just want to make sure that the kids will be treated equally and not favouritism or comparing going on as they will see your baby every day and shopping etc. and X and baby when LM gets time off. Also we don't want X to feel left out as he is used to going upstairs and stuff at (the grandparent's) and one baby is going to be a shock, another is going to be a mega shock, plus four of us in NP's room wouldn't fit, X, LM and I barely fit and we have a small carrycot for baby to sleep in like X used to so that and the travel cot wouldn't fit so staying over will be a juggle'.

41. There was a further exchange and QR said,

'We think after this baby'(Y) 'Might not be able to have anymore but at least I wouldn't have to think about birth control. After this baby I have to have an op so maybe no more kids'.

42. CD responded, saying they will be able to see each other when the babies were born. QR's reply was that:

'The difficulty as LM only gets two days off and he is the only one that drives. I'm going to have to go back to work after nine months, you're lucky you drive, that is a bonus with kids and you are lucky you have EF working a nine to five week day job as these shifts LM and I do make childcare hard and even more tiring for us girls raising the kids as when LM's on nights or weekend I have got to look after X all day and night, don't know how I will cope with the night feeds with baby when he is on nights and then X all day too, the energy bunny'.

43. It is clear to me from these texts that QR was upset at the prospect the parents' move into the paternal grandparent's home, she was worried about how her children would be treated and how they would fit in along with the additional pressure of a new baby.
44. Turning to the availability and usage of Tramadol, all of those interviewed by the police were asked about this and it was clear that only two people who had any connection with Tramadol were GH and QR.
45. In GH's interview with the police on 6 January 2017, she said that she remembered QR had Tramadol a few years ago when GH had a pain in her side. QR asked her if she wanted to try some of her Tramadol. GH said she went to the doctor about the pain and mentioned the Tramadol she was given by QR but could not remember at the time of the police interview whether her GP subsequently prescribed it. This was before her medical records were disclosed to the police.
46. GH's medical records note on 25 February 2014 that she had ongoing chest-wall pains – struggling. For stronger analgesia, taking daughter's tramadol. She was referred to physiotherapy and prescribed Tramadol 50mg (100) capsules to be taken one or two when required, four or six hourly for pain.
47. GH was interviewed again on 25 February 2017 after disclosure of her medical records. She was asked about the prescription and again said that QR said to take the tablets, they were really strong painkillers and to ask her GP for a prescription. She went on to say that despite the doctor, who was a locum, having prescribed Tramadol, she was concerned about the reaction with her epilepsy medication. In the course of the hearing, GH produced a leaflet in relation to Tramadol which clearly states that medical advice is required before taking Tramadol if you have epilepsy. GH had also heard how addictive they can be and decided not to take them. She is unsure as to whether she actually took the prescription to the pharmacy and obtained the drugs.
48. QR's records disclose that she was given Tramadol in hospital on three occasions:

(i) 6 July 2011: hospital admission for investigation into gastric problems or suspected appendicitis. She was given it on request for pain relief.

(ii) 29 July 2012: hospital admission she was given it again on request for pain relief, this admission being for gastroenteritis.

(iii) 29 November 2012: hospital admission for drainage of a pilonidal cyst, she was given it twice on request during that admission, on 29 November and 3 December 2012.

49. QR's case in relation to the Tramadol she gave to GH is that on discharge on 4 December 2012 she was given a strip of Tramadol capsules that had been in the locker with the rest of her medication. This does not appear anywhere in her records. She told the police that the hospital gave her a sachet and said, 'You can tell us if you've got pains'.
50. Initially, QR was not interviewed by the police but gave a statement on 20 January 2017, as I have already indicated. In it she was very clear that she does not take Tramadol and had no drugs with her on 2 January 2017. She was not asked about GH' account which she had already given to the police in her interview on 6 January 2017. It is unclear to me what Inspector Warrick knew about the case or indeed the contents of GH's interview at the time he took QR's statement.
51. After GH's interviews on 6 January and 25 February 2017, the decision was taken to interview QR under caution and she was asked in the course of the interview about GH's account. The police officer told QR in the interview that she would see her medical records. QR said, 'It would not be on her medical records' and that the Tramadol was given to her in hospital when she had a cyst on her back drained in 2012. She said she had been in hospital twice during that year, the first for sepsis, an ulcer when she was given Tramadol for pain relief and again when she had the sinus drained. She told the officer that on discharge in December 2012, she was given a sachet of Tramadol. She said it made her sleepy but found it great for pain, it just made her too drowsy. She gave three or four capsules to GH, they were yellow and green capsules. GH took them and said it worked. QR said she told her to go to her GP and get some more.
52. Subsequently in her statement in these proceedings she said that the hospital had offered her what was left of the medication which she thought was about six capsules and she took one when she was at home and she was left with four or five capsules. On the "To Take Out" (TTO) form written up on 4 December 2012, there is no record of Tramadol being given to QR albeit other pain relief is prescribed, namely Paracetamol and Ibuprofen. In evidence, QR told me that the Tramadol was included in the pack containing the dressings for her wound and not specifically given to her by a member of staff or a nurse.
53. LM said in evidence that he did not collect QR from hospital on that occasion but he remembered she came back with Tramadol although he did not remember her taking it.
54. QR said the following in her statement:

'I was prescribed Tramadol as pain relief following a back operation in November 2012, it was provided to me as what is known as PRN medication which means it can be asked for when a patient is in pain on the ward. It was kept in a locked box and given to me when I requested it. When I was discharged, the hospital offered me what was left of the medication which was about six capsules. I think I took one for pain relief following a dressing change. I was therefore left with four or five capsules. It is not correct that I was prescribed tramadol for MRSA although I did have MRSA'.

She goes on:

'Not long after my operation GH was suffering from back pain, she said she had tried all over the counter medications and none of them had worked. I told her that tramadol had worked for me and offered her my remaining capsules. She later told me that they had worked for her and that she obtained a prescription for them from her GP. I also believe from the police evidence that I have seen that GH was prescribed further tramadol about two years ago'.

