Surrey County Council v B & Ors (Non – Accidental Injuries)

1. The Court is concerned with a baby boy, Z who is the subject of public law proceedings brought by the Local Authority, Surrey County Council (LA). Z was born on a date in early 2024 so is now 15 months old. His mother is B and his father is C. Father likes to be known as a variation of his first name, C. He has parental responsibility for Z by virtue of being on his birth certificate. I will refer to the parents as mother and father. I mean no disrespect in doing so. Z is represented in these proceedings by his Guardian who is Liz Vicary.

2. The other significant individuals for Z are his relative, D (D) with whom he is living and his maternal grandmother, E (MGM).

3. I am very grateful to all parties and their representatives for managing these very difficult proceedings with dignity and sensitivity. The legal representatives have been of great assistance. They are Ms Jessica Lee for the LA; Mr Martin Kingerley KC leading Ms Kate Claxton for mother; Mr Sam Momtaz KC leading Mr Haroon Rana for father and Ms Sarah Nuttall for the Guardian. Application and Issues Before the Court Local Authority

4. The LA issued an application for a Care Order on 19 th March 2024 and an interim care order was granted on 22 nd March. The LA seeks findings with regard to injuries that Z sustained while in the care of his parents. This is not a single issue case. The LA threshold sets out concerns about the parents’ ability to care for Z that go beyond the injuries he has suffered.

5. The LA final care plan is for Z to live with D under the auspices of a final Care Order. The LA will support D to apply for a Special Guardianship Order (SGO) in due course if she wishes to. Following inquiries made during the hearing D was clear that she wished for there to be a Care Order. The revised contact plan for the parents follows the Children’s Guardian’s recommendations set out below and was confirmed in an e mail dated 3 rd April 2025. Mother

6. Mother denies causing or having any knowledge of how or when Z suffered injury. However, in light of the other matters pleaded in threshold, she does not contest that threshold is crossed nor the LA care plan. She does not seek to have Z back in her care, acknowledging the very good care that he will receive from D. She is content with the proposal for fortnightly contact and hopes that it can move from being professionally supervised by the LA to being supervised by D in due course. Father

7. Father also denies causing any injury to Z. Since the parents have now separated, he would prefer that Z lives with him. He acknowledges that mother does not seek Z’s return to her care. If Z cannot live with him then he accepts that the best place for Z is with D. However, he would prefer that to be under an SGO but accepts that at present D seeks a Care Order.

8. Father would like as much contact as possible, preferably weekly. He seeks a s34 order for contact in circumstances where that level of contact is not supported by the LA. It can be supervised by D. Weekly contact for father is supported by D which she says she can support. Children’s Guardian

9. The Children’s Guardian proposed a number of changes to the LA care plan which by the end of the hearing the LA adopted. These were: (i) Contact between Z and his parents to be fortnightly (ii) Contact between Z and his father to be supervised by D (iii) If D wishes to facilitate contact with father once per week, the LA supports D’s decision – making (iv) Contact between Z and mother will be professionally supervised for the time being (v) Mother’s contact to be kept under review within the CLA review process (vi) Video contact to continue to take place as arranged and agreed with D

10. The LA adopted these amendments and, in those circumstances, the Guardian supported the amended Care Plan. However, the Guardian would like there to be a summary in the Care Plan of how professionals should work with these vulnerable young parents including assisting them with further parenting work to help them develop their parenting skills. The parents will also need to work with the LA to enhance those skills. The Issues before the Court

11. As a consequence of the positions taken by the parents and D the issues are narrowed. First the court must consider whether any of the injuries suffered by Z are non – accidental in nature and if they are whether a perpetrator or perpetrators can be identified. Secondly, the court must consider whether either or both parents failed to protect Z. Finally, as part of the welfare consideration the court needs to consider the LA care plan including whether Z can be returned to father’s care. Evidence

12. I have a full trial bundle including a bundle of mobile phone records and police video disclosure. I heard evidence from a number of medical experts, Dr Oates; Dr Saggar, Mr Jalloh, Dr Allemaddine and Dr Cleghorn. I also heard from treating medical professionals, Dr Jafri, together with midwives, Ms Louise Jenner, Ms Surushpadi Ignace and Ms Ana Garrido. For the LA I heard oral evidence from social worker, Mr Bishnu Pokharel. In addition, I heard from mother and father, the MGM and D and finally the Children’s Guardian. The Law

13. I can do no better than to quote the summary of the law in Re JS [2012] EWHC 1370 (fam) in which Baker J set out the factors to be considered as follows: “In determining the issues at this fact finding hearing I apply the following principles. First, the burden of proof lies with the local authority. It is the local authority that brings these proceedings and identifies the findings they invite the court to make. Therefore, the burden of proving the allegations rests with them. Secondly, the standard of proof is the balance of probabilities ( Re B [2008] UKHL 35 ). If the local authority proves on the balance of probabilities that J has sustained non-accidental injuries inflicted by one of his parents, this court will treat that fact as established and all future decisions concerning his future will be based on that finding. Equally, if the local authority fails to prove that J was injured by one of his parents, the court will disregard the allegation completely. As Lord Hoffmann observed in Re B : "If a legal rule requires the facts to be proved (a 'fact in issue') a judge must decide whether or not it happened. There is no room for a finding that it might have happened. The law operates a binary system in which the only values are 0 and 1." Third, findings of fact in these cases must be based on evidence. As Munby LJ, as he then was, observed in Re A (A Child) (Fact-finding hearing: Speculation) [2011] EWCA Civ 12 : "It is an elementary proposition that findings of fact must be based on evidence, including inferences that can properly be drawn from the evidence and not on suspicion or speculation." Fourthly, when considering cases of suspected child abuse the court must take into account all the evidence and furthermore consider each piece of evidence in the context of all the other evidence. As Dame Elizabeth Butler-Sloss P observed in Re T [2004] EWCA Civ 558 , [2004] 2 FLR 838 at 33: "Evidence cannot be evaluated and assessed in separate compartments. A judge in these difficult cases must have regard to the relevance of each piece of evidence to other evidence and to exercise an overview of the totality of the evidence in order to come to the conclusion whether the case put forward by the local authority has been made out to the appropriate standard of proof." Seventh, the evidence of the parents and any other carers is of the utmost importance. It is essential that the court forms a clear assessment of their credibility and reliability. They must have the fullest opportunity to take part in the hearing and the court is likely to place considerable weight on the evidence and the impression it forms of them (see Re W and another (Non-accidental injury) [2003] FCR 346). Eighth, it is common for witnesses in these cases to tell lies in the course of the investigation and the hearing. The court must be careful to bear in mind that a witness may lie for many reasons, such as shame, misplaced loyalty, panic, fear and distress, and the fact that a witness has lied about some matters does not mean that he or she has lied about everything (see R v Lucas [1981] QB 720 ). Ninth, as observed by Hedley J in Re R (Care Proceedings: Causation) [2011] EWHC 1715 Fam : "There has to be factored into every case which concerns a disputed aetiology giving rise to significant harm a consideration as to whether the cause is unknown. That affects neither the burden nor the standard of proof. It is simply a factor to be taken into account in deciding whether the causation advanced by the one shouldering the burden of proof is established on the balance of probabilities." The court must resist the temptation identified by the Court of Appeal in R v Henderson and Others [2010] EWCA Crim 1219 to believe that it is always possible to identify the cause of injury to the child.”

