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IN THE FAMILY COURT AT
NOTTINGHAM
B e f o r e :
THE HONOURABLE
MR
JUSTICE KEEHAN
____________________
|
NORTHAMPTONSHIRE COUNTY COUNCIL |
Applicant |
|
and |
|
|
M and N |
|
|
(A Child, through his Guardian, Suki Gill) |
2nd Respondent |
____________________
MR
D SHERIDAN (instructed by
Northamptonshire
CC) appeared on behalf of the Applicant
MS
J PORTER appeared on behalf of the 1st Respondent
Mother
MR
J SAMPSON appeared on behalf the Child through his Children's Guardian
____________________
HTML VERSION OF JUDGMENT
____________________
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&
nbsp;
MR
JUSTICE KEEHAN:
Introduction
- I am concerned with one small child,
N,
who was born on 30 September 2015 and so, is two years of age. His
mother
is
M
and his father, T. He has played
no
role in these proceedings
nor
in
N's
life to date.
- The
maternal
grandmother is C and the
maternal
stepfather is T (I shall for the purposes of this judgment refer to them as 'the
maternal
grandparents'). The Local Authority,
Northamptonshire
County Council issued an application for a care order on 12
May
2017 and on the same date,
N
was
made
the subject of an interim care order. He was initially placed in foster care but, shortly thereafter, he was placed with the
maternal
grandparents, where he remains to date.
- The Local Authority alleged that the
mother
had fabricated and exaggerated
medical
symptoms in
N
throughout the whole of his life until he was taken into care. They sought findings of fact against the
mother
which if
made
by this court, would lead them to apply for a special guardianship order to be
made
in favour of the
maternal
grandparents.
- The Children's Guardian supported the stance of the Local Authority,
namely
the findings of facts sought and the order to be
made.
The
mother
opposed the findings sought in relation to the allegations that she has exaggerated or fabricated
medical
symptoms for
N,
although she does accept that she was an overly anxious
mother.
She sought the return of
N
to her care. If this was
not
possible, she supported the placement with her
mother
and her stepfather, but under the auspices of a child arrangement order and
not
a special guardianship order. This
matter
has been listed before
me
for a composite fact-find and welfare hearing.
The Law
- In relation to the findings of fact sought, I remind
myself
that the burden of proof is on the Local Authority. The standard of proof is the simple balance of probabilities, Re B (A Child) [2008] UKHL 35.
- I remind
myself
in relation to lies told by a witness that I should take account of a revised Lucas direction. Accordingly, I shall only have regard to a lie told by a witness if I am satisfied there is
no
innocent explanation for a witness to have lied in his or her evidence.
- The Court of Appeal considered the approach to be taken in respect of a Lucas direction in Re H-C (Children) [2016] EWCH Civ 136.
McFarlane
LJ emphasised the following at paragraph 100:
'One highly important aspect of the Lucas decision, and indeed the approach to lies generally in the criminal jurisdiction,
needs
to be borne fully in
mind
by family judges. It is this. In the criminal jurisdiction the "lie" is
never
taken, of itself, as direct proof of guilt. As is plain from the passage quoted from Lord Lane's judgment in Lucas, where the relevant conditions are satisfied the lie is "capable of amounting to a corroboration'. In recent times the point has been
most
clearly
made
in the Court of Appeal Criminal Division in the case of R v
Middleton
[2001] Crim. L.R. 251. In
my
view there should be
no
distinction between the approach taken by the criminal court on the issue of lies to that adopted in the family court. Judges should therefore take care to ensure that they do
not
rely upon a conclusion that an individual has lied on a
material
issue as direct proof of guilt'.
- I entirely accept that the
mere
fact that a lie has been told does
not
prove the primary case against the party or witness who has been found to have lied to the court. Findings of fact are based on the evidence, including inferences that can properly be drawn from the evidence, and
not
on
mere
submission, surmise, speculation or assertion: Re A (a Child) (Fact-finding Hearing: Speculation) [2011] 1 FLR 1817 and Re A (Application for Care and Placement Orders: Local Authority Failings) [2016] 1 FLR 1.
- There is
no
obligation on a party to prove the truth or an alternative case put forward by their own defence. A failure by that party to establish the alternative case on the balance of probabilities does
not
of itself prove the Local Authority's case. Re X (
No.
3) [2015] EWHC 3651 Fam and Re Y (
No.
3) [2016] EWHC 503 Fam
- When I consider issues of
N's
welfare, I have well in
mind
that his welfare best interests are the court's paramount consideration, s.1(1) of Children Act 1989 and when considering what orders I should
make
in respect of
N,
I have regard to the welfare checklist:s.1(3) of the 1989 Act.
- When considering whether the threshold criteria are satisfied, I have regard to the provisions of s.31(2) of the 1989 Act.
- At all times, I have regard to the Article 6 and Article 8 rights of both
N
and of his
mother
but bear in
mind
that where there is a tension between the Article 8 rights of a child on one hand and the Article 8 rights of the parent on the other, the rights of the child prevail, Yousef v
Netherlands
[2003] 1 FLR 210.
The Background: The
Mother
- The
mother
is 24 years of age, she had a
normal
childhood and a
normal
early development. In 2001, her parents separated and subsequently divorced. At the age of 13, she
met
a young adult
male
through the internet. She became infatuated with him and was deeply upset when her father brought the association to an end. She later came to realise and accept that this individual had been grooming her. Around this time, she undertook voluntary work with St John's Ambulance.
- At the age of 14, the
mother
showed apparent lapses of consciousness and was assessed by a
neurologist.
She was later referred to Child and Adolescent
Mental
Health Services and underwent cognitive behavioural therapy. She had a
number
of relationships which were characterised by domestic abuse in her late teenage years. At the age of 19, she
made
a suicide attempt. Thereafter, she commenced a relationship with T and she became pregnant with
N,
but the relationship ended before his birth. Save for his attendance at an emergency pre-birth scan, the father has played
no
further part in
N's
life or that of the
mother
and the father has
not
seen his son.
- In January 2016, the
mother
formed a
new
relationship and subsequently became engaged. In early 2017, she discovered she was pregnant but suffered a
miscarriage
eight weeks gestation. Sometime later, she and her fiancé separated. As I have said,
N
was removed from his
mother's
care under the auspices of an interim care order in
May
2017. A further pregnancy was terminated by an abortion.
- The
mother
later recommenced a relationship with B with whom she had previously been in a relationship.