55. This is not consistent with GH's records or indeed of her account to the police. On both occasions she said she was given tramadol by QR when she complained about the pain in her side. QR told her to go to the GP and ask for a prescription as it was a really strong painkiller. The entry is GH's medical records is dated February 2014, some 14 months after QR was discharged from hospital in December 2012. This is a significant discrepancy between their accounts.
56. Turning to A, he was born at 45 minutes past midnight on 21 December 2016 weighing 3.26kg. He was a much wanted baby and on the basis of the somewhat sparse obstetric records, he came into the world with ease after a short labour. He was welcomed into the family home. The parents, as I have already made clear, had close family support. The midwifery notes for the home visit on 23 December 2016 described him as well, alert, good tone with slight jaundice, Mother noted to be pain-free, emotionally well and no concerns. A was breastfed initially.
57. On 24 December 2016, his parents were worried that the remainder of his umbilical cord was infected and they took him to hospital. He was noted to be dehydrated and slightly jaundiced and they were advised to supplement his breast milk with formula. I understand that he was kept in overnight and discharged on Christmas Day. In any event by 26 December 2016, the parents had decided to move to bottle-only feeding and they purchased a box of Cow and Gate First Infant milk formula from Tesco's. He was given 4oz bottles made up of 4 ozs of water and an equal amount of formula. A was fed on a three-hourly basis. CD explained to me that she pre-prepared A's bottles by filling the bottles with boiled water and storing them in the fridge until they were needed. I understand that the bottle was then heated in the microwave and the formula scooped into the bottle. This meant that the bottles would be made up individually rather than in batches. Both parents made up A's bottles. Mother said that she did rather more of the night-time ones and Father fed A during the day. They had, of course, a fairly short period to establish a routine. A ingested the Tramadol on 2 January 2017, only eight days since A's admission to hospital and the decision to move to bottle feeds.
58. On 26 December 2016, LM and family, visited the grandparents and great grandparents. QR and LM left the children with the grandparents as QR was bleeding and she thought she was having a miscarriage. The following day, QR texted CD telling her she was going to have a D and C (Dilation and Curettage), as the doctor thought she had miscarried twins, although it was possible that she had lost just one with one sac remaining. She would have to wait two weeks but the bleeding was heavier now. The next message was that the doctor had called and said that she could not have the D & C and would have to wait until the next Friday, that is 30 December 2016 or until the scan date on 10 January 2017 and have the operation or hope it cleared naturally.
59. On 27 December 2016, the midwife visited and described A as alert, active and feeding better, his weight is recorded at 3.240kg and there were no concerns, mum, well, happy, coping well. On the same day QR sent text messages to CD saying that there was pre-made formula in the great grandmother's fridge if CD wanted to try A on it and there was some reference to different brands. CD's said that A was doing okay, he was on Cow and Gate and putting on weight although she was going to try to express breast milk as well. This is in contrast to the assertion in QR's second statement prepared in these proceedings, that she was not aware that A was being fed formula until 2 January 2017. She said she thought he was either being breastfed or bottle-fed with expressed milk.
60. The parents purchased a second carton of Cow and Gate formula from Sainsbury's. EF thought it was purchased on 30 or 31 December 2016 and CD thought that they bought it on 1 January 2017. GH told the police she thought it was 30 December 2016 because she had asked them to buy her a drink (Orange Baileys) and they said they could not get it in Sainsbury's.
61. CD told the police in interview on 3 January 2017, that she remembered opening the new box and described removing the silver foil seal from the box. The remaining powder from the first box, that is the Tesco's box, was tipped into the new box of formula. CD did not remember seeing any tablets inside the box. In evidence she told me she opened the second carton after 31 December 2016. She said she did not pay attention to whether the packaging was intact although she was clear that she had removed the foil and it did not look odd. She thought quite a few bottles would have been prepared from the second carton although the top layer was the remaining formula from the Tesco's box.
62. On 1 January 2017, GH texted her son, LM 'Happy New Year my lovely first born' and asked him over for lunch the following day. LM responded saying that they were at P, a friend's but would be popping in afterwards.
63. On 2 January at 1.13pm QR texted CD, 'Still sore, cramps, bleeding loads, also sad as turn out to be twins I lost but can have the clear-out next week, how are you and A? We will be popping over later tonight'. There was no reference to any such procedure in QR's medical records, the discharge record dated 27 December 2016 notes "bleeding, early intrauterine pregnancy unknown viability".
64. When she was asked why she had lied about (a) miscarrying twins and (b) being booked in for a d&c, she said she thought the family did not approve of her pregnancy. Her reasoning being that when she thought she was having a miscarriage, they said that she already had one of each, which she interpreted as meaning that they did not think another pregnancy a good idea. When asked if she had said these things for attention she said, 'Well I only got one text from GH.
65. CD says that QR posted on her Facebook account a reference to finding it difficult to being around new-born babies at that time. CD clearly recollects such a post which she took a picture of with her phone to show EF but he had already seen it and so she deleted it. The Facebook post which she says she saw was subsequently taken off the Facebook account. QR was very clear that she did not put this on her Facebook site but she did post a poem which came up from a Facebook miscarriage support group which she had followed since 2015. The poem is exhibited to her statement in these proceedings.
66. EF told me he expected to see LM and family on 2^nd January, as he was aware of the text messages. NP also expected them and JK said that his wife had told him the day before, on 1 January 2017, that there was a plan for lunch on 2 January 2017 but it had been moved to the evening.
67. On 2 January A's routine was as normal. His grandparents took him for a walk at about 3.00pm. He was fed whilst they were out. CD had prepared a bottle of pre-boiled water along with the correct amount of formula to make up his bottle when it was needed. The grandparents gave the bottle to CD on their return and she said that A had 3 ounces of his feed.
68. The family sat down to dinner between half past five and six, NP thought he tried to feed A after he had finished eating. GH remembered that NP picked A up but not that he fed him. CD is very clear he did not. In her police interview she said she had fed him his bottle at 6.00 pm just before the bath. She thought she had made it up and that she fed him. She said there was no problem with this bottle which he finished.
69. I observe in passing that NP told the police that he spent the rest of the evening upstairs in his room when clearly he did not. He came down to see his older brother, LM and family, when they arrived around 7.45 – 8.00 pm.
70. There are important factual issues between the witnesses in respect of what happened during this visit and in summary are as follows:

(i) Was this a pre-planned visit?

(ii) Did CD or EF feed A whilst they were there?

(iii) Did CD put A's bottle onto the windowsill whilst they were there?

(iv) Did QR go into the kitchen on her own?

(v) Did LM go into the kitchen with her to retrieve some baby bottles?

(vi) Did LM comfort Y whilst QR was in the kitchen?

(vii) Was Y held by GH whilst LM was in the kitchen with QR?

(viii) Was A sleeping or snoring during the visit?