14. In addition, the court must consider the role of expert evidence and must consider it along with the other evidence before the Court. In BR (Proof of Facts), Re Peter Jackson J (as he then was) stated: [2015] EWFC 41 “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.

10. Lastly, where there is a genuine dispute about the origin of a medical finding, the court should not assume that it is always possible to know the answer. It should give due consideration to the possibility that the cause is unknown or that the doctors have missed something or that the medical finding is the result of a condition that has not yet been discovered. These possibilities must be held in mind to whatever extent is appropriate in the individual case” Findings Sought – Schedule of Allegations - Injuries

15. At the conclusion of the evidence, the LA refined its schedule of findings. The injuries in respect of which it seeks findings are as follows: (i) Bruise on left forehead/temple 2 x 1cm (ii) Bruise on left cheek 2cm (iii) Bruise on right cheek 1cm (iv) Fracture to the lateral aspect of the left clavicle (v) Small contusions in the left frontal lobe (vi) Subdural haemorrhage in the left frontal region (vii) Subarachnoid haemorrhage in the left parietal – occipital region

16. The LA conceded: (i) Fingertip bruising – no finding was sought; there was agreement among the experts that this was suffered while Z was in hospital (ii) Eyelid bruising – the LA position was that the Court may strain to make a finding in respect of the eyelids – this might be accounted for by Z’s propensity to bleed (mother’s case) or likely sustained while in hospital (father’s case). Background Mother

17. Mother is a young mother. She had a very difficult childhood which I will not set out here save to say that she was subject to care proceedings and at the age of six was adopted by the MGPs. She has been diagnosed with PTSD and therapy was recommended for her. In June 2017 she was placed in a specialist educational and residential home, as a social work assessment had concluded she was beyond parental control. In the previous proceedings, the then Guardian, Helen Ingledew reported that her parents had struggled with her while trying to provide her with good care. She considers them to be caring parents.

18. Mother is a regular user of cannabis which she acknowledges. She is undoubtedly a vulnerable adult given her experiences.

19. Dr Dowsett carried out a cognitive assessment within these proceedings. His report is dated 1 st May 2024. He did not consider that she had a general learning disability; instead, she has some significant processing issues and difficulty retaining information. He recommended that mother would benefit from an intermediary. Mother has been supported in the final hearing and in giving evidence by an intermediary and the Court and advocates have followed those recommendations. Father

20. Father is also a young and vulnerable parent. He has a history of mental health issues and also suffers from epilepsy. He was in foster care following serious behavioural incidents. The report from his GP identifies difficulties in foster care due to his behaviour including serious threats to self-harm and emergency psychiatric assessment when he was 11. In June 2012, he is referred to as having Autistic Spectrum Condition with attachment difficulties influenced by the loss of his father’s presence, poor self-esteem and frequent social upheaval. In 2019 he was identified as being a suicide risk and on 27 th July 2022 his record notes a paracetamol overdose. Recently (2023) an ambulance was called because he cut himself on the arms and neck. There was also involvement from the relevant Local Authority Children’s Services between 2012 and 2018.

21. Dr Dowsett conducted a cognitive assessment of father (report dated 1 st May 2024). Dr Dowsett did not diagnose a learning disability. However, he found that his presentation, and diagnosis of ASD and possible ADHD traits suggested that adaptions would need to be made by professionals working with him. His auditory working memory was poor and he would struggle with new people and places. Dr Dowsett recommended an intermediary. Father was not willing to engage with an Intermediary Assessment until late in the proceedings. However, a Communicourt assessment was commissioned and an intermediary obtained for the final hearing.

22. Both parents have found these proceedings very hard. Both have significant vulnerabilities which have made it difficult for them to engage with the professionals, for example with the parenting assessment with Ms Corinna Brown. However, both have been well served by their legal representatives and their intermediaries to whom thanks must be given by the Court. Father, in particular, has struggled with the proceedings and with events that have happened during the proceedings. His mental health has been very fragile. However, despite these difficulties both parents have done their very best to attend. Both found the courage to give evidence, and both have done their best for Z.

23. I propose that anyone working with either of the parents should have access to the Communicourt assessments and should adapt the recommendations to the work they are doing. Precipitating Events

24. Z was admitted to hospital on a date in March 2024. He was 15 days old. Ms Penny Russell, the health visitor who had visited the parents and child that day had noticed some bruising on his face and head, and she advised the parents to take him to a local Hospital. The parents acted on this advice and arrived at the local hospital at around 2.00pm. The triage nurse notes the bruises on his head and face and noted that the bruise on the right cheek had been noticed 2 days previously. Dr Jafri saw Z later at 5.40pm. He was then admitted onto the ward.

25. Following detailed investigations, the injuries which are the subject of this hearing were noted. These did NOT include the fingertip bruise. The hospital considered there was no reasonable explanation for the injuries and mother, father and MGM were arrested. Z remained well on the ward – feeding well and showing no neurological symptoms or pain. He was discharged into the care of D in March 2024.

26. The LA issued proceedings on 19 th March and an interim care order was made on 22 nd March. Expert Evidence

27. In considering the expert evidence, I have followed the route suggested by Mr Momtaz KC to look at the reports, then the experts’ meeting and Dr Cleghorn’s report and then to consider the oral evidence.

28. Mr Ibrahim Jalloh, Consultant Paediatric Neurosurgeon - provided one report to the Court dated 21 st June 2024. He also attended the experts’ meeting on 12 th February 2025. Mr Jalloh and Dr Oates provided their reports almost simultaneously and did not see the other’s report before filing their own.

