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England and Wales Family Court Decisions (other Judges)
You are here: BAILII >> Databases >> England and Wales Family Court Decisions (other Judges) >> B (Application for leave to withdraw care proceedings)  EWFC B25 (28 March 2019)
Cite as:  EWFC B25
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B e f o r e :
|WEST SUSSEX COUNTY COUNCIL
291-299 Borough High Street, London SE1 1JG
Tel: 020 7269 0370
This transcript has been approved by the judge.
MS BHARI appeared on behalf of the First Respondent, M, instructed by Woolens Solicitors
MS EARLEY appeared on behalf of the Second Respondent, F, instructed by Helen Fitzsimons Family Law
MR AMIN of Bosley & Co appeared on behalf of the children C, D, E and F through their Children's Guardian Theresa Seale.
Crown Copyright ©
'In summary, therefore, I consider this to be a difficult case. It involves a very transient encephalopathy following a fall that was not witnessed by an adult, the details of which are not clear in the documentation.
No neurological sequelae resulted from this event but investigation identified some features that are associated with non-accidental, inflicted shaking injuries but also a number of vulnerabilities in terms of a deficient blood clotting factor and a mild change in the subarachnoid spaces.
It would therefore be a case that would be worthy of multidisciplinary discussion involving paediatricians, paediatric haematologists and paediatric neuroradiologists'.
'Against the background of apparent good health, C was involved in an event which was not witnessed by an adult that as speculated involved him being dropped a short distance, following which he had an acute short-lived change in his neurological behaviour which had resolved by the time the emergency services attended. In hospital he remained clinically well, the only abnormality being a head circumference at the upper limit of normal which had increased from the 75th centile to the 99th centile since birth. Specialist neuroradiological investigation found fresh blood over both cerebral hemispheres along with fluid which may represent either a chronic subdural haematoma or acute traumatic effusion and some spinal subdural blood. A mild deficiency of clotting factor VII has been identified along with low vitamin D levels'.
'This is a slightly complex case. There is documentation of an injury, although not witnessed by an adult, in which it is speculated that there was a low level fall with C possibly being grabbed during it by a 12-year-old. There is no clinical or radiological evidence of impact from this event. Following this event, there was, as described by Mother, a very short episode where he was described as unconscious, which had recovered almost completely by the time the emergency services attended and was recovered completely on arrival in hospital and remained that way. This could be a short-lived episode of encephalopathy, encephalopathy being the general term describing impaired neurological function. Whether this was a seizure or not cannot be determined on the basis of the documentation but whatever it is, it was short-term with rapid recovery'.
'On the basis of the neuroradiological investigations, the possibility of non-accidental inflicted injury has been considered. There was fresh subdural blood radiologically, fluid which may represent chronic subdural haematoma or acute traumatic effusion and spinal subdural blood. These are all radiological features associated with non-accidental inflicted head injury, particularly of this shape and variety, and they are generally thought not to occur as a result of low level falls, which is current radiological mainstream opinion. I have no disagreement with this view and would agree that in those infants whom are imaged following low level falls the presence of fresh subdural blood, fluid which may represent chronic subdural haematoma or acute traumatic effusion and spinal subdural blood is rare, whereas it is more common in infants who have been subject to non-accidental inflicted head injuries of this shape and type. However, it has to be appreciated that the majority of infants who suffer low level falls never get imaged because they were clinically well. From a neurosurgical perspective, in those infants who are imaged the findings in this case are unusual for a low level fall, we don't know whether these findings are more common in infants who appear well following a low level fall. It used to be said that birth never caused subdural bleeding except in rare catastrophic cases, but research projects which imaged well infants after birth identified that subdural bleeding was much more common than believed. I have no idea whether this would apply to low level falls if similar research projects were carried out. On current technology, because of the need for sedation or general anaesthetic, such research project is unlikely to be carried out. I as a neurosurgeon therefore I'm not sure whether low level falls cannot cause the changes identified in C for I have no data that allows me to say that these changes can be caused by a low level fall'.
'Ophthalmic investigations and skeletal survey have identified no other features associated with non-accidental inflicted head injuries'.