Most
if
not
all the
mother's
relationships involved elements of abuse. During the parenting assessment undertaken by the social worker, the
mother
asserted she recalled that
many
of her previous partners had abused her or various abusive actions, including rape and physical assaults.
The Background: The Child
- The consensus of the evidence from the
medical
records of the treating clinicians and from Dr Vaughan is that
N
was born after a
normal
pregnancy. He was a healthy baby and developed
normally.
He had and has
no
significant or long-term
medical
conditions or disabilities. I shall consider his
medical
history in some detail a little later in this judgment, but the overview
may
be summarised as follows:
(a) in the first 20
months
of his life,
N
presented to the general practitioner and other healthcare professionals for a variety of
medical
issues,
most
commonly apparent seizures on
no
less than 90 occasions.
(b) in the same period, he was admitted to Accident & Emergency Department at various hospitals on
no
less than 13 occasions and, as before, always by and with his
mother
and
(c) he was admitted to hospital for examination at his
mother's
behest on
no
less than
nine
occasions.
- In very
marked
contrast, during the last
nine
months
while he has been in the care of his
maternal
grandparents, he has
no
presentation to a general practitioner or admissions to Accident and Emergency Departments or Hospitals other than for his
normal
annual GP check-ups. He has
not
been observed or reported to have suffered any seizures or epileptic-type fits. The only change in his social and developmental
medical
condition during this period is that his day-to-day care have been transferred from that of his
mother
to that of his
maternal
grandparents.
- The
medical
consensus remains that
N
is a perfectly
normal
little boy, with
no
significant, unusual or long-term
medical
conditions or disabilities. There is
no
medical
explanation for the very
marked
change in
N's
presentation for
medical
treatment when in the care of his
mother
compared with
no
presentations for
medical
treatment when in the care of his grandparents, save for routine
medical
appointments. The question I have to answer is what is the reason, or what are the reasons, for this complete volte face.
The Expert Evidence
- Mr Furlong, a childhood psychologist prepared a report for the court dated 16 August 2017 on the cognitive functioning of the
mother
and
made
various recommendations relevant to those working with the
mother.
His report was uncontentious, and he was
not
called to give evidence.
- Dr Campbell is a consultant
neuropsychiatrist.
He prepared a report on the
mother
dated 24
November
2017, followed by an addendum on 29
November
2017. In his substantive report Dr Campbell said as follows:
'
M
has presented with episodic seizure-like activities since the age of 14. Investigations of possible epilepsy have consistently proved
negative.
Her condition has variously been described as a somatisation disorder or dissociative seizures.
More
recently, her condition has been described by her treating
neurologist
Dr S as a
non-epileptic
attack disorder. All of these diagnoses refer essentially to the same condition. The variation arising principally from the perspective of the treating doctor. For the sake of consistency, I adopt Dr S's diagnosis of
non-epileptic
attack disorder.
N
has been described by his
mother
as exhibiting episodic seizure-like activity since the age of six
months.
Seizure activity has
not
been observed by others except perhaps by
Ms
T,
nursery
nurse
in April 2016. Extensive investigation, including a 24-hour ambulatory electroencephalogram with video
monitoring
on 9
May
2017 has
not
revealed evidence of his epilepsy. His condition has been described as factitious or induced illness. This resulting in the safeguarding concerns which have led to
N's
reception into care. In summary, therefore, based on the available
medical
information,
M
exhibits a
non-epileptic
attack disorder.
N
exhibits a factitious or induced illness, in this case
meaning
he does
not
have epilepsy but his
mother
is imputing this condition onto him'.
- A little later in the report, Dr Campbell asserted as follows
'At the time of
my
own assessment,
M
was able to provide a very extensive account of both herself and her son. She seemingly accepted her diagnosis of
non-epileptic
attack disorder but still remained convinced that she had been experiencing epileptic attacks. For example, she reported having a
massive
seizure during the course of her pregnancy with
N.
She also appeared convinced that
N
also suffers from epilepsy and is at risk of serious harm if
not
properly
managed.
For example, when
N
was in hospital during
May
2017, she feared he would become dangerously ill if
not
provided with oxygen. However, in
my
opinion,
M's
beliefs do
not
have the unshakeable and fantastic quality typical of psychotic dilutions so they are better classified as over-valued ideas.
M
did
not
report any other inter-current psychological symptoms such as anxiety or depression. On the face of it,
M
currently presents with a specific overvalued idea concerning her own health and her son's health. In themselves, overvalued ideas are
not
diagnostic of any psychiatric condition. In view of the absence of intercurrent psychological symptoms or any diagnostic
medical
state of abnormalities, I consider that
M
is
not
suffering from any overt
mental
illness at the present time. In summary,
M
presents with an enduring overvalued idea,
not
amounting to a delusional belief concerning her diagnosis of epilepsy. She seemingly
maintains
that she is suffering from such a condition even though at an intellectual level, she can identify the diagnosis of
non-epileptic
attack disorder. She has also become concerned that her son has suffered from epilepsy since the age of six
months
and remains concerned about his ongoing health, in spite of the absence of a confirmed
medical
diagnosis. Although
not
currently
mentally
ill, she displays a pattern of behaviour which
may
plausibly arise from an underlying borderline personality disorder. In terms of prognosis, I consider that by their very
nature,
M's
overvalued ideas concerning both her own and her son's health are likely to persist indefinitely'.
- Then a little later in his report, he observed:
'Over-valued ideas can prove debilitating for the person experiencing them, but usually do
not
become seriously dysfunctional, unless they extend to involve other people such as, for example, in cases of harassment and stalking. Currently, there is
no
medical
treatment which can reliably alter the course of over-valued ideas. Psychological approaches such as cognitive behavioural therapy have been attempted, but the academic literature provides little evidence for sustained benefit. Counselling approaches have also been attempted but this is
more
supportive in
nature,
rather than a
method
for altering the course of a strongly-held idea. Overall, there is currently
no
clearly beneficial therapeutic approach which can be recommended. In respect of prognosis, over-valued ideas typically persist for years and sometimes for life. In
M's
case, Dr S's
nudge
approach to anti-convulsant
medication
withdrawal seems entirely appropriate, although it appears that little act or progress has been
made
to date.
