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England and Wales High Court (Family Division) Decisions
You are here: BAILII >> Databases >> England and Wales High Court (Family Division) Decisions >> Re 5 Children (Induced and Exaggerated Illnesses Pattern of Behavior)  EWHC 3750 (Fam) (10 December 2021)
Cite as:  EWHC 3750 (Fam)
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SITTING AT THE ROYAL COURTS OF JUSTICE
Strand, London, WC2A 2LL
B e f o r e :
| Kent County Council
|- and -
|(1) The Mother
(2)-(3) MGM and MGF
(5)-(9) V, W, X, Y and Z (By their Children's Guardian, Ms KR)
Damian Woodward-Carlton QC and Katie Phillips (instructed by Fraser Hollands Solicitors) for the First Respondent
Penny Howe QC and Lydia Slee (instructed by Boys & Maughan Solicitors) for the Second and Third Respondents
Paul Storey QC and Stephen Chippeck (instructed by Patrick Lawrence Partnership LLP) for the Fourth Respondent
Sally Stone QC and Patrick Paisley (instructed by Creighton & Partners) for the Fifth to Ninth Respondents
Hearing dates: 1-5, 8-12, 15-16, 18, 22, 24-26, 29 and 30 November and 1, 6-7 and 10 December 2021
Crown Copyright ©
Williams J :
i) A. Fabricated or Induced Illness (FII)
a) Allegation (1) relates to the Mother's exaggeration, over-reporting and/or fabrication of V: (a) asthma; (b) joint/hypermobility problems; and (c) constipation.
b) Allegation (2) relates to the Mother's exaggeration, over-reporting and/or fabrication of W's: (a) symptoms of cow's milk protein intolerance; (b) symptoms of gastro-oesophageal reflux disease; and (c) symptoms of asthma.
c) Allegation (3) relates to the Mother's exaggeration, over-reporting and/or fabrication of Y's: (a) difficulties in swallowing and choking/gagging on food; and (b) symptoms of wheezing/suspected asthma
d) Allegation (4) relates to the Mother's
i) exaggerating, over-reporting and/or fabricating the frequency of X's cough and vomiting;
ii) inducing his vomiting, thereby hindering his nutrition and development;
iii) further or alternatively, depriving X of nutrition; and
iv) inducing illness on at least one occasion on 19 September 2020 but likely on other occasions in particular on 16th January 2020 when X had produced a "very different" vomit, which was brought up effortlessly and accompanied by an "unusual smell".
The Mother does not accept these assertions save that she accepts that the evidence shows she must have introduced bleach into X's stomach tube, but she says she has no recollection of doing so and does not know why she did it. She says she misled police and professionals because she feared going to prison.
ii) B. Physical Harm: Attempted Poisoning Of X By The Mother
a) Allegation (6) relates to the events of 19th September 2020, addressed above.
iii) C. Neglect
a) Allegation (7) relates to V's very low school attendance. This is accepted by the Mother, albeit she proffers some mitigation for what she says was a struggle on her part to encourage V to attend.
b) Allegation (8) alleges that it is likely that X's developmental delay was exacerbated by neglect (including under-stimulation) whilst in his Mother's care, the Local Authority relying upon the significant progress that X has made since leaving her care. The Mother does not accept this.
c) Allegation (9) particularises, in 16 subparagraphs from (a) to (p), what the Local Authority submits was the Mother's neglect of X's health and developmental needs. The matters pleaded include cancelling or missing important medical appointments, refusing to agree to medical tests, resisting HV visits and in-patient admissions and, ultimately, discharging X from his elective admission to Hospital A on 11th September 2020 against medical advice. The Mother had to be persuaded by children's social care to return X to the hospital two days later. The Mother's response, in terms, is that whilst it is accepted that these appointments did not go ahead, mother would assert that there was a reasonable reason why those appointments were not attended. She also asserts that all would have been re-scheduled. The reasons were likely, illness of one or all the children, time clash with other pre-booked appointments, lack of travel time to get from one appointment to another, time clash with school/nursery pick up/drop off, family being on holiday, no childcare, signalling issues (when remote appointment) and around the time of Planned Admission to Hospital for X.
d) Allegation (10) particularises, at (a), (b) and (c), missed/cancelled appointments or non-engagement with services for V, W and Y respectively The Mother's case is that she does not accept there was non-engagement although accepts some appointments may have been missed for good reason.
iv) D. Exposure To Domestic Abuse And Mental Health Difficulties
a) Allegation (11) avers that V, W and Y were exposed to domestic abuse in the relationship between the Mother and CD, and that she returned to that relationship despite the risks she was aware that he posed to her and the children. The Mother accepts she suffered domestic abuse but does not accept the children witnessed it.
b) Allegation (12) relates to alleged domestic violence in AB's previous relationships, and the allegations made by the Mother about her own relationship with him. The Mother alleges AB stalked her around the time X was born. AB denies stalking the Mother in May 2017 and whilst he accepts the fact of findings made against him by HHJ Davies and of criminal convictions for breaching a non-molestation order he denies he poses a risk of domestic abuse.
c) Allegation (13) particularises the harm which exposure to domestic violence can cause to children and pleads that efforts to support the Mother to develop insight into the impact of domestic violence were not successful, as she did not engage with the domestic abuse programmes made available to her. The Mother's response to this paragraph of the schedule is that she does not accept it.
d) Allegation (14) relates to the Mother's significant history of mental ill-health as a child and adolescent The Mother accepts, she has suffered from mental health problems.
e) Allegation 15 relates to the emotional availability of the Mother when low. The Mother accepts that at times when she has been feeling low, she is likely to have been emotionally unavailable to the children.
v) E. AB
a) Allegation (16) pleads that at the relevant date AB had no involvement in X's life whatsoever and had been unable or unwilling to mitigate the significant harm he sustained in the care of his Mother. AB's response to this allegation accepts that he had no involvement in X's life at the relevant date but submits this was not unreasonable "in light of him being unaware of X's existence" and given that he "had no knowledge of X until after the commencement of these proceedings".
b) Allegation (17) pleads that AB was the subject of adverse findings in care proceedings. He denies having a history of domestic violence although accepts being involved in verbal arguments. He accepts findings made by HHJ Davies including that he was in a pool of perpetrators of a bruise to a child, that he had sought to frame a child's father, that he neglected a child.
" The authorities make it plain that, amongst other factors, the following are likely to be relevant and need to be borne in mind before deciding whether or not to conduct a particular fact-finding exercise:
a) The interests of the child (which are relevant but not paramount);
b) The time that the investigation will take;
c) The likely cost to public funds;
d) The evidential result;
e) The necessity or otherwise of the investigation;
f) The relevance of the potential result of the investigation to the future care
plans for the child;
g) The impact of any fact-finding process upon the other parties;
h) The prospects of a fair trial on the issue;
i) The justice of the case.
 I am well familiar with the concept of 'necessity', arising as it does from ECHR Art 8 and, indeed, from the pre-Human Rights Act 1998 case law to which I have been referred. It is rightly at the core of Mr Tolson's submissions in this
case and, without overtly labouring the issue by including substantial descriptive text in this judgment, it is at the forefront of my consideration of the point. Amongst the pertinent questions are: Is there a pressing need for such a hearing? Is the proposed fact-finding hearing solely, as Mr Tolson puts it, 'to seek findings against the father on criminal matters for their own sake'? Is the process, which will be costly and time consuming, with potentially serious consequences for the father if it goes against him, proportionate to any identified need?"
The enquiry put before the court by the Local Authority is too broadly drafted to be capable of a fair hearing and the court will be left with evidence that is of poor quality and little value. It is submitted that this would apply to allegations 1 (V), 2 (W) and 3 (Y), 4 (in relation to X) – save for 4(d) which relates to specifically pleaded allegations capable of identification and determination.
In his oral submissions Mr Woodward-Carlton broadened this a little more and submitted that the court should confine its enquiry to matters relating only to X as they covered exaggerated, over-reported and/or fabricated allegations, inducing vomiting, depriving X of nutrition, and inducing illness by introducing bleach into his feeding tube which essentially covered all the behaviours alleged in relation to V, W and Y. This he submitted was what was necessary to properly inform any risk assessment of the Mother and thus the welfare evaluation and was proportionate having regard to the nature of the issues engaged, the huge amount of non-specific evidence contained in the bundle and risk of unfairness to the Mother in seeking to evaluate her evidence so long after the event. He also submitted that the allegations relating to missed appointments for X and the other children (allegations 9 and 10) were disproportionate and impossible to adjudicate fairly.
The Legal Framework
The burden and standard of proof
(2) A court may only make a care order or supervision order if it is satisfied –
(a)that the child concerned is suffering, or is likely to suffer, significant harm; and
(b)that the harm, or likelihood of harm, is attributable to –
(i)the care given to the child, or likely to be given to him if the order were not made, not being what it would be reasonable to expect a parent to give to him; or
(ii)the child's being beyond parental control.
"8. Each piece of evidence must be considered in the context of the whole. The medical evidence is important, and the court must assess it carefully, but it is not the only evidence. The evidence of the parents is of the utmost importance and the court must form a clear view of their reliability and credibility.
9. When assessing alternative possible explanations for a medical finding, the court will consider each possibility on its merits. There is no hierarchy of possibilities to be taken in sequence as part of a process of elimination. If there are three possibilities, possibility C is not proved merely because possibilities A and B are unlikely, nor because C is less unlikely than A and/or B. Possibility C is only proved if, on consideration of all the evidence, it is more likely than not to be the true explanation for the medical findings. So, in a case of this kind, the court will not conclude that an injury has been inflicted merely because known or unknown medical conditions are improbable: that conclusion will only be reached if the entire evidence shows that inflicted injury is more likely than not to be the explanation for the medical findings."
"My Lords, the late Sir Arthur Conan Doyle in his book The Sign of Four, describes his hero, Mr. Sherlock Holmes, as saying to the latter's friend, Dr. Watson: "How often have I said to You that, when You have eliminated the impossible, whatever remains, however improbable, must be the truth?" It is, no doubt, on the basis of this well-known but unjudicial dictum that Bingham J. decided to accept the shipowners' submarine theory, even though he regarded it, for seven cogent reasons, as extremely improbable.
In my view there are three reasons why it is inappropriate to apply the dictum of Mr. Sherlock Holmes, to which I have just referred, to the process of fact-finding which a judge of first instance has to perform at the conclusion of a case of the kind here concerned.
The first reason is one which I have already sought to emphasise as being of great importance, namely, that 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 the 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 burden of proof if he can legitimately 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 of proof is the only just course for him to take.
The second reason is that the dictum can only apply when all relevant facts are known, so that all possible explanations, except a single extremely improbable one, can properly be eliminated. That state of affairs does not exist in the present case: to take but one example, the ship sank in such deep water that a diver's examination of the nature of the aperture, which might well have thrown light on its cause, could not be carried out.
The third reason is that the legal concept of proof of a case on a balance of probabilities must be applied with common sense. It requires a judge of first instance, before he finds that a particular event occurred, to be satisfied on the evidence that it is more likely to have occurred than not. If such a judge concludes, on a whole series of cogent grounds, that the occurrence of an event is extremely improbable, a finding by him that it is nevertheless more likely to have occurred than not, does not accord with common sense. This is especially so when it is open to the judge to say simply that the evidence leaves him in doubt whether the event occurred or not, and that the party on whom the burden of proving that the event occurred lies has therefore failed to discharge such burden."
"57. I accept that there may occasionally be cases where, at the conclusion of the evidence and submissions, the court will ultimately say that the local authority has not discharged the burden of proof to the requisite standard and thus decline to make the findings. That this is the case goes hand in hand with the well-established law that suspicion, or even strong suspicion, is not enough to discharge the burden of proof. The court must look at each possibility, both individually and together, factoring in all the evidence available including the medical evidence before deciding whether the "fact in issue more probably occurred than not" (Re B: Lord Hoffman).
58. In my judgment what one draws from Popi M and Nulty Deceased is that:
(i) Judges will decide a case on the burden of proof alone only when driven to it and where no other course is open to him given the unsatisfactory state of the evidence.
(ii) Consideration of such a case necessarily involves looking at the whole picture, including what gaps there are in the evidence, whether the individual factors relied upon are in themselves properly established, what factors may point away from the suggested explanation and what other explanation might fit the circumstances.
(iii) The court arrives at its conclusion by considering whether on an overall assessment of the evidence (i.e. on a preponderance of the evidence) the case for believing that the suggested event happened is more compelling than the case for not reaching that belief (which is not necessarily the same as believing positively that it did not happen) and not by reference to percentage possibilities or probabilities."
"24. This analysis, given in a civil case, applies also to family proceedings. There are two questions that the judge must address in a case where there is a dispute about the admission of evidence of this kind. Firstly, is the evidence relevant, as potentially making the matter requiring proof more or less probable? If so, it will be admissible. Secondly, is it in the interests of justice for the evidence to be admitted? This calls for a balancing of factors of the kind that Lord Bingham identifies at paragraphs 5 and 6 of O'Brien.
25. Where the similar fact evidence comprises an alleged pattern of behaviour, the assertion is that the core allegation is more likely to be true because of the character of the person accused, as shown by conduct on other occasions. To what extent do the facts relating to the other occasions have to be proved for propensity to be established?...
26. Again, this analysis is applicable to civil and family cases, with appropriate adjustment to the standard of proof. In summary, the court must be satisfied on the basis of proven facts that propensity has been proven, in each case to the civil standard. The proven facts must form a sufficient basis to sustain a finding of propensity but each individual item of evidence does not have to be proved."
 Any judge appraising witnesses in the emotionally charged atmosphere of a contested family dispute should warn themselves to guard against an assessment solely by virtue of their behaviour in the witness box and to expressly indicate that they have done so.
"Evidence from an individual instructed pursuant to FPR Part 25 clearly results in 'expert' evidence. In a general sense expert evidence though is in reality opinion evidence. The court permits an individual to give opinion evidence because they have an 'expertise' in a particular field. A report from a treating clinician will contain opinion evidence. That clinician is qualified to give an opinion in the medical sense because they are a qualified doctor. The more senior that individual is the more likely the court would accept that they had expertise which allowed them to offer opinion evidence to the court. A consultant level medical professional would I think barring some oddity, bring them into the bracket where the court would be likely to view them as an expert qualified to give an opinion. The opinion of a relatively junior doctor on a relatively straightforward issue might also be accepted by the court as qualifying as expert evidence because it would fall within expertise on that issue. Conversely the opinion of a relatively junior doctor on a matter of considerable complexity might not.
However there is at least one significant potential limitation on the weight that might be given to the opinion evidence of the treating professional. The situation of the medical professional who is called upon to treat a child generates an opinion in a very different context to that of the part 25 expert. The focus of the treating professional is to treat the child by ascertaining the most likely cause of the condition or injury. This may be undertaken as a result of a process of elimination or otherwise. The imperative is to address the condition and to adopt an appropriate plan to treat or protect the child. The treating professional may develop a personal relationship with the child or indeed with the carers. Having formed an opinion in the crucible, perhaps of an emergency it may be difficult for the treating professional to detach themselves from that and apply a purely objective approach. The situation of the part 25 expert is of course entirely different.
In assessing the relative weight to be given to the evidence of a treating professional as against that to be given to the part 25 expert a court ought to bear these factors in mind."
"FII is a clinical situation in which a child is, or is very likely to be, harmed due to parent(s) behaviour and action, carried out in order to convince doctors that the child's state of physical and/or mental health and neurodevelopment is impaired (or more impaired than is actually the case). FII results in physical and emotional abuse and neglect, as a result of parental actions, behaviours or beliefs and from doctors' responses to these. The parent does not necessarily intend to deceive, and their motivations may not be initially evident.
It is important to distinguish the relationship between FII and physical abuse / non-accidental injury (NAI). In practice, illness induction is a form of physical abuse (and in Working Together to Safeguard Children, fabrication of symptoms or deliberate induction of illness in a child is included under Physical Abuse). In order for this physical abuse to be considered under FII, evidence will be required that the parent's motivation for harming the child is to convince doctors about the purported illness in the child and whether or not there are recurrent presentations to health and other professionals. This particularly applies in cases of suffocation or poisoning."
"The term Perplexing Presentations (PP) has been introduced to describe the commonly encountered situation when there are alerting signs of possible FII (not yet amounting to likely or actual significant harm), when the actual state of the child's physical, mental health and neurodevelopment is not yet clear, but there is no perceived risk of immediate serious harm to the child's physical health or life. The essence of alerting signs is the presence of discrepancies between reports, presentations of the child and independent observations of the child, implausible descriptions and unexplained findings or parental behaviour."
"FII is based on the parent's underlying need for their child to be recognised and treated as ill or more unwell/more disabled than the child actually is (when the child has a verified disorder, as many of the children do). FII may involve physical, and/or psychological health, neurodevelopmental disorders and cognitive disabilities. There are two possible, and very different, motivations underpinning the parent's need: the parent experiencing a gain and the parent's erroneous beliefs. It is also recognised that a parent themselves may not be conscious of the motivation behind their behaviour. Both motivations may be present although usually one predominates.