71. LM and QR are adamant that the visit was unplanned. LM told me that they were on the way back from their visit to the friend in Gravesend, when he decided to stop off at his parents as he had a calendar for his father. In his statement prepared on a Section 9 form dated 20 March 2017, he said it was , 'A spur of the moment decision to stop off and give his father the desk calendar' despite the fact that he also told me that his children have a strict routine and that QR enforces a regimental bedtime and bath-time. In evidence, LM told me he did not say anything to QR about the visit until they were on their way back from Gravesend, which is clearly contradicted by the text messages I have already referred to between QR and CD.
72. Inspector Warrick gave evidence in respect of the statements he took from LM and QR. He told me that he asked the questions he was told to put. He knew that A had been found to have consumed Tramadol. He said he would have expected to have been told by QR if she had been previously prescribed this medication. I note the following from LM's statement of 20 January 2017: they arrived at eight o'clock; this was an unplanned visit; A was asleep when they arrived but he did wake up; LM held him for a short time; QR did not hold him at all as they had just been somewhere with dogs and she felt dirty; LM saw CD try and feed A with a bottle but he did not appear to want it and she did not persevere; LM did not know where she got the bottle from but did remember CD putting it on the windowsill; Y was upset and crying and LM dealt with her; QR went into the kitchen to prepare a bottle for Y but she used milk they had with them which was different to A's milk; QR gave the bottle to Y but GH was also involved; LM picked up a bottle and milk powder they had left on 27 December; LM did not see anything that would indicate that A was unwell; neither he or QR take tramadol.
73. In her statement of the same date, QR said the visit was unplanned. She saw CD give A a bottle but he did not drink it, he was quite sleepy when they arrived. She thought CD put the bottle on the sofa and did not see what she did with it after that. She did not prepare a bottle for A or see anyone else do so. She did prepare a bottle for Y. It was made with milk that they had bought. In the time that they were there, A slept most of the time and he had a really loud snore. She saw nothing that would indicate he was unwell. She does not take any medication other than folic acid. She does not take Tramadol and had no drugs with her that day.
74. On 1 March 2017, in her police interview, she said, 'We were visiting friends in Gravesend in the morning and passed by the grandparents address to get to the motorway'. QR said to LM that they would go to their friends first. The decision on the way back was on the spur of the moment. After they arrived, she went into the kitchen to make Y a bottle. She thought they had just made a bottle for A, so the kettle would be warm and she could warm up Y's milk. LM followed her into the kitchen to pick up some bottles and a milk container and when the police officer asked her whether he was there for the whole time she said, 'Pretty much'. She said he left a second before she did. She thought A was sleeping and had a really loud snore. She denied posting on Facebook anything that said she was struggling to be around new-born babies.
75. It is notable that they both describe the visit as unplanned, that QR prepared a bottle for Y and that CD fed A during the visit. It is also striking that despite the fact that they both knew QR had had Tramadol in the past, neither of them mentioned it to the police.
76. There is no dispute that the family were in the living room when LM, QR and the children arrived. At some point JK went into the kitchen to make a coffee for LM. As I have already indicated, as far as the layout of the property is concerned, the kitchen is separate to the living room and it is not possible to see into the kitchen from the sitting room. In LM's statement dated 20 March 2017, he said that QR said that she was going to make a bottle for Y as EF had just made one for A so the kettle was still hot. He said that he was in the kitchen with QR. CD was absolutely clear that she had fed A between six and seven and not after LM and QR arrived. She was adamant he was not fed whilst they were there.
77. CD and EF make the point that they did not use the kettle but the microwave. It was put to EF by LM that he was holding a bottle for A when the family arrived and EF was clear that this was wrong. He was asked whether he saw A being fed during that time and EF was again clear he was not fed when they were there. GH and JK were equally clear that A was not fed during the visit either by CD or EF. JK made the point that A had already been fed before they arrived.
78. CD, EF, GH and NP were sure that QR went into the kitchen alone and that LM did not join her as he was in the sitting room holding Y. In evidence, CD and EF said that LM went into the kitchen at some point but this was by himself. GH told me that Y is very much a daddy's girl, she was crying and her son, LM , asked QR to go into the kitchen to make up her bottle which she did but he, LM, remained in the living room. She said:

'the baby, was on my lap and became upset and she is a daddy's girl and LM took her off me and said to QR can you make her a bottle please? And QR went off to make a bottle and LM was holding Y, sitting in front of the fire. I was there the whole time. I am very clear that she, QR, went into the kitchen and LM stayed in the lounge. QR came back with the bottle and gave it to LM and Y and he said "Do you want to feed her?" and so I did and then he went to get the bottles'.

GH said that as Y was upset, both parents would not have left her in the sitting room, one would have stayed with her.

