England and Wales High Court (Family Division) Decisions

IN THE HIGH COURT OF JUSTICE

		Mold Crown Court
		4th March 2014

MR JUSTICE MOOR:-

1. This was to have been a fact finding hearing in relation to a seven year old boy, AS. He was born in 2007. He was diagnosed in June 2012 with Type 1 diabetes. This requires that he is treated with insulin twice per day to reduce his blood sugar levels.
2. His Mother is JS. I will refer to her as "the Mother" for the sake of convenience. She was born in May 1976 and is therefore aged 37. She has had a troubled past in many respects. She accepts that she has had mental health problems. She has been depressed. She has attempted suicide on a number of occasions, saying on one occasion that "suicide has been my best friend". It is alleged that she has had anger management problems and alcohol related difficulties. The root of this may well be sexual abuse perpetrated on her when she was a child. For that, she bears absolutely no responsibility at all and the court has nothing but sympathy for her. Regrettably, her mental health difficulties appear to have had a significant impact on AS, as I will explain later.
3. AS's father is SB. He does not have parental responsibility and has had nothing to do with AS during his life. He lives in the Newcastle-upon-Tyne area. He has very recently been contacted by the Local Authority but has not, as yet, replied.
4. The Local Authority, Denbighshire County Council instituted care proceedings on 2nd September 2013. At the time, AS was an in-patient at BB Hospital. Since 6th September 2013, AS has been subject to interim care orders. The Mother did not agree with but she did not actively oppose the orders. On his discharge from hospital, AS was placed with foster carers but in early February 2014 he moved to his maternal aunt and her husband, Mr and Mrs W and their children. At the time of placement, his contact to the Mother was reduced to allow him to settle but the contact has recently been restored to three contact sessions per week plus two telephone contacts.
5. The Local Authority's threshold document says that AS has suffered and is likely to suffer significant harm attributable to the care being given to him by his Mother. The nature of the harm was said to be physical (arising out of the Mother's conduct in 2013) and emotional (arising out of her behaviour between 2010 and 2013).
6. The Local Authority's case is that this is a case of Fabricated or Induced Illness (FII). The physical harm is said to have been Induced Illness, in that it is alleged that the Mother has, at times, given AS excessive doses of insulin which have caused him to suffer hypoglycaemic episodes (very low blood sugar levels). This is undoubtedly extremely serious. Dr B, a consultant paediatrician at BB Hospital, says that excessive doses of insulin can lead to loss of consciousness, real risk of coma or even death. Prolonged and frequent episodes of low blood sugar can adversely affect cognitive function and intellect. It is alleged that the Mother caused a significant number of these incidents in the summer of 2013 which led to AS being admitted to BB Hospital on four occasions between June and August.
7. The emotional harm is said to have arisen in part as a result of Fabricated Illness, albeit in relation to the Mother herself rather than in relation to AS. It is said that the Mother has fabricated cancer and that AS was aware that she had done so.
8. The Mother strenuously denied the allegations of physical harm. At an early stage of the proceedings, she acknowledged that she had fabricated the allegations of cancer. She has recently accepted the basis for the allegations of emotional harm, accepting that AS was told of the cancer but has said throughout that AS did not actually suffer emotional harm. She says that he has presented throughout as a happy, polite, engaging little boy and has coped well with his prolonged hospital admissions.
9. The Mother has never admitted that she induced illness into AS. On 20th February 2014, I approved an instruction to Dr Ng, a paediatric endocrinologist to report as to the likely reasons for the hypoglycaemic episodes undoubtedly suffered by AS. She reported commendably quickly on 26th February 2014. She said that it was "highly probable that the cause of AS's recurrent and prolonged hypoglycaemia was secondary to exogenous insulin resulting in the clinical presentation described". In other words, he had been given excess doses of insulin.
10. The Mother has been very properly advised by Ms Ruth Henke QC and Ms Bethan Japheth that, in the circumstances, it was highly probable that I would find, on the balance of probabilities, that the hypoglycaemic episodes did not have an organic (natural) cause and that they were likely to have been caused by the administration of excess external insulin by injection. Given that, in those circumstances, there was only one realistic candidate for giving AS the excess insulin, the weight of the evidence pointed to the Mother having given AS that excess insulin. The Mother accepted that advice. She equally accepted that it followed, as sure as night followed day, that I would find the Local Authority's threshold criteria proved. She is still unable to admit to me that she did indeed induce the illness in AS by secretly giving him excess doses of insulin but she has instructed her legal team not to contest an amended threshold document in those terms which Ms Gwynneth Knowles QC and Mr Michael Sellars for the Local Authority have prepared overnight.
11. Before I turn to that document, I want to make a few preliminary observations:-

(a) I have read the papers in this case in great detail. I have formed exactly the same view as Ms Henke and Ms Japheth, namely that it was inevitable that I would find, on the balance of probabilities,, that the threshold criteria were established for the reasons given by the Local Authority and, in particular, that I would have concluded that there was induced illness in relation to AS by the Mother secretly giving AS excessive dosages of insulin. At this stage, I do not know why she did so. This will be a matter for the welfare hearing that is fixed for May.

(b) The binary system adopted in this jurisdiction means that my findings become a fact. In other words, it would no longer be open to the Mother to challenge those findings. The case would proceed on the basis that this is what happened. The assessment I have already ordered by Professor A Mortimer, Consultant Adult Psychiatrist will be conducted on the basis that the Mother has indeed induced illness in AS, which was, of course, extremely serious and potentially life threatening. The Mother understands and accepts this.