(i) In the first, the parent experiences a gain (not necessarily material) from the recognition and treatment of their child as unwell. The parent is thus using the child to fulfil their needs, disregarding the effects on the child. There are a number of different gains - some psychosocial and some material. Some parents benefit from the sympathetic attention which they receive; they may fulfil their dependency needs for support, which might include the continued physical closeness of their child. Parents who struggle with the management of their child may seek an inappropriate mental health diagnostic justification in the child such as Attention Deficit Hyperactivity Disorder (ADHD) or Autism Spectrum Disorder (ASD). Material gain includes financial support for care of the child, improved housing, holidays, assisted mobility and preferential car parking.
(ii) The second motivation is based on the parent's erroneous beliefs, extreme concern and anxiety about their child's health (eg nutrition, allergies, treatments). This can include a mistaken belief that their child needs additional support at school and an Education Health and Care Plan (EHCP). The parent may be misinterpreting or misconstruing aspects of their child's presentation and behaviour. In pursuit of an explanation, and increasingly aided by the internet, the parent develops a belief about what is wrong with their child. In contrast to typical parental concern, the parent exhibiting such behaviour cannot be reassured by health professionals or negative investigations. More rarely, parents may develop fixed or delusional psychotic beliefs about their child's state of health. The parent's need here is to have their beliefs confirmed and acted upon, but to the detriment of the child.
… It is important to stress that understanding the parents' motivation is not essential to the paediatric diagnosis of PP/FII in the child. This is important because a paediatrician is not expected to understand parental motivation, but simply to understand the cause of the child's presenting illness.
In FII, parents' needs are primarily fulfilled by the involvement of doctors and other health professionals. The parent's actions and behaviours are intended to convince health professionals, particularly paediatricians, about the child's state of health. It is important to note that, as is common in child neglect, the parent is not usually ill-intentioned towards their child per se. Nonetheless, they may cause their child direct harm, unintentionally or in order to have their assertions reinforced and believed. Parents engage health professionals, in the following ways:
(i) The most common form is by presenting and erroneously reporting the child's symptoms, history, results of investigations, medical opinions, interventions and diagnoses. There may be exaggeration, distortion, misconstruing of innocent phenomena in the child, or invention and deception. In their reports, the parents may not be actually intending to deceive, such as when they hold incorrect beliefs and are over-anxious, to the child's detriment…
(ii) A less common way of engaging health professionals is by the parent's physical actions. These actions nearly always include an element of deception. They range from falsifying documents, through interfering with investigations and specimens such as putting sugar or blood in the child's urine specimen, interfering with lines and drainage bags, withholding food or medication from the child and, at the extreme end, illness induction in the child. All of these are carried out in order to convince health professionals, especially paediatricians, about the child's poor state of health or illness.
"In children with FII, iatrogenic harm is caused by the doctor's need and wish to trust and work with parents, which is fundamental to most elements of paediatric practice, and not to miss any treatable cause of illness. Even in cases where FII might be suspected, there is still a tendency to believe parents, to avoid complaints, and sometimes uncertainty about how to proceed in what are usually complex cases. A child often has an existing medical diagnosis, or had started out with an underlying illness, which will make assessment more difficult. The parent's accounts may therefore be true, partially true, or mixed with other accounts that are fabricated or misconstrued. This makes it more difficult to explore their credibility."
i) the child's health and experience of healthcare: undergoing repeated (unnecessary) medical appointments, examinations, investigations, procedures and treatments which are often experienced by the child as physically and psychologically uncomfortable or distressing; genuine illness may be overlooked; illness may be induced.
ii) Effects on child's development and daily life.
iii) Child psychological and health-related well-being.
The guidance notes that the severity of FII can be considered in two ways; the severity of the parent's actions and the severity of the harm to the child. In relation to the severity of the parent's actions the guidance notes that this can be placed on a continuum of increasing severity which ranges from anxiety and belief related erroneous reports, to deception by fabricating false reports, to interfering with samples through to illness induction. The earlier 2009 guidance contained a table "spectrum of cases where FII concerns may arise" which would appear to be reflected in paragraph 4.3.1 of the 2021 guidance. Dr Rose referred to this as a helpful reference point but it does not appear to repeated in the 2021 guidance which supersedes the 2009 guidance. It seems to me that the continuum more accurately reflects the clearly blurred boundaries between the examples included within the table. Indeed it seems the parent's behaviour may fall concurrently at various points along the continuum particularly where there is more than one child involved and that the behaviour may ebb and flow along the continuum and back, particularly where events occur over many years. Indeed the continuum would seem to contemplate rightly that at the lowest end of the continuum the behaviour of the parent is no more than simple anxiety, lack of knowledge, over interpretation or other relatively benign behaviour which may be simply addressed. At the other end of the spectrum is the most serious form of induced illness, for instance poisoning. In between are many other variations. The guidance emphasises that FII can coexist with other genuine illnesses in a child.
The Parties' Cases: A summary
The Local Authority
i) The totality of the evidence supports a conclusion that the Mother has exaggerated illnesses, misreported illnesses and induced illnesses. The expert evidence remained unshaken in their conclusions; indeed, Dr Rose was more supportive of X's developmental delay being more attributable to the Mother's care than he had been in his report. Dr Salvestrini was more supportive of the Mother having induced vomiting than she was in her report and the possible presence of an underlying illness contributing to vomiting does not undermine this.
ii) The evidence shows an escalating pattern over time culminating in the bleach incident in September 2020 which is clearly an induced illness. There is evidence of the Mother sabotaging referrals, misreporting and exaggerating symptoms.
iii) The Local Authority seek a finding of deliberate administration of bleach. It was witnessed by Nurse J, the Mother went to extensive lengths to dispose of the evidence in different bins outside the hospital, she used a decoy syringe, she lied for as long as she could in police interview and in her witness statement and now lies about her lack of recall. Her lies meet the modified Lucas test and support not only deliberate administration on that occasion but on other occasions. Her removal of X from the hospital demonstrates a lack of concern which corroborates her having done it before. Her preoccupation with cleaning at home and elsewhere may have masked her administration of bleach to X before.
iv) The evidence supports a conclusion that the Mother induced the overwhelming majority of the vomiting that X experienced up until his removal from her care in September 2020. That the precise cause cannot be identified does not prevent the court inferring that she was responsible; there is an analogy with nonaccidental injuries where the precise mechanism cannot be determined but the medical evidence supports that conclusion. In particular, the following support that conclusion:
a) The expert evidence identifies no condition which would explain his vomiting in the way evidenced in the documents. Whilst occasional vomiting related to secretions or discrete illnesses might have occurred, they cannot explain the extensive vomiting described by the Mother and witnessed by others including Mr K.
b) Dr Salvestrini's opinion is that it was either induced or exaggerated but she could not say 100% which.
c) The Mother's complaints of dampness in the house would not be relevant to vomiting and there is no real likelihood of unknown explanation.
d) After his removal from her care, the vomiting ceased almost entirely which both rules out an unknown explanation and points to the Mother's culpability,
e) The circumstances of the 19 September 2020 incident in particular the use of a decoy syringe and the Mother's lack of concern after the administration of bleach support the conclusion that she had done so before. How could she have been so relaxed about X's well-being such that she took him out for an hour and away from medical support if she did not have experience of him being well after vomiting?
f) The description of 16 January 2020 effortless vomiting of clear liquid and a funny smell which caused Ms L such concern that even as a supporter of the Mother (and not looking through the lens of September 2020) she felt compelled to write about her concerns to Ms M.
g) The Mother's description of the vomit on 15 September together with its close connection in time with her having purchased bleach and the gastric trial also suggests this was an identifiable incident of induced vomiting.
v) X's failure to thrive was a result of the Mother failing to give him the nutrition that he required, and which had been prescribed by the clinicians. His failure to thrive led to multiple hospital admissions, the insertion of a PEG- J, his being fed by pump rather than normally and led to his being identified as a sick child even by his siblings which interfered with the development of relationships as well as his general development.
a) His progress in terms of weight gain since the Mother was removed from his care supports her role.
b) The fact that he was able to gain weight both in her care and subsequently shows that there is no underlying condition with absorption or gut dysmotility.
c) Dr Salvestrini and the dietician were of the opinion that the changes in his nutrition could not explain his failure to thrive.
d) The evidence of his Vitamin B12 deficiency at a time when his feed should have been delivering in excess of 1000% of his daily need shows he was not receiving the nutrition.
e) The Mother was solely responsible for the delivery of his nutrition for almost the entirety of his life. She understood clearly what she had to do.
f) The Mother's anger at her removal from his feeding regimes whilst at Hospital B point to her preoccupation with being involved in his feeding.
g) It is relatively straightforward for the Mother to have either interfered with feeding in a hospital environment but more importantly to have failed to give him feeds whilst at home.
vi) X's development was significantly delayed as a result of the interplay of lack of nutrition, tiredness from vomiting and lack of stimulation. The evidence of Mr K and the developmental charts together with the assessments of the paediatricians and others show very significant delayed development. Targets which were set were put back because he was incapable of reaching them. His progress since the Mother was removed from his care has been variously described as miraculous, remarkable, a different child, exceptional. His progress across the centiles in terms of weight and his developmental progress in foster care is steady and significant.
a) Dr Rose amended his position having seen the portage worker developmental charts and opined that the contribution of any potential underlying developmental delay was less than he had originally considered might be the case.
b) He considered that lack of nutrition leading to tiredness and lack of interest could be a significant contributing factor as could lack of stimulation.
c) If there was an underlying developmental issue the Mother's actions are potentially more harmful.
d) The evidence of the hospital play therapists seen by Ms N to potentially show a higher level of development then she had considered was present and which thus undermined her evaluation of his remarkable progress when she saw him in October 2020 has to be considered in the light of him being in hospital and receiving nutrition and not vomiting.
e) Ms L emphasised the difference in X between when she saw him on 18 September and when she saw him again on 28th of September, and likened it to the change that had been observed when he came back from Hospital B in May 2018.
vii) In relation to V the Mother has exaggerated and overreported in relation to constipation, asthma and hypermobility.
a) The dosage he was on for Movicol was extraordinarily high and for a very prolonged period. The maternal grandmother's evidence of his lack of problems when she was caring for him both prior to September 2020 and subsequently illustrate there was no underlying chronic constipation as reported by the Mother.
b) Dr Rose's evidence supports the conclusion that the Mother exaggerated V's asthma. The maternal grandmother's evidence of his lack of problems since living with her supports the Mother's exaggeration. He may have had some mild problem but it was not at the level the Mother reported and hence the concerns that Dr O had over the Mother's reports and the conclusions from tests carried out. The extensive investigations carried out at Hospital C were unnecessary and may have left V with a legacy of believing he is more unwell than he is.
c) The Mother pressed for a specialist buggy for V when the assessments by the paediatricians simply did not support any hypermobility issue which required specialist provision. This was generated by the Mother.
d) The Mother also neglected V's development in relation to his education by failing to get him to school. The maternal grandmother has had no difficulty.
viii) The evidence establishes that the Mother has exaggerated and overreported conditions in each of the other children. They have all suffered harm as a result of the Mother's behaviour which has spanned many years and a range of conditions concurrently and sequentially.
a) The children have been worried and distressed by X's condition; V speaks of crying and being worried about X.
b) The children's needs have been overlooked by the Mother's preoccupation with X.
c) In respect of Y the Mother clearly exaggerated his difficulties with eating and swallowing. Although he had enlarged tonsils the evidence from Dr Rose was that this would not have caused any difficulty with his ability to eat or swallow.
d) In relation to W the distance between her alleged dairy allergy or cow's milk protein intolerance and the Mother's reporting that the school yet giving general dairy products in her picnics illustrates her inaccurate reporting.
e) The grandparents have not experienced any of the health problems with V, W or Y that the Mother says she had.
ix) The Local Authority do not need to prove a motive for the Mother's actions. It may be that subsequent assessment of the Mother may shed light on this.
x) The Mother knowingly exposed the children to the risks of domestic abuse in pursuing and resuming a relationship with CD. She knew V was affected by what he had witnessed. She alleges she was raped but the court does not need to determine the allegation. The court should be sceptical of her account of Z's conception and her reasons for not disclosing CD was the father simply do not add up; her family did not disown her. The truth is that she was well aware that a resumption of any relationship with CD would lead to Local Authority concern. His track record in terms of abusive behaviour is serious and the risks to the children were clear and acknowledged by the Mother and yet she resumed some sort of relationship with CD despite having undergone domestic abuse work in the Freedom Programme.
xi) The evidence establishes that AB presents a risk to the children in relation to abusive behaviour within a relationship including convictions, findings by HHJ Davies and the evidence of the lists. In addition the pool of perpetrator finding raises a risk directly to children. The Mother embarking on a relationship with him and conceiving a child represent another exposure of the children to a risk of domestic abuse.
i) The court should be wary of approaching this case from a perspective dominated by the bleach incident. Other clinicians have allowed that to happen. The court should also consider the case from the starting point chronologically with V's birth. The court should also consider the case through the perspective of the Mother's mental health.
ii) At least two of the professionals have allowed the events of 19 September 2020 to reframe their evaluation of the case to the extent that a malign interpretation is now put on all of the Mother's actions which were previously regarded as benign. That was most obviously the case with Ms P whose August assessment which identified many positives was entirely overlooked when she came to write her almost entirely negative statement following the bleach incident. The same is true of Ms M whose chronology is clearly written with an infected viewpoint. She was unable to explain why her chronology was not balanced by what were clearly genuine entries from the records. Dr Q's opinion letter together with Dr T also demonstrates this infection.
iii) In the evaluation of the Mother's evidence in particular in relation to her memory for events, she cannot be expected to recall all that has happened down the years even with the benefit of the medical notes.
iv) The court should be alive to the risks which arise from the subjective nature of language. Ms L described videos showing vomiting, which they did not by the definition given by Dr Rose. Dr O described V's asthma as significant, but this was not a recognised category according to Dr Rose, but it is hardly surprisingly Mother understood it to be serious. Care has to be taken in evaluating whether the Mother has exaggerated when one takes account of the language used by others.
v) The Mother's anxiety that has been a feature of her mental health for many years indeed since childhood is key to understanding what has happened in the case.
a) Her anxiety has led her to consult her GP or other medical professionals when others might not have. Dr U confirmed she was an anxious mum, indeed quite anxious at times and so she presented her children more often than normal, but Dr U did not say abnormal. She tends to be overprotective and to focus on the worst possible explanation. It is possible she has imported anxieties over her older children into her younger children when she has spotted similar signs. Dr Rose confirmed this could lead to misinterpretation not necessarily exaggeration.
b) What she as a mother interpreted as pain may not have been seen by a medical professional as pain, but this is interpretation not exaggeration.
c) The medical records demonstrate more frequent attendance in relation to younger children and less frequent attendance in relation to the older children this is a commonly encountered pattern.
d) Her anxiety makes her wary in relation to professionals who she considers have judged her unfairly. She was aware in 2018 that medical professionals were suspicious about her and her care of X. She was right to be concerned; this was why she was side-lined from X's feeding. It is not surprising that she felt suspicious about professionals judging her constantly.
e) Having regard to the RCPCH guidelines her anxiety is part of the acceptable anxiety on that spectrum. It is not accepted that it has become harmful to the children.
vi) It is clear that the Mother has experienced multiple stressors over the years which will have impacted upon her anxiety and thus her behaviour. It is clear that the Mother's mental health deteriorated at the point that social services first became involved because of concerns about V's school attendance and possible exposure of V to domestic abuse. Both Ms M and Ms L gave evidence that they had sought support for the Mother because they witnessed genuine problems but had been blocked by children services. This is most obvious in relation to the bleach incident. At that time there is strong evidence that she was experiencing a constellation of stressful events which impacted on her mental health. Professionals such as Ms P commented upon her presentation whilst at hospital in September 2020. Moving house, the stress of CD's abusive behaviour, being pregnant, the anxiety about X being admitted, the worries about childcare would all explain why her mental health deteriorated to the extent that she did something inexplicable; namely injecting bleach into X.
vii) What many of the professionals have referred to over the years falls into the category of perplexing presentation. They do not describe significant harm having been caused to the children.
viii) It is clear that there have been significant periods of time when there have not been concerns about the Mother's care of the children. The children were stepped down from a child protection plan to a child in need plan and subsequently to Early Help because of the progress the Mother made. X's perplexing presentation was not considered a sufficient child protection concern to lead to more extensive social services involvement. Had events with X not occurred in September 2020 there is no indication that children's services would have intervened or that threshold would have been met in relation to the other three children. In respect of various aspects of the Local Authority's case in relation to W and Y Dr Rose may have said it was a pain but it cannot be equated with harm, still less significant harm.
ix) It is clear in relation to each of the children that professionals and the experts identified genuine conditions that they experienced.
a) V clearly had constipation at times; Dr Rose and Dr Salvestrini confirm this from the x-rays. The Mother accepts that at times V was not reliably taking all of his medication because she could not force him to and she managed his condition until it no longer presented a problem.