M's
over-valued idea concerning her own epilepsy has resulted in her extensive involvement with
medical
services, including both emergency services and investigative procedures. If this pattern were to continue, it would reduce her availability to provide continuity of care for her child. This could have a substantial
negative
impact in the absence of a supportive partner. In
M's
case, her over-valued idea has extended to incorporate her son. Consequently, from the age of six
months,
N
has experienced a substantial
number
of hospital attendances for both emergency and investigative purposes. However, in respect of possible epilepsy, these attendances cannot have been beneficial, except only to exclude the condition. This also reduced
N's
opportunities for
more
normal
family life and participation and developmental opportunities. The impact is likely to become
more
significant as
N
grows older. For example, through failed
nursery
or school attendance. Overall,
M's
specific over-valued idea concerning epilepsy is likely to distract her away from her parenting role and cause her to pursue a course of action in respect of
N
which could
not
be positively beneficial for him. Inevitably, assessment of future risk is somewhat speculative. The
most
likely outcome could be
N's
withdrawal from appropriate, developmental or educational opportunities through unnecessary
medical
attendances. This could arise particularly if
M
were to seek a succession of further opinions in support of her own idea. This could also include frequent relocation in her search for support. Somewhat
more
speculatively,
M
could seek to treat
N
for epilepsy by sharing her anti-convulsant
medication
with him. Furthermore,
M's
current overvalued idea could plausibly extend to other
medical
conditions for which she
may
seek
medical
attention. For example, she was briefly concerned that
N
may
have a hole in his heart. I emphasis the extent of these possible risks is unquantifiable'.
- In his oral evidence, Dr Campbell confirmed the opinion set out in his report. He told
me
the
mother
is aware of what she is doing and treatment at a pre-contemplation stage is a waste of time. The evidence is
not
strong enough to
make
a diagnosis of borderline personality disorder.
- Dr Vaughan is the consultant paediatrician instructed to provide an expert
medical
opinion on
N.
Her report is dated 28 September 2017. In that report she said:
'
N
has had a high
number
of contacts with health professionals in his 21-
months
of life. This is unusual for a child who has
no
diagnosed long-term disorder and
no
objective persisting clinical signs. This pattern of contact is also unusual because of the high occurrence of
normal
physical signs of investigation results, despite being presented frequently as unwell. There are an unusually high
number
of health contact for which there is
no
documented corresponding clinical signs identified by the assessing health professional.
N
has recently been confirmed to have iron deficiency for which he is receiving iron supplements. The cause is usual
nutritional
in toddlers,
N
is otherwise in good physical health and is
meeting
his developmental
milestones.
There are long-standing concerns by the
mother
that
N
has seizures, despite assurances to the contrary by his paediatric
medial
team. Reported events have
not
been verified by third party observations and clinical observations. There have been diagnostic challenges as the pattern of description of these
movement
seizures have
not
tallied with known
medical
conditions such as epileptic seizures or epilepsy
mimics.
Epilepsy is a common
neurological
disorder characterised by a high incident of inaccurate diagnosis and up to a third of people with a diagnosis of epilepsy have indirect diagnosis. Video telemetry done in
N
did
not
identify any abnormal
movement
or behaviour and the EEG was reported as
normal.
In
my
opinion, there is
no
evidence to suggest
N
has epilepsy seizures'.
- A little later in the report, Dr Vaughan said as follows:
'There are concerns by the
mother
that
N
has seizures, reported events such as vacant episodes and responsiveness and abnormal
motor
movements
have
not
been verified by either third party observations or clinical investigations. There have been diagnostic challenges as the pattern description of these
movements
or events do
not
tally with known
medical
conditions. Clinical and laboratory examination after these events have been
normal.
The events have
not
been independently observed and there was a
normal
EEG. EEG is a test that detects electrical activity in the brain. The EEG during reported events and in between events have been reported as
normal.
A reported event by the
mother
during the video telemetry did
not
reveal any abnormal
movements.
The view of his local
medical
team is that the reported events are
not
epilepsy fits.
N
is
now
24-
months-old
he has an unusually high
number
of contact with health professionals, 13 A&E attendances,
nine
in-patient admissions and 90 communications with health are quite unusual for a child that has
no
diagnosed long-term disorder and
no
persisting clinical signs. This is also unusual because the absence of abnormal verified symptoms and
normal
physical signs investigation results. The challenges of
medicine
are usually
more
of interpretation over
normal
physical times and abnormal laboratory investigation results that do
not
fit recognised physiological processes. From the
medical
records
made
available to
me,
there is
no
evidence to suggest that
N
has any long-term disorder. He has iron deficiency and iron deficiency in a toddler is a time-limited condition and would resolve once his iron stores are replenished with iron supplementation.
N's
daily life and function
must
have been confusing and chaotic with frequent contact with
multiple
stranger professionals. The impact of the frequent health physicians he visits, and physical examinations
may
be difficult to fully understand because of his very young age.
N
was reported to be very distressed when an ECG was attempted in April 2017. Whilst this is
not
unusual in children, it cannot be ignored. The impact on interaction with peers due to frequent clinical appointments
may
lead to poor stimulation with potential to socialise isolation and poor social communication skills. It is unclear what opportunities
N
has for regular peer interaction, apart from the play activity he was reported to attend at a play centre in
Milton
Keynes. There is a very strong danger of perpetuating and
medicalising
the unknown with further risk of subjecting
N
to unnecessary anxiety by further investigations. FII is a diagnosis continuing. The factors that cause carers to progress along the continuum are
not
fully known.
N
is at risk of induction of symptoms'.
- In her oral evidence, Dr Vaughan confirmed the opinions set out in her report. She had provided the court with an incredibly helpful coloured chart, setting out the timeline of
N's
contact with health professionals and his hospital admissions. Of importance were those events
marked
in green which were legitimate contacts,
mostly
in the early
months
after his birth and those
marked
in red which were contacts where there was
no
objective
medical
evidence to support the presentation of
N
to a health care professional or to a hospital.
