|[Home] [Databases] [World Law] [Multidatabase Search] [Help] [Feedback]|
England and Wales High Court (Family Division) Decisions
You are here: BAILII >> Databases >> England and Wales High Court (Family Division) Decisions >> Bristol City Council v A Mother & Ors  EWHC 1367 (Fam) (11 April 2014)
Cite as:  EWHC 1367 (Fam)
[New search] [Context] [View without highlighting] [Printable RTF version] [Help]
Strand, London, WC2A 2LL
B e f o r e :
| IN THE MATTER OF THE CHILDREN ACT 1989 AND IN THE MATTER OF AB (A MINOR) BRISTOL CITY COUNCIL
|- and -
|A MOTHER (1)
A FATHER (2)
A MATERNAL GRANDMOTHER (3)
AB (by his children's guardian) (4)
Nkumbe Ekaney QC and Tabby Macfarlane (instructed by Kelcey and Hall) for the Mother
Robin Tolson QC and Elizabeth Harris (instructed by Fosters and Partners) for the Father
Claire Wills-Goldingham QC and James Cranfield (instructed by Bobbets Mackan) for the Maternal Grandmother
Stephen Roberts (instructed by Kirby Sheppard) for AB, by his children's guardian
Hearing dates: 10 - 21 March 2014
Crown Copyright ©
The Honourable Mr. Justice Baker :
"Based on the information available to us, we are of the opinion that there are some very concerning features in this case which raise the suspicion of a mechanical head injury with evidence of a previous episode of hitherto unexplained rib fracturing, albeit the latter having occurred during hospitalisation. However, the background medical history of this child is extremely complex. S suffered a number of episodes of apnoea and desaturation during her time in hospital and, whilst these required less intervention as time progressed, it would appear that these continued in the days leading up to her discharge from hospital. It is therefore very difficult to determine the exact causation of the death with any degree of certainty. We therefore believe that the cause of death should be considered unascertained."
The cause of death was therefore described as: "sudden unexplained death in an infant showing some features that raised concerns of mechanical head injury but on a background of a poorly understood genetic abnormality and its medical complications." The police, having considered this report and interviewed the parents, concluded that there was a collection of injuries and medical conditions that were of concern but could not be conclusively put down as inflicted. It was noted that the parents' accounts were consistent and gave no scope for challenge. The case was not referred to the Crown Prosecution Service.
"In a case where the medical evidence is to the effect that the likely cause is non-accidental and thus human agency, a court can reach a finding on the totality of the evidence either (a) that on the balance of probability an injury has a natural cause, or is not a non-accidental injury, or (b) that a local authority has not established the existence of the threshold to the civil standard of proof The other side of the coin is that in a case where the medical evidence is that there is nothing diagnostic of a non-accidental injury or human agency and the clinical observations of the child, although consistent with non-accidental injury or human agency, are the type asserted is more usually associated with accidental injury or infection, a court can reach a finding on the totality of the evidence that, on the balance of probability there has been a non-accidental injury or human agency as asserted and the threshold is established."
i) A group of injuries which appeared to be about 2-3 days old at the time of death;
ii) A group of fractures which appeared to be around a week old at the time of death and;
iii) A group of injuries each of which was definitely more than two weeks of age and maybe some weeks older than that.
Each group involved both posterior and anterior fractures. Dr James advised, however, that the way in which the ribs showing similar appearances were grouped together tended to corroborate a single event causing each of the individual groups. He could not see any evidence of abnormal bone structure such as a metabolic bone disease or bone fragility syndrome or nutritional deficiency. He concluded in his report that there had been at least three episodes of significant chest compression, one during the hospital admission but two after her discharge.
"It is not possible to determine with certainty the clinical impact of these malformations but in my opinion these are significant abnormalities and represent anatomical manifestations of a substantial disturbance of normal brain development and may well be the morphological correlate of neurological problems."
i) that this was not a head injury at all and the doctors have been fooled;
ii) that S was abnormally fragile and therefore suffered the head injury in circumstances where such injury would not be expected;
iii) that an event occurred which, because of their mental capacity at the time, carers did not appreciate would constitute a significant head injury or
iv) that a carer or carers are aware of an event likely to have caused significant head injury but for some reason have chosen not to inform medical investigators.
In this case, given S's complex medical and genetic history, Mr Richards advised that the first and second possible explanations were worthy of some consideration. He noted that S had suffered a number of collapses whilst in hospital but added that these were of an order of magnitude significantly less than her final collapse so that it was therefore unlikely that the fatal event was the result of the same pathology. Given the fact that she had a number of microscopic structural abnormalities within the brain and her brain was not growing normally, the possibility of an unknown fragility as the cause of her neurological symptoms could not be excluded. Mr Richards raised the possibility that, in the panic following her collapse, S may have been shaken excessively as part of a resuscitation process, or that she had been put forcibly onto the floor without adequate support in a panic. He observed that the degree of force required to cause such injuries had not been scientifically measured, although clinical medicine indicated that it requires forces greater than those encountered in every day life or rough play. Cross-examined by Mr Ekaney QC on behalf of the mother, Mr Richards agreed that the subdural haemorrhages in this case were thin film and low volume. He accepted that a number of factors associated with a greater degree of force in non-accidental head injury were not present in this case factors such as tears, intra ventricular haemorrhages, mid-line shifts, global hypoxic ischaemic damage or damage to the nerve and root ends of the spine. He agreed that, as S was an extremely small baby, below the 0.4 centile, common sense suggested that less force would be required to cause the neurological injuries seen in this case. He agreed with Miss Wills-Goldingham QC on behalf of the grandmother that S was a very frail baby. He agreed with Mr Tolson that in this case a force not very much out of the ordinary could have caused these injuries.
"An area of diffuse light swelling measuring approximately 3 cm in maximum diameter in the right parietal region centred 5 cm above the right ear. There was possible faint discolouration of the skin surface but the area was more easily detected on pulpation rather than visually. This overlay a haematoma in the scalp that measured 2 cm by 1.5 cm. There was no associated skull fracture. "
"S was noted to have an area of bruising to the scalp over the right side of the head. This indicates an injury to the area. Microscopic examination of the bruise showed some iron staining which raises the possibility that this occurred a few days prior to death. It is known that scalp electrodes were used in the process of cerebral function monitoring whilst in hospital but this was over a month prior to her death. We are not aware of any other medical explanation for the scalp bruise. Whilst the bruise appears relatively recent and more in keeping with having occurred after discharge from hospital, it is well recognised that the dating of bruises is not an exact science."
Medical Evidence: Further Discussion
THE EVIDENCE OF FAMILY MEMBERS
"History from parents. This evening: on mum's lap awake. Made retching noise. Dad picked her up and tilted her up as if to vomit but she didn't. Then felt floppy/relaxed. Took one deep breath. Over about four minutes trying to position and stimulate her. Put her on floor. Gave mouth to mouth and cardiac massage, while mum called ambulance."
"Repeated history; [the mother] said she picked her up off mat, woke up handed her to dad and went out for a fag. Didn't notice a retching noise then (mentioned other day that she made these retching noises) Dad held her for a few minutes. Then made gulping noise after (the mother) came back in. Dad had her upright, leaning onto his right hand to tap back with left. Went floppy plus arm out (relaxed position) breathing very weak, normal colour put her on floor to start CPR and called ambulance."
Later, the note continued: "Retching noise heard before but with vomiting, this time didn't vomit. Last feed 8 pm (next due 11pm)."
FURTHER DISCUSSION AND CONCLUSION