79. NP told me that whilst he was not privy to any of the texts about the visit he was aware that the family were coming that day with the children. He too was very clear that LM comforted Y in the sitting room when QR was in the kitchen preparing the bottle.
80. In relation to QR's text to CD earlier that day, she was asked by Mr Goodwin QC whether she had been bleeding throughout the day and in pain. She said, 'Yes, like I was on Boxing Day, I was bleeding, in pain, discomfort but I don't want to ruin the plans'.
81. CD, NP, GH and EF were very clear that A was not snoring, that they have never heard him snore or have any breathing difficulties until the events late on 2 January 2017. It was not mentioned by LM in his first statement or his second statement despite referring to A being handed round to be held.
82. LM and his family stayed for an hour and they left by about nine o'clock. At that point A was given another bottle. CD was clear that she made up this bottle although EF initially said he did. He accepted in evidence that it was in fact CD. They agree that JK gave A his bottle to feed him. JK said he was not interested and A really treated the bottle like a dummy. He did not take much of it at all. CD said in interview there were about 3 ozs left out of a 4 oz bottle. She took A upstairs after 11.00 pm with the same bottle. She had read it was fine to re-use a bottle within that timeframe. She checked it by squeezing the teat onto her wrist. Nothing came out. She examined the teat and found a white lump on the end of the teat obstructing the flow. CD thought the milk had coagulated and she called EF. He had a look at it and went into the kitchen to make up another bottle.
83. EF told me after the first two scoops he saw lumps in the formula. He said he found an object similar to a small tablet. He told the police that when he found the tablet he had another look at the formula and found two more biggish bits and two or three little bits. He told me he made the bottle up with only two scoops, i.e. 2 ozs of formula and 4 ozs of water and took it upstairs with the tablet. He tasted it and said it was minty with a bitter aftertaste. He showed it to CD and he described a 'T' and a '50' stamped on the back of the tablet. He went into GH's bedroom next door. She tasted it as well and also said that it tasted minty with a bitter aftertaste.
84. CD did not try A on the second bottle, they were both worried that he needed food, particularly given the earlier hospital admission over Christmas. They agreed EF would go out and get another box of formula. EF thought A was all right at this point, although CD was clearly upset. He left and GH went in to see CD and A, she immediately thought there was something wrong. She called out to JK to call an ambulance and she and CD rushed downstairs with A. CD was hysterical by this point. GH was given instructions by the operator on how to test A's breathing. EF returned and the first Responder arrived. An oxygen mask was put on A's face. The paramedic took the formula and the two bottles that had been made up and he looked at the tablet and Googled it and it came up with Tramadol. The parents went with A in the ambulance and the grandparents followed by car.
85. On admission A was described as being in severe respiratory depression. He responded within an hour to treatment. A preliminary analysis of urine showed a positive reaction for methadone but subsequent GCMS analysis showed the presence of Tramadol and the metabolite desmethyltramadol. GH said that when they were in Resus they saw the nurses sieving the formula and that they had bagged the tablet. There seemed to be more little bits in the formula. The tablet was thrown away and the nurses had to go through the bins to find it. The police were called and at 3.15 am, A was taken into police protection. His parents were arrested at 4.15am on suspicion of child cruelty and taken to Sutton Police Station.
86. The police seized a number of items at the hospital, including an evidence bag of white tablets which were the fragments retrieved from the formula, exhibit LEF01. Two Tommy Tippy baby bottles, LEF02 and LEF03 and the opened carton of Cow and Gate baby formula. Forensic analysis of the milk in the baby bottles, calculated that the concentration of Tramadol in LEF02 was the equivalent of 6 ½ x 50mg tablets and in LEF03 the equivalent of 4 x 50mg tablets.
87. EF was interviewed at 12.39 pm that day and CD at 4.07 pm. They gave their account and were released on police bail with a condition that their contact with A must be supervised by the Local Authority. On 4 January 2017, the parents signed the Section 20 agreement with the local authority and as I have already indicated A was initially discharged into the care of LM and QR.
88. The summaries of the police interviews were disclosed to the Local Authority on 9 January 2017. The social worker originally allocated to the case, Hannah Poole, noted in the first statement filed on behalf of the Local Authority that they were concerned by GH's interview which indicated that QR had previously been prescribed Tramadol and on at least one occasion had shared a tablet with GH for pain relief. They also noted that LM and QR had been in the home the day A had ingested the Tramadol. The local authority no longer considered it safe for A to remain in their care. The parents were contacted and agreed to an overnight stay with foster carers and thereafter, A moved to his maternal great grandparents.
89. The Officer in the case, PC Colenut, gave evidence. She accepted that the focus of the police investigation was on who fed A rather than who had access to his feed. She failed to explain, satisfactorily to my mind, why LM and QR (initially) were not interviewed under caution. She agreed that there were seven adults in the household that potentially had access to A's formula and only one of them was not interviewed under caution and that person happened to be a serving police officer. PC Colenut told me she was guided by her Inspector.
90. There is no record in the CRIS reports of any discussion of the decision not to interview LM and QR initially and in the summary of her interview with GH, she wrongly recorded that QR had a prescription for Tramadol. She did not follow up her interview with QR by seeking disclosure of her hospital records despite it being clear that QR had not been prescribed Tramadol as the officer originally thought. She accepted in evidence that this was a significant failure in the investigation.
91. She told me that she had discussed examination of the opened carton for fingerprints with her forensics team. They decided not to bother as it might have been touched by hundreds of people, another matter not recorded in the CRIS reports. She accepted there was no organised search of the family home. They attended the scene and did not even realise that NP was upstairs. There was no search of the bin in the kitchen or the medical cabinet and obviously no search of LM and QR's home. She agreed that they did not know what they were looking for.
92. She obtained a statement from the manufacturers of Cow and Gate milk formula, which described the manufacturing process whereby the powder is passed through a fine mesh sieve and flushed into a sealed bag. Prior to packaging the powder is sieved a second time through a 1.6mm gauge mesh. The packing process is in a sterile and controlled environment. The sealed can of powder is weighed and given a constant permanence statistical weight record. Any carton unacceptably under or overweight is rejected. The packs are boxed and each case is passed through an x-ray machine. Samples are taken which are tested against their chemical, physical and microbiological standards which include odour, flavour, colour and texture. Precautions against insects entering the factory are taken and only authorised personnel are allowed in. There are regular environmental hygiene audits and all visitors are required to wear electronic security passes. As far as transportation is concerned, the powder is packed into 900g cartons which are sealed with a foil lid with an airtight seal and a plastic lid with a tamper-evident band is placed onto each carton. The cartons are placed into cardboard outers containing six packs. These cardboard outers are sealed and labelled with the product and best before date. The cases are placed onto pallets at Wexford which is where the factory is and the pallet is covered with plastic wrapping before the whole pallet is put into a trailer for transportation to the UK. Each trailer is sealed. Once the trailer reaches the warehouse in the UK there is a visual inspection of the trailer and of each pallet as they are unloaded. Each pallet is labelled with a unique barcode which is scanned as it is unloaded and placed into a specific area within the warehouse.
93. The manufacturers state that the individual packs are contained within a sealed cardboard case and on a pallet cupboard in the plastic wrapping making contamination during transport impossible or at least highly unlikely. Danone was asked to confirm whether there had been other complaints of tramadol contamination received in the last 12 months which they said there had not been. The production volumes from the factory are vast. In 2016 there were approximately thirty one and a half million units for the UK. There have been two complaints in relation to tablets in August 2013 and July 2015. In August 2013, one white tablet, 10.4mm in diameter marked MY135 was reported. The factory report was that this tablet was too large to pass through the sieve, identified as a tablet likely to be prescribed for IBS and likely to be sold in Irish pharmacies, not of factory origin. In July 2015 half a brown tablet, 1.1 by 0.4cm without any markings was reported, again the factory report was that the tablet was too large to pass through the sieve but unable to identify the nature of the tablet.
94. On 7 March 2017, the acting Detective Inspector reviewed the investigation and concluded that having appropriately interviewed all parties, obtained statements from the product supplier and evidence from medical professionals, the police unable to prove to the criminal standard, who placed the drugs in the baby food. The evidence would not substantiate child neglect either, most particularly, the wilful element and the case was closed.
95. In my judgement this was not a robust investigation. The deficiencies have been pointed out. Most particularly the failure to appreciate from an early stage that LM and QR were suspects as much as the other family members were, to conduct a proper search of the paternal family home and LM and QR's home, to undertake any forensic examination of the milk carton. It may be that a more thorough investigation might have provided further evidence of wrongdoing but I must consider the evidence before me and not speculate.