b) V clearly had chest infections and doctors observed wheeze, creps or crackling that was seen on examination. The lung function tests carried out by the RBH showed a deterioration in lung function between December and June which supported his having asthma according to Dr Rose. The RBH bronchoscopy also identified an abnormality consistent with mild asthma. V himself reported symptoms consistent with asthma. It was clearly reasonable for the Mother to approach V's condition as him having asthma.
c) It was the RBH who diagnosed V with reflux on the basis of medical tests they conducted. Dr Rose confirmed that on their findings reflux was indicated although Dr Salvestrini disagreed, but it is clear that it was reasonable for the Mother to rely on their diagnosis. It would take a brave parent to go against it.
d) The Mother's request for a specialist buggy (not a wheelchair) was supported by her own and her mother's experience of hypermobility and by physiotherapists' examinations which confirmed a degree of hypermobility. The fact that the school and others did not observe it does not detract from the fact that it was reasonable for the Mother to rely on physiotherapists' evaluations.
e) In relation to W, when she had a rash the doctors advised avoiding dairy as did the health visitor and the dietician. This narrative was reinforced by repeated professional advice. The issue did not persist beyond summer 2020 and it is hard to see how W sustained any harm from it.
f) In relation to W the commencement of the trail in relation to her asthma is to be found at her admission to A & E when she was considered to have a wheeze and salbutamol was prescribed. The continued prescription of that medication was the decision of doctors not her and Dr Rose was quite clear that he could not point to anything in the medical records which amounted to an exaggeration or fabrication of symptomology. When further medication was experimented with, no one then stopped it. The Mother in any event says that she stopped giving medication in summer 2020.
g) In relation to Y, he was assessed as being hypermobile and Ms N said that following her examination specialist boots would assist him. It is clear that Y had large tonsils; he has now had them removed. It was not unreasonable for the Mother to associate difficulties in choking and swallowing with his enlarged tonsils.
x) The evidence in relation to the Local Authority's allegations in relation to X are based largely on inference or speculation.
a) Issues with X started with the diagnosis that he had an unsafe swallow which was diagnosed by the SALT team. It was the surgical team which recommended the insertion of the PEG-J which Dr Salvestrini has subsequently criticised as not being founded on an adequately objective evidence base of X's feeding difficulties. This cannot be laid at the Mother's door.
b) The delay in X's admission to hospital between late 2019 and September 2020 is entirely explicable by the obstacles that existed, ranging from childcare difficulties through to concerns about Covid, bad weather, the logistics of getting a move organised. They are documented. Prior to the bleach incident Ms M was positive about the Mother's willingness to work with them to get X in, having regard to the barriers that faced the Mother.
c) The evidence in relation to his nutrition and vomiting does not establish a clear pattern which could be said to be the Mother's responsibility. For a considerable period of time he gained weight in the Mother's care. Whilst he was in hospital and subsequent to September 2020 his weight patterns have been intermittent which would suggest that something else is at play. In particular, the trajectory he followed after going into foster care appeared to mirror that which he was demonstrating prior to his admission to hospital.
d) The evidence supports X having a long-standing problem with vomiting which took a variety of forms. It was witnessed by many professionals including doctors, occupational therapists and the portage worker. This is not consistent with the Mother being the cause. There is evidence of genuine conditions which would have explained X vomiting; Dr Rose identified various childhood illnesses which would contribute to him vomiting. Dr Salvestrini also identified that secretions and mucus accumulations could cause vomiting. The pattern of X's vomiting over the years is not static but changes. A number of other factors point against the Mother inducing vomiting.
i) Dr Rose confirmed there was no evidence in the medical records to support a conclusion of induced vomiting.
ii) Dr Rose confirms there is no derangement in X's physiology which would support the administration of any substance.
iii) Dr Salvestrini confirms that had bleach been administered in undiluted form, serious damage would have been evident. Her view on balance was that if diluted bleach was administered there would have been evidence of damage.
iv) The evidence as to how vomiting might be induced by the introduction of water was very uncertain.
v) There was no evidence of overfeeding.
vi) If the Mother was inducing vomiting, she was doing it in a variety of different forms with a variety of different results in terms of the nature of the vomit and when it was initiated. There is no explanation of how this could be achieved.
e) In relation to September 2020, the first time the Local Authority has alleged that 15 September was an example of bleach induced vomiting was in their closing submissions, although some questions were put to the Mother to that effect. There is no evidence in relation to the wet babygro that suggests bleach was a factor in this vomiting.
f) In relation to 16 January 2020 the contention that effortless vomiting of clear fluids is unusual is not supported because others (Ms E) had experienced similar events. Nobody at the meeting expressed concern when it occurred and, despite Ms L's email, no other professional was sufficiently concerned to follow up.
g) It seems clear on the basis of Dr Rose's opinion that X probably has an underlying developmental disorder which is contributing.
xi) The totality of the evidence shows a complex pattern of weight loss and weight gain which was the subject of consideration by professionals over some time as to whether it was a perplexing presentation or a fabricated or induced illness. They did not reach a conclusion that it was FII. The following matters point against the Mother being responsible for X's failure to thrive:
a) Even whilst X was in hospital with his feeding being monitored, in particular when he was at Hospital B, there is a fluctuating pattern which suggests an underlying cause not the Mother's intervention.
b) There are other factors in play including the regular changes in feeds or feeding patterns, the impact of medications which may all contribute to the fluctuating weight loss and gain.
c) There are causes of unknown aetiology or at least an identified aetiology such as delayed myelination, immunoglobin responses which might explain the fluctuating pattern.
d) The Mother's behaviour for instance in stopping the pump whilst at hospital is explicable; a parent seeing a child vomit would naturally stop feeding.
e) The Mother's evidence is clear that she delivered the nutrition that she was advised to deliver and there is no direct evidence that she did not. Those who were involved with X's care saw him attached to his feeding pump and there is no issue raised in the documents of the Mother not complying with the regimes imposed.
xii) In relation to the September admission once she had arranged matters the Mother attended on 7 September late at night having completed her move that day. She left having been told by Dr A that it was up to her whether she left or not. With social services intervention it is legitimate for her to say that she believed she had the approval of the professionals to leave.
xiii) It is clear that in relation to 19 September, the Mother was terrified by what had happened and that the multiple stressors she was working under at the time may have influenced her actions and memory. In the police interviews it is clear she was shocked. She is an intelligent woman and knows that it might be to her benefit to admit it; this supports the genuineness of her inability to recall what happened.
xiv) The Local Authority's case that events after 19 September demonstrate the Mother was the cause of X's difficulties does not withstand scrutiny.
a) The evidence of his alleged very significant developmental progress was put into context by Ms N's evidence that the hospital records of the play therapy showed that X had indeed developed significantly prior to his admission to hospital and that his trajectory of development was smoother than had originally been suggested.
b) The alleged significant weight gain is not supported by the centile and weight evidence which shows that for a period of several months after his discharge from hospital X's weight was essentially static and Dr Rose said that had this static position occurred whilst in the Mother's care it would have raised concerns. The errors in the recording of weight have to be taken into account.
c) A very significant change which may explain his subsequent improvement in feeding is that the Peg J was abandoned, and he began to be fed into his stomach. If Dr Salvestrini is right that the Peg J was inserted without adequate consideration this might explain why X made better progress when it was dispensed with.
d) In relation to the other aspects of X's health the changes have not been as stark as have been suggested. He continued on prophylactic medication for some time which has helped with his asthma and chest infections. He continues to have some mobility issues.
xv) Ultimately the court must be cautious not to evaluate the case on the basis that the events of September 19 explain all. A far more nuanced picture emerges on careful consideration.
i) The court should be alive to the risk of expecting too high a standard of conduct of AB. He may be a rough and ready character, but he is hard-working and committed to his children.
ii) The evidence from the protracted private law proceedings demonstrate that AB is committed to his children despite the obstacles put in his way and that his relationship with the children is positive. The Cafcass reports on him are positive. These proceedings paint a different picture to that which has been put before the court in this case and the conclusion reached in the parenting assessment in these proceedings which is infected by the assertion that there are 73 police reports concerning him, including allegations of sexual misconduct and the Mother is also given information that he has serious offences including firearms offences. These are inaccurate. The court should make clear that those are not findings which can be held against him. In fact, many of the police reports involve him being the victim of unpleasant assaults. This court should set the record straight.
iii) The psychiatric assessment of AB gives him an essentially clean bill of health.
iv) The findings by HHJ Davies stand. The pool finding does not justify a finding that he presents a risk to children. The correct approach from Re J is that a pool finding may be taken together with other evidence but not on its own. His previous convictions are of little relevance.
v) The evidence supports the conclusion that this was a short relationship; a one-night stand and social messaging. The children have never mentioned him and nor has the maternal grandmother. The Mother did not stand by her assertion that he had taken her to antenatal appointments.
vi) The police report of May 2017 does not support the Mother's allegation that AB was domestically abusive; either in May 2017 or during the course of their relationship. Her assertion that he had demonstrated controlling behaviours she recognised was inadequately evidenced.
vii) The evidence is that he was sent a photo of a pregnancy test with an assertion that he was the father. Given it was a one night stand he was entitled to be sceptical. Thereafter there was almost no attempt to involve him until early 2020 and this was not then pursued. The Local Authority face a fundamental problem in causation in relation to their allegation that his failure to be involved in X's life could have lessened his exposure to harm. Given the extensive medical involvement the father's ability to alter the trajectory would have been non-existent.
viii) Ultimately, he is committed to developing a relationship with X and providing a home for him and he should not be ruled out as a result of previous findings without any further findings made.
i) They find themselves in a very difficult position trying to balance prioritising the care of their grandchildren whilst also having a naturally protective instinct in relation to the Mother.
ii) Their commitment to the children has been immense. The maternal grandmother is the rock on which the family has rested. She has stepped up whenever required moving in with the children in 2015, 2016 and 2020, having V live with them and otherwise providing often daily support to the Mother and the children. There are very many examples over the years of the extensive support that the grandparents had been prepared to offer often at a moment's notice.
iii) They have made huge efforts to understand what has occurred both since 19 September last year but in particular during the course of these proceedings.
iv) The maternal grandmother is clearly an honest and sincere witness who has done her best to help the court understand what has happened. The maternal grandfather has found himself in a harder position having continued to live with the Mother in September last year. He has made direct efforts to seek to establish from the Mother what happened, and she has told him variously that she couldn't remember or that she didn't know. It is clear that the account the Mother has given to her father has not been an accurate one in relation to what happened at the hospital or the actions of social services and medical professionals beforehand. The maternal grandfather cannot be blamed for accepting at face value what the Mother said that has influenced the way he frames responsibility for events.
v) It is clear to the maternal grandparents that the Mother seeks to externalise responsibility for matters away from herself. She experienced mental health problems in her teenage years but was unwilling to accept support to address the problems.
vi) They were worried about X whilst he was in the Mother's care and believed him to be a very ill baby whose condition was unexplained.
vii) Now they have heard all of the evidence a clearer picture has emerged although they are still trying to understand how their daughter could have acted in the way it seems she did.
viii) The children appear to be doing well in their care and many of the problems which were apparent when they were living with the Mother have abated either entirely or to a very significant extent. They accept that the children have suffered harm in a variety of ways but, in particular, they believe that what has happened has been emotionally harmful to the children and the relationships they have developed. They have had to re-educate Y and W in relation to X; they saw him as a baby incapable of very much but now they are learning that he is a normal toddler not a sick baby. That failure of the children to develop relationships with X in the way that they might have done is a form of harm.
ix) The grandparents continue to offer a home for the children and have now made a further commitment to that by the maternal grandfather moving in with the maternal grandmother and the three children.
i) the RCPCH Guidance of 2021.
a) The Guidance and table 1 in its predecessor illustrate that the behaviour which falls within the categorisation of perplexing presentation or FII is a continuum rather than compartmentalised categories.
b) As Dr Rose emphasised FII is an uncomfortable diagnosis to make and before clinicians reach that conclusion it may often be characterised as a case of perplexing presentation. That is evident in this case where the issue of V and his constipation and his asthma were clearly perplexing to the clinicians who could not marry up the Mother's descriptions of his problems with their findings; with X where professionals were unable to explain his vomiting or his failure to put on weight and with W where she was said to have a dairy allergy but was actually being given dairy products by the Mother.
c) The reasons why a parent might act in this way are explored in the guidance but clinicians don't need to understand or identify a motive in order to identify behaviour consistent with FII.
ii) The evidence supports a finding that the Mother has induced illness in X, has exaggerated symptoms in all of the children and has misreported symptoms. She has also failed to comply with recommended medical treatments.
iii) Harm: a variety of forms of harm or risk of harm can be identified from the actions of the Mother. The RCPCH Guidance identifies the range of harm and in this case the following harm can be discerned:
a) the obvious physical harm and risk of the administration of bleach on more than one occasion;
b) the harm and risk of harm of the placement of a PEG-J under general anaesthetic, with replacements under general anaesthetic, with the risks of infection and the ongoing medications;
c) the harm and risk of harm of ongoing and extensive invasive investigation and examination leading to the risk of a child who sees himself as seriously unwell;
d) the developmental delay consequent upon the lack of nutrition and vomiting;
e) the harm to the sibling relationships caused by X's condition and the other children's belief that he was a sick baby;
f) the emotional harm to the other children of their worrying about X; illustrated by V's expressed fear that he didn't want to go to school because he feared that X might die;
g) the harm to each of the children who were over medicalised by taking unnecessary medication (or medication carrying some risk of side effects even if not carrying medium to long-term ill effects as a matter of course), the extensive and invasive investigations including bronchoscopy and blood tests which were unnecessary;
h) the risk of the children coming to see themselves as unwell and that affecting their emotional development;
i) the risk of physical and emotional harm arising from their Mother engaging in relationships with men who were abusive to her either in or out of their presence. V's fear and potentially his allegedly aggressive behaviour to the Mother are direct examples of this;
j) there are some examples where further harm might have insulated had the events of September 2020 not occurred; planned neurological and immunological investigations were not pursued after he began to thrive following the Mother's removal from his care.
a) In terms of general approach to the evidence the bleach incident is important in informing the evaluation of earlier events but it is not determinative.
b) There is no reason to question the accuracy of the documentary records.
c) The Mother's evidence is clearly not credible.
i) There are obvious lies; illustrations ranging from the lies about the bleach incident itself during interview; in relation to holiday activities; in relation to Z's paternity; she says there was a trial of water on 11 September which contributed to her decision to leave hospital but there is no record in the medical notes of this occurring.
ii) The Mother's current account that she cannot remember what happened on 19 September is unbelievable. In particular having regard to the contents of the interview of 19 September when she is lucid, calm, responsive and answers questions in a natural and descriptive matter.
iii) She had a selective memory, being able to remember apparently innocuous details but unable to recall other significant matters which one would expect her to remember. The claimed lack of memory of the events of the 19th is undermined by her apparent ability to remember events in the police station.
iv) She was evasive or obstructive in aspects of her evidence
v) In oral evidence she gave evidence or adopted positions which she had not articulated before; Z's conception by rape and the definition of vomiting being two examples.
vi) It is clear that despite her assertion that she follows medical advice, she does not; the most obvious is her failure to agree to X's admission to hospital in November 2019.
v) The relevance of History. A particular challenge in FII cases is the fact that all clinicians will have a starting point that a history given by a parent is reliable. That is critical in any case but in particular in relation to some of the conditions which are said to be present in this case. Dr U and Dr Rose emphasised the reliance placed by clinicians on parental history particularly in relation to constipation, asthma and reflux and vomiting.
vi) X and Feeding. The evidence supports the conclusion that his failure to thrive was attributable to a failure by the Mother to reliably deliver nutrition to him.
a) Both experts conclude there was no problem with X's ability to absorb nutrition; his weight gain in 2018/19 and since September 2020 demonstrates this. That also rules out gut dysmotility which was queried by Dr B but which Dr Salvestrini comprehensively rejects.
b) Dr Salvestrini says there is no known condition which would result in fluctuating weight gain and loss. His progress since September 2020 also points against any unknown or unidentified fluctuating condition.
c) The combination of medications does not provide an explanation according to the experts and in any event both in 2018/19 and after September 2020 he continued on various medications but began to thrive.
d) The weight charts provide a vivid depiction of his fluctuating state prior to September 2020 and his steady progress since. His dramatic weight loss of 16% from summer to autumn 2019 points plainly to a failure to deliver nutrition. The clinicians were simply unable to explain it and had tried everything including additional supplements in order to address the issue; delivering nutrition which was usually reserved only for children with severe neurological or other conditions which compromise their ability to thrive. The Mother consistently told them that she was giving him the nutrition that they were prescribing.
e) Despite the Mother's attempts to suggest that others including the children would have known had X not been receiving his feeds, this was quickly demonstrated to be unsustainable.
f) He was not vomiting his feeds; apart from one example when he was being bottle-fed and was observed to vomit nearly a full feed long after it was said to have been consumed or reports of vomiting are not of feed.