'The question of whether there is a pre-existing chronic subdural haematoma or not is unclear. The head circumference did grow from the 75th to 99th centile a feature which is associated with chronic subdural haematomas but he also has prominent subarachnoid spaces frontally which is also feature associated with a degree of excess head growth. The sutures which normally separate excessively if there is abnormal enlargement of the head for whatever reason (e.g. tumour, hydrocephalus, benign enlargement of the subarachnoid space, chronic subdural haematoma) are not separated. There is therefore no clear reason apparent for the head circumference change which still remains within normal limits and it should be monitored to see how it progresses.
'If the fluid that was in the subdural space that was not fresh blood was chronic subdural haematoma rather than acute traumatic effusion then it is known to be associated with fresh subdural bleeding following minor trauma or even spontaneously. Therefore the speculative fall might explain the fresh subdural bleeding identified. However, it would not explain the subdural blood seen in the spinal canal and, given that there was no blood seen within the third intracranial compartment, which any blood moving from the cerebral hemispheres through to the spinal canal will have to pass through, it would suggest that the subdural blood identified originated in the spinal canal rather than migrated there'.
'If the fluid in the subdural space that is not fresh blood is chronic subdural haematoma the question has to be considered as to why it was there. To have a chronic subdural bleed it has to start with fresh subdural blood. There are a number of medical causes for fresh subdural bleeding but if they are eliminated then a traumatic cause is what remains. Traumatic causes are known to include birth although as yet no birth fresh subdural bleeds have been identified as progressing to chronic subdural bleeds, accidental trauma and non-accidental shaken trauma. Community-based studies will indicate that non-accidental inflicted shaking injuries are the commonest cause of chronic subdural haematomas but the same community-based studies have identified a cohort of between 9-15% depending on how the statistics are viewed as unknown'.
'The above comments relate to children where there are no potential vulnerabilities leading to fresh subdural bleeding from events where fresh subdural bleeding would not be expected. In this case, it has been identified that there is a mild factor VII deficiency. I would defer to a general paediatrician or paediatric haematologist on the significance of this both as a primary cause of chronic subdural haematoma or re bleeding from trauma that would not normally cause subdural bleeding. I also note that the subarachnoid spaces frontally are prominent, although not excessively so, and given that the head circumference remained within the normal limits, this would not qualify from a neurosurgical perspective as a condition known as benign enlargement of the subarachnoid space (BES), which is a larger than normal head in a well child where the subarachnoid spaces are larger than normal on imaging. This condition, usually resolves spontaneously without long-term effect by the age of two. BES is believed, although not proven, to allow subdural bleeding to occur in circumstances where subdural may not be expected if there was no BES. However it has to be accepted that there will be a close line between what is considered to be upper limit of normality in terms of the size of the subarachnoid space and lower level BES and it is unknown what influence such a situation may have on the force required to cause subdural bleeding. This may, or may not be such a situation. I do not know'.
'This report will show that in my professional opinion C was at increased risk of subdural bleeding because of enlargement of the subarachnoid space, which was probably more pronounced prior to the head trauma than found on newer imaging after the event. I think that the subdural bleeding and the acute traumatic effusions were most likely caused by the fall as described. I think that C also probably had rickets but this did not increase the risk of the intracranial and spinal bleeding'.
'1) The factors increasing the vulnerability to the intracranial bleeding would have been present earlier and so rendered C at increased risk if earlier subdural bleeding.
2) I think it most likely that C sustained the injuries during a single event. In other words, I think it unlikely that there was an earlier (older) intracranial bleed'.
'The spinal subdural blood was found on the MR scan done on 24 August 2018. There were no other features of spinal injury. It is quite common to find spinal subdural blood after effusive head trauma, yet my experience of the three cases detailed above causes me to think it is not diagnostic of abuse. I am aware that some neuropathologists hypothesise (other potential mechanisms are also hypotheses) that subdural bleeding in such cases is the result of hyperflexion /hyperextension of the neck putting a traction force along the spinal course but then I defer to Mr Richards as to whether he feels this is plausible'.
'I think an experts' meeting is required only if Mr Richards disagrees or has significant doubts about the factors I identified in my report as increasing the vulnerability of C to an injury caused by a purported accident. I will be content if there was no experts' meeting'.
'I commented that in clinical practice this would be a case worthy of discussion to form a consensus as to what happened. If the court is happy that the consensus has emerged from the individual reports that is sufficient to assist the decision-making process then a meeting would not be required'.