29. Dr Jalloh says in his conclusions, “On balance, based on Z's asymptomatic clinical presentation and pattern of brain injury on scans with subdural, subarachnoid and parenchymal haemorrhage (contusions), non-accidental injury and birth-related injury are both plausible. If the other experts consider that his other injuries were inflicted and if the neuroradiology expert ages the brain injury to a time more recent than his birth, then non-accidental injury is the most likely cause.”

30. There is no issue with regard to the identification of the injuries themselves. Mr Jalloh looked at the possible causes as follows: (i) Birth related trauma – He does not discount a birth related trauma, saying, “4.18 In summary, given that Z was less than 2 weeks old at the time of initial scanning, asymptomatic with regards to a brain injury, and that the lesions found on his scans can all be found in asymptomatic newborns associated with the normal birthing process, birth-related trauma is a possible cause.” However, he modifies this, deferring to the neuroradiologist, but commenting on the density of the subdural blood which might mean the injury was more likely 10-11 days old. (ii) Accidental Injury - He discounts the explanation of Z hitting his head on a changing table, considering that the forces would be too small to cause a brain injury. (iii) Non – accidental injury – Mr Jalloh considers the pattern of subdural, subarachnoid and parenchymal haemorrhage (contusion) to be more consistent with an impact – type or crushing – type injury than an acceleration – deceleration type injury such as shaking. He considers that the bruising to the left parietal region of the head is consistent with the pattern of brain injury being caused by an episode of trauma caused by blunt impact or crushing force to the left side of the head.

31. Mr Jalloh is unable to comment specifically on the level of force required but it is likely to be greater than normal force in everyday life.

32. Z’s behaviour does not assist in timing the injury as he was asymptomatic when he attended hospital; there are no disclosures as to any change in his behaviour and no clinical information that would assist in determining a likely time for an episode of non-accidental injury.

33. Dr Adam Oates, Consultant Paediatric Neuro Radiologist – provided two reports, his first is dated 14 th June 2024 and his addendum is dated 3 rd July. He also attended the experts’ meeting and gave oral evidence.

34. Dr Oates provided his report without having seen any other expert evidence. He states, “In an infant less than 2 weeks old at presentation, the possibility of birth-related injuries has to be considered. However, and even allowing for the limitations of radiological dating, I believe it is unlikely that the injuries extend back to the time of birth.” Brain Injuries

35. Dr Oates found evidence of multiple small areas of haemorrhage within Z’s brain substance, most notably at the left superior frontal region, the left occipital lobe and the left inferior frontal lobe. At the second MRI scan on 26 th March 2024 the changes in the inferior frontal lobes and left superior frontal lobes had formed areas of cystic encephalomalacia (CE). This means that in those areas of the brain, the brain tissue is irreversibly damaged and replaced by fluid and scarring. Dr Oates considers these are most likely to be secondary to trauma.

36. Dr Oates considers that these types of injuries can never be thought of as a “normal finding ” and are not expected in a normal uncomplicated delivery. He considers that the intracranial injuries are most likely secondary to an inappropriate level of force. He suggests that in the absence of a skull fracture or soft tissue swelling to suggest a recent impact with a hard surface, a shaking injury should be considered. However, the injuries do not present as shaking injuries because there are no large volume subdural haemorrhages. Dr Oates cannot explain this but considers the “very immature brain being particularly susceptible to shearing brain injury” .

37. He also considers whether Z was not directly shaken but possibly dropped or thrown onto a relatively soft surface such as a bed. He makes clear that this is only a hypothesis to explain the “presence of the brain injury but the relative paucity of subdural haemorrhage” .

38. Dr Oates cannot be categorical about the dating of the injury. He says that “Dating of injury has to be considered an inexact science and given that Z was only [under two weeks old] at presentation (on 08/03/2024) it is particularly challenging. ” He considers that given the presence of high attenuation haemorrhage on the CT scans of 8 th March the bleeding is less than approximately 10 days old. He also considers that the MRI scan of 11 th March suggests that the injury was less than 10 days old. He concludes, “Collectively, cross referencing the CT and MRI scans, I believe it is most likely that the head injury was sustained within approximately 7 days of presentation on 08/03/2024. I should emphasise, given the limitations of radiological dating and that Z was only [under two weeks old] at presentation, I cannot state categorically that it did not occur going back to the time of birth, however I believe this is unlikely.” Clavicle Fracture

39. Dr Oates identifies two possible causes for the clavicle fracture: (i) A direct blow/compression to the clavicle, or (and less likely in his opinion) (ii) A very forceful pull on the left upper limb

40. A clavicle fracture might occur by accident, if for example the child was dropped and landed on their shoulder region. This would need a traumatic event and would not occur during everyday handling. He also notes that clavicle fractures can occur at the time of birth. However, in Z’s case he did not consider the injury dated back to birth because there was no convincing healing response on any of the images taken for the skeletal survey on 12 th March 2024. He considered the difference in appearance between the first and second skeletal survey suggested that the clavicle fracture was less than approximately 10 days old on 12 th March 2024.

41. Dr Oates considered mother’s statement and did not consider that either the incident of Z knocking his head on the car seat or knocking his head on the changing mat at the local shopping centre would have caused the injuries.

42. Dr D Cleghorn, Consultant Paediatrician – provided one report dated 15 th July 2024; she was unable to attend the experts’ meeting but provided an addendum afterwards on 25 th February 2025. She subsequently gave oral evidence.

43. Dr Cleghorn identified in her evidence: (i) Z’s clotting factors IX and XI were slightly low (ii) Trauma can occur without any bruising. It is also possible to bruise with minimal trauma eg from normal handling if there is a clotting disorder. Her opinion was, “My understanding as a paediatrician is that the level of factors IX and XI seen in Z are not unusual for infants of this age and unlikely to indicate a bleeding or clotting disorder but if the court wishes to be assured of this then I would recommend that a paediatric haematology opinion be sought.” (iii) Dr Cleghorn provides her opinion that there is no bleeding or clotting disorder. (iv) It is now accepted that the petechial spot on Z’s finger was not present when Z was admitted to hospital. However, Dr Cleghorn erroneously proceeds on the basis that it was and that as it is an unusual place for an injury it is more likely to be inflicted. She considers that in the absence of explanations for the eye bruises they are more likely to be inflicted. (v) She says there are no features of the bruising that help determine how the bruising occurred (v) She states it is possible for the forehead bruise to be caused as recounted by mother from Z hitting his head on the changing areas but considers this would be unusual. (vi) She does not accept that rolling over and /or lying on a dummy would cause the bruises, nor that Z could have caused bruising to the eye lids by poking himself in the eye.