g) He continued to be reported to vomit extensively even whilst he was thriving in terms of weight gain. During that period he was reported to be ill on 17 occasions with coughs, fevers, sort throats and was on antibiotics and other medications.
h) The start of the issues with feeding can be seen in the Mother's lies about his difficulty latching on in January 2018.
i) The insertion of the PEG-J was the end product of a process that commenced earlier in the year and arose out of the continued concerns about X vomiting.
vii) Induced vomiting. The Guardian does not disagree with the way the Local Authority puts the case on vomiting. Although one cannot identify precisely what was happening the evidence points to induced vomiting.
a) The evidence of 19 September is clear and it has ramifications for the likelihood of her inducing vomiting on other occasions.
b) It is clear that the Mother could have induced vomiting by introducing something either into his gastric port or into his feeds.
c) The effortless vomiting observed by a number of individuals is unusual in a child one year of age or more. That was observed from September 2018 onwards by Ms L, Ms C, Dr D, Ms E, and at the child in need meeting on 16 January 2020.
d) Ms L was a supporter of the Mother and whose opinion in January 2020 was unaffected by the bleach incident and yet she was sufficiently concerned by what she saw in terms of the effortless nature of the vomit, the unusual smell and the difference between that vomit and what she had previously experienced, such that she felt it necessary to write to the safeguarding lead.
e) Whilst there is evidence of other vomits (and one needs to bear in mind the differing definitions) which are probably genuine in origin there are others which are inexplicable.
f) Both Dr Rose and Dr Salvestrini were unable to identify any medical reason which might cause X to vomit in clusters as the Mother described and as were witnessed by Mr K. Dr Salvestrini considered that some vomits might be the accumulation of mucus or saliva in the gut but, once vomited, it would take time to accumulate again and thus would not explain clusters of vomiting.
g) At the time of reports of clusters of vomiting the medical records do not demonstrate that X was suffering from any other illness such as a chest infection or tonsillitis which might contribute to vomiting.
h) When X was admitted to hospital in September 2020 the medical records demonstrate that frequent vomiting was not a feature.
i) Since his discharge X's vomiting has been limited to isolated occasions with identifiable causes.
j) There is nothing identifiable which explains a change in his vomiting since September 2020.
viii) Non-co-operation: the Mother's reasons for not wishing to have X admitted to hospital do not stand up to scrutiny; a "suggestion" was clearly medical advice; his case was clearly not too complex for Hospital A; there clearly was input from Hospital B where necessary; childcare would have been available either from the maternal grandmother or from the hospital if requested; there is no evidence X was distressed by admissions; the house move had been a possibility since March and when dates arrived that the Mother said it was due to occur, they did not materialise; the Mother clearly was not overly concerned by Covid given her actions in the summer of 2020. This all amounts to clear evidence of her seeking to avoid admission. At this time, there was also an increase in X's weight which suggests the Mother was seeking to take steps to avoid an admission by maintaining a proper feeding regime. The Mother seeking to avoid admission and her anger at being excluded from X's feeding at Hospital B begged the question of why she was so anxious to maintain sole control over X's feeding.
ix) Development. The evidence supports the conclusion that the Mother's actions delayed X's development for a number of reasons.
a) Her failure to feed him properly meant he was physically unable to follow normal developmental patterns.
b) Her inducing vomiting led to him being exhausted.
c) She failed to stimulate him adequately; the multiple observations of how much time he spent in his buggy and her inability or failure to implement advice
d) Although the hospital observed signs of a higher level of development in X in September 2020 than were visible beforehand, Ms N attributed this to the fact that he was not exhausted by vomiting whilst in hospital. The evidence of Mr K and others was that when he was not exhausted, he showed signs of great promise.
x) V. There is clear evidence that the Mother exaggerated or misreported symptoms which led to unnecessary medication and investigations.
a) The Mother's request for a specialist buggy for V was clearly an exaggeration. He had been seen by paediatricians and others who confirmed he had no problems with mobility or balance and yet within days of being seen by Dr O or by Dr F the Mother was reporting to her GP that he had pain or mobility problems requiring a specialist buggy from the wheelchair service. The contrast between the Mother's reports and the observations of the professionals and of his nursery is obvious.
b) Although there is evidence that at times V was constipated, the Mother's portrayal of V as chronically constipated was not supported by the examinations of him over time. In particular, her portrayal of him as chronically constipated and in considerable discomfort if he did not have his medication, led to him being on unusually high prescriptions of movicol and lactulose. The Mother maintained to professionals that he was taking his full dosage and that left them perplexed as to his apparently continuing severe constipation. The evidence supports the conclusion that the Mother was not in fact giving him the full amounts; the x-ray findings and the opinions of Dr Rose and Dr Salvestrini confirmed that it is highly improbable that he could have had continuing severe constipation if he was taking that level of medication. The Mother's more recent explanation that he occasionally did not take his medication is not something that begins to appear until 2016 although he had been on very high levels of medication since 2009.
c) In relation to V's asthma, he may have had mild asthma but the Mother's reports led doctors to be concerned that he had much more serious asthma than in fact was the case and which led to extensive investigations at Hospital C.
d) There may have been some underlying mild genuine issues, but they were substantially exaggerated and misreported by the Mother.
xi) W. The evidence supports the conclusion that the Mother exaggerated her dairy or cow's milk protein intolerance. The Mother was maintaining to her school that she had a dairy allergy and yet she was providing dairy products in her picnic. Her account was inconsistent. This attitude encourages a child to believe that they are ill when they are not.
xii) Y: The Mother maintained over a considerable period of time that Y was suffering from repeated choking and swallowing difficulties which in her evidence she effectively described as a one-off. This was entirely inconsistent with what she was reporting at the time.
xiii) Domestic Abuse: The Mother failed to protect the children from exposure to domestic abuse or the risk of exposure.
a) The evidence including CD's PNC demonstrates his history of abusive and dangerous behaviour is extensive.
b) The Mother reported physical, sexual and emotional abuse at his hands. She underwent domestic abuse programmes such as the Freedom Programme and maintained that she had learned from it.
c) However, she allowed CD back into the children's lives both in 2015 and 2016 and subsequently prior to Z's conception. Her account of how she came to allow him to have contact with the children and how she came to conceive Z are inconsistent and hard to understand.
xiv) Mental Health. The Guardian does not accept that the Mother's mental health was as the Mother now portrays it. Throughout 2016, 2017 and 2019 the evidence demonstrates that the Mother was offered support in relation to her mental health including medication and referrals to Highland House but declined them. She had extensive offers of support and actual support from health and other professionals and her attempt to attribute responsibility to a lack of support is unfounded.
Expert Medical Evidence
|Child||Issue||Dr Rose||Dr Salvestrini||Agreement|
|V||Constipation||The x-rays do show constipation in 2012 and 2013 and in 2013 he would have prescribed a disimpaction regime. The problem was though the constipation did not resolve despite a high level of medication.
||Does not consider that V had intractable constipation. Does not agree with the interventions to increase his laxatives [E509-E510].
Of the four abdominal x-rays only one showed faecal loading [E486-500; E510].
|Agreement, by deferral.|
|Level of Movicol||There were very high doses of Movicol, up to eight sachets, which is virtually impossible to take, and seemed to have no effect. Highly unlikely that V was treated with the prescribed level of Movicol [E405; E510]. At that level it would be unsurprising if V didn't want to take it. It being prescribed at that level which is consistent with a dis-impaction regime would likely be because Dr O was told it was not working at lower levels.||V has been on an incredibly high dose of Movicol.
Suspect he did not receive the entire prescription.
He received some Movicol, but impossible to quantify how much [E510].
|GORD||Agrees with Dr S [E511].||V did not suffer from GORD as a baby. The diagnosis of GORD was not appropriate [E230; E280-E281].||Agreement.|
|Asthma||Mismatch between the amount of inhaled steroid, courses of oral steroids and V's reported continuing respiratory problems.
The referral to Hospital C resulted in extensive and invasive investigations, all of which were normal.
V's exacerbation of asthma was exaggerated both in extent and frequency [E404]. He may have had mild asthma which warranted some medication.
|V was prescribed multiple asthma treatment, but Dr S cannot comment on appropriateness [E282].||Agreement as to multiple asthma treatment save that Dr S cannot comment on appropriateness|
|Exaggerated Symptoms||Severity of asthma exaggerated.
Cannot say as to seizures [E404; E511].
No need for wheelchair or boots [E405]
Hypermobility possibly exaggerated [E511].
|Has been exaggeration of symptoms; limit as to areas upon which able to comment given area of expertise [E230; E511].||Agreement as to exaggeration.|
|W||CMPI||No objective evidence that W had CMPI [E406]. Reliant on M's report and may resolve with maturation||Dr S agrees [E289-90; E512].||Agreement|
|GORD||No independent medical evidence that W had gastro oesophageal reflux. [E406]||Dr S agrees [E512].
Distinguishes between gastroesophageal reflux and gastroesophageal reflux disease.
|Asthma||No independent medical evidence that W had asthma. [E407]||Dr S does not comment on asthma in respect of W.|
|Healthy child or not||A healthy child with normal development and no underlying medical problems [E406].||Dr S agrees [E512].||Agreement|
|Exaggerated Symptoms||Considers M exaggerated W's symptoms [E513].||Considers that M has exaggerated W's symptoms [E231; E513].||Agreement|
|Y||Excessive Drooling||Dr R agrees no clinical evidence.||No clinical evidence [E513].||Agreement|
|Choking||Dr R agrees no clinical evidence.||No clinical evidence.||Agreement|
|Feeding / swallowing
|Dr R agrees no clinical evidence||No clinical evidence. [E231; E295]||Agreement|
|Healthy child or not||Developmentally age appropriate and has no underlying medical problems [E407; 513].||Agrees [E513].||Agreement|
|Exaggerated Symptoms||Y is a normal healthy child. All the reported symptoms have been exaggerated [E514].||Dr S agrees [E231; E514].||Agreement.|
|X||Vomiting & Choking||Defers to Dr S [E514].
The evidence suggests he did not vomit milk but gastric juices, mucus, bile or saliva. Vomiting in clusters as described by the Mother is hard to understand physiologically. There is no medical evidence to support the Mother having induced vomiting.
|X did not choke, as he did not feed.
X did bring up mucus and water, that was not a fabricated symptom, but the frequency, intensity, and importance of that has been exaggerated [E514].
Induced vomiting on 19.9.20 if court finds M administered bleach. [E231]
|Agreement, by deferral.|
|PEG, PEG-J, NG tube and NJ tube||Dr R agrees [E515].||PEG, PEG-J, NG tube and NJ tube all unnecessary [E252-253; E514].
Lack of robust assessment by clinicians.
|Sufficient Nutrition or not||Dr R agrees. The only reason that X would lose weight, or gain weight, or has his weight pausing, is down to the number of calories [E516]. His low B12 is also likely due to lack of feeding not non absorption as the gastric juices and intrinsic factor should be present in the jejunum||X has had weight loss, faltering growth and weight gain.
From 1 year of age to 1 1/2 years, X gained weight in the care of his mother. Apart from this period, the reason for X's weight loss and scarce weight gain is not receiving appropriate calories [E515].
|Weight & Gut Functioning||Dr R agrees [E517].
There is no medical evidence of an underlying condition currently affecting his ability to absorb nutrition, including B12 and agrees gut dysmotility in the past is not indicated.
|X's faltering weight is due to number of calories.
No issue with X's gut functioning [E516-E517].
|Exaggerated Symptoms||Agrees with Dr S that vomiting exaggerated [E517].
Adds that X may have some level of undiagnosed global developmental delay, which is not exaggerated [E517]. Incapable of conclusion until further time has passed given his more recent improvement.
|Vomiting exaggerated [E230].
||Agreement in respect of exaggerated vomiting.|
|All Children||Inherited Connective Tissue Disorder||No evidence of any inherited connective tissue disorder [E518].||Dr S agrees. No evidence that any of the children are suffering from EDS [E518].||Agreement.|
i) V and X attended their General Practitioners on multiple occasions. W and Y on fewer occasions. A previous General Practitioner commented that V was one of the most frequent attenders at the GP surgery. X does have underlying physical and developmental abnormalities which would be a reasonable factor in explaining his frequent attendances at his General Practitioner's surgery. There were multiple occasions when X attended his General Practitioner following which a diagnosis was made, for example upper respiratory tract infection, ongoing cough, otitis media for which he was frequently treated with antibiotics and intermittently treated with short courses of steroids. It would appear that neither W or Y attended the General Practitioner Surgery excessively frequently.
ii) The medical notes indicate that V has eczema, asthma and constipation and had evidence of moderately severe gastro-oesophageal reflux disease. The General Practitioner notes indicate that he attended surgery frequently but for minor childhood illnesses only such as upper respiratory tract infection, otitis media and chickenpox. He was admitted with a possible seizure on 20/7/09 and 3/11/09, his EEG was normal. The diagnosis of seizures depends almost exclusively on the history in that seizures are not frequently seen in the GP surgery or in the acute hospital setting. The diagnosis of febrile seizures therefore was dependant on the history given by the Mother. There is insufficient medical information though to be able to determine whether the seizures did or did not occur. The EEG is normal following a febrile fit so is not helpful in determining whether V did or did not suffer febrile seizures.
iii) V suffered recurrent otitis media resulting in documented glue ears. There was independent ENT assessment that he required adenotonsillectomy with bilateral grommet insertion… V's referral for further management of his asthma to Hospital C was initiated by the paediatric team at Hospital A. The severity of a child's asthma is largely dependent on parental history unless there are admissions for acute exacerbation of asthma on a frequent basis which was not V's history. It is clear that Dr O was concerned at the apparent mismatch between the Mother's indication of frequent respiratory problems and V's appearance as being robust during the appointment on 12/4/11… Dr O's referral to Hospital C for further investigations was prompted by the mismatch between the amount of inhaled steroid, courses of oral steroids and V's reported continuing respiratory problems. The referral to Hospital C resulted in extensive and invasive investigations, all of which were normal. The biopsy of the lining of the lung in my interpretation is that it was not consistent with a diagnosis of asthma. In my experience it is unusual for a child to have such frequent exacerbations of asthma requiring moderate doses of Flixotide and repeated courses of oral steroids without hospital admissions. Clinically it is possible therefore only to indicate that there is some evidence that V's exacerbation of asthma was exaggerated both in extent and frequency.
iv) On 2/8/12 when V was 4 1/4 years of age the Mother requested a special buggy from the GP. There seems to be no physical reason why V needed a buggy at that age and no reason why the GP should have referred V on for measurement by the practice nurse. It is equally unclear who told the Mother that V had joint hypermobility when she requested prescription of a wheelchair from Dr U on 17/10/12. It is my opinion that there is, as a minimum exaggeration of V's problems. It is unclear to me how the Mother managed to acquire medically unnecessary Piedro boots for V in early 2013. There appears to be no medical indication for the use of such boots although on 6/9/13 Dr O notes that V had marked joint hypermobility. V was only 5 years of age and would be likely to be still fairly flexible. Physiotherapy assessment on 15/4/16 returned a Beighton score of 6/9 which is consistent with benign hypermobility. Such children do experience some discomfort but do not require Piedro boots or wheelchairs. V's hypermobility resolved with age, being described by Dr D on 14/1/15 as having mild hypermobility only. Dr D was unclear as to why V needed Piedro boots. V had intractable constipation. Chronic constipation in childhood is very common the reasons for which are rarely determined in that the presentation with constipation with such symptoms as infrequent bowel actions and abdominal pain presents many months after the initiating trigger leading to that constipation. V's constipation was confirmed by abdominal x-ray showing marked colonic faecal loading for which he was appropriately treated with laxatives…. I find it difficult to believe that V was actually treated with 8 sachets of Movicol Paediatric daily. This is at the upper but not top end of a Movicol Paediatric disimpaction regimen which if used on a daily basis would have resulted in rapid colonic evacuation. V's continued faecal loading was confirmed on abdominal x-ray. It is my opinion therefore that it is unlikely that V received 6 - 8 sachets of Movicol Paediatric on a daily basis. Non-compliance with his medication led to protraction of his chronic constipation. There seems little doubt that V suffered from eczema. Recurrent otitis media resulted in glue ears requiring ENT operative intervention. It is unclear whether he had anything other than mild asthma. Asthma does improve with time so the lack of need for anti-asthma therapy now does not negate the possibility that he had asthma as a younger child. His hypermobility has resolved.
v) W: It is my opinion that W is a healthy child with normal development and no underlying medical problems. She was diagnosed as having possible cow's milk protein intolerance (CMPI) by her GP based on a rash on 21/10/14 and from a history of vomiting and rash in clinic on 13/12/16. W has not had formal investigations to determine whether she had cow's milk protein intolerance. The suggestion that she had CMPI continued following a dietetic review on 12/1/17 and continued following a telephone consultation with the GP when the Mother indicated that W had had an allergic rash on 14/4/20. However, following transfer of care to her maternal grandmother W: W was placed on a normal diet with no ill effects. Cow's milk protein intolerance tends to improve with age so her lack of intolerance whilst in the care of her grandmother does not negate the possibility that she may have had cow's milk protein intolerance as an infant, however, there is no objective evidence that she had CMPI. The diagnosis was made on the history from her mother as was the diagnosis of gastroesophageal reflux on the history of W vomiting. There is no independent corroborative medical evidence that W ever had CMPI or gastro-oesophageal reflux. W was treated with a significant amount of asthma therapy, Ventolin, Clenil and Montelukast, the diagnosis was made on the history. W was not admitted for exacerbation of asthma. There is no independent medical confirmation of the diagnosis. She is no longer using anti-asthma therapy. It is highly unlikely that W's asthma could have improved to such an extent that she was on 3 modalities of anti-asthma treatment in mid 2019 but then did not need any medication towards the end of 2020.