'F is obviously delighted that the Local Authority seek to withdraw these proceedings and that the family can be reunited. The court is aware from the previous hearings of the distress caused to the parents and the children of the enforced separation since August of last year'.
'The family have always maintained that C was not the victim of abusive or neglectful parenting and his injuries were caused by an unfortunate accident when he was dropped by his sister. The expert reports of Dr Cartlidge and Dr Richards indicate the parents' position'.
'There are important lessons to be learnt from this case from a safeguarding, medical and medicolegal perspective and therefore the court is asked to deliver an anonymised judgment that can be published on BAILII and shared with professionals. It is crucial for this family that the parents are clearly exonerated and all medical professionals proceed on the basis that C's injuries were the result of an accident. In addition, the father seeks the experts' reports to be disclosed to C's treating medics'.
'Professionals should explore whether children can be safeguarded in their home – it was the case of the Local Authority and the guardian that all four children should be removed from the home and placed, separately in foster care. Had the court approved this plan the consequences for the children would have been emotionally traumatic and would have resulted in a wholly unwarranted six months' separation for these children'.
'It is imperative that treating medical professionals understand the need to swiftly disclose all material when there are ongoing court proceedings. Dr Landes of Alder Hay Hospital wrote to Dr Katta (lead paediatrician for C at East Surrey Hospital) on 7 September 2018 providing details of a radiological analysis and there is evidence of rickets shown on C's skeletal survey. This was flagged by Dr Cartlidge as a potential issue, in light of C's low vitamin D levels, on 9 January. Dr Landes' analysis only came to light as a result of a court order on 7 January requiring the Alder Hay Children's Hospital and St George's Hospital access to records teams to provide al medical records relating to C. However, disclosure of it had been made against East Surrey Hospital on 9 October yet Dr Landes' report was not included in their disclosure. Although the fact that C has rickets was not ultimately linked by Dr Cartlidge to a subdural bleed, early knowledge of this fact would have put the parties on notice that there was cogent evidence C had an organic condition that may well explain his injuries (rickets of course being linked to low level vitamin D which can be linked to subdural bleeding LB of Islington and Al Alas and Wray  EWHC 865 (Fam)'.
'It is imperative when treating medical professionals have made a diagnosis of non-accidental injury that they keep this under review and update this diagnosis when new medical evidence is received and give active consideration to convene a multidisciplinary meeting. Dr Katta's letter of 31 August opined that C's low level vitamin D and calcium were "an unrelated issue". It seems that neither Dr Katta or his colleagues revisited his opinion on their view that non-accidental injury was 'highly likely'.
'Had the Local Authority and the court been relying solely on the treating medics the outcome of this case would be vastly different and a travesty of justice. In his January "view" the President spoke of the current difficulty locating paediatric experts to report in cases such as C. This case highlights how imperative it is that the parties and the court can have timely access to experienced experts who can provide an independent analysis'.
'The publication of research papers on the incidence of birth-related subdural haemorrhage fundamentally altered the understanding as the incidence of intracranial bleeding in babies. Subdural haemorrhages were considered rare in normal deliveries. Medical research and medicolegal cases have shown that in fact they are common in babies after all types of delivery. Similarly, it had long been mainstream medical opinion that low level falls do not result in extensive subdural bleeding (see paragraph 40 of Re N (A Child: Low level falls)  EWFC B29 for Dr Richards' summary of the debate on this issue. Dr Cartlidge sets out at page 20 of his report, three medicolegal cases where similar injuries were sustained in these circumstances; not all of these are reported. It is important for all those involved in child protection that the details of C's case are anonymously available to be added to that list and properly inform future diagnoses made by treating medics, experts and ultimately conclusions drawn by the family court'.
'Dr Cartlidge's report is dated 23 January; he reported earlier as he was acutely aware that his expert opinion was at variance with the treating doctors. Upon receipt of his report and that of Dr Richards, those representing the parents urged the Local Authority to view the arrangements and allow C and his mother to return home under the ICO until the matter could be returned to court. It was pointed out to the Local Authority that they share PR with the parents and are able to make this decision and to maintain the enforced separation of the family in the absence of safeguarding reasons was an unjustifiable interference with their right to family life. The Local Authority refused to permit the mother and C to return home, wrongly stating that they cannot do so until the court has approved such a plan'.