44. She considers various medical conditions that might increase the risk of intercranial haemorrhages such as clotting disorders but considers it unlikely. There are no other medical conditions that she considers would be responsible for the neuroradiological findings. She accepts that they can occur within normal births but defers to Dr Oates and Mr Jalloh. Fracture to the Clavicle

45. Dr Cleghorn defers to Dr Oates with respect to the radiological aspects of the fracture. However, she notes from a paediatric perspective: (i) Fractures are the result of trauma. However, if there are certain medical conditions minimal trauma is required. She considers various bone diseases and discounts all of them for Z as there is no evidence for them. This includes osteogenesis imperfecta (OI). She thinks it is unlikely he has a bone condition that would increase his susceptibility to fracture. (ii) She notes that clavicle fractures can occur during birth but that this is more likely with obstetric complications. Dr Cleghorn has not found any record of complications. She also notes that the timing of the fracture means that in Dr Oates’ opinion it is unlikely to be related to birth. (iii) Neither of the incidents reported by mother would be likely to have caused the injuries. (iv) She notes that fractures are painful when they first occur but she considers it likely that Z would have been distressed and cried out. However, he is likely to have been soothed quickly. She does not consider that a clavicle fracture such as this would have caused him much ongoing distress except when they are lifting their arms but she notes, “young infants of this age often cry when being dressed or undressed and so it is possible that parents might not realise that any crying was due to an injury rather than just general newborn crying.”

46. Dr Cleghorn notes , “6.7.3. Other than reported crying and the occasional vomiting, Z did not present with any other concerns and there were no neurological concerns about him when he was admitted nor while he was on the paediatric unit.”

47. Dr Allameddine Allameddine, Consultant Haematologist – report dated 4 th November 2024. He also attended the experts’ meeting and gave oral evidence.

48. Dr Allameddine was instructed following the recommendations in Dr Cleghorn’s report in which she identified that there were lowered levels of clotting factors IX and XI.

49. Dr Allameddine confirmed a diagnosis of mild factor XI deficiency (Haemophilia C). This was as a result of genetic tests being carried out on 30 th May 2024. It is a rare clotting disorder affecting about 1 in 100,000 worldwide. The effect of the disorder is that the body does not produce enough of the factor XI protein to help blood clot.

50. Dr Allameddine considers that the factor XI deficiency may have been a contributory factor to Z presenting with intracranial bleeding and superficial skin bruising but not for the fracture. Spontaneous bleeding or bruising would be uncommon.

51. He suggests that the coagulation system in newborns is immature and the low factor IX might have been transient, acquired or as a result of his immature coagulation system.

52. He did not consider that the bruises on the eyelids and fingertip were typical of non-accidental injuries.

53. He notes, “i. It's possible that the clavicular fracture occurred during labour. Clavicular fractures are the most commonly reported fractures in neonates. These are birth- related fractures that may be avoidably occurring during the process of labour and delivery. The incidence of clavicular fracture in the newborn is between 0.2% and 4.5%.”

54. His conclusion states, “32. Based on these findings, it's difficult to conclude on whether the bruises and bleedings suffered by Z were accidental or not. However, the presence in the background of haemophilia B and C, and the immaturity of the coagulation system at this age, have certainly contributed to lower the threshold necessary to trigger these bruises and bleeds and their extension following trauma or injury if this was the case.”

55. Professor Anand Kumar Saggar, Consultant in Clinical Genetics – report dated 10 th February 2025. Professor Saggar also attended the experts’ meeting and gave oral evidence.

56. He confirmed the diagnosis of factor XI deficiency which is associated with a bleeding disorder Haemophilia C. He does not identify any genetic susceptibility to fracture or spontaneous vascular rupture or fragility. However, he does identify a potential susceptibility to “bleeding and bruising more easily through a clotting disorder.” He defers to the haematologist with respect to the degree of clinical risk for easier bruising/bleeding but says, “Haemophilia C is an inherited clotting disorder, while Haemophilia B in this case was an acquired clotting disorder. Individuals with these conditions are at higher risks of bleeding or bruising. Such risks may be more prominent in neonates due to the coagulation system being immature before the age of 6 months.”

57. He also notes that given the family history of hypermobility, Z has at least a 50% risk or higher chance (around 75%) of inheriting HSD at some point in his life, but there is very limited evidence to suggest that he had it at the time of examination. He notes that Z has no clear diagnostic features. He also notes that HSD would not be associated with acute or chronic subdural/subarachnoid bleeds in the absence of force. It would not explain the cerebral contusion.

58. He says in respect of the cerebral bleeding, “In summary, it is a controversial issue as to whether a lesser force is required to cause cerebral bleeding in children/or adults with hypermobile EDS. It is my clinical experience that such patients do not present with spontaneous cerebral bleeding. I have not seen subdural bleeding described in HSD patients after normal handling.”

59. In discussing the risk of fracture, Professor Saggar is clear that there would still need to be a memorable event to explain the fracture to the clavicle. He says, “In the absence of OI or similar bone fragility disorder, it is a contentious issue as to whether milder forms of HSD can be associated with fractures after a lesser force in small children albeit not in babies under the age of one (Rolfes, 2019, Yeung, 2024). Whilst controversial, there would still need to be a clear 'memorable' event to explain each fracture. In other words, if Z has inherited HSD, then it would not lead to an increased susceptibility to fracture after normal handling and or any activity appropriate for their age at presentation. A memorable and precipitant force would be required to produce any fracture. Fractures do not occur spontaneously. The forces, in my opinion would be knowingly abnormal. I have deferred to the paediatricians about the descriptions of the force events as possible precipitants for the clavicle fracture. I also defer to the other experts on mechanisms required for that fracture.”

60. In his review of the research papers, Professor Saggar explains that there is very limited research into the susceptibility to fracture of babies under the age of one; the DEXA bone scan for bone mineralisation issues has not been carried out on children under five to his knowledge and there is no standardised criteria for bone density in such small children; in a recent study, EDS or HSD “was associated with having fractures during childhood with an odds ratio of 3.4 (95% CI: 1.20-9.66). Importantly, no fractures were found in EDS infants or controls under the age of one.” Further Professor Saggar notes that all fractures in that study were in ambulatory children and after an associated and memorable force.