vi) Y: It is my opinion that Y is a healthy young child with no underlying medical problems. The developmental assessment indicates that he has been functioning at an age appropriate level although he did walk late, at the age of 21 months (normal range 9 - 18 months). Y was reported to be dribbling excessively by the Mother. I could not determine that he had any significant feeding problems. He was diagnosed as being hypermobile, using a scale that is unclear, by physiotherapy on 16/10/19 at the age of 3 years 3 months. xlv. I would hesitate to diagnose hypermobility in a child of that age all of whom have inherent inflexibility. However, on 30/1/20 there was a further physiotherapy comment about hypermobility requiring supportive boots. There is therefore independent medical evidence of hypermobility. Y had enlarged tonsils requiring adenotonsillectomy, however they would not cause him to choke on food as enlarged tonsils are very common findings in children and even if the tonsils virtually meet in the mid line so are grossly enlarged normal swallowing can occur. The only suggestion of Y choking on his food emanated from his mother. There is no independent medical corroboration that Y had any difficulty in his swallowing.
vii) X: X has undiagnosed developmental delay. The foster carer diaries and Dr Q's report indicates that following placement in foster care X's development has improved but he was not functioning at an age appropriate level. X has now been in foster care for some 10 months…... [a further developmental assessment] would aid determination as to whether a factor of his developmental delay was neglect. X's developmental skills were assessed on multiple occasions by different medical professionals. It is clear that he had significant global developmental delay. He was investigated intensively and exhaustively both at Hospital A and Hospital B and no diagnosis has been forthcoming. The cause of X's developmental delay is therefore unknown. X was admitted for faltering growth. He was extensively investigated for causes of faltering growth both at Hospital A and Hospital B. No cause for his faltering growth was determined. His growth faltered following the PEG-J insertion regardless of whether he was at home or was in hospital. Indeed, when he was discharged into foster care his discharge weight was lower [subject to his views on weight recording] than his hospital admission weight. In foster care X was beginning to take all feeds orally and was experimenting with solid feeds. However, even if his weight and length have moved through the centiles it could not be suggested that the cause of X's faltering weight was related to maternal neglect as he failed to gain weight in hospital [qualified by oral evidence] A factor in X's faltering weight was considered to be his recurrent vomiting. Could the extent of X's vomiting have been exaggerated by the Mother, could X's vomiting have been induced by the Mother? It is not possible to determine whether the Mother exaggerated the extent of X's vomiting whilst in her care. He continued to vomit in hospital observed by medical professionals and his weight gain was poor at home, in hospital and initially in foster care. There is therefore no medical evidence that the Mother exaggerated X's vomiting. Vomiting can be induced by the use of outside agents such as excess salt. X continued to vomit in hospital, he was extensively investigated, and no electrolyte nor metabolic abnormality was determined. There is therefore no medical evidence of induced vomiting by a chemical agent. It is possible to induce vomiting by overfeeding; vomiting could therefore have been induced by introducing extra bolus feeds to X's gastric tube or by increasing the hourly volume into his PEG-J tube. However, it is likely that the extra volume of feeds would have been noticed by the nursing staff. X vomited when fluid was introduced into his stomach. It was also commented on that his difficulties with gastric contents was such that a gastric bag to allow free drainage of gastric contents was suggested. Deliberate administration of fluid into X's stomach could have induced vomiting. There is no independent medical evidence. X was not tolerating gastric feeds although he was tolerating jejunal feeds albeit with occasional vomits by 19/9/20. Following the removal of the Mother from his care X was tolerating full gastric feeds within 4 days. There can have been no physiological change in that short period of time which would have altered his gastric function from being intolerant to tolerant. The implication is that X's vomiting was induced. X continued to vomit in hospital and failed overall to gain weight despite being in a controlled environment when the volume of feed infused into the PEG-J was carefully monitored. There is therefore no medical evidence of excess vomiting and faltering weight at home followed by a period of reduced vomiting and weight gain either in Hospital B or in Hospital A. The cause of X's food aversion and faltering weight remains undetermined. His food aversion has now resolved. X is reported to have suffered a seizure on 7/5/18. When he was reviewed by the paramedics his GCS (Glasgow Como Score) was grossly depressed at 3 (normal 15/15). He was also described as unresponsive. His later blood gas was consistent with a period of hypoxia (low oxygen) consistent with a prolonged seizure. X had a further episode of abnormal movements witnessed in hospital requiring active treatment. There is therefore independent medical evidence that X suffered from seizures. X was described as having arthrogryposis at birth. This is untrue. It is unclear as to who gave that history. Arthrogryposis is flexion contractures of joints such that the limbs cannot be extended fully. However, he did develop metatarsus adductus which required active treatment. It is unclear therefore whether the term arthrogryposis was an interpretation of the history given by the Mother did not initiate his treatment, but X's treatment depended largely on the history given by his mother. Exaggerated symptoms influence the decision process of the medical professionals when determining the appropriate treatment regimens. Should the Court find that the Mother was either fabricated or exaggerated.
i) Since being in care X has shown catch up through the centiles in both his height from below the 0.4th to the 0.4th centile and his weight from the 0.4th to the 9th. The cause for his faltering weight was unclear. X had a protracted admission to Hospital A during which time his weight fluctuated. There are concerns that X's vomiting and choking may have been exaggerated by his mother leading to a reduction in his calorie intake affecting his weight gain.
ii) Since being in foster care X has been able to feed himself orally, his PEG J tube has not been used for nutrition, he had not choked on his food and he has gained weight indicating there is no underlying medical problem which restricts X's ability to thrive. X demonstrated significant developmental delay when Dr G undertook a video consultation on 15/10/20, when X had been in care for some 3 weeks, and then the face to face consultation on 4/1/21 when he had been in care for some 4 months. Dr G notes developmental progress following her review on 9/6/21 when X had been in care for just under 9 months. There had been developmental progress but he was still showing significant development delay with overall functioning at around 2 1/2 years of age.
iii) There is therefore no clear evidence that X has shown significant developmental catch up [later revised in light of Portage Developmental Assessment]. His developmental progress is commensurate with his increase in age but he still does show significant developmental delay of around 12 months. This argues that X does have an underlying undiagnosed developmental problem causing his developmental delay which is likely to continue.
iv) There is evidence that X has shown physical catch up in that his height and weight centiles have improved. The implication is that X was not receiving sufficient nutrition for him to maintain his natural centiles until he was in foster care. ii. The multiple developmental assessments have indicated that X continues to have developmental delay at a similar level in early and mid 2021. iii. There is therefore no clear evidence that a component in X's developmental delay is neglect.
i) The 2009 RCPCH guidance on FII has been supplemented by the 2020 guidance. He said in his clinical practice the issue is a difficult one and an uncomfortable one. It represented an end of a spectrum of behaviour which did not involve a hard jump but rather a continuum from acceptable anxiety to unacceptable anxiety. He emphasised that in his clinical practice it would be he who was ultimately reaching a decision on whether FII or perplexing symptoms were present and he of course would take into account a bigger picture than a purely medical picture. He emphasised that in his role as a medical expert it was ultimately for the court to determine what the conclusion was, taking into account all of the evidence and that his report should be read on the basis that his expressions of opinion were those which he could draw from the medical evidence. The evidence in relation to V's alleged hypermobility and the request for a specialist buggy and boots when he appeared to have hypermobility within the normal parameters for a child and where one would expect him to be rushing around developing his physical skills might be an example of unacceptable anxiety becoming exaggeration or possible fabrication.
ii) Paediatricians will always approach the history given on the basis that it is true; they may ask questions to clarify. The range of responses of a medical professional to a presenting complaint will also vary and it is not possible to say one response is necessarily right and the other necessarily wrong in cases where there is a range of acceptable responses.
iii) Although ultimately the expertise on gut function lay with Dr Salvestrini the overall picture which emerged from the medical evidence (notwithstanding Dr B's concern about gut dysmotility) was that there was no underlying condition affecting X's ability to absorb nutrition. His periods of weight gain and weight loss were not consistent with any known condition but were consistent with variation in the amount of calories provided to him. His apparent vitamin B12 deficiency was also most likely due to insufficient supply of B12 rather than an inability to absorb it. Although the intrinsic factor which attached itself to B12 was produced in the stomach and the resultant product was processed in the jejunum there was no reason why the intrinsic factor should not pass from the stomach to the jejunum and attached to the B12 there.
iv) The medication X received: Ranitidine and Omeprazole were to limit or stop the production of gastric acid and were linked to vomiting and would not affect nutrient absorption. Alimemazine was to counteract possible gut dysmotility and so should not have affected nutrient absorption. Antibiotics would not affect calorie absorption either although the underlying illness might require the body to use more calories and so one would expect weight loss with an infection even in a Peg J fed child.
v) Babies and infants are known to vomit for no physiological or pathological reason and can do so effortlessly and without obvious distress, but they tend to grow out of it; usually by 12 months certainly by 18 months to 2 years.
vi) If the Mother was inducing vomiting and not giving calories the faltering weight gain outside the Mother's care and in particular in the hospital environment where, whilst the Mother was not supervised or observed constantly, no evidence of her failing to feed or inducing vomiting has been seen and this has also to be taken into account. There is no suggestion from the blood analysis that salt, or another mineral was being introduced to X to cause the vomiting nor is there evidence of dehydration. The introduction of significant amounts of water into his stomach might cause vomiting and the difference between 20 ml and 10 ml is not such as to give rise to X vomiting.
vii) Some care has to be taken in interpreting recorded weight. Different scales in different locations may give highly variable weights and the circumstances of the weighing will also have a potential impact. Weighing the baby with the Mother or weighing a baby clothed, when in a nappy or naked may all affect the reliability of the recorded figures. Children might be expected to gain somewhere in the order of 25g weight per day at the relevant age but this is variable. If he wasn't eating at all, a loss of 50-120g might be the expected range. We do not know what X's natural centile position is and this also influences our interpretation of his weight gain and loss. An apparent weight loss over time is compounded by the fact that a child should be gaining weight. The weight chart could suggest that there had been periods of time whilst X was in hospital in September 2020 and since his discharge when he has lost weight or failed to gain the weight that would be expected of him. There are a variety of factors which might be relevant to this including variations in the reliability of the recorded figures, changes in the way in which he was being fed and the amounts he was being fed and the medication he was on (in particular steroids).
viii) X showed significant global developmental delay up until his admission to hospital. His developmental assessment after he left his Mother's care showed progress but by summer 2020, he was still recorded as having significant delay. The most recent developmental charts prepared by the portage service suggest that X is continuing to catch up in terms of his development. However, he is not yet at a developmental stage commensurate with his chronological age. He may have an underlying undiagnosed developmental disorder, or he may yet catch up. It is entirely possible that if he had an underlying condition (which might include myelination as noted by one paediatric radiologist) that this would contribute to developmental delay and that environmental factors including lack of nutrition or lack of stimulation may have added a further layer of developmental delay. In relation to early gross motor skills, neglect or lack of nutrition is a less likely explanation because they are linked to the making of neurological connections rather than stimulation although it is possible that a lack of nutrition could contribute to delayed development even in these fields as the body would prioritise other functions. In relation to other aspects of development, in particular more sophisticated motor skills and communication and interaction, these could be affected by lack of nutrition as well as lack of stimulation. However, unless one reaches the level of severe malnutrition the lack of calories is unlikely to impact on brain development itself, but fatigue which prevented a child undertaking tasks or hunger would impact on ability to engage and thus gain developmentally. The fact that X has caught up suggests that environmental factors are a significant part of the causation rather than an underlying neurological condition being mainly responsible. His sudden improvement must be linked to some change in his situation; including more stimulation. Neglect may explain some of his developmental delay; this represented a change in opinion since his report which he explained by reference to the most recent evidence which supported a great catch up than he had earlier understood to be the case.
ix) In relation to V's asthma, he remained of the view that he had been over treated for this including the admission to Hospital C. He said this because V had never been seen in acute distress or admitted to a paediatric ward in relation to an asthma-related event and so the extensive investigations were not founded in his medical history but arose from the Mother's reports. He himself would not have undertaken those investigations without a firmer medical evidence base. He accepted that the use of the word 'significant' in a letter from Dr O might have been interpreted by the Mother as meaning severe; he was himself concerned about the amount of medication he was taking and the lack of observable symptoms which was why he was referred to Hospital C. There was some limited evidence from Hospital C of reduced lung function. It is not possible to say at present whether V's complaints are learned behaviour or because he genuinely has asthma still. Overall it was not asthma at the level which he was being prescribed medication for.
x) In relation to V's hypermobility if a medical professional such as a physiotherapist said he had it, the Mother could be expected to rely on that and its reported severity. The community paediatricians thought differently.
xi) In relation to W, the cow's milk intolerance was diagnosed by medical professional and she was put on a different diet as a result. Her asthma was based on the Mother's reporting. The resolution of those issues since W was in the care of her maternal grandparents' points to her never having had asthma (or at most very mild) or a cow's milk intolerance. The development of her being prescribed salbutamol was inappropriate, but it was prescribed by doctors on the Mother's reports. It moved from being prescribed as an acute treatment for a viral wheeze through to regular prescription without a proper basis. The last prescription sought was in July 2020. It may be as she grew older that her immune system became more robust and so her wheezing or coughing was less noted.
xii) In relation to Y, all of his issues resolved on moving to the care of his grandparents and there is no physiological reason for his feeding difficulties. He had enlarged tonsils and they were removed and although there is no link between choking and enlarged tonsils one could understand why a parent might think there was. The housing situation that the children lived in if there were mould spores would tend to exacerbate asthma.
xiii) All of the children had various documented childhood illnesses which are observed by GPs and other medical professionals such as upper respiratory tract infections, chest infections, enlarged tonsils and similar.
i) That each of the children had various normal childhood ailments for which appropriate medical treatment was sought and given.
ii) That each of the children also had symptoms of commonly encountered childhood ailments which, based on the Mother's reports, led to them being over investigated and over medicated. In relation to V this was most obviously in relation to his constipation for which he received extensive investigations and medications which were unlikely to have been given as prescribed and which prolonged the fact of and treatment of the problem but also in relation to the extent of his investigation and treatment for asthma which probably existed but was mild. In relation to W this took the form most obviously of the over medication in relation to asthma which at worst was mild. In relation to Y this was in relation to his feeding and swallowing.
iii) The cause of X's initially reported poor weight gain and subsequent vomiting is not established. What is clear is that despite extensive dietician and paediatric input he did not gain weight, and this was not due to any underlying physical condition. The only explanation is a failure to deliver the calories which were being prescribed and this must lie at the Mother's door. The evidence suggests that he was not vomiting his feeds and thus it should have been available to his body to absorb. This is illustrated by his subsequent progress after he left her care. In addition, this development was significantly delayed whilst in her care which could have been as a result of an underlying issue, lack of nutrition and lack of stimulation. His progress developmentally since suggests environmental factors relating to the Mother's care were a significant component. The medical treatment that he experienced including nasogastric and naso-jejunal feeding, his extensive inpatient stays and his PEG- J were unnecessary and essentially a product of the Mother's failure to provide him with the nutrition he required.
i) X has been the subject of numerous investigations and interventions to deal with reported symptoms of persistent and treatment resistant vomiting and FTT. It is my opinion that he was excessively medicated without robust assessment prior to escalation of treatment. As a result, he became feeding tube dependant, did not learn to eat at the right time, developed significant developmental delay. After 3 years of being significantly medicalised, he made rapid progress towards normalisation of his feeding and hence growth and developmental delay. This coincided with him being removed from his mother's care. I believe his mother was responsible for exaggerating/over-reporting/inducing his symptoms.
ii) V's constipation management involved an extraordinarily high dose of medications without the expected results. He also was prescribed multiple asthma treatments at a young age and needed several medications to be used at the same time. V was also treated for Gastro-oesophageal Reflux Disease (GORD) without typical symptoms and relying only on one test, which findings I believe are controversial. V was a young boy with the burden of needing to take a significant number of medications for 3 different conditions. He failed to attend school and was reported to have behavioural difficulties. Since he was placed with his grandmother and removed from maternal care, he stopped needing medications for GORD or constipation and had no further asthma exacerbations. I believe his mother was responsible for exaggerating/over-reporting his symptoms.
iii) W was brought to her GPs very often (14 times in the first 3 months of life) and had been diagnosed with URTIs and prescribed numerous courses of antibiotics, sometimes without a physical examination or convincing findings. She was feeding less well when poorly which is common. Her issues with cow's milk allergy resolved promptly once she was placed with her grandmother. I believe his mother was responsible for exaggerating/over-reporting her symptoms.