96. Turning to the hair-strand testing. Hair-strand tests were undertaken as I have already indicated of all of the intervenors and the parents for tramadol and the results were negative in relation to them all.
97. There has been a risk assessment of the parents. They volunteered in the course of the assessment, brief historic cannabis use. In the viability assessment of the paternal grandparents, GH and JK said they drink socially, JK smokes cannabis very rarely and has used cocaine, recreationally and not at home. He disclosed this to the social worker when he gave a sample for the hair strand test. He said he has used cocaine twice in the last four months. NP said he had very occasionally used cannabis and this was socially, away from home and some time ago.
98. Turning to the scientific analysis, Dr Coulson provided an analysis of the data in relation to the identity of the quantity of Tramadol consumed by A and the timing of ingestion. His analysis is agreed by Drs Skeet and Sharp. There is a difference of opinion in terms of timing as between Dr Coulson and Professor Johnson which I will come to. Dr Coulson noted the following: the statements of A's parents described A being fed at approximately 3.30 pm, 6.00pm, 9.00 pm and 11.00 pm on 2 January 2017, that the father noted A drank very little of his 9.00 pm bottle and the same bottle was used for the 11 o'clock feed. On the basis of the description of the tablets given by the father and the attending paramedic, they are plainly Zamadol Melt, 50mg tablets. Zamadol Melt is a trade name for an orodispersible, i.e. it can be taken without liquid. It is a formulation of tramadol hydrochloride 50mg, manufactured by Meda Pharmaceuticals Limited. It is indicated for the treatment of moderate to severe pain including chronic pain syndromes and cancer pain. The summary of product characteristics makes note of its distinctive minty taste. In the UK tramadol, including the tradename Zamadol and Zamadol Melt are available by prescription only and the advisory committee on the misuse of drugs observed that Tramadol is widely prescribed in the UK with over 11 million prescriptions in 2012.
99. In evidence he told me that generic tramadol is prescribed in capsule form and is less expensive than the tablet which is targeted for specific patients with difficulty in swallowing or in chronic pain, such as stroke or cancer patients. The capsules are green and yellow. There is also a trade version which comes as a white capsule. There is no evidence that either form of capsule was used to contaminate A's feed. Dr Coulson was quite clear that the tablets were plainly Zamadol Melt.
100. There is limited data on the effects of tramadol in neonates. In adults the plasma concentration of Tramadol peaks around 1.6 to 2 hours after ingestion and symptoms could reasonably be anticipated to occur around this time. Dr Coulson noted from A's medical records that he weighed 3.26kg on admission. Symptoms can be anticipated at doses above a therapeutic dose with serious toxicity characterised by seizures at 4.8mg per kilo and potentially fatal respiratory depression at 7.9kg per kilo. Equating to quantities of 4.8mg per kilo x 3.26kg or the equivalent of 15.6mg and 7.9mg. In terms of the low and high dose bottles, there was 15.6mg in the low dose and 25.8mg of tramadol in the high dose. Dr Coulson calculated that if 4.8mg per kilo of bodyweight is taken as an estimate for the dose required to produce significant toxicity then exposure to a single dose of either the low dose or the high dose would be anticipated to cause significant toxicity.
101. He noted that the volume of milk ingested by A is not known with any accuracy and it is estimated at 10mg given that the residual volume in the bottle was 110mg and the milk formula is usually reconstituted to 120mg. He acknowledged the limitation of this arbitrary approach and noted that the daily volume of feed required for a neonate is approximately 150mg per kilo per day, for A this equated to 489mg per day or 20mg per hour. An estimate of 10mg at each feed is therefore conservative and underestimates the degree of exposure. Features would be expected within two hours in a neonate of 3.26kg following a single exposure of more than 6.4mg of tramadol. A single exposure of 10mg of either the low or high concentration of Tramadol would be sufficient to produce significant toxicity. Even 4mg of the low dose would exceed the therapeutic dose and would be expected to cause significant toxicity.
102. The scenario of accumulative effects from multiple exposures is less likely, although not impossible given the low volume of tramadol required to cause toxicity. Drs Skeet and Sharp agreed with Dr Coulson. In their opinion the tramadol found in A's urine came from the contamination of his feed between 9.00pm and 11.00pm on 2 January 2017 and they agreed that the description given of the fragments of the tablets found indicate that they were Zamadol Melt 50mg tablets.
103. Professor Johnson concurred in relation to the identity of the tablets and their toxicity. On the basis that the tablets were Zamadol Melt which weighed 500mg and contained 50mg of tramadol, his analysis of the powder in LEF01 represented 1.2mg of Tramadol or in excess of two tablets. In relation to the contents of the bottles he observed that, allowing for the amount of milk in each bottle this would suggest around six tablets in LEF02 and four tablets in LEF03. In his opinion, the two bottles of made-up milk seized by the police each contained sufficient tramadol to kill a baby of the age and weight of A after a single feed. Accordingly the total number of tablets found was 12. He was unable to provide an opinion on timing in the absence of blood concentration data and the likely dose of tramadol ingested. He found it impossible, in those circumstances, to make any assessment of when and over what period A was given tramadol.
104. Dr Coulson was also asked to comment on two further matters, whether QR's account of being given Tramadol when she left hospital was plausible and whether there is anything of note in relation to GH's prescription for Tramadol on 25 February 2014. In relation to the first question, he did not find any record of Tramadol being prescribed to QR in November 2012. It was clearly documented that she received it in hospital but there was no reference to it on the TTO form. In his opinion he found it implausible that she would have been given a prescription-only drug by hospital staff in these circumstances. He was asked whether it would be safe practice to hand out medications not listed on the TTO. He was clear it would be not only unsafe but would also cause confusion for the GP for obvious reasons. He confirmed his opinion it was highly unlikely that QR would have been given Tramadol without prescription as she asserted.
105. He did not consider that there was anything unusual in GH's prescription. He confirmed that the capsules referred to in the prescription would be the green and yellow capsules commonly used in the NHS rather than Zamadol Melt. Drs Skeet and Sharp and Professor Johnson were not asked about these matters.
106. I have no hesitation in finding that the tablets were indeed Zamadol Melt, 50mg. On the basis of the analysis of A's bottles and the formula, there were at least 12 tablets in the feed. In terms of timing, I accept Dr Coulson's evidence that the likelihood was that this was a single ingestion rather than consumption over a longer period by way of a low dose or dosages. The evidence is compelling in terms of the toxicity and the timing of A's presentation. I do not accept the submission on behalf of QR that this may have been the accumulation of small dosages of tramadol. I accept the evidence that CD fed A at approximately 6.00pm. I prefer her evidence on this point as I will explain in due course.
107. The likelihood of the 6.00pm or an earlier bottle being made-up with the minimal quantity of Tramadol given the scientific evidence is fanciful in my judgement. The distribution and quantity of Tramadol fragments within the milk powder renders that argument without substance. I am satisfied that the bottle that poisoned A was the one made up at 9.00pm.
108. I accept the submission advanced on behalf of the father by Mr Twomey QC, namely A ingested Tramadol from his nine o'clock feed, probably at a point between 11.00pm and midnight this ingestion resulted in his respiratory collapse. It is of note that when his stomach was aspirated, 10mg was obtained via his nasogastric tube. This corresponds with the 110mg remaining in LEF02 as opposed to 120mg in LEF03.
109. It is submitted that I cannot exclude the likelihood of contamination having occurred away from the house. The evidence from the manufacturer has not been challenged beyond the general proposition that the Local Authority must prove its case. In my judgement, the processes described by Danone extremely robust as evidenced by the tiny and statistically infinitesimal episodes of contamination. In my judgment, it is entirely unlikely that contamination occurred outside of the home.
110. CD was clear when she was interviewed by the police on 3 January that she opened the Sainsbury's box at some point after 31 December and tipped in the remains of the Tesco box. A had something in the region of five to six feeds from it. His father thought perhaps a few more. When she removed the silver seal she did not observe any evidence of the package having been tampered with. Whilst I accept she said in evidence she did not pay close attention this was some months after the event. At least five to six 4 oz feeds had been made up from this box and whilst I take into account the fact that the remains of the Tesco's box had been poured on top of the Sainsbury's formula, I am sure that if the formula had been contaminated at some stage before it was opened by CD, inevitably A would have consumed poisoned milk well before 2 January 2017. In conclusion on this aspect of the evidence, I find that A ingested Tramadol as a consequence of his formula powder being adulterated with fragments of the Zamadol Melt representing at least 12 whole tablets. On the basis of my findings, it follows that contamination was by human agency and not the result of any flaw in the manufacturing process. Tramadol must have been added to his feed at some point after 6.00pm and before the 9.00pm bottle was made up by his mother.
111. Turning to my impressions of the parents and the intervenors. First of all in relation to the mother, I note the observations made on her behalf in the closing submissions prepared by Mr Goodwin QC and Miss Adams and they are as follows:

(i) she has no psychiatric history and no record of psychological frailty;

(ii) there are no concerning social factors to set alarm bells ringing;

(iii) she abuses neither alcohol nor drugs;

(iv) she has never taken or had access to tramadol;

(v) her medical history is unremarkable;

(vi) there are few GP visits, no overreliance on medication, no hypochondria and no attention-seeking;

(vii) she is in a well-supported and loving relationship;

(viii) A was a planned and much longed-for child;

(ix) the pregnancy and birth were unremarkable;

(x) Post-birth Mother was happy and well-supported. Her health visitor recorded this during her home visits;

(xi) the visit to hospital to address A's infected umbilical cord supports the picture of a normal parent responding normally to a health issue and placing the child's needs first;

(xii) the move to formula feed by Boxing Day demonstrates Mother accepting and implementing the hospital advice so as to guard against dehydration;

(xiii) all family members without exception spoke highly of Mother's ability as a mother and her bond with A. No-one levelled the slightest criticism against her parenting. From the witness box Mother spoke of her son in genuine and tender terms. All social work and independent social work assessments were fulsome in their praise of her parenting.

(xiv) Mother's affect when A deteriorated on 2 January 2017 was mentioned by several witnesses. She was instantly shocked and highly anxious at his presentation, in fact, hysterical. The independent social worker noted in her report months later that Mother remained traumatised by the events of that night. It is submitted on her behalf that this was hardly consistent with pre-planned perpetration.

(xv) Mother co-operated throughout with the police and children's services. She held nothing back. She accepted full responsibility for making A's feeds, even when Father mistakenly took responsibility in his interview for the nine o'clock bottle. She has never tried to distance herself from opportunity.

112. I found nothing in Mother's evidence contrary to those submissions. My overwhelming impression is of a devoted mother and a well-balanced young woman. Her account of events were consistent both in interview with the police and throughout these proceedings. The social worker, Miss Coyston, queried her delayed response after it became apparent that there was something wrong with A's feed when Father showed her the tablet. I accept that her immediate response was genuine and focused on ensuring that A was fed within the context of their recent experience of dehydration and alongside her lack of experience as a parent. I do not criticise her in those circumstances for sending EF off to get food rather than immediately seeking medical attention. This was such a bizarre and unexpected event, that it would cause even an experienced parent to be wrong-footed. It is hugely fortunate that GH was on the scene given her many years of experience with babies and small children.
113. I found that CD was willing to acknowledge matters against her own interests which have already been touched upon, notably making up the 6.00 and 9.00pm feeds, admitting that she did not observe six broken Tramadol tablets when she made up the 9.00 pm feed and that she should have called an ambulance straight away. She admitted historical cannabis use to Miss Coyston.
114. She clearly had the opportunity to contaminate A's feeds but apart from that one factor there is no evidential basis to support a finding she did so. In terms of her explanation of how the tramadol got into A's feed, whilst she had concluded it was QR she was clearly reluctant to do so. In answer to questions put by her counsel, she said,

'Do you find it almost impossible to think anyone could harm him and so the most likely explanation is factory contamination?', 'I do',

'If the court decides a family member is responsible you would consider it likely to be QR?', 'Very hard',

'Do you bear a grudge against her?', 'No',

'Do you understand why she would be upset at the suggestion?', 'Yes'.