61. His conclusion is that the clavicle fracture would have required some level of force; the fracture would have been as painful as in any normal individual; Z would not have suffered a fracture after normal handling. The Experts’ Meeting – 12 th February 2025

62. Dr Cleghorn was unable to attend the experts’ meeting.

63. The matters that can be drawn from this are: Clavicle Fracture (i) Dr Oates says that the most common cause of a fracture in a 15/16 day old would typically be a birth related fracture and “clavicle fractures are one of the most common if not the most common birth related fracture. A birth related fracture is a possibility.” He says that he cannot “exclude the fracture extending back to birth” . (ii) He identifies the other possible causes of such a fracture as (a) a compressive force over the shoulder region for example the perpetrator’s hands pressing very forcefully on the shoulder region; (b) the child has been dropped so that the shoulder impacts on a hard surface; (c) occasionally a fracture by pulling the upper limb so that the muscle attachments to the shoulder are put under pressure. He does not consider that any of the explanations given are likely causes for the fracture. (iii) Dr Oates says that with regard to timing there are limitations with radiological fracture dating for a 15/16 day old baby. He says that it is ultimately very difficult to say with certainty that is not a birth related fracture. He says, “I can't say for certain it does not extend back to the time of birth but what I have done is give, what I think is the most likely timeframe and that is less than about 10 days old.” (iv) However, Dr Oates goes on to say that on 12 th March 2024 there was no convincing evidence of a healing response; he accepts that is a subjective assessment; on 26 th March there is a significant fracture healing response. He concludes that “it is most likely to have occurred within 10 days of the first radiograph of 12 th March”. (v) Professor Saggar reiterates what he has said in his report that even if there were hypermobility issues, there would still need to be a force in excess of normal handling to cause a fracture. Bruising (i) Dr Allemaddine summarises his position that, “where some of the bruises can be described in non-accidental, other bruises are not typical of non-accidental so the fingertip happened 5 days later it's unlikely to be non-accidental, it's likely to be accidental and probably the eyelids bruises is more typical of being accidental rather than non-accidental. The eyes sclera as well I can't imagine how abusing a child you can cause bleeding in the sclera or the eyelids this is my consideration.” (ii) Dr Allameddine describes the three elements that contribute to bleeding and therefore bruising – clotting factor; platelet functionality and vascular integrity. He says that in an immature baby, the platelet functionality is not as effective as a baby of six or 12 months; hypermobility can add to the dysfunctionality of the platelet function. As the platelet function improves due to maturity any bleeding or bruising propensity decreases. Professor Saggar asked, “So much less force earlier on and more force required later?” . Dr Allameddine replied, “yes, yes”. (iii) There is no accurate way of aging the bruises – the fingertip one seems to have occurred in hospital. Brain Injury (i) Dr Oates focusses on the CE in Z’s brain – damage to the brain that occurs when areas fill with fluid and causes damage to the brain itself. He says, “The reason why I think the areas of cystic encephalomalacia are important because they are certainly not typical of an uncomplicated delivery.” He considers it to be quite a significant injury. However, in light of the evidence from Professor Saggar and Dr Allameddine and the clotting issue he speculates whether the bleeds were originally birth related but continued to seep and resulted in CE. He continues that “The majority of the haemorrhage was actually in the brain substance which again was slightly atypical and made me think well perhaps there was this ongoing seepage of blood vessels within the substance of the brain rather than accumulating in the extracoital space, the subdural space.” (ii) Dr Oates becomes less certain as the discussion progresses saying, “with this greater understanding about the issues with the bleeding, I am less, less definitive that I can say this was an abusive type injury because it could have been a birth related event but just with a continued seep that ultimately produced the more extensive brain injury that you would typically see as a consequence of a birth event.” (iii) Mr Jalloh accepts that contusions and subarachnoid haemorrhage can follow normal deliveries in otherwise asymptomatic infant and that “the fact that he was only 12 days old, makes it difficult to exclude birth trauma as a cause of his brain injury” . However, he considers that an “episode of trauma outside of birth” is more likely and “specifically the diffusion restriction and the distribution of the contusions in the brain substance which for me are bit more with trauma than a birth related injury” . He considers the injury to be consistent with a shaking type of injury. (iv) Dr Allemaddine is clear that the effect of the reduced clotting factor will not cause spontaneous bleeding but it would lower the threshold for bleeding. He is also clear that the bruise to the finger and the injuries to the eyelids both happened when the child was not with his family. He is less convinced that they are non – accidental “and more probably contribution of the birth as trauma with underlying bleeding tendency and immaturity” . (v) With regard to timing Mr Jalloh explained that the high density blood seen on the CT scan generally means that bleeding has occurred within 10 to 11 days. However, as Z was only [under two weeks old] he considered that would fall within the time frame. (vi) Dr Oates concludes that he is less confident in light of the discussions of the brain injuries not being birth related but he comes back to the clavicle fracture and his position on the timing of that does not change. Dr Cleghorn’s Response to the Expert Meeting – 25 th February 2025 Clavicle Fracture

64. Dr Cleghorn noted the views of Dr Oates and noted, “there is a possibility that the clavicle fracture occurred during birth but note Dr Oates opinion that this is less likely. There is no clinical information to either support the fracture occurring during birth nor to exclude it as a possibility.” She agrees with the mechanisms described by Dr Oates. She goes on, “If the clavicle fracture occurred during birth, then it should be noted that there are considerable forces occurring during birth and this would be considered to be outside the normal range of handling”. Bruising

65. Dr Cleghorn considers that the account of Z thrashing on the changing mat could account for the forehead bruise and possibly for the bruise on the cheek, given that Z has an increased risk of bleeding. She also considers that the marks on his eyelids could be accounted for similarly. Lying on his dummy might also cause the bruises. She notes that it is not possible to date bruises nor to say whether they occurred at the same time. Brain Injury

66. In respect of these injuries Dr Cleghorn defers to the other experts. Oral Evidence

67. Dr Oates – the information about the clotting disorder has impacted on his views. In response to Mr Kingerley KC, he said that before he knew about the clotting disorder, he was confident it was not a birth injury. However, it is now difficult to say it is not birth related. He continued to be of the view that if there has been birth related bleeding due to the clotting issue there could also be seepage. He said that CE was very unusual but less so if there was a clotting issue and it would be more difficult to say it was not birth related given how close the bleed was to birth and the young age. He did not consider the clotting issues would delay the healing response.

68. Dr Oates accepted that bones could heal at different rates and with neonates any assessment would be within a range which could be subjective. He also accepted that if father’s version of what happened at the birth with him puling Z out was accepted then pulling on the arm would be a possible mechanism for the fracture.