- From about
March
2016, the red
markers
dominate the timeline. In her exceptionally clear and powerful evidence, Dr Vaughan
made
the following five principal points:
(a) the video of the EEG on 3
May
2017 showed
no
signs whatsoever of
N
suffering any form of seizure;
(b) even where there were legitimate reasons for
N's
presentation, the
mother
exaggerated his symptoms;
(c) breath-holding in a baby or young child always has identifiable triggers which, if frequent, a parent can recognise the trigger and avert the breath-holding. She described the
mother's
accounts of
N
breath-holding as unlikely;
(d) at
no
time did
N
suffer severe reflux or associated back pain, Sandifer Syndrome as asserted by the
mother;
and,
(e) there is
no
evidence that
N
suffers seizures.
The Evidence: Treating Clinicians
- Dr S is the
mother's
treating consultant
neurologist
and has been since 2015. He confirmed the diagnosis of
non-epileptic
attack disorder ('
NEAD')
which had first been
made
by the
mother's
former treating consultant in 2010. Dr S told
me
that
NEAD
is a very difficult condition to
manage.
Furthermore, if the court found that
mother
denied or did
not
accept she had been diagnosed with
NEAD,
this would demonstrate a real lack of insight into her condition.
- Dr H was one of the consultant paediatricians responsible for
N's
medical
care. She told
me
she found it very difficult in her first
meeting
with the
mother
on 17 February 2016 to reassure her that
N
was a well and healthy baby. During her examination of
N
on 17 February 2016, the
mother
told her
N
had had three episodes where he became unresponsive. He had had a further episode the
night
before when he was struggling to breathe and was then pale and unresponsive. By the time the ambulance had arrived however,
N
was back to
normal.
She further told Dr H that she was concerned about the strength and power of his upper limbs and that he was
not
opening up his fingers, but this had improved recently.
- Two observations on these concerns:
(a) on physical examination the consultant found
no
problems with
N's
upper limbs and fine
motor
skills. He was developmentally
normal
and;
(b) the
mother
never
mentioned
either of these issues to her health visitor S. Dr H told the
mother
she did
not
have any concerns about
N's
development or the power of his upper limbs.
- The
mother
told Dr H she suffered from epilepsy.
- Dr H reviewed
N
on the 8 June 2016, she
noted
the EEG performed on 21
March
2016 was
normal,
nevertheless,
the
mother
said
N
was still having vacant episodes three or four times a day, lasting for a few seconds, but there were
no
tired or sleepy episodes afterwards. Further, she said that every four to six weeks he would have episodes of shaking of his body and limbs, especially after feeding, but there was
no
history of head-
nodding
or jerky
movements
of his arms or legs. Dr H told the
mother
that
N
was developing appropriately, he looked very well, he had
normal
power and tone in all four limbs and the episodes described by the
mother
were
not
suggestive of epilepsy: these were short-lasting episodes with
no
postictal event and they
may
be
normal
movements.
They did
not
suggest any significant condition.
- Dr H reviewed
N
finally on 14 December 2016, all was well, and he was discharged back to the care of his general practitioner. She did
make
a referral to a dietician because the
mother
had said he was a fussy eater. The
mother
did
not
keep the appointment with the dietician.
- Dr HW was the senior consultant paediatrician responsible for
N's
care. He was a clear and careful witness. His oral evidence
may
be summarised as follows:
(a)
N
did
not
suffer from epilepsy;
(b) the video of 3
May
2017 did
not
show any of the seizures alleged by the
mother
or, indeed, any abnormal
movements
at all. At the
material
time,
N
was a quiet baby, seeking to sleep;
(c) the EEG does
not
show any abnormal brain activity and, in particular,
no
evidence of a seizure;
(d) the EEG would have detected
movement
by
N
if it involved his head and
neck.
At the
material
time,
no
movement
was detected.
(e) the
mother
had been told to press a button on the EEG control panel if there was any sign of abnormal
movement.
This would place a
marker
on the trace recording. Although the
mother
opened the bag containing the control panel immediately after she alleged
N
had suffered three seizures, she did
not
press the button;
(f) further, the
mother
had been instructed to press the call button to summon a
member
of the
nursing
staff if
N
had any abnormal
movements.
The
mother
approached the call button after she said there was alleged shaking by
N,
but she did
not
press it. Instead, she left
N's
side room to summon the
nursing
staff;
(g) without any adverse history, the
mother
demanded of Dr HW that
N
undergo an ECG procedure. In doing so, she was very assertive and verging on complaining;
(h) Dr HW, has had very considerable experience of interacting with parents of unwell children. He was of the firm view that the
mother
enjoyed the situation of
N
being in hospital. She was preoccupied with
medical
procedures and she did
not
come across as concerned or worried about her child; and
(i) he was of the view, especially after the video of 3
May
2017, that the
mother
was and had been exaggerating and fabricating symptoms in
N.
They, the clinical staff therefore intervened very quickly because an FII parent who is
not
believed can very quickly escalate
matters
and
move
from exaggerating and fabricating symptoms to inducing symptoms. Dr Vaughan was in complete agreement with this analysis.
- Dr R, another consultant paediatrician, saw
N
in
May
2017. When he examined
N,
he found
no
basis for
N
undergoing an ECG. It was put to him on behalf of the
mother
that a
nurse
had told him she had observed
N
having a shaking episode. Dr R's reply was a firm '
No'.
He confirmed that when he examined
N
in April 2017 the
mother
had told him that
N
would have episodes of shaking, going stiff or limp five or six times per week for the previous year.
Evidence: General
- S was
N's
health visitor. She had had regular contact with the
mother
and
N
from shortly after his birth until
May
2017 when
N
was removed from his
mother's
care. S was clear that she did
not
agree with the Local Authority's decision to close the child in
need
referrals in 2016 and 2017 because she was of the view that the
mother
required a high level of support to care for
N.
She, like other health professionals, had had very real concerns about the
mother's
ready use of
medical
terms in relation to
N.