iv) Y did not suffer from sustained feeding difficulties. He struggled to feed only when unwell with an acute infection. This presentation is common and self-resolving as reflected in his steady growth. I believe his mother was responsible for exaggerating/over-reporting his symptoms.
i) The advantage she has as an expert looking back over the entire history and with the benefit of knowing what has happened to X and V since September 2020 enables her to approach the case in a different way to that which she would have had to approach it as a clinician treating the children. In particular, knowing how X has responded since September 2020 enables various potential causes of his vomiting and failure to thrive to be ruled out. His situation since September allows one to exclude chronic conditions such as metabolic disease, and anatomical abnormality or other underlying condition. What has changed since September is the Mother is no longer involved in his care. The change to gastric feeding from jejunal feeding is of course a change but the evidence suggests that had it been attempted earlier he would always have been able to tolerate gastric feeding. While she was alive to the possibility of an unknown medical cause she could not formulate any possibility, which had existed for three years and which resolved within days and simultaneously with the Mother's removal from his care.
ii) The use of a Peg J at such an early stage without a robust period of observation and nurse led feeding was not something that doctors should have supported. In particular she identified the absence of specialist paediatric gastroenterological input as a flaw in how she would have approached it. She also considered that the significant decisions on escalating the complexity of devices and changing feeding regimes were not supported by a robust period of observation and that the treating clinicians at the time plainly thought it was appropriate. She also noted that the Mother had failed to bring X to a number of paediatric gastroenterological appointments and X had been discharged in summer 2019.
iii) When Peg J feeding is undertaken, in order to ensure the child receives the appropriate level of nutrition, one has to ensure that the pump is running so as to deliver the required amount. The Mother was noted to have stopped the pump at times during X's inpatient admissions and whilst it may have been understandable for her to stop it on a couple of occasions, if she was concerned about him vomiting she would have had it explained to her how important it was that the pump continued to run and that it was not linked to his vomiting.
iv) X does not have any underlying condition which prevented him being able to absorb calories provided to him. The periods of his life when he has gained weight demonstrate that physically his body is able to absorb calories provided to it. During those periods there were no other significant changes in respect of medication, presence or absence of vomiting, illnesses and his ability to gain weight since September 2020 all support the probable conclusion that it was the amount of nutrition rather than the ability to absorb nutrition provided. In particular the trajectory after September 2020 and a period of weight gain in 2018/19 point away from his having any significant gut condition either then or now. Gut dysmotility is often linked to a neurological condition which is not X. The issue therefore is whether he was provided with sufficient calories or whether he retained them in his body. The same was true in respect of his ability to absorb vitamin B12 where she considered the only explanation for his low levels was a lack of nutrition being provided.
v) None of the medications provided to X, either individually or in combination, would have an impact on his body's ability to absorb nutrition.
vi) His vomiting appeared unconnected with his failure to thrive. Throughout the period summer 2018 to summer 2019 he was reported to be regularly vomiting but was putting on significant weight both in real terms and in his progression through the centiles.
vii) The decision to reduce X's weight gain was not one which Dr Salvestrini would have implemented in the way it was. She considered that the appropriate course of action was to maintain feeding at a level (rather than increasing it) which would reduce the Kcal/kg bodyweight ratio and thus X would have come down through the centiles. She considered that the plan which was implemented which was actually to reduce his feeds and to reduce his weight was potentially harmful particularly given his weight instability history and that it would have led to him in effect being starved whilst his weight reduced. However, although she was critical of that approach, she ruled out the change having any physiological consequences in terms of X's ability to absorb nutrients thereafter.
viii) All of the medical records suggest that X was not vomiting feed and thus his body would appear to have been retaining the feed that was provided to it, in particular by the time it was provided either by the naso-jejunal tube or by the Peg J tube. The delivery of feed directly into the jejunum is the ultimate treatment for vomiting as the food is delivered into the jejunum which is beyond the stomach and the ileum. Although feed can return back into the stomach it is rare and this is not what was reported for X in any event. It is a relatively simple process to interfere with the feeding pump whether at home or in hospital in such a way as to prevent the feeds being delivered. It can be done in such a way that the pump would record the feed being delivered in terms of volume but if the tube was disconnected from the port and the feed delivered into a bottle the pump would provide a misleading figure of the total feed delivered.
ix) A clinician would distinguish between a posset, regurgitation and vomiting. It is possible a parent might describe them differently. The videos recorded by the speech and language therapist do not show vomiting, but he does have mucus in his mouth always seems to be straining to produce something. The reasons for X's vomiting needed to be looked at according to different stages of his life. As an infant of a few weeks old, young children will often swallow mucus and saliva and together with secretions in the stomach they may vomit them in particular when they are ill with viral infections or upper respiratory tract infections and are producing and swallowing more. Typically, they may vomit in the morning after they have been recumbent and may then vomit when there is sufficient build-up in the stomach again. However, these are unusual and usually not significant in volume. However, this would tend to come and go with the illness causing the increase in mucus et cetera. X was on omeprazole which is intended to reduce acidic stomach secretions and so it should reduce the volume. Vomiting can be induced by the introduction of fluid into the stomach; a large amount of cold water might prompt a vomit due to the mechanical distension of the stomach being beyond its capacity. As an infant of a few weeks old the oesophageal sphincter may not be fully developed, and this will often be the cause of young babies regurgitating or vomiting their feed; it is physiological not pathological and usually resolves within a few months as the sphincter matures. Some babies overfeed (happy spitters) but they put on weight and it is hard to overfeed a baby in any event. However, they should put on weight. If Mother was feeding X as much as she reported (which was 1 ½ times the amount recommended for him) how could he be vomiting it all up and not growing? Overfeeding is not compatible with his dropping through the centiles and it becomes irrelevant to the issue of vomiting when jejunal feeding was introduced. Illness can cause children to vomit. Young children will often swallow mucus and saliva and together with secretions in the stomach they may vomit them in particular when they are ill with viral infections or upper respiratory tract infections and are producing and swallowing more. A medication mixed with water might irritate the stomach but the stomach is a relatively hostile environment being accustomed to a strongly acidic content. No one observed anything being done of this nature and it would be in the territory of an assumption for me. Cow's milk protein allergy is also ruled out in respect of his vomiting as he was both given the formulas which are prescribed in CMPA cases without any alteration in symptoms and since September 2020 he has tolerated dairy. Gastro oesophageal reflux disease is also not indicated; it is irrelevant after the jejunal feeding was introduced in any event. When he was having nasogastric feeding in late 2017 there was no reported significant vomiting which is not consistent with GORD. His tolerance of gastric feeding after September 2020 also points against GORD. After lockdown most of the symptoms were reported rather than observed and it appeared to be a story of chronic ongoing mucus.
x) Some of the medications X was on could be linked to vomiting. Omeprazole can cause vomiting and lactulose can cause bloating and discomfort. The antibiotics are unlikely to be linked as vomiting was reported when he was not on antibiotics.
xi) Bleach is a highly dangerous substance to ingest. If it is ingested orally it can burn the mouth and oesophagus which can cause narrowing and long-term feeding problems. In X's case its introduction to the stomach which is accustomed to chemical aggression probably resulted in less damage to the stomach as it was mixed with stomach contents as well as diluted and vomited. It is standard protocol to undertake an urgent endoscopy when bleach is consumed. For an infant this involves a general anaesthetic. No damage was detected to the mucosal lining of X's stomach. Had bleach been administered on a regular basis it seems likely the mucosal lining would have shown signs of inflammation or other damage.
xii) There is nothing in the medical notes to suggest that any medical professional connected any of X's vomiting with a smell of bleach and chlorine is a noticeable smell.
xiii) The evidence, including the x-rays does not suggest that V had chronic constipation. The Mother never reported soiling which is common in chronic constipation where liquid faeces will be ejected involuntarily. When he was admitted to hospital for disimpaction it was the enema which resulted in emptying rather than the Movicol which takes 24 to 48 hours to have any impact. The amount of Movicol that was being prescribed is unlikely to have been consumable by a child of his age. If he had been consuming that amount it is unlikely, he would have wanted to consume any other food or drink. It seems likely that he was not consuming the amount of Movicol that he was prescribed. The medical notes do not suggest that the Mother was telling the treating clinicians that he was not consuming the amounts prescribed but allowed them to believe (at best) that he was consuming his prescribed medication. It is certainly understandable that a child would struggle to consume those amounts and would seek to avoid consuming those amounts but the onus is on the parent to report accurately to the clinicians what the child is doing and to oversee them to ensure that they are consuming their prescribed medications.
xiv) In looking at weight gain, one should focus more on the centiles rather than the absolute weight as it can vary so significantly depending on the time of day, whether the child has urinated or defecated, whether the feed has recently been ingested et cetera. Weighing is usually done twice a week in identical circumstances in order to give a consistent picture. The trajectory in late August/early September suggest some weight was being gained at home and in hospital. When the bleach was administered X was not fed for up to 36 or 48 hours. When his feeding regime resumed it was quickly changed to try gastric feeding and the process began with dye or a light and then a small amount of feed which explains the dip in his weight around 24 September and then the regaining of weight thereafter. It is significant that, prior to the Mother's departure from his care, X was consistently below the 0.4th centile but thereafter he began to climb through the centiles. This was not a dramatic change in weight; one would not want him to put on weight too quickly as that would become fat rather than muscle. What it shows is that he had a functioning gut which quickly adapted to gastric feeding despite being nil by mouth for nearly 2 years.
i) There was no underlying physiological or pathological condition responsible for X's failure to gain weight. The cause was a lack of nutrition. The absence of vomiting feed, on balance, rules out X vomiting his feed as a cause of that lack of nutrition. The logical consequence is that X was not being given the amount of nutrition that the dietician and others were recommending. That lies at the Mother's door.
ii) In terms of his vomiting, Dr Salvestrini seems fairly clear that at various times there would be probable explanations for vomiting, including deposits, regurgitation as a baby and more frank vomiting as an older child which would be linked to identifiable issues such as a lax oesophageal-sphincter, to childhood illnesses including viral infections and upper respiratory tract infections which would cause a build-up of mucus, saliva and stomach secretions which would be vomited.
iii) However, the reported history of constant vomiting is not explicable by these known causes. Nor was he vomiting in any way linked to the failure to thrive as X gained weight from June 2018 to June 2019 during which time the various professionals involved in his care were regularly reporting observing him vomit.
iv) A possible explanation for some of the observed vomits particularly those which were noted to be unusual would be the Mother having taken some action to introduce something into the gastric port either water or some other fluid which caused X to vomit copiously or frequently.
v) The absence of a logical explanation for the reports of vomiting throughout X's life implies that the Mother was to some degree exaggerating how frequently he was vomiting and that this contributed to the implementation of the naso-jejunal and ultimately Peg J feeding and X being nil by mouth for nearly 2 years. Had the concerns over vomiting not existed a move towards gastric feeding would have commenced much earlier. It was largely Mother's resistance to this and the continued reports of vomiting which contributed to X being fed by Peg J for so long.
vi) In relation to V, it seems unlikely that he did experience chronic constipation; the x-rays and the maternal grandparents' reports do not suggest this nor do reports of the school or other factors such as the absence of reported soiling. What does appear more likely to be the case is that the Mother maintained that she was giving V the medication, in particular the Movicol and was reporting continued constipation when in fact V was not as constipated as he was and the doctors were misled as to the impact the medication was having because the Mother was not frank about the extent to which she was not giving the medication.
Clinical and Social Work Witnesses
i) Over the period of her involvement with X there were ongoing concerns in particular about his failure to thrive with poor weight gain and periods of weight loss. The Mother reported frequent vomiting, and this was on occasion seen by clinicians.
ii) His weight chart showed a deterioration in his weight from birth to under the 0.4th centile within a few weeks of birth and that this had been the main long-term concern. His weight chart showed a period of time where he appeared to thrive but was then followed by a deterioration back to under the 0.4th centile. The fluctuation in his weight and his failure to thrive also incorporated a period of inpatient treatment; although during these periods the Mother would have been present almost continuously.
iii) He progressed from bottle feeding through to nasogastric feeds to naso-jejunal feeds through to a gastrostomy and then a jejunostomy. The purpose of feeding into the jejunum was to minimise the possibility of X vomiting food from the stomach. Whilst feeding into the jejunum does not eradicate the possibility of vomiting, it reduces it significantly and is intended to allow the body to absorb the nutrition.
iv) Despite the placement of a PEG-J feeding tube X continued to fail to thrive. Investigations had ruled out any physical condition which prevented the absorption of the nutrition and the period of time when X had thrived and put on weight was inconsistent with it being due to a physical condition preventing absorption of nutrients. The other alternatives were non-delivery of the prescribed amounts of nutrients or vomiting up of sufficient of the nutrients to prevent absorption and deliver weight gain.
v) No cause of X's vomiting had been discovered.
vi) After the Mother was removed from his care, following the incident in September 2020 X's weight gain had been relatively consistent whilst placed with foster carers and when seen most recently had progressed to between the 9th-25th centile. He moved from continuous jejunostomy feeds to bolus gastrostomy feeds which he tolerated successfully, and no further vomiting was noted. Very soon after his placement in foster care his need to be fed by the PEG had reduced significantly and he had begun taking food orally. At the most recent review it was noted that the PEG-J had only been used twice in recent months in order to ensure X remained hydrated when he was poorly. Whereas the Mother reported vomiting several times a day whilst X was in her care, the foster carers had not experienced any significant vomiting save in association with an illness or food poisoning. His anti-sickness medication had been discontinued in December 2020.
vii) During the period of Dr Q's care there had also been concerns about X's developmental progress. In September 2020 his developmental level was around one when his chronological age was three. When he was seen in the care of the foster carer some six weeks later, he had made significant progress; both the paediatrician and the neurologist were very surprised by his rapid progress.
viii) X had had multiple referrals for chest infections and had been on antibiotics in over 40 occasions. Chest x-rays were unremarkable. Although the medical notes demonstrate occasions when the GP diagnosed tonsillitis and prescribed antibiotics and although a child of his age in a household might expect to be seen up to 6 times a year for viral or other infections, the number of times X was seen was significantly more than would be expected. Since he had been in foster care, he had not had any particular chesty symptoms or reported chest infections although remained on prophylactic antibiotics at the direction of the paediatric respiratory consultant at Hospital B but is awaiting further review.
ix) Dr Q said that X's failure to thrive was most concerning in that during lockdown she had advised that he be admitted to hospital to monitor, observe and document his feeding. His descent across three centile boundaries was very worrying and she believed she had made it clear to the Mother how concerned she was and how important it was that he was admitted. Initially the Mother had agreed to his admission in July 2020 but subsequently withdrew saying that it was not convenient because she was due to move house. The overall effect of Dr Q's evidence was that there were occasions when the Mother was resistant to advice or failed to attend appointments or referrals which had been made.
x) Eventually the Mother had agreed to X being admitted on 7 September but then discharged him against medical advice when it was proposed to give him a gastrostomy feed but later on the advice of the social worker (Dr Q considered that X was at risk of significant harm if not admitted and by implication care proceedings might have ensued) brought him back to the hospital where his feeds were administered by the staff. The Mother asked for his care to be transferred to Hospital B, but they refused to take him.
xi) Overall, she was of the opinion that X was likely to have been subjected to fabricated and induced illness with a possible combination of neglect and reporting of exaggerated symptoms; the possibility of interference in his treatments (feeding regimes) and possible deliberate induction of symptoms on occasions other than the injection of bleach. Whilst she considered various facets (other than the observed injection of bleach) were only possible and she could not be sure, the overall combination she considered enabled her to conclude it was likely that FII was the problem.
xii) In giving her evidence she was measured and, I thought, careful. She certainly not did not appear to be hostile to the Mother in any way and was able to acknowledge aspects of the case which were consistent with the Mother providing good care and there being areas of X's care where it was clear that doctors had considered his problems were genuine and had treated him accordingly. The evidence from the safeguarding meetings suggest that she did not take on X's care with any preconceived notion of FII, I accept that her evidence was genuine when she said that at the outset she would listen to the Mother and seek to find an underlying organic cause. She said that "when there are signs and symptoms for which no underlying diagnosis can be found it is reasonable to have FII in your list of differential diagnoses.".
xiii) Although her evidence was given as one of X's treating team, she is of course an expert in her field. Albeit her evidence was not given under the mantle of duties to the court that encompasses, I am satisfied that in so far as a treating doctor can deliver a balanced and objective appraisal that she did so. What she returned to was that the overall constellation in relation to X ultimately pointed in her opinion to FII whilst accepting that there were aspects of X's care which either showed genuine illness or which could not definitively be identified as a discrete event of fabrication, inducing or neglect.