115. Turning to the father, he similarly came across as devoted both to A and CD. He accepted he lied to the police when he was asked why he did not immediately call an ambulance. He told the police that CD had asked him to do so. She did not and this was a lie. His explanation is that he felt terrible and stupid for not having done so. By this point he had been in the cells for 10 hours and he felt dreadful. He agreed that CD made up the 9.00pm bottle and that he was trying to protect her from criticism.
116. The observations in relation to CD could, in my judgement, equally be made in relation to EF. He is clearly a hard-working young man, devoted to his partner and his son. I note that the current arrangements for A's care mean that he has to leave for work extremely early and is of course back later than he used to be when they lived with his parents, nevertheless, he has gone along with matters and cooperated fully. He also thought QR must be responsible. He told me, 'I believe QR put it there. I think around that time, just before she discovered the miscarriage and a few lies came out and I believe it is her'. He said that he thought this was the case since the evidence from Cow and Gate was disclosed but was unable to explain why he had not said anything before now.
117. Both parents were asked whether they had discussed their views with each other and the wider family. They were very clear that they had each arrived at their own view.
118. The case has had an appalling toll on this family as was apparent in the course of cross-examination of the father on behalf of QR. He was asked, 'What lies do you say QR is telling?' he said, 'Going to the kitchen on her own, about a bottle that had been made up, that they weren't planning to come round' Mr O'Brien put to him that LM had said the same things, and asked 'Why not blame him?' He said, 'I don't believe my brother would do that' and collapsed in a state of some distress.
119. In my judgement, this young father found the prospect of anyone doing this to his son almost too hard to contemplate and most particularly any member of his family including his brother's partner. Whilst, he has arrived at this conclusion in relation to QR, he still found it hard to think that it might be her.
120. As far as GH is concerned, she is very clear she does not blame QR. When she was asked about family discussions, she said, 'We were all very upset and shocked that A has been poisoned. We are a close-knit family and try to be strong for each other. We don't like to talk about it when we are together'. She told me that Hannah Poole, the initial social worker, put it into their minds but she, GH, was still not saying it was QR.
121. My impression of GH is that she plainly adores her children and grandchildren. It must have been wonderful for her to have EF and CD move in when CD was pregnant. CD told me she looked upon GH as a second mum and her feelings were obviously reciprocated. The special guardianship assessment was extremely positive in terms of GH's qualities as a parent and one can well see why. In regard to her prescription of Tramadol, I remind myself that she raised it with the police and there is no evidence that she had obtained prescription drugs at any point unlawfully. The only occasion when she used a drug not prescribed to her was when it was given to her by QR.
122. As far as her husband is concerned, he was clearly hugely embarrassed by his illicit drug use of cannabis and the cocaine. I accept his evidence that it was very infrequent and that he profoundly regrets having done this. I do not find it has any bearing on this case. He has not used Tramadol or indeed any prescription drugs. He is equally plainly devoted to his children and grandchildren. He cannot bear to think that any member of his family is responsible including QR. He told me he asked them all directly whether they did it. He told me he asked QR when LM was there. He looked her in the eye and she was crying and said she did not do it and he believed her.
123. NP told me he likes to be the fun uncle. He described this event as a dark moment in his family history and of course, he is right. He said he tried not to discuss matters. He wanted to keep things light. In his police interview on 6 January 2017, he completely omitted the visit by LM and his family, he said he was still in a state of shock. He was unable to say how it happened, he just does not know. It seemed to me NP was an honest witness trying to do his best in an impossible situation.
124. Turning to LM, I have no doubt that he is an equally devoted father to his children and partner. I assume he must be because, sadly, I am driven to conclude that he has lied to me. His evidence, I found to be unsatisfactory, evasive and lacking in credibility on key issues. First of all whether the visit on 2 January 2017 was a planned visit. The evidence is overwhelming that this visit was arranged or planned between him and his mother on 1 January 2017. It is equally clear to me that given both he and QR are concerned about their children's routine, the visit would have been discussed with QR in advance.
125. LM told me in the course of his evidence that there has been some friction between his mother and QR. He described them as being strong women. In my view, this supports my finding that he most certainly told QR in advance of the visit as her text to CD made it clear. I find that she was well aware of the plan to stop by after their visit to Gravesend. On the question of whether this was a planned visit, I find his answers utterly lacking in credibility and at times frankly hopeless. His explanations range from denial to a forlorn attempt to argue semantics. He told me that planned can mean different things at different times, to seek to explain away the overwhelming evidence on this point. His statement on 20 January 2017 was a blatant lie, when he said in the clearest terms that the visit was unplanned. He repeated that lie in his statement of 20 March 2017, which he prepared himself, when he said the visit was a spur of the moment decision. It was not. In my judgement these were deliberate lies.
126. This equally applies to his assertion that EF had just made up a bottle for A. In his 20 March 2017 statement he said that EF had just done this and the kettle was hot. It would not have been hot for A's bottle as the parents used the microwave and I accept their evidence on this point.
127. I equally prefer the evidence of CD, EF, GH, JK and NP that A was not fed whilst LM and QR were there, either by CD or anyone else. There would have been no need as he had recently been fed by CD after she finished her dinner. In my judgement it is inconceivable that the entire family colluded on this point. CD told the police that she fed A at 6.00pm. EF said he thought it was between 6.30 and 7.00pm. NP thought it was about 5.30 pm, after he had picked up A. GH said she did not see CD feed A at 6.00 as she was in the bath but she was absolutely clear, as was her husband, that CD did not feed him when LM and family were there. The combined effect of their accounts is that my overwhelming impression and finding is that A was not fed whilst LM was there. He was fed at 6.00 pm or thereabouts given his feeding regime.
128. I prefer their evidence that QR went into the kitchen alone to prepare a feed for Y whilst LM comforted her in the sitting room. This was, in my judgement, the thrust of LM's statement to Inspector Warwick. He said, 'Y, my daughter was a little upset and was crying and I was dealing with her. QR did go to the kitchen to prepare a bottle for Y but she had used the milk she bought with us as she had a different type of milk to A. There is no mention of him following QR out to the kitchen. He told me, however, that he had left Y with his mother, as after all he had done so on 27 December when he and QR went to hospital. He hardly thought his mother would be incapable of consoling his daughter. He thought the family had either colluded on this point or at least had discussed it ad nauseam so they came to believe it to be true. I do not accept his account. In my judgement reading his initial statement as a whole, I find that QR went into the kitchen whilst he was dealing with Y in the sitting room which is entirely consistent with the evidence of his mother and other family members.
129. LM told me that he knew that QR had been given Tramadol in December 2012 on discharge from the hospital. He said he did not see her take it but nevertheless he was sure he knew about it. He made no mention of this fact to the police and indeed told them that neither he or QR take Tramadol. I find this to be deliberately misleading by omission. I also note that in his statement dated 20 March 2017, he repeats the same assertion and does not seek to correct his account that he knew that QR had indeed had Tramadol in her possession.
130. I was also struck by his answer as to whether he had asked QR about her access to Zamadol Melt, he said, 'No because he did not believe it was QR" despite the fact he knew it was given to stroke and cancer patients and she had worked on those wards. In view of the seriousness of this matter, I am astonished that he did not ask her.
131. For the avoidance of doubt, as I have made clear, I do not accept his theory that his family had colluded against them to protect themselves. I found them all to be credible, reliable witnesses. I do not find that any of them colluded. I am sure there must have been some discussion between EF and CD but it is abundantly clear from the consistency of their individual accounts and the fact that they have held back until this hearing from alleging that QR was responsible that they did not devise a strategy to deflect blame from themselves. The same applies to the other family members although, of course, GH, JK and NP have determinedly avoided blaming anyone in contrast to LM's assertion that there is a conspiracy against QR.
132. As far as QR was concerned, I was rather struck by what seemed to me to be her unusual presentation. She seemed very flat with limited emotional affect despite the situation. I bear in mind, of course, that this must be terribly difficult for her and the evidence in relation to her previous mental health problems.
133. On the basis of the history, it seems to be she was less than truthful with her employers. Her explanation that she minimised matters in order to get an appointment and that, in any event, her medical history would be available was disingenuous. She did this twice and it seems to me she did not expect them to pick up on this.