Further, she expressed a view that on occasions, the
mother's
care of
N
was
merely
basic. There were times when
N
and/or the home were dirty. Contrary to the evidence and/or assertions of the
mother,
S told
me
that:
(a) so far as she was aware,
N
had
never
had a breathing
monitor
attached to his
nappy;
(b) she had
never
seen
N
have a seizure or a tremor;
(c) she had
never
criticised the
mother's
care of
N
and
never
sought to undermine the
mother
as a parent;
(d) at
N's
eight-
month
developmental check-up the
mother
agreed with her assessment that
N
was developing well and his limb
movements,
etc., were satisfactory;
(e) the
mother
had
never
reported to her that
N
could only tolerate certain
makes
of
nappies
or that he had a significant problem with developing rashes on his body.
- Ms T was a
nursery
nurse
who worked alongside the health visitor to provide practical support and advice to the
mother,
e.g. how and when to prepare his bottles and how best to feed him. The
mother
did
not
consistently follow this advice and
Ms
T found it
necessary
repeatedly to go over old ground. She visited the
mother
and
N
at their home on at least 20 occasions between October 2015 and
March
2017 and would typically stay for one to one and a half hours. She
never
saw
N
suffer a seizure or a tremor. Her initial view was that the
mother
was anxious but as time went on, she considered the
mother's
anxiety had become excessive. It was a cause of real concern for her that the
mother
was keen to talk in very great detail about
N's
most
recent hospital admissions. The
mother
appeared to enjoy talking about
N's
medical
conditions and admissions to hospital. Further, rather than telephoning her when she, the
mother,
was worried about
N's
health, she would only contact
Ms
T when she, the
mother,
was at or shortly after having taken
N
to hospital. The only occasion when the
mother
telephoned
Ms
T prior to taking
N
to hospital, the
mother
did
not
follow the advice
Ms
T had given to her.
- Ms C is a paediatric epilepsy
nurse.
She
met
the
mother
and
N
at the epilepsy clinic at
Northampton
General Hospital on 21
March
2017.
Ms
C took contemporaneous
notes
during her conversation with the
mother.
She
noted
that in contrast with
most
parents who are devastated when their child has a seizure and are distressed by it, the
mother
was smiling during her account of
N's
hospital admissions and seizures. The
mother
appeared to gain enjoyment from talking about the same. At
no
time did the
mother
exhibit any upset or distress.
Ms
C
noted
the
mother
as having reported the following:
(a)
N
had been diagnosed as suffering from palliative breath-holding spells;
(b) she, the
mother,
had been diagnosed with epilepsy. She
made
no
mention
of having in fact been diagnosed with
non-epileptic
attack disorder;
(c) prior to
N's
birth, the
mother
had been told that he had brain and heart defects and
may
die within six weeks of his birth;
(d) armed police were present on the
maternity
unit when she gave birth to
N
for her protection in respect of alleged threats
made
by
Mr
T;
(e) she had been advised by a specialist that it was likely
N
would get epilepsy at six to 12
months;
and
(f) she administered physiotherapy to
N
and limb therapy because of
N's
difficulties in using his limbs. He would
not
use both simultaneously.
- None of the foregoing statements are true.
- It was put to
Ms
C that she had pre-conceived ideas about the
mother
prior to this
meeting
because she had been alerted by a colleague to concerns about the
mother.
It is the case that
Ms
C discussed the
mother
and
N
with safeguarding colleagues before
meeting
with the
mother.
Rather than in any sense prejudicing her against the
mother,
however, I take the view that this
meant
Ms
C was acutely aware of the importance of
making
an accurate
note
of her conversation with the
mother.
I am satisfied this is precisely what she did.
- The Children's Guardian confirmed the contents of her final analysis. She told
me:
(a) the
mother
has
no
insight into her behaviour or actions as was demonstrated by her oral evidence;
(b) she has consistently expressed a view to the Guardian that apart from being an overly anxious
mother,
she has done
nothing
wrong;
(c) there is
no
prospect of the
mother
gaining any insight;
(d) the
mother
has shown herself to be very
manipulative;
(e) there was
no
safeguard which could be put in place which would enable the
mother
to resume the care of
N.
The risks were too great and the risk of the
mother
moving
on to induced symptoms in
N
was real;
(f) it is essential for
N's
welfare that his
maternal
grandparents have a special guardianship order in their favour so that they have the upper hand in exercising parental responsibility; and,
(g) it is
necessary
that an order is
made
for contact at a frequency of once per
month
plus such other occasional holiday periods as the
maternal
grandparents
may
agree so that they and the
mother
are clear about what level of contact has been approved and permitted by the court.
- The Guardian was content with the revised provisions of the special guardianship support plan, as were the
maternal
grandparents. Accordingly, she supported the
making
of a special guardianship order in their favour. I heard evidence from the social worker who gave evidence in line with that received from the Children's Guardian.
- I deal finally with the evidence of the
mother.
I regret to find that she was a
most
unsatisfactory witness. She changed her accounts during her evidence and gave contradictory versions of events. She has repeatedly lied to the clinicians treating
N
and to other health professionals and she repeatedly lied in her evidence to this court. I have considered whether there are any innocent reasons for her lies. I am completely satisfied there are
none.
I have come to the above conclusions of repeated lies for
no
innocent reasons for the following 12 reasons:
(a) at the beginning of her evidence, the
mother
wished to amend an account in her second statement of
N
having suffered a collapse on one occasion at home. She told
me
he had
not
collapsed but had a shaking episode and became floppy. Why the difference in the
mother's
account? She could give
me
no
explanation;
(b) the
mother
told
me
she was devastated by
N's
presentations and sometimes cried her eyes out. This account is wholly contrary to the weight of the evidence of the clinicians and healthcare professionals,
many
of whom described the
mother
as enjoying talking about
N's
medical
history and
not
exhibiting any stress about him or concern for him. These observations chime with
my
own observations of the
mother
over the course of this hearing and during her time in the witness box. Save for two very brief occasions when she became emotional, she smiled throughout
most
of the evidence;
(c) in April 2016, the
mother
made
an application for disability living allowance in respect of
N.
She said she was assisted to complete the form by a voluntary organisation. The
mother
accepted that she gave the information to a person who completed the form for her. She claimed that she had
never
previously seen the completed form, although she accepts that her signature appears twice on it. The alleged symptoms and conditions suffered by
N
is set out in the application form, there are
no
relation to accounts given by the
mother
from time to time to the clinicians;
(d) the
maternal
grandmother told the Guardian that the
mother
had said she could
not
attend the wedding of the
maternal
grandmother and
maternal
step grandfather because she had cancer. The
mother
denied this and told
me
she had been banned by the
maternal
grandmother from attending the wedding.