69. Mr Jalloh – was unable to confirm whether the mechanism was likely to be a shaking type of injury or an impact. He said that CE was a striking feature of the case. It was put to him that it was more likely to exclude birth trauma. He said that when he wrote his report, he thought both were likely; but seeing the CE persuaded him that post – natal injury was more likely than birth. He said that if there was an ongoing bleed due to blood clotting disorder than a birth related trauma would be more likely to produce CE. As a result, he thought the clotting disorder was a “ game changer ”. However, he thought the distribution of blood was atypical of a birth related injury, but he also accepted that given there is a clotting disorder it would be more likely for bleeding to occur, even if it was not an inflicted injury. He also accepted that the density of blood would not be a robust marker for timing due to the clotting disorder.

70. Dr Allameddine – was asked about the impact of the clotting factor deficiency. He explained that there were reasons why it might fluctuate; in a baby of this age the liver might not be mature enough to replenish it; the child had been ill the week beforehand and it might be reduced. This would all impact on the ability to clot effectively. He was clear that with the clotting deficiencies identified in Z it was likely that he would have bled with lesser force and any bleed is likely to have gone on for longer. He also accepted that the birth process is traumatic; that with an underlying clotting issue there might be a bleed at birth which could have continued (seepage). He also confirmed that in his view the bruising on the fingertip and eye lids did not have the appearance of non-accidental bruising and he thought they were more likely to be accidental.

71. Professor Saggar – did not add to his report and his discussion at the experts’ meeting. However, he did comment that if the factor IX (not XI) disorder is acquired then that might improve with age and platelet functionality is likely to mature which may mean that Z shows fewer bruises now than at under two weeks old. He also accepted that Z’s bruising could have been caused by normal handling.

72. Dr Cleghorn – accepted that babies can have bleeding in the brain as a result of the birth process. She was also very clear that there was no scientific way to age bruises. Dr Cleghorn confirmed that from the medical notes it appeared that the birth was within the range of normal, there was no shoulder dystocia. She discussed with Ms Lee, mother’s early discharge and confirmed that ideally mother would not be discharged late at night but would stay until morning. In this case there were also multi – agency concerns and the medical and social care teams would want to ensure that everything was in place. She did not consider that mother’s cannabis use would have impacted on Z in any significant way.

73. With regard to the clavicle and brain injuries, Dr Cleghorn deferred to Dr Oates and Mr Jalloh. She agreed that there was the potential for a rebleed from an innocuous event due to the clotting issues. She accepted that medical professionals do not always pick up fractures to the clavicle as often there would be no clinical signs. Similarly bleeds in the brain can be silent. She also accepted that with the clotting disorder the events described by mother as happening on the changing mat which might otherwise be called normal handling might result in bleeding for Z. She also confirmed that the eye bruising and the cheek bruising might have been caused by him poking himself or lying on the dummy. Other medical evidence Dr Mohsin Jafri, Consultant Paediatrician, Local Hospital – statement dated 25 th June 2024

74. Dr Jafir was the on call paediatrician in A&E on the date of attendance in March 2024. He saw Z at 17.40. Z was with his mother and MGM. Mother explained that bruising had been observed by the health visitor who advised them to bring Z to A&E. He also spoke to father who said that Z was a wriggly baby and that the bruising might have happened when Z was moving while being changed and hit the corner of the mat. Dr Jafir examined Z who was said to be alert and playful. He noted three bruises – one on the left forehead about 2 cm in diameter, one on the left cheek about 2 cms in diameter and one on the right cheek about 1 cm in diameter. No other injuries were noted. The statement was drawn from notes prepared at the time. Midwives and Health Visitors

75. The LA called a number of health visitors and midwives but none could give direct evidence in respect of the birth or injuries.

76. I heard from Ana Garrido, midwife; Surushpadi Ignace, midwife and Louise Jenner, community midwife. All have filed statements and were referred to the hospital or other notes.

77. None of the midwives was present at the birth. With respect to the injuries to Z, none had any specific evidence to give. However, Ms Garrido’s evidence goes to whether father was controlling of mother by remaining on the telephone while she was in the room and not wanting her to have a shower until he arrived. He was concerned about anyone other than the parents looking after Z. She was concerned that if he did not want anyone else looking after the baby, then he could have been there – parents can attend for 24 hours. Ms Garrido had obviously formed an unfavourable view of father and despite only meeting him briefly and him making it clear that he had nothing personal against her, she felt he was controlling of mother.

78. Ms Ignace managed Z’s discharge, late at night and described both parents being upset and swearing; they appeared upset with the involvement of social services. She said that although father was swearing, he was calm and seemed concerned about the care that mother was receiving. She said she did not feel intimidated by him and just let him talk.

79. Ms Jenner visited mother and Z at home two days after birth. It was a routine visit. She found the flat tidy and Z properly looked after. She and mother were having a positive conversation before father came in and at that stage, she felt the atmosphere changed. There was discussion about how to make up the bottles of formula and things became tense with father saying that he did not trust professionals and his mother knew best. She felt that father came across as intimidating and “ disbelieving of all the information given ”.

80. She accepted in her oral evidence that she had probably not taken account of father’s diagnosis of ADHD and autism. However, she was clear that she found his attitude to be intimidating but accepted that he did not swear and was not openly threatening. Family Evidence E, Maternal Grandmother

81. MGM’s statement is dated 18 th July 2024. She also gave an interview to the police on 13 th March 2024 which is in effect no comment. I was also referred to a number of text messages passing between her and mother. E is not a party to the proceedings, nor is she an intervenor. She seems to have been involved in supporting mother both before, during and after the pregnancy. However, as mother is adopted MGM pointed out that she did not have experience of babies. She suffers with her mental health and was clear in her oral evidence that her memory was not as good as it could be. It was clear from her evidence that she felt that both parents needed extra help and support to be parents. She was not able to identify what that support might be but did not feel that they had had sufficient help.

82. MGM was asked about the birth. She had been present during the birth and was asked to consider mother’s account of it. She confirmed that mother’s account was correct, and that father pulled out Z from the shoulders.

83. She said that following the birth the midwife kept checking Z’s arms and shoulders – she says he was checked two to three times she could not remember exactly which. She sets out in her statement the circumstances in which a midwife came to check Z’s shoulders and arms. She thought it was rather odd.