(c) I have already noted that the Mother has not been able to bring herself to admit to me that she did this. I wondered for a time whether it was therefore necessary for me to conduct a fact finding after all but I concluded that counsel were right when they said I did not need to do so. The Mother is prepared to accept today that I will make the same findings as I would have made if I had heard evidence over eight days. There seems absolutely no purpose therefore in doing so. I have to remember the overriding objective of dealing with cases justly. This includes ensuring that the case is dealt with expeditiously and fairly in a way that is proportionate. I must also consider the need to save expense. I cannot see that it would have served any useful purpose to proceed with a very emotionally draining hearing, which would inevitably have caused immense unnecessary distress to the Mother. I am quite sure there would be no material advantage in doing so as the findings of fact I would have made after a contested hearing would have been exactly the same as the ones I make now. I therefore approve unreservedly the course of action urged upon me.

(d) The fact that the Local Authority has proved its threshold document does not mean that there will inevitably be a final care order. I will have to consider that issue in May, acting on the basis of what is in the best interests of AS.

(e) Finally, I do accept that it has taken considerable courage for the Mother to accept the inevitability of my finding of induced illness. I have already indicated that I am sure she was right to do so. It follows that I commend her for the position she has adopted and confirm that the advice she has received was undoubtedly correct. She is to be praised for having accepted it and taken what I entirely accept will have been a very difficult decision for her.

12. It follows that what I am about to relate contains my findings of fact. AS's presentation after the diagnosis of diabetes was that of a typical child diagnosed with diabetes. He experienced fluctuations in his blood sugar from time to time. He required relatively small amounts of insulin initially, probably because his pancreas was still producing residual insulin but the need for insulin increased in early 2013 as his pancreas ceased to work. Prior to mid-June, his diabetes was relatively well controlled.
13. From mid-June, however, he experienced multiple episodes of hypoglycaemia which necessitated his admission to hospital on four separate occasions. The episodes were recurrent, prolonged and difficult to treat. They were unusual in that they did not follow the typical pattern of variation in blood glucose seen in young children and they were difficult to explain given that only small amounts of insulin were prescribed to AS in the periods during which many of these events occurred.
14. Extensive investigations were carried out and organic causes, such as inborn errors of metabolism or tumours of the pancreas, were excluded. Other rare and unusual medical causes could also be excluded. Tests for growth hormone and insulin like growth factor were found to be normal.
15. From 21st August onwards, AS began to have only supervised contact with his Mother. He no longer suffered from the recurrent prolonged and difficult to treat episodes of hypoglycaemia. This of itself suggested strongly that the Mother was responsible for the episodes.
16. In summary, the Mother was responsible for repeatedly inducing episodes of troublesome and recurrent hypoglycaemia necessitating inpatient admission in the summer of 2013. She did so by giving AS additional insulin by injection beyond that prescribed for him.
17. I now turn to emotional harm. There is, of course, a significant element of emotional harm as a result of AS having been given the additional insulin. This will have caused him not only unpleasant physical symptoms but also the emotional stress of ending up in hospital.
18. Additional to that, however, is the effect on him of the Mother's deception as to her having cancer and the alleged medical treatment to her flowing from that. The Mother admitted the deception. She had no real alternative given that there was no material in her medical records supporting her story, yet she had told so many different people, including professionals, that she was very ill with the disease and had had extensive treatment. For example:-

(a) She told her GP in July 2012 that she had colon cancer in 2004-6 and became angry and agitated when Dr K challenged her in that regard. She says she was put on the spot by the GP and therefore lied.

(b) She told HE, AS's speech and language therapist in November 2010 that she had been diagnosed with cancer and was due to commence a second course of chemotherapy. She was observed to be wearing a headscarf. In December 2010, she told Ms E that she was tired as she had chemotherapy the week before. In April 2011, she told her she was due to start radiotherapy after Easter.

(c) She told AS's school in January 2011 that she had cancer and was having chemotherapy. She said that AS could not attend school because of her treatment.

(d) In September 2011, AS's class teacher said that the Mother had said that she was seriously ill and due to start radiotherapy soon.

(e) In November 2011, she told Dr RS that she had two more sessions of radiotherapy whereupon her treatment was complete.

(f) In December 2011, she told the school that she had relapsed and needed an operation. In January 2012, she told the school she had postponed the operation, fearing that Christmas 2011 would be her last. She was noted to have difficulty walking. Staff members had to assist with picking AS up and dropping him off at school.

(g) In January 2013, she told CD, a learning support assistant at the school that her stomach cancer had returned and, as a result, she was on medication that prevented her driving.

(h) She told her sister she had cancer.

(i) She told CS, her mother's cousin in August 2013 that she had terminal ovarian cancer and had been receiving treatment.

(j) To strengthen her account, she shaved off her hair and eyebrows.

19. She told AS that she had cancer and was very unwell. Although at the age of six or seven, he may not have appreciated the significance of cancer, he would have been upset by her saying she was very unwell. She talked about it in front of him such that he told his school teacher that his mother was unwell and said in school assembly that she had cancer. On 23rd September, AS told JE, the contact supervisor, that his mother had cancer but it went away "because she took three tablets every day".
20. It will be a matter for me to decide in May as to whether or not AS suffered emotional harm as a result of all of this. At this point I merely note that this was all entirely avoidable and, whether he suffered harm or not, the risk that he would suffer such harm should never have been taken.
21. It follows that I am quite sure that the threshold criteria are established. I approve the amended draft and make the findings set out in this short judgment.