No
reasons for the ban were given to
me.
I
note,
however, on 9 April 2014, Dr
M,
a consultant oncologist, reassured the
mother
she had
not
got breast cancer. Thirteen days later, on 22 April 214, the
mother
is recorded as telling the doctor at Kettering General Hospital that she had recently been diagnosed with breast cancer. The
mother
denied saying this. Where there is a conflict between the evidence of the
mother
and a clinical
note,
I prefer the latter. Accordingly, I am quite satisfied that the
maternal
grandmother is telling the truth and the
mother
is lying;
(e) the
mother
told
me,
as she repeatedly told others, that
N
suffers from palliative breath-holding spells. She said the diagnosis was
made
by a consultant treating
N,
but she could
not
remember the
name,
other than it was a
male
doctor. When I asked her how
many
male
consultants had seen
N,
she gave the utterly absurd and false answer of 10 to 15 consultants. The condition of palliative breath-holding spells is unknown to
medical
science. The
mother
was, once again, lying;
(f) the
mother
has repeatedly told clinicians and health professionals that she has been diagnosed with and/or suffers from epilepsy. The
mother
has known since 2010 that she does
not
have epilepsy. She has been diagnosed with
non-epileptic
attack disorder, as confirmed by her treating
neurologist,
Dr S. The
mother
may
not
like this diagnosis and, indeed, she said she was angry when first told of it, but I do
not
accept the
mother's
account that she tells professionals she has epilepsy because they will
not
or do
not
understand
NEAD.
She was deliberately seeking to
mislead
professionals into believing she had epilepsy;
(g) the
mother
said in evidence that she accepted the report and opinions of Dr Vaughan. Given that Dr Vaughan is of the opinion that the
mother
exaggerated and fabricated symptoms in
N
which the
mother
adamantly does
not
accept, the
mother
plainly does
not
accept the opinions of Dr Vaughan;
(h) the
mother
asserted that Dr Hewittson had told her in December 2015 that
N
had a bacterial infection. First, there is
no
reference in any of
N's
medical
records of him ever having suffered a bacterial as opposed to a viral infection. Second, this assertion was
not
put to Dr Hewittson when he gave evidence. It is a lie by the
mother;
(i) the
mother
said in evidence that she was worried that
N
may
have an immunosuppressive disorder because he had suffered, 'So
many
viral infections'. There is
no
evidence that
N
has ever had an immunosuppressive disorder and
no
clinician has ever suggested the same. Further, at the time the
mother
raised this issue with the clinicians,
N
had only suffered two
mild
viral infections. This is a clear example of the
mother
exaggerating symptoms and
medical
conditions;
(j) on 3
May
2017, the
mother
told the
nursing
staff that
N
had just suffered three short episodes of shaking along the whole length of his body. This account was given before the
mother
had viewed the video recording. In her evidence, after she had viewed the video, she gave a different account. She said his head and one arm, which cannot be seen on the video, was shaking. When asked why she told the staff it was the whole body, she gave the wholly implausible answer that she had told the
nursing
staff what she thought she had seen. When asked why she was giving a different account in her oral evidence, which she had
never
given before, she had
no
answer. She was lying and giving a false account against overwhelming evidence to the contrary.
Not
just the video recording, but Dr HW's s evidence that the equipment would have detected
N's
head and
neck
shaking or
moving,
and it did
not;
(k) in her oral evidence, the
mother
asserted she had been told by a doctor in 2015 that she had erroneously been informed at an early scan of
N
in-utero, had revealed that he had two holes in his heart. A few
matters
arise. First, the
mother
has
never
before said that the information about
N's
heart was given to her in error. Hitherto, she has always asserted that pre-birth scans had shown he had a hole in his heart. Secondly, previously, the
mother
has asserted
N
had a hole in his heart. In her oral evidence for the first and only time, she has referred to being told in error or otherwise of two holes in his heart; and
(l) she had asserted in the disability living allowance application forms that
N
had eczema over the whole of his body. He has
never
had such extensive eczema, only small patches in some of the folds of his skin. When challenged about this, the
mother
sought to explain the contradiction by claiming that the phrase, 'whole body'
meant
the small patches in some folds of his skin. A quite incredible explanation but the
mother
was lying.
Analysis
- I am satisfied on the balance of probabilities; indeed, I am satisfied so that I am sure, that
N
was and is a perfectly
normal
baby who has had
no
significant
medical
conditions or disabilities and certainly
none
that are long-term. He has
not
and does
not
suffer from epilepsy. He has
not
and does
not
suffer from any epileptic,
non-epileptic
or any other forms of seizures or vacant episodes.
- I am wholly satisfied that any account to the contrary by the
mother
is false and fabricated. In other words, I am wholly satisfied that when she said
N
had suffered a fit or a seizure or an epileptic event, she was lying. I am wholly satisfied and find that these were
not
the actions of an overly anxious
mother.
These were the actions of a
mother
who has, as I have found, lied about her own
medical
condition and has chosen to lie about her son's
medical
presentation from time to time.
- Dr Campbell in his report and in his oral evidence drew the distinction between delusional beliefs which are psychotic in origin and over-valued ideas which are
not.
The latter is an innate part of an individual's behaviour and functioning. It is
not
necessarily
a life-long affliction but in a person who does
not
recognise the
need
to change, it is an immensely difficult condition to treat. Indeed, there is
no
recognised treatment.
More
importantly, the individual with over-valued ideas knows what they are doing. They are aware of their actions and the consequences of same. A person with over-valued ideas is
more
susceptible to be diagnosed as suffering from a borderline personality disorder. Dr Campbell was hesitant about
making
this diagnosis in respect of the
mother
and, ultimately, did
not
do so.
- The
most
egregious examples of the
mother
fabricating symptoms in relation to
N
are
(a) the video
made
by the
mother
with a
neurophysiologist
which the
mother
asserted demonstrated
N
suffering a seizure event but which the doctor recorded as '
N
sitting quietly'; and,
(b) during video telemetry on 3
May,
when the
mother
asserted and continued to assert at this hearing that
N
had suffered three three-second seizure events.