84. MGM gave evidence about the incident that took place in the changing rooms at the local shopping centre on 6 th March 2024. She explained that she had gone with mother to a Universal Credit appointment and then went shopping. She went into the changing room with mother to change Z’s nappy. She sets out in her statement, “Z was lying on a changing table waiting to have a clean nappy put on. He rolled to the left and hit the side of his head on the edge of the hollowed out part of the changing table. Jess checked Z. He appeared to be unhurt, if a little grumpy. She carried on changing him and picked him up. He seemed fine and we carried on with the day with absolutely no further drama.”

85. She was unable to add anything in her oral evidence to what was set out in the written evidence except that she denied ever being asked to hold Z’s head. She maintained she was the other side of the changing room. Nevertheless, she sets out in her statement her concerns about the changing “ mat ” so much so that she sought to report the issue to the social workers. She said there was only one trip to the changing room. Her statement is more concerned with the upset she feels at being accused of possibly harming Z. Mother

86. Mother has filed a statement dated 1 st July 2024 and one dated 5 th March 2025. She has made the very difficult and child focussed decision not to oppose the LA care plan and for Z to live with his relative.

87. During almost the entirety of the proceedings mother and father presented as a couple. However, following an incident on 1 st March when it is alleged father hit mother, she has separated from him and father has bail conditions not to contact her or return to the home address.

88. She described the relationship with father as being one where they had tiffs. They would both get upset and then take it out on the other. Both grandparents would be involved by them. She said that the incident at the beginning of March arose from being depressed with the situation with Z, mixing her alcohol having not had a drink for 6 months and then arguing. She left the house and when she returned the argument continued, culminating in her suffering minor injuries. She says she does not know how she obtained them.

89. She did not accept that the relationship with father was volatile; nor that they normally had fights. She said she loves father and would hope to get back together.

90. She denied that she had ever caused Z an injury. She said she felt sick that people might think that.

91. Mother clearly felt that the birth had not gone smoothly. She said she wanted to start pushing too soon and she felt the midwife did not want to pull the baby out of her whereas she just wanted him out. She said that the midwife threw father a pair of gloves and father had to do the rest.

92. Mother was shown a number of the text messages sent following the birth and returning home, in which she expressed enormous upset at dealing with Z, his crying, struggling to settle him, the fact that she did not feel he had bonded with her and her worries that he might not want her. She also searched internet sites that reflected her worries and concerns. It seems clear that she was not finding it easy to care for her baby, she did not trust professionals and she was struggling to cope with lack of sleep.

93. On 5 th March mother and MGM went to the shopping centre. In her statement she refers to one visit to the changing room to change Z. However, in her oral evidence she said that she had gone twice. She was clear that MGM’s recollection was incorrect. The visit when the incident occurred was the first visit before going to the universal credit appointment.

94. She said that she had specifically asked MGM to hold Z’s head. She said she remembers she put a blanket in the middle and then asked her to hold his head. She said that her mother’s memory was not good. She said he was very wriggly, and she believes that her mother must had lost her grip and he hit his head on the edge of the table. It was hard plastic (photograph confirms). She said she consoled him and he was fine.

95. The second visit she was on her own and the change only took a few minutes.

96. Apart from an occasion when Z might have knocked his head on the car seat, mother could not think of any other time when he might have hurt himself. Father

97. Father has prepared two statements dated 4 th September 2024 and 24 th February 2025. He also gave a police interview on 13 th March 2024. He confirmed that he would like Z returned to his care. If he is not living with him, he would like to spend as long as possible with him. He loves mother and wants to see how they can work things out in future.

98. Father struggled during the course of the final hearing. Following the incident on 1 st March, father was accommodated in a hotel and there were concerns about his mental health as he was on his own with little support from mental health services, although the LA did its best to try and obtain support for him. He was not always willing to accept the support offered. As a consequence, the matter was adjourned for a day; he accepted to Ms Lee that he had been continuously suicidal since being at the hotel.

99. Father painted a very positive picture of his relationship with mother. He said they fell in love pretty quickly. He knew about the trauma that mother had gone through and knew that she struggled with her mental health. He said he was able to empathise with her because he struggled with his own mental health.

100. He accepted that they had disagreements, he did not agree they were arguments. He agreed that on 1 st March mother was drunk when she got home from visiting her brother, she thought he could have shown a bit more empathy. He said he had not had enough cannabis and his head was not feeling normal. An argument developed and they were shouting; he said that he could not calm mother down; he felt the last 13 months had all been too much for her. He called D; he has no friends apart from D and mother. He denied knowing anything about her having a cut lip or a lump; he denied punching her. When the police arrived, he was arrested. Apart from being in Court, he has not seen her or spoken since.

101. Father was very frank in his evidence about his cannabis consumption, accepting that he smokes regularly and that after Z was born, he smoked an excessive amount ranging from 1-2 joints a day to 10-15 on occasion. Since being at the hotel, he has smoked less but there has not been a convenient dealer.

102. Father accepted that when he was a child, he and his mother had not always got on well. He had a diagnosis of Aspergers, and he thought their communication was poor although it has now improved. Nevertheless, there are still arguments.

103. Father accepted that he had a distrust of professionals. He wanted to record the sessions with Corinna Brown who was to do the parenting assessment and she refused. He felt he was within his rights to record it without telling her. He was worried she would lie in court. He did not have a good relationship with the social worker, Mr Pokharel saying that he does not like him and he is sure he does not like him; he accepted that he was agitated with Ms Jenner, the health visitor. He did not consider he was intimidating, he said that “any man who is upset is scary to women these days” ; it was suggested that she felt uncomfortable but said, “it is not my problem she was in my property” . Father has a real distrust of professionals and felt that the only advice they could rely on was from his mother.

104. In his answers to Ms Nuttall, he said he was a very hands-on father, preparing bottles and changing nappies. He seemed to have an odd perception that it was not right for a woman to change a boy baby’s nappy and vice versa. He denied ever rolling onto Z in bed or putting him down too firmly.

105. Father was not involved in the trip to the shopping centre but sets out in his statement that when mother and Z returned, they were fine, and it was later that day they noticed a bruise on his head. Father is very clear that he has not harmed Z. In cross – examination, he said that mother had told him that the changing room bed (changing mat) was awkward and there was not enough room; MGM was holding his head and he “ flailed ” and she lost control of his head and he hit his head.

106. In his statement, father sets out that he was expected to pull Z out during birth. In oral evidence, he said he thought it was a joke but he said the midwife “chucked him blue gloves ” and he took Z out by the shoulders; he said he then held him and graphically describes him as “ slimy and gross ”. He said he refused to cut the umbilical cord and MGM did so. It was put to him that a baby could not be pulled out by shoulders but he explained that the head was born and then he pulled Z out.