i) X presented over a 3 year period with the following - Persistent and incessant chest infections with no obvious cause; had multiple antibiotics (40+ prescriptions) which did not appear to relieve symptoms; CXR not performed until October 2019 Chesty cough - persistent and unresponsive to asthma medications - unclear why Perplexing fluctuating weight - birth weight was normal (50th centile) but he had lost weight at Day 10. This pattern of weight loss and gain was a feature of the first 3 years of his life. He did not respond in an expected way to treatment and importantly did not respond to high calorie feeds; it is recognised that some children will require a high calorie intake [for any number of reasons] but there is always the assumption that they will put on weight; this did not happen with X. No explanation as to why. Consideration must be given to the theory that either he was not given the correct feeds, or his equipment was tampered with. Developmental delay - he presented as a child with gross developmental delay in all areas. All assessments showed this. No cause for this was ever found. The progress that he has made since going into foster care has been remarkable. There must be an assumption that his home environment was so neglectful and under stimulating that he was never given the opportunity to progress. Consideration should also be given to whether his carer 'enjoyed' the status of looking after a very sick child and was unable to allow X to progress as she would lose her 'heroic mother' status (and possible funding). Feeding and vomiting - X was noted to have started vomiting by day 10. He was prescribed a variety of anti-reflux medications and milk. No treatment plan appeared to have been effective and vomiting was a feature of his day to day life. This must be contrasted with his foster carers reporting minimal or no vomiting. Consideration must be given to whether his Mother was inducing the vomiting. There is no evidence except for the 'bleach' incident but professionals may wish to surmise that this was not a one off incident.
ii) Carer engagement with professionals - evidence that Mother actively sought to sabotage health advice and admissions; she declined to have X admitted to Hospital A or Hospital B.
i) The Mother appeared to be well aware of the risks to the children that exposure to domestic abuse posed and was able to articulate this. She struggled to implement advice whether it was engagement with the Freedom Project, domestic abuse support work, applying for orders or otherwise taking precautions to avoid CD. The level of threat from CD appeared to be quite significant. However, she did ultimately obtain an order and did undertake work and notified police of concerns.
ii) V appeared to have been exposed to at least emotional abuse from witnessing arguments between the Mother and CD. He had also been exposed to abusive behaviour by the maternal aunt's boyfriend towards the maternal aunt. It did not appear that he had been exposed to any physical or sexual abuse of the Mother by CD.
iii) V's behaviour at home with the Mother could be challenging. The Mother seem to struggle to implement boundaries in relation to V and described him in quite extreme terms; saying she thought he was mental and that he had tried to strangle her. Neither the school nor the maternal grandmother who cared for V for extended periods of time had any difficulties with his behaviour. He was described by them in positive terms behaviourally and generally.
iv) Social services became involved initially due to concerns about exposure of the children to domestic abuse but when they became involved, they also had concerns about the Mother's mental health and over medication in relation to V. Over time, the issues relating to domestic abuse receded as the Mother took some steps but the concerns about the Mother's mental health and her engagement with the children in particular remained. V was a particular concern in this regard but when younger children arrived, or the Mother's mental health fluctuated her ability to continue to be engaged with the older children was a source of real concern. V ended up living with the maternal grandparents due to concerns about the Mother's attitude to him. At times the Mother was attentive and loving; at other times she was withdrawn from the children.
v) The maternal grandparents, in particular the maternal grandmother were a source of huge support and showed considerable commitment to the children. The maternal grandmother moved into the Mother's home on occasions to support the Mother which resulted in significant improvements in the situation including school attendance. V lived with the maternal grandparents for a considerable period of time because the Mother's attitude to him was concerning. He experienced significant distress about this as well as other issues related to his parentage; the maternal grandmother showed insight into these.
vi) The Mother's engagement was sporadic. The times she appeared to be receptive to advice and expressed a desire to access support but then did not follow up on it. At times she was defensive and hostile to social work involvement.
vii) In relation to the concerns about the levels of V's medication and other medical concerns in relation to X social services were led by the advice received from the health professionals. I got the impression that social services retained some concerns about the medical issues even when the family were stepped down from a child protection plan to a child in need plan and ultimately to Early Help.
i) Prior to X's admission to hospital in September 2020 her experience of him was that during physiotherapy appointments he was more often than not unwell, tired and disinterested as a result. Progress in implementing physiotherapy was therefore very limited. He was often seen to vomit including on one occasion what appeared to be feed. When he was not unwell, he appeared to have much potential and sessions could be far more productive.
ii) During his admission to hospital the notes record him being able to demonstrate gross motor skills which she had not seen him demonstrate whilst at home albeit she had not visited him at home since the spring of 2020. During the hospital sessions he was recorded as active, interested and clearly not in the same condition as he was when she saw him at home.
iii) After his discharge into foster care she continued to be involved with him and he made significant and rapid progress in his gross motor skills. This to her head appeared more rapid than was actually the case because she had not seen the hospital records of his abilities demonstrated whilst he was in hospital.
iv) In relation to Y she had referred him for stiffer boots, and she considered that the Mother's interest in a BEAM class was warranted given his scoring on the Beighton test. In this respect her evidence appears to confirm some concerns in relation to Y's hypermobility
i) Throughout her involvement with X the predominant problem with his feeding was vomiting. In most of her visits (all by appointment) X vomited or was otherwise unwell and she was unable to implement much in the way of feeding regimes because of his continued problems with vomiting. She said that at times he was assessed as having an unsafe swallow but at other times he was able to feed from a bottle. During his admission to Hospital A in March to May 2018 she said she considered he was so unwell that she considered end of life care at a hospice might be required. She had been involved with children who had been unable to feed and had subsequently died.
ii) She described seeing him vomit having seen it happen many times herself and having seen many videos of it. She said it was usually saliva or gastric juices or secretions in mucus and was obviously vomiting of bodily fluids. It had occurred in the absence of the Mother as well as in her presence. His vomiting was not usually preceded by coughing or retching. When he was in discomfort, he would throw himself around. On one occasion when it occurred at the meeting on 16 January 2020, she said it was obviously different, did not appear to be stomach contents but a clear fluid and she was sufficiently concerned that she wrote to the safeguarding lead Ms M about it. The suction machine was recommended; that is very rare and is usually only done in hospitals. They are quite complex to operate.
iii) The only period of time when she observed X to be significantly better was after his return from Hospital B in May 2018 when she described his recovery as having been dramatic. After his return from Hospital B the plan (advised by the team there and supported by her) was to introduce messy play to encourage X to feed. However, the Mother reported that his vomiting had resumed and so this fell by the wayside. At that time, they thought he had turned the corner, his medication was reduced. His skills had improved, and he was gaining weight indeed again so much it had to be addressed. She said the same was true when she saw him on 28 September 2020. She expected progress in relation to his feeding to be very cautious and to move slowly and this was the advice she gave. However he progressed from jejunal to gastric feeding and subsequently to oral feeding far more rapidly than she had ever experienced with any other child she had been involved with and in particular he showed little or no aversion to oral feeding which is usually a significant barrier. She described herself as having been shocked by how rapidly he progressed. She gave a very vivid description of her observation of him in October 2020
He loved having the plate – when I saw him in October 2020 – he wanted to have food and a taster plate in front of him – he wanted to have some solid food in front of him – he wanted to have it before him – he might put it to his mouth – he'd put it to his mouth and look for a response. He wanted to be part of the family eating
It was a truly amazing recovery That is the same now. He continues to eat normally – with the skills he has, he has come on so fast and I would be looking for him not using the PEG at all and to be orally fed which he is achieving. He is just amazing – he has improved beyond my wildest dreams – it is so fantastic.
i) Her involvement with the Mother and the children began when she was conducting a child and family assessment which was concluded in August 2020. Much of the information available to her was taken from the files and she met the Mother and children on a couple of occasions.
ii) In the course of her assessment she found the Mother to be cooperative but rather negative in her outlook. She noted many positive aspects of the Mother's interaction with the children and her care for them in the CFA; particularly in relation to W and Y but also in various aspects in relation to V and X. Her latest social work statement concentrated on the negative aspects and she accepted that it was unbalanced as a result. She accepted that the concerns about domestic abuse (save for CD's occasional re-emergence) and the Mother's mental health had largely abated and that it was X's weight gain and feeding and developmental issues that were at the forefront of the CFA. Her initial assessment was of an individual who was having to cope with multiple stressors with little support. Hence Ms P went above and beyond in terms of the support she offered the Mother in particular around the time when X was due to go into Hospital A for further observation and tests. The text messages demonstrate the extent to which Ms P was offering support and taking on aspects of childcare, including completing school entry forms and offering to take the children to school and collect them from school.
iii) It was clear that she felt the Mother had not been frank about the extent to which she could rely on the maternal grandparents for support; in the CFA she had suggested they were limited in what they could offer but when it came to X's admission to hospital they demonstrated that they were prepared to do anything that was needed in order to support the children. She said she was not surprised that the grandparents knew so little about V's condition as she felt that the Mother had been selective in information provided to her and thought the same would be true of her provision of information to the family. It seems also that V had been reluctant to speak to the social workers when in the care of the Mother. He became more open when he was in the grandparents' care.
iv) Most importantly, I think the Mother's conduct in relation to the administration of bleach to X in hospital caused Ms P to completely re-evaluate her interactions with the Mother and inevitably when she has looked back she has framed her evaluation of the Mother within the cloud of concern the bleach incident gives rise to.
v) Whilst X was in the Mother's care, she observed that he was usually in his pushchair or sat on a tablet. When she saw him in hospital after the removal of the Mother from his care was sat on the floor playing and she described the change in him as being quite overwhelming. She accepted that the play therapy initiated by the hospital had been occurring whilst the Mother was involved in his care but it was clear that she regarded the change in X as being really significant.
vi) It came across to me fairly clearly that Ms P felt somewhat duped or let down by the Mother given her initial evaluation was of someone who was trying but needed support (which she had offered in full) but this had changed both as it dawned on her that the Mother was creating barriers to X remaining in hospital but most importantly with the knowledge of the administration of bleach and she said that when she saw X after that she wondered what they could have done differently and if they had known that earlier how X's position could have been different
Psychological Assessment of Mother by Dr Conning
i) The Mother's estimated Full Scale IQ score of 88 lies in the Low Average range, and at the 21% percentile. Her Verbal Comprehension Index score of 76 lies in the Borderline range, and at the 5th percentile. Her Perceptual Reasoning Index score of 88 lies in the Low Average range, at the 21% percentile. Her Working Memory Index score of 114 lies in the High Average range and at the 82nd percentile.
ii) Comparison of the Mother's Index scores indicated that her Verbal Comprehension Index score of 76 was statistically significantly lower than her Perceptual Reasoning and Working Memory Index scores; and that her Working Memory Index score of 114 was statistically significantly higher than her Perceptual Reasoning Index score by 26 points.
iii) Her area of relative cognitive weakness lies in Verbal Comprehension, that is, verbal abilities that require reasoning, comprehension, and conceptualization. Her area of relative cognitive strength lies in Working Memory, that is, verbal abilities that require reasoning, comprehension, and conceptualization. [I think there must be an error in one of these two as they appear to be mutually contradictory and are unexplained].
iv) The Mother has an unusual cognitive profile. There are statistically significant and unusual differences between her Index scores. There is considerable scatter in the scaled scores she obtained on the individual subtests: her scores range from 4 (Picture Completion) to 17 (Digit Span).
v) Having a cognitive profile in which there are considerable differences between different areas of functioning can be a disadvantage to people because their ability to perform in some areas of cognitive functioning is not in accordance with their ability in other areas. The Mother has a very strong ability to recall lists of numbers and to manipulate the numbers, that is, very good rote learning, but she is less able to use information she recalls, particularly if this is verbal information.
Psychiatric Assessment by Dr Adshead
vi) The Mother does not currently present as mentally unwell. She is currently experiencing a degree of anxiety and depression, but this is not at a clinical level. It is possible that she meets the criteria for a mild-moderate degree of personality dysfunction, based on her history (see below). But without the current adult notes it is not possible to provide a firm opinion,
vii) In my view, there is historical evidence that the Mother was diagnosed with a moderately severe psychiatric condition and psychological difficulty as a teenager. In her late teens, she was diagnosed with somatisation disorder in which she presented with multiple physical symptoms without any medical explanation. These symptoms were thought to be physical expressions of psychological distress. The medical investigations showed that the Mother had no organic disorder or disease that would account for her symptoms; which did improve somewhat after psychosocial treatment in Unit D.
viii) I am not able to say with certainty whether the Mother could now be diagnosed with somatisation disorder. This would depend on how she has related to medical services in adulthood. It is not unusual for young people to "grow out of" somatising disorder as they age; however, it is also not uncommon for women who were somatisers as young people to stop somatising as they get older but then have children who somatise and who have medically unexplained symptoms. There is a strong relationship between mothers with somatization disorder and children with somatising disorders, such that researchers have referred to the 'transgenerational transmission' of somatising behaviour.
ix) I think there is evidence that the Mother's psychological disfunction has had a significant impact on her ability to make and maintain enduring relationships in adulthood, especially friendships and emotional partnerships. Any individual who struggles with interpersonal function is likely to struggle in their relationships with their children. This does not mean that they do not love them; only that they may struggle with the emotional demands of parent-child relationships…..People with insecure attachment ... and somatising disorder and personality disorder) may often struggle with being vulnerable and accepting help from others. I note that in the past the Mother has repeatedly insisted that she does not need help from anybody and she needs to rely on herself and this inability to make use of other people's help when she is vulnerable is another aspect of impaired personal functioning.
x) In the three years prior to September 2020, there are no references in the GP notes to the Mother presenting with any major mental health concerns; nor any evidence of the resumption of the abnormal illness behaviour that had been a feature of the Mother's teenage years and early adulthood. It is notable that her mental health does NOT appear to have suffered during all her pregnancies, although she did develop postnatal depression in April 2008; and remained on antidepressants for it for years. I also note her own reports of feeling stress in the maternal role. However, neither the Mother's stress nor mild mood disorder appears to have manifested itself as abnormal illness behaviour or further eating problems or any other physical expression of distress.
i) I conclude from a review of these notes that the Mother's abnormal illness behaviour ceased when she left her family home and became a mother herself. It may be relevant that the first reappearance of the 'collapsing' behaviour took place in September 2020, when the Mother was taken to the police station to be interviewed in relation to possible child abuse
i) When V was in their care prior to September 2020 he never seemed to have a problem with constipation. The Mother occasionally gave the medication for him but sometimes did not send it when he was with them, he did not need it. They put it down to them providing him with a healthier diet than the Mother. The grandmother's level of knowledge of V from a young boy into a teenager seem to be genuine and I see no reason not to accept her evidence in relation to his constipation. Since September 2020 he has had no problems in this domain and has no medication. He has used his asthma inhalers to a limited extent. He has a tendency to exaggerate symptoms if he is ill; recent examples include him hurting his wrist and complaining to such an extent that the doctors considered he had soft tissue injuries which might take weeks to recover but in fact he was better within three days; another was when they thought he might have Covid but he said he had no symptoms until a PCR test showed positive. He also misses his Mother and would like to reconstitute the family unit. He has had some issues at school with being teased about what the Mother is alleged to have done and are not sure that he knows the truth. He does not appear to have spoken to the other children about it. He has had some behavioural issues as a result but nothing serious. His school attendance is good, and he is coping academically. He has had no problems with hypermobility and she had been unaware that it was considered he had any issues with it.
ii) W's medication when she began living with them included omeprazole, montelukast and to asthma inhalers. They only found out about W having been prescribed omeprazole sometime after she went into their care. She has shown no signs of reflux or asthma in their care. Nor has she shown any problem with milk intolerance. When they used to cook for the children or when they bought them ice cream, she did not appear to have a problem with dairy although she would say she wasn't allowed to have dairy. She is quite sensitive and lacks confidence but is physically well. She misses her mother.
iii) Y is on no medication and has no medical issues. The only problem he had was in relation to recurrent tonsillitis and he has now had his tonsils removed. He is an active and confident little boy who loves wrestling. He also misses his mum.
iv) They had less to do with X than with the other grandchildren because they were unable to deal with his feeding pump and so the Mother had pretty much full-time care of him. Occasionally they witnessed him vomiting. When they were on holiday with the Mother in Hastings in 2019 and 2020, they witnessed him vomiting. They never had any suspicions that it was anything other than sick. They believed that he was genuinely ill and that was why he required the feed pump. She felt guilty for a while because she has IBS and the Mother suggested that perhaps X had inherited something from her. She said in evidence that that had made her feel bad and that when she realised having heard all of the evidence that X probably did not have stomach issue she seemed upset that the Mother had allowed her to feel guilty about something which was not her fault. A suction machine was provided for X, but she did not remember ever seeing the Mother use it. The Mother had not explained to them how important X's admission to hospital was considered to be in 2019 /2020 and had given them the impression that the hospital were fine when she discharged him on 11 September. It was only later that it became clear to them that the hospital wanted him back in there and then they offered to care for the children. Had the Mother asked she would have stayed in hospital with X herself to enable the Mother to continue to care for the children. The Mother did have a lot on her plate in summer 2020 with the move but she did spend the summer in Hastings at the family caravan. She had no knowledge of AB and had never met him.