- All of the treating clinicians and the
medical
experts are clear that there are
no
episodes of usual, still less, seizure activity to be seen in this video telemetry. The agreed
medical
chronology has
many
other examples of the
mother
fabricating and/or exaggerating symptoms in
N.
In fairness to the
mother,
it is right to recognise that
(a) a
number
of
N's
appointments with
medical
professionals were quite
normal
and routine
medical
appointments; and
(b) a
number
of hospital admissions in the early
months
of
N's
life were the result of feeding problems and of him suffering two bouts of bronchiolitis in December 2015 and January 2016.
- Thereafter, there is an incremental increase in the
mother
giving a false history and then of fabricating and/or exaggerating symptoms said to have been suffered by
N.
On 17 December 2015 at 10.30 in the evening, the
mother
took
N
to
Northampton
General Hospital because he did
not
rouse easily when awoken for a feed.
N
was found to be a healthy, well baby and was likely to have just been in a deep sleep. He was discharged without any treatment.
- On 31 December 2015,
N
was admitted to
Northampton
General Hospital, having been brought by ambulance because the
mother
was said to be concerned about his breathing and was anxious about him getting bronchiolitis again. On examination, the child was
noted
to be alert and smiling, well perfused with
no
respiratory distress. He was discharged.
- On 5 January 2016,
N
was admitted to
Northampton
General Hospital and was diagnosed as suffering with bronchiolitis. The following day, the
mother
telephoned the
nursery
nurse,
L and told her that
N
was in hospital and had bacterial pneumonia: this was
not
true.
- On 7 January 2016,
N
had been discharged from hospital and was seen at home by the
nursery
nurse.
The
mother
told her that she was concerned that
N
would be admitted to hospital again and was angry about the
medical
staff in the hospital and the way she had been treated.
- On 28 January 2016, the
mother
had taken
N
to his general practitioner because she was worried that he could have sepsis after she had seen a programme on television. The GP reassured the
mother
there was
no
factual basis for fearing that
N
might
have sepsis.
- In the early hours of 31 January 2016, the
mother
had taken
N
to
Milton
Keynes Accident and Emergency Department because he had been, 'unwell for
months'.
N
appeared well to the clinician who examined him, and all observations were within
normal
limits. The
mother
said that she was concerned that
N
had an underlying immunosuppressive disorder. There was
no
objective basis for this concern. The opinion of the clinician was that it was 'far
more
likely that he had been exposed to recurrent infections with repeated attendance at
medical
centres'. The
medical
notes
ended with the entry, 'Have advised that for her own peace of
mind
she should attend the lobotomy and get the blood tests she requests. It was
not
necessary
to perform urgent bloods'.
- On 16 February 2016, there is the first reference to
N
being unresponsive and breath-holding. He was taken by ambulance to
Northampton
General Hospital. After being told by the triage
nurse
that the wait was likely to be three and a half hours, the
mother
left with
N
because she had an appointment with the consultant paediatrician the following day. At the out-patient's appointment on 17 February, the
mother
reported that
N
had had three episodes of
not
being responsive, lasting a few
minutes.
The episode previous
night
had caused her to phone for an ambulance. When the ambulance arrived,
N
was responsive and back to
normal.
The consultant advised that the unresponsive episodes
might
be related to reflux.
- The following day, the
mother
telephoned the
nursery
nurse
and said she was
not
really happy with the paediatrician that
N
had seen the day before. She said the paediatrician felt that
N
may
be having epileptic seizures and that is why he struggled to breathe and goes blue. The paediatrician did
not
record in his
notes
that
N
may
be having epileptic seizures,
nor
that
N
struggled to breathe
nor
that he had gone blue. The
mother
is
not
recorded as having reported any of the above to the treating paediatrician on 18 February 2016. Cyanosis had
never
been
mentioned
before in
N's
medical
notes.
- On 14
March
2016,
N
was seen at
Northampton
General Hospital Accident and Emergency Department in the
morning.
The
mother
said she had switched care to
Milton
Keynes General Hospital because she was
not
happy with
Northampton
General Hospital. She said she had epilepsy and was seeing a specialist who told her the child was likely to get epilepsy at six to 12
months.
There was
no
clinical
note
of any such advice ever having been given. She then described for the first time of
N
allegedly suffering a chronic seizure, which lasted about 20 to 30 seconds. On examination,
N
was found to be alert and orientated, the
mother
reported the seizures are exactly the same that she has.
- Later the same day, the
mother
reported that these absence episodes or going blank for a few seconds had been experienced by
N
twice a day since he was two
months
of age. These incidents at this frequency have
never
been recorded in
N's
medical
records prior to this date.
- In April 2016, the
mother
reported that the
maternal
grandmother had witnessed a few vacant episodes with
N.
The
maternal
grandmother denied any such events occurred. By June 2016, the
mother
was reporting that
N
was having three to four vacant episodes a day. Dr H explained to the
mother
that these episodes were
not
suggestive of epilepsy as they lasted a very short period and are
not
associated with postictal periods. Therefore, it
may
be
normal
movement
and does
not
suggest any significant condition.
- As I have
mentioned
above, Dr H discharged
N
back to the care of his general practitioner on 14 December 2016 because all was well with
N,
save the
mother
asserted he was a fussy eater and therefore, Dr H
made
a referral to a dietician which the
mother
did
not
keep.
- On 27
March
2017, the
mother
telephoned 111, the call recorded the
mother
saying
N
had been having seizures since he was six
months
old and she felt they are getting worse. She allegedly told the call handler that she was a
nurse.
- In April 2017, the
mother
told Dr R that
N
had been having seizures, going stiff or going limb on five or six occasions per week for the last year. This is in complete contrast to the account given to and the examination undertaken by Dr H in December 2016.
- We then have the events of 3
May
during the 24-hour EEG and video telemetry which I have dealt with above.
N
was then removed from his
mother's
care, placed for a short time in foster care and then placed with his
maternal
grandparents where he remains to date. The events of 3
May
2017 confirmed the treating clinician's growing concerns that this
mother
was exaggerating and fabricating symptoms in
N.
Their very real concern for
N
was that the
mother
would quickly
move
to the
next
stage of FII and would induce symptoms in
N.