107. He was asked to comment on the various text messages passing between himself and mother in which mother seems unhappy with Z, calling him a “ moaning little shit ”; wanting to look at day care and nursery. He thought mother was struggling to cope and struggling that Z did not want to be put down. He denied that mother had at any time hurt Z by banging his head or his shoulder. He denied being responsible for hurting Z.

108. Further, he did not believe the bruises were particularly significant and did not see a problem in waiting 3 days for the health visitor to come before doing anything. He thought that would be soon enough. D, The Relative

109. D’s statement was not filed until 28 th March 2025. She also gave oral evidence. She is clear that she wishes for Z to live with her under a care order and for her to be a kinship foster carer. In her oral evidence she said she understood the differences in the orders and this was the one she was seeking. She was concerned to have support while the extent of any neurological damage to Z was ascertained. She felt she would want to have as much support as she could after her experiences with father.

110. She says that Z is very settled in her care. She gave a very warm and loving description of him - cheeky, mischievous, bright, loves puzzles; physically active – he walked early.

111. She was confident that she could manage contact weekly with father and having previously worked well with mother she said the incident on 1 st March had damaged the relationship. She would not be able to supervise mother’s contact at present although she was hopeful she would be able to rebuild the relationship and they had had some very recent communications about Z. Ms Liz Vicary, Children’s Guardian

112. The Guardian’s final analysis is dated 21 st February 2025, she also gave oral evidence. She gave really positive evidence about Z’s development. D was very child focussed and knowledgeable. She said she could not have asked for a better placement for Z. She was satisfied that D understood the differences between the orders and had sought the one most appropriate for her needs as carer.

113. She was satisfied that contact for both parents should be a minimum of fortnightly. Father’s could be supervised by D and if she could manage it there was no issue with this being weekly. She considered that given the relationship between the parents, mother’s needed to be professionally supervised. She did not consider this was unfair as father has demonstrated a really good bond with Z whereas mother has been less committed. She has considered the contact notes carefully and Z seeks comfort from father; mother does not have quite the same emotional response. She recommends that a family support worker be allocated to provide mother with support and if that goes well the contact could be increased.

114. In her oral evidence she commended both parents for giving evidence and was very supportive of the LA Care Plan as amended following her proposals, that Z should remain with D. Analysis – Non accidental injury The Injuries

115. There is no dispute with regard the identification of the injuries to Z. The LA does not pursue the fingertip bruise. Its position with regard to the eyelid bruises was equivocal but accepted in closing submissions that in light of the evidence there was unlikely to be a finding.

116. Both parents accept that there are three other bruises. They also accept the existence of the clavicle fracture and the brain injuries. Underlying Medical Condition

117. The LA pleads (para 2) that Z does not have an underlying medical condition that would predispose him to fractures. This is accepted and is the evidence of Professor Saggar. However, this does not consider the evidence of Dr Allemaddine, the discussions between the experts and the evidence of Dr Cleghorn, all of which suggests that on the balance of probabilities Z did have an underlying medical condition that predisposed him to an increased risk of bleeding. At the time he had a likely transient factor IX clotting disorder and a genetic clotting disorder of factor XI. Both would have pre – disposed him to a greater risk of bleeding. Nature of the Injuries

118. I remind myself that the burden of proving that the injuries are non – accidental is on the LA. It must prove its case on the balance of probabilities. If the parents raise a reasonable explanation for the injuries, it is for the LA to prove that it is not reasonable. It is for the LA to put the primary evidence before the Court in support of its pleaded case. In making its findings, the Court must look at the wide canvas of the evidence. I agree with the submissions made on behalf of the parents that the Schedule of Findings seems to take little account of the evidence of Dr Allameddine or Professor Saggar; nor the expert meeting. It has remained static to all intents and purposes since September 2024 and does not reflect the nuance of the evidence. The LA was invited to review its schedule but did not do so. Bruising

119. Fingertip bruising – not pursued as it appeared some five days after admission and clearly as a result of normal handling. Eyelid Bruising

120. When the health visitor Ms Penny Russell visited the parents’ home on 8 th March 2024 at 11.10am she encouraged the parents to take Z to hospital in light of the bruising to his head and cheeks. Had there been bruising to the eyelids at that stage it seems very likely that she would have noted it. Dr Jafri did not notice the eyelid bruising when he examined Z at 5.40pm on 8 th March. The bruising was first noted on 9 th March after admission. Even if bruising takes some time to appear there is a long gap between being seen by the health visitor and Dr Jafri and the bruising appearing the following day.

121. Dr Allemaddine is very clear that the eyelid bruising should be regarded as accidental. He considers that it very likely appeared while Z was in hospital and was sustained while he was n hospital.

122. Finding – I find these bruises to be accidental and to have arisen as a result of normal handling. Other bruising

123. The LA position is that the bruises seen on Z on admission to A&E cannot be accounted for by the explanations given by the parents – Z falling asleep on his dummy, rolling onto it; knocking against a car seat or knocking his head against the hard plastic of the changing mat in the shopping centre. The LA says that these bruises are more likely to be inflicted. There is no time frame for the bruises. The Changing Table Incident

124. I heard evidence from both mother and MGM in respect of this. Their accounts differed as set out above. Although mother’s account varied in her oral evidence, I thought she was an honest witness trying to assist the Court. I do not believe there is any significance in the variation in her account. Nothing significant happened in the second visit to the changing room. I thought mother’s account was largely credible. MGM was not consistent; her memory was poor which she accepted; she was not a convincing witness. In my judgment she came across as distancing herself from the incident claiming that she was not involved in holding the baby’s head. However, somewhat contradictorily after the event she thought it was sufficiently serious that she wanted to complain.

125. I prefer mother’s account and find that there was an incident in which MGM was holding Z’s head; she lost her grip and he knocked his head. Looking at the picture of the changing area, the “ mat ” is not a mat at all but a hard plastic egg-shaped hollow. Mother informed father shortly after what had happened and MGM intended to tell the social workers.

126. The LA conceded that if the Court finds that there was such an incident than it might explain the bruising to the head but not the brain injuries.

127. Although Z has suffered some bruising since, there has been nothing significant. Dr Allemaddine identified three factors relevant to a propensity to bleed for Z. First there is the issue with the clotting factors, one of which (factor IX) might resolve; secondly the immaturity of his coagulation system and the platelet functioning and finally possible issues with his vascular integrity in the event that he has some inherited HSD (which has not