v) The Mother told the grandmother that she had put water in the gastronomy; she has never said that it was bleach. She told the grandfather that she bought the bleach in order to clean the hospital room because she considered it to be dirty. Since then, when she has asked the Mother why she did it, she has just said she doesn't know. The grandfather says he had had the Mother in tears pressing her as to why she did it but she still maintains she does not know.
vi) Although they were aware that the children had various health issues they seemed to be okay when they were cared for by the grandmother. The house whilst it was damp did not seem to be the cause of the illnesses; they put the children being ill when cared for by the Mother down to her being out and about with them more.
vii) The Mother herself suffered a lot of mental health issues as a teenager which were a conversion or somatoform disorder. The Mother was unable to walk and had to use a wheelchair, but the doctors could find nothing wrong. She was reluctant to accept help for her mental health and did not accept treatment when she was discharged from hospital when she was 16.
viii) They were aware of CD's reputation and had personal experience of him to some degree. The grandmother said that he would say that he was not the person they thought he was and yet she had seen him shouting and banging on the Mother's door and had to tell him to back off herself.
ix) Having heard the evidence she herself now believes that the Mother had injected bleach into X, had not fed him and had exaggerated the children's symptoms and illnesses.
i) Although in his response to threshold he said that he had not been aware of X's existence until the commencement of these proceedings the evidence that was put to him and his responses made it quite apparent that whilst on a very literal interpretation that might be true it was very far removed from reality. Of course he could only know for sure he was X's father when a DNA test was carried out but it is quite clear that he was aware that the Mother was pregnant very early in the pregnancy as she sent him a copy of a positive pregnancy test and a text message saying "it's yours". Thereafter it is clear from his evidence that there were periodic communications over X either from the Mother or from her sister and that he on occasions responded. The relationship was clearly something more than a one-night stand albeit was also hardly a relationship in the commonly understood meaning of that expression. The friendship may have lasted a few weeks at most and I doubt that he was involved in antenatal appointments with the Mother. In particular in early 2020 there were exchanges in which the Mother told him that X was in ill health and he proposed that they meet to discuss the situation. It seems that the Mother did not pursue it and neither did AB. He also acknowledged that he had received a telephone call from a social worker, and I do not accept that his claimed inability to remember what had happened was true. It is demonstrably clear that as a minimum he suspected or more probably believed that the Mother was pregnant with his child and in due course had given birth to his child however he expressed no interest in getting involved. Whilst he may be right that at times the Mother denied that X was his child had he really been interested in X at that time he could have pursued a course which would have enabled him to establish the truth and be there for X. Ultimately whilst he bears some blame for this, the principal responsibility lies at the door of the Mother for not confirming his fatherhood and encouraging his involvement.
ii) The father's evidence in relation to allegations of harassment or stalking of the Mother was that on the two occasions he had simply been at the school or in the street at the same time as the Mother. The contents of the police report show that they saw her complaints as being innocuous. Given the father was in a relationship with another woman whose child was at the same school as V (this fact appears to be corroborated by the hostile messages sent by the Mother's sister) and prepared to accept that the father's presence at the school and in the street were coincidence.
iii) The father's evidence in relation to other complaints of controlling or abusive behaviour was less satisfactory. Whilst he was able to say that domestic abuse can take many forms, his explanation of the "don't do" list written out by AB's former partner and the "What [AB] likes" list rang hollow. I have little doubt that he had made clear his likes and dislikes and that AB's former partner had felt it important enough to write them down. His denial of the finding that he had been overbearing or controlling was consistent with his denial of what appeared in black-and-white. I am therefore satisfied that AB does have an element to his personality which is overbearing and is capable of some degree of controlling behaviour. He appeared to be a man who likes to get his way and did not like being contradicted.
iv) Having said, that I thought his assertion that he had been "a bit of a twat" not becoming involved earlier and his upset at what had happened to X were genuine.
X: Feeding and Weight Gain
i) X's ability to gain weight from May 2018 through to the summer of 2019 demonstrates that physiologically he was able to absorb nutrition. There is therefore no underlying condition which prevents his being able to absorb nutrition delivered to him. The fact that he has been able to absorb nutrition since September 2020 also supports this. Dr Salvestrini could think of no physiological condition which would explain being able to absorb nutrition during one period of time, thereafter, losing that capability before regaining it. She was clear that X's progress since September 2020 rules out any condition which was previously considered as potentially relevant such as gut dysmotility.
ii) The evidence from X's infancy also demonstrates that when he was being fed regularly in hospital that he was able to gain weight as a young baby which also points away from any underlying condition. The other evidence at the time suggests that there were some problems feeding with a bottle but not that he was unable to feed with a bottle; see the entries 23 and 28 February 2018. It thus seems that his failure to gain weight at that time was more connected with how he was being fed although illnesses such as bronchiolitis also intervened.
iii) Both experts were clear that no combination of medication could have had the effect of rendering X in capable of absorbing nutrition delivered to him
iv) The evidence of the mother and of the professionals involved with X were clear that whilst he was either reported to have been vomiting or observed to have been vomiting, he was not vomiting feeds. The Hospital B records from spring 2018 record some vomiting of milk and this was part of the reasoning for transferring from gastric to jejunal feeding. Thus, one can rule out feeds being delivered but not being absorbed because they were vomited out. Given the whole purpose of jejunal feeding is to minimise the possibility of vomiting because the physiology of the body makes it much harder (albeit perhaps not impossible) to vomit jejunal feeds this does not explain X's failure to gain weight.
v) The changes in feeds do not explain the failure to gain weight either. During times of poor weight gain feeds which should have been easier to absorb (they being hydrolysed to a greater extent) were provided.
vi) Although Dr Salvestrini was critical of the process that was adopted in the summer of 2019 to manage X's excessive weight gain she was clear that whilst it was undesirable and potentially harmful in that it would have left X feeling relatively starved it could not have any impact on his ability to absorb nutrition.
vii) I accept that the vitamin B12 deficiency noted in the autumn of 2019 is indicative of the failure to provide the advised level of feeds. The content of the feeds should have provided in excess of 1000% of the recommended requirement and the evidence of Drs Rose and Salvestrini was that whilst intrinsic factor is produced in the stomach and would usually join with B12 to be absorbed in the intestines there was no reason why the delivery of B12 to the jejunum would not have joined with intrinsic factor there and been absorbed.
viii) There is some evidence that the Mother stopped feeds to X when he was reported to be vomiting. I do not consider this to be of much assistance in this regard. What is clear is that the Mother was fully informed as to the operation of the pump and how the feeds were to be delivered, that she was solely responsible for delivering his feeds when he was at home and for significant periods of time whilst he was in hospital, but it would be relatively easy not to deliver the feeds either by simply not running the pump overnight or even to interfere with the delivery of feeds in hospital by running the feeds into another container rather than the jejunal feeding port and at the Mother's suggestion that she was at all times in the presence of others who would have observed that X was not being fed is unsustainable. For very considerable periods of time both during the day and in particular at night no one would have been either present or awake or in a position to monitor the delivery of feeds.
I am also satisfied that the Mother did place obstacles in the way of X's admission to hospital from November 2019 onwards. The Mother's assertion that she has always followed medical advice is most starkly demonstrated to be a lie by her failure to cooperate with his admission at a time when his failure to thrive was particularly serious. He had lost 16% of his body weight. It must have been obvious to the Mother, as it was to the professionals, that this needed to be addressed. The Mother of course would have been aware herself that the reasons for it were that she was failing to deliver his feed but rather than confess to this and to address it in a sustained and meaningful way she continued to maintain that she was complying with his feeding regime and to divert attention from the real cause. I'm satisfied on the balance of probabilities that the range of excuses she put up in order to avoid his admission were because she knew the real reason for his failure to thrive and feared that this would be exposed on his admission. These excuses shifted or were repeated over the following months whilst the concerns of the professionals and their desire to have X endured even when the Covid pandemic intervened. I accept that the maternal grandmother in particular was available and willing to help with childcare, that the hospital and social services were willing to support the Mother and that none of the reasons put forward by the Mother for deferring his admission had any real substance to them. Most parents in the position the Mother found herself in would have moved heaven and earth to ensure that X could be admitted if they had genuine concerns over his medical condition. The Mother's failure to do so lends further support to the conclusion that she was aware that his failure to thrive was due to her failing to comply with his feeding regime and that there was no underlying condition. That she continued to encourage the professionals to believe that there was some unidentifiable condition led to considerable anxiety amongst those treating X but also amongst those family members around him.
i) Aug 2018 (age 11m) this shows significant deficits in physical development, health and self-care, and personal social skills as well as more modest deficits in other domains
ii) Aug 2019 (age 22 months) this shows that much of what he should have been able to do at one year of age in the field of gross motor and health and self-care has only be achieved at age 2 and there remain significant deficits in gross motor and fine motor skills that should have been achieved by age 2 as well as significant deficits in expected development in health and self-care at age 2 and in communication and language. However, in literacy and expressive art he was achieving goals in the 2-3 year range.
iii) November 2020: (aged 37 months): he was only then reaching goals in gross motor skills which she ought to have reached in his first year and his second year, was reaching goals in fine motor skills which she should have attained in his second year as well as goals in health and personal care which he should have been meeting in his first and second years as well as significant communication and language goals that he should have met in his second year.
iv) Assessments in Jan 2021 and 30 April 2021 together with the evidence of Mr K demonstrated him filling in the gaps in his earlier milestones that he should have achieved in his second and third years and beginning to achieve some of the expected levels of development in his fourth year
i) The Mother was told at around 10am when Dr T did his ward round that they would be trialling 10 ml of water into X's gastrostomy port.
ii) The Mother had previously purchased a bottle of bleach on 15 September which she had kept in X's buggy. I do not accept that the bleach was purchased in order to undertake cleaning; there is no evidence from the records that the Mother complained about the state of the hospital or that she was seen cleaning and she was unable to describe how she cleaned and indeed in her police interview maintained that she had not cleaned using bleach; although that point may be of dubious reliability given her dishonesty in the rest of the interview. The bleach was likely purchased in order to demonstrate vomiting. Given that the bottle was empty when found by the police it would seem that the Mother must have disposed of a significant amount of the bleach at some point probably after the vomiting had been induced and prior to her leaving the ward. Neither cleaning or using it to induce vomiting would explain the use of a whole bottle of bleach in the three and ½ days since it was purchased
iii) At some point during the course of the morning the Mother prepared a syringe into which she squirted bleach from the bottle that she had bought four days earlier from WH Smith together with water, probably from the open bottle of sterile water which was in X's room. A dry syringe was found in the bin in the room which suggests Mother had not used the syringe she was given by the nurse and replaced it with a syringe she had already prepared which had bleach in it.
iv) When Nurse J told her that the trial was to take place the Mother produced the syringe which she had previously prepared and attached it to the gastrostomy port. The amount of time the nurse was out of the room for and the possibility that the nurse might not have left at all immediately prior to trialling the water persuades me on balance that the Mother had prepared the bleach solution in the syringe at some point earlier that morning. On the basis of the accounts given both by the Mother in interview and by Nurse J I do not think it was possible for the Mother to have acted on the spur of the moment in getting the syringe, in squirting some bleach into it and then hiding the bleach bottle, in adding water and in attaching the syringe to the gastrostomy port all in a matter of moments. It was thus very much a deliberate act involving preparation.
v) When nurse J returned the syringe was attached and ready to be delivered. In plain sight and in the presence of a nurse the Mother deployed the syringe and injected the bleach water mixture into X's stomach. This I consider took considerable bravado on the Mother's part. Had the syringe been prepared on the spur of the moment with the intention being to inject the mixture prior to nurse J's return I doubt very much that the Mother would have had the boldness to then administer the mixture. The facts thus point to the Mother feeling confident in deploying the mixture into X's stomach such that she was able with confidence to say to nurse J 'look I've done it'. Apart from the odd appearance of the contents of the syringe Nurse J does not make any observation of the Mother appearing to be nervous or hesitant or in any way demonstrating some sense of guilt. I'm satisfied that the Mother could only have felt such confidence that she was able to administer a bleach water mix to X in full sight of a nursing professional if she had both administered a bleach water mixture to X before but also on balance that she had done it within the hospital environment and within potential eyesight of health professionals.
vi) Thereafter X rapidly vomited almost immediately, and the Mother was matter-of-fact in cleaning him up. Thereafter she took such steps as she could to ensure that what she had done could not be detected. She refused the offer of nurse J to take the baby gro to wash it and thereafter the Mother left the ward with X.
vii) The CCTV evidence of her both outside the hospital and in Costa coffee show her disposing of the bleach bottle and the syringe in separate bins. She interacts with staff in Costa coffee. There is nothing in her demeanour which suggests random, anxious or unconsidered actions. On the contrary the disposal of the syringe and bottle in separate bins suggest a clear and planned course of action to dispose of the evidence of her actions.
viii) This together with her apparent lack of anxiety over X and his removal from the ward where medical support would be immediately on hand were he to experience an adverse reaction to the administration of the bleach water mixture clearly point on the balance of probabilities to the Mother having administered such a mixture on other occasions such that she was confident that he having vomited that he would thereafter not suffer further adverse consequences.
i) 15 September 2020 when X was reported by the Mother to her sister to have been 'megasick' by 13:48 hours which was subsequently noted in the nursing notes. That this was within 38 minutes of the Mother having purchased bleach in WHSmith provides further support for the Mother having bought that bleach specifically with the intention of administering it in a bleach water mix she having been told that morning by Dr T that they intended to trial water through the gastrostomy port.
ii) 16 January 2020 when X effortlessly vomited a considerable amount of clear fluid which had an unusual smell. This was within five minutes of the Mother joining the multidisciplinary team meeting which was attended by Dr Q, Ms L, and a variety of other professionals and where the plan in relation to X including admission to hospital both Hospital B and Hospital A were under consideration.
i) In respect of V, the Mother has exaggerated, over-reported and/or fabricated-
a) The extent of his asthma, both in severity and frequency.
b) The extent of any mobility problems, in particular in relation to his need for a special buggy which was not clinically required.
c) The extent and severity of his constipation and in particular in failing to ensure at times that his medication was taken and in mis-reporting the extent to which he was taking his medication.
d) Although Dr Salvestrini considered he did not have GORD its diagnosis by RBH leads me to conclude the Mother is not responsible for that.
ii) In respect of W, the Mother has exaggerated, over-reported and/or fabricated-
a) Her symptoms of cow's milk protein intolerance.
b) Her symptoms of asthma.
iii) In respect of Y, the Mother has exaggerated, over-reported and/or fabricated:
a) His difficulties in swallowing and choking/gagging on food.
b) His symptoms of wheezing/suspected asthma for which she reported that she was regularly giving him Ventolin.
iv) In respect of X the Mother has
a) Prior to his admission to hospital in March 2018 and since approximately July 2019 failed to provide X with adequate food and nutrition
v) Exaggerated and overreported the extent of his vomiting.
vi) Induced his vomiting by introducing bleach water mix into his gastrostomy tube on at least two occasions 15th and 19th September 2020 and induced his vomiting by introducing water or water mixed with other substances into his gastrostomy tube on other occasions including 16 January 2020.
vii) In consequence the children have suffered significant harm and/or been placed at risk of suffering significant harm from
a) undergoing repeated unnecessary medical appointments, examinations, investigations, procedures and treatments in particular for X which were particularly invasive.
b) The children have taken medications which they did not require, and which had the risk of side effects.
c) X's growth was hindered by the lack of nutrition.
d) X's gastrointestinal system was placed at risk of significant harm through the introduction of bleach water into his gastrostomy tube.
e) X's development was hindered by the combined effect of his lack of nutrition and lack of stimulation and by the Mother's care which was a significant factor in his experiencing vomiting throughout the time he was in her care.
f) V's school attendance hindered his educational progress.
g) The children were worried about the health of X and their relationships in particular with X did not develop to the extent that they ought.
h) V in particular has a false view that he is more unwell than he is.
i) I do not consider it necessary or proportionate to make findings in relation to allegations nine and 10 which relates largely to the failure to attend appointments save in one respect which relates to the Mother's failure to ensure that X was admitted to hospital in late 2019.
j) V, W and Y were exposed to domestic abuse in the relationship between the Mother and the father of W, Y and Z, CD, perpetrated by CD. The Mother resumed a relationship with CD knowing of his propensity to violent or abusive behaviour both in 2015/16 and in later 2019 despite the risks she was aware that he posed to her and the children.
k) V, W and Y were exposed to a risk of domestic abuse in the relationship between the Mother and AB. Although the relationship was short-lived and AB only saw the children in a public place he has a history of abusive behaviour to partners including behaviour amounting to controlling and emotionally abusive behaviour as found by HHJ Davies, by his convictions and by his behaviour to another partner in seeking to dictate how she behaved towards him (the lists).
l) The Mother has a significant history of mental ill health in her teenage years and has continued to suffer with variable psychological or psychiatric health as an adult. She has failed to take adequate steps to access help for these problems; whether psychological or psychiatric. At times these have impacted upon her ability to provide good enough care for the children and in particular have caused her to be emotionally detached from them.