Findings of Fact
- On the totality of the evidence, the expert witnesses, the treating clinicians, the healthcare professionals and the
mother,
I am in
no
doubt at all that this
mother
deliberately and consciously exaggerated and fabricated symptoms in
N.
For the avoidance of any doubt, the evidence in support of this finding is so overwhelming that I am satisfied to the criminal standard of proof and so
make
the finding. I am satisfied on the balance of probabilities that if the clinicians and Local Authority had
not
intervened and removed
N
from the care of the
mother,
it is likely that she would have progressed in short order to induce symptoms in
N.
- I
make
this finding principally on the basis of the
mother's
actions on 3
May
2017, when she alleged he had suffered three seizures when, in fact, he was at all
material
times a still and sleepy baby.
My
conclusion is reinforced by the
mother
maintaining
her account in her oral evidence against the overwhelming weight of the evidence and by giving a contradictory account to that which she gave to the
nursing
staff on 3
May
and as was captured on the video recording.
- I am wholly satisfied to the extent that I am sure, that I should
make
the other ancillary findings sought by the Local Authority set out in the schedule which
may
be summarised as follows:
(a) the
mother
exposed
N
to unnecessary
medical
treatment and procedures;
(b) she has fabricated and exaggerated
medical
symptoms in
N;
(c) she has asserted repeatedly and contrary to the unanimous
medical
opinion that
N
suffered seizures;
(d) she has an admitted history of violent and abusive relationships;
(e) she has an admitted diagnosis of
non-epileptic
attack disorder;
(f) she has been diagnosed with suffering from over-valued ideas; and,
(g) she has repeatedly demonstrated volatile behaviour.
Welfare Best Interests of
N
- There are two placement options for
N.
The
mother
sought his return to her care. The Local Authority and the Children's Guardian opposed a rehabilitation to the
mother.
The Local Authority, supported by the Guardian, contended that
N's
long-term welfare interests will best be
met
by him remaining placed with his
maternal
grandparents' subject to a special guardianship order. The latter is
necessary
to enable the
maternal
grandparents to exercise their parental responsibility for
N
without undue influence from or involvement of the
mother.
It is submitted that it would be contrary to
N's
welfare for the
maternal
grandparents simply to share parental responsibility with the
mother.
- In the event this court decides that
N
should
not
be re-habituated to the care of his
mother,
she supported a placement with the
maternal
grandparents but subject to a child arrangements order and
not
a special guardianship order.
- I accept the opinions of Dr Campbell that (i) this
mother
was
not
at a stage where any possible treatment of her over-valued ideas would have any prospect of success and (ii) there is, in any event,
no
recognised treatment for this condition in which it is immensely difficult to effect any
meaningful
and lasting change in an individual suffering from over-valued ideas.
- Accordingly, there is a very real risk, if
not
a likelihood, that if
N
were to be rehabilitated to the care of his
mother,
he would be subjected to the same style of parenting as he was before his removal to foster care. On the totality of the evidence, I am satisfied on the balance of probabilities that the
mother
would fabricate and/or exaggerate symptoms in
N
and present him for repeated and frequent appointments for examinations by healthcare professionals and, worse still, would start to induce symptoms in
N.
- I am satisfied that such behaviour would cause
N
to suffer physical, emotional and psychological harm. He would be at real risk of:
(a) suffering unnecessary painful and/or distressing
medical
assessments and procedures;
(b) with frequent presentation as to GP surgeries and hospitals where he would be exposed to a wholly unnecessary risk of acquiring illnesses and infections;
(c) would suffer unnecessary disruption to his school and daily life and routines; and
(d) a risk of him coming to believe that he does suffer from epilepsy and/or a range of other
medical
conditions when he is, in fact, a perfectly
normal
and healthy child.
- N has settled extremely well with his
maternal
grandparents. He is very happy and very secure with and attached to his grandparents. He has
not
suffered any untoward or unusual illnesses in their care. If he is rehabilitated to the care of his
mother,
he will suffer harm from being removed from his
maternal
grandparents and he will be at very real risk of being caused physical, emotional and psychological harm by his
mother
in her care.
- The only proportionate course for this court to adopt in the welfare best interest of
N
is to secure his continued long-term placement with his
maternal
grandparents. Given the findings of fact I have
made
and
my
findings of the risks to which
N
would be exposed if he was rehabilitated to the care of his
mother,
I am in
no
doubt that it would be wholly inimical to his welfare if his carers, the
maternal
grandparents, simply shared parental responsibility with his
mother.
They
need
to have the upper hand and to be able to
make
all decisions about his future life without any
need
to consult with or be influenced by or involved with the
making
of decisions with the
mother.
This is the only appropriate order in
N's
welfare.
- Therefore, in
N's
welfare best interest, I do
not
make
a child arrangements order but I do
make
a special guardianship order in favour of the grandparents.
- The Local Authority had originally considered fortnightly contact with the
mother
would be in
N's
best interest. Having taken account of the Guardian's views, the Local Authority amended its plan to one of
monthly
contact. I agree.
- The paramount
need
is to permit
N
to remain settled and secure in his
maternal
grandparents' long-term care and to accommodate his and their daily commitments, both in terms of family and the grandparent's working lives. This paramount
need
leads
me
to conclude that contact once per
month,
with additional contact in the school holidays as determined by the
maternal
grandparents, will
meet
his welfare interests to
maintain
a relationship with his
mother.
This contact
must,
at all times, be supervised. I emphasise the word, 'all'.
- More frequent contact
may
meet
the
mother's
needs
but
not
N's.
A very clear
message
must
be sent to and received by this
mother
about the very limited role she
now
has and
must
play in her son's life.
Conclusions
- For the reasons I have given, I
make
the findings of fact set out above. I am entirely satisfied that it is in
N's
welfare best interest that I
make
a special guardianship order in favour of his
maternal
grandparents. I wholly accept the advice of the social worker and the advice of the Guardian that in
N's
interest, the
mother's
contact should be limited to once per
month
and shall be supervised by the
maternal
grandparents, and that there
may
be such additional school holiday contact as they
may
agree.
- I would wish to offer
my
grateful thanks to counsel for the very helpful and economic
manner in which this case has been conducted.
End of Judgment
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