134. I did not detect any remorse at having been untruthful in this way. It seemed to me that her attitude was that the ends justified the means. This is consistent with her attitude in relation to her own medical needs. She and LM decided within a few months of getting together that they wanted to start a family. I suspect this may have been part of the difficulty with GH, who may have thought it was too soon. In any event by September 2013 she was obviously frustrated that they had not thus far been successful. She lied to her doctor in order to obtain fertility treatment when she said her periods had been regular when in fact the truth was the converse.
135. A few weeks later she obtained a fertility drug, Clomate, whilst she and LM were on holiday in Spain. I find it difficult to believe her account that she did not know what she was being given. She speaks Spanish and by that time, was a recently qualified nurse. In my judgement, it was obvious from her entry in her medical records in 2015 that she well knew what she had purchased and that she would not have received this sort of treatment in the UK without a proper assessment by a fertility clinic to ensure it was a safe and appropriate form of treatment. As put to her on behalf of the mother, it is not recommended for women who have had ovarian cysts, which she had suffered from.
136. It is particularly striking that when she wanted to conceive again she asked her GP for a repeat prescription in April 2015, knowing that it had not been prescribed to her. As I have already alluded to, this clearly demonstrates that she knew Clomate was prescription only in the UK and again her willingness to lie to achieve her ends. She admitted to the doctor in June 2015 that she used it in Spain in order to conceive X. He advised her not to self-prescribe which she was, no doubt, well aware of given her training. In relation to her failure to mention the miscarriage in June 2015 at her appointment on 30 June of that year, I assume that she thought it would impede her referral to the fertility clinic.
137. I do not accept her explanation that the Tramadol she gave to GH, was put in her discharge pack on 4 December 2012. The records are very clear that the nurse was scrupulous in observing the correct procedure when QR was given Tramadol during her admission upon her request for additional pain relief. The TTO form recorded the pain relief given to QR. Dr Coulson's evidence was clear, that is, to give a patient a drug without recording it on this form is contrary to professional standards and he told me that he had never come across this before. He said, at most a patient might be given some paracetamol without it being recorded on the TTO form, whereas of course, paracetamol was recorded here. I accept his evidence that it was highly implausible that she would have been given this medication on discharge without it being prescribed. I find that she has lied about how she obtained this drug. There is no doubt that she had it some 14 or 15 months later when she gave GH the tramadol capsules. In view of my finding, I do not know how she obtained this prescription only medication.
138. I also find that her attitude towards giving strong prescription only analgesics to GH despite her training, to be entirely consistent with her attitude as demonstrated in relation to the fertility issues. She does not hesitate when she should, both in relation to herself and others. She accepted in evidence that she had suffered pain for a number of years. I do not doubt that she found Tramadol to be a more effective form of pain relief than the over the counter medication, such as the paracetamol and ibuprofen given to her on discharge in December 2012.
139. In terms of her statement given to the police that she was not prescribed Tramadol, I find it was deliberately misleading and again a lie by omission. She did not know at the time that GH had already told the police that she had been given Tramadol by her and her account was obviously intended to distance her from any suggestion that she might have been the source of the contamination.
140. I also find that she has suffered over the years with depression, anxiety and low self-esteem. This was particularly evident in respect of her feelings about CD. She did not deny CD's account that she felt LM would prefer her looks and in effect felt marginalised by CD's arrival within the family.
141. I have already noted LM's observation as to the difficulties between QR and his mother. I am sure that CD's developing relationship with GH would have been a source of pain to QR and that these feelings would have been more entrenched on hearing of CD's pregnancy. Her text to CD in that regard and the move into the grandparents' home was striking in terms of her fears that her children would be considered second-best. It is compelling evidence that this simply added to her feelings of insecurity and poor self-worth. I do not accept her evidence to me that A's arrival would make it easier for her as it would give her and LM of more time together and relieve them of the burden of having to visit the grandparents as frequently as they had done before. I find this utterly implausible. I have no doubt that LM loved taking his children to his parents and I am sure that QR enjoyed the maternal role and the positive attention this gave her. In any event I was told that they visited perhaps fortnightly which, given their proximity, they live in LB, hardly seems unduly onerous. In my judgement QR resented CD's pregnancy and saw it as further evidence that she and her family were being slowly excluded from their family life.
142. My conclusion is further supported by her text about her miscarriage of Z's twin. Her explanation that this was in response to what she perceived as a general disapproval on the part of the paternal family to a further pregnancy makes no sense. Their comments were entirely reasonable and sensible. I struggle to see how QR could interpret their observations as negative. This is further evidence in my judgement of her neediness and desire for attention. Her observation that she did not get much attention from GH in response to the hospital admission on Boxing Day, just one text, was in my judgement telling.
143. In relation to the Facebook entry, I accept CD's evidence. QR had posted something to the effect that being around new-born babies after a miscarriage was difficult. I find it hard to understand QR's evidence on the issue that she had received Facebook messages from other women who had suffered miscarriages. At the time she had had one very early miscarriage in June 2015 and subsequently a miscarriage of one foetus on 26 December leaving a surviving baby. Whilst I do not deprecate her distress, she nevertheless had two children and a third viable pregnancy. In my judgment, it is telling that she was seeking solace in a Facebook group for women who had experience miscarriages. It seems to me that she did indeed post something of the sort noted by CD and I find this to be further evidence of her emotional neediness.
144. In relation to her account of the visit on 2 January 2017, I have already made it clear that I find that she and LM were lying when they said the visit was not planned and that QR was well aware that LM had agreed to stop off at his parents. I found that they lied about CD feeding A and that QR went into the kitchen with LM. I find that she went into the kitchen by herself. I also find in relation to her statement that she did not know that A was being breastfed until 2 January 2017 to be a lie given her earlier text exchange with CD. I equally do not accept that A was snoring, this may be a minor matter but I prefer the evidence of his mother, father and grandfather on the point.
145. Turning to my conclusion. I have been clear that the source of contamination came from within the family household. Accident is entirely excluded. For the avoidance of doubt, I find it was by deliberate human agency. I, of course, apply the Lucas direction. It seems to me that the basis for LM's lies was driven by his desire to protect his partner and their life together. He made it plain in the statement he read from the witness box, particularly the final sentence. In his desperation to protect LM he has lied to me on oath.
146. I explored in the course of submissions, motivation and its role in my findings. Ultimately my findings must, of course, be solidly based on the evidence and any inferences I draw must be based on those findings. It is argued on QR's behalf that there is no evidence that she handled Zamadol Melt. I have however found that on two occasions known to the court she obtained prescription only medication without a prescription. She lied in order to try and obtain a further prescription of Clomid. Of the greatest concern is the fact that she had Tramadol in her possession and I do not know how she obtained it. In my judgement this clearly opens the door to finding that she was able to obtain other prescription only medication unlawfully and most particularly, pain relief. I find that she did indeed obtain Tramadol and not just in capsule form. I cannot know how she did this, as I do not know how she obtained the Tramadol she gave to GH.
147. I find that she had Zamadol Melt tablets on her person when she went into the paternal household on 2 January 2017. It may be that she had them with her for her own use given her earlier text about cramps and her evidence that she was in pain. In my judgement she was extremely unhappy over the Christmas and New Year period. She felt further rejection by the paternal family, not only of her but also of her children. I find that in a moment of madness, she succumbed to her feelings of resentment and despair and adulterated A's feed with at least 12 fragmented tablets with the appalling consequences that followed.
148. I do not find, as alleged by the Local Authority that she did so with the intention of causing A serious harm although inevitably she must have been reckless in that regard.
149. I have been asked to exonerate the parents in particular from any finding of negligence in relation to obtaining urgent medical attention for A. I have no hesitation in so finding. The fact that A's feed had been contaminated with a potentially lethal drug was utterly outside of their contemplation or indeed any reasonable parent. They were very new first-time parents and as I have already noted, thankfully GH was on hand. In my judgement, these parents are devoted to their son as they have consistently demonstrated throughout these proceedings and I particularly note their continued co-operation with the Local Authority, despite the time it has taken to resolve matters.
150. Clearly my findings also exclude the grandparents, NP and LM as perpetrators. In relation to the grandparents and NP, their evidence, demeanour and conduct throughout these proceedings only does them credit and serves to reinforce my findings in relation to them.
151. For the avoidance of doubt, I do not find that LM colluded with QR but that in order to protect her, as I have found, he has lied as I have set out above and that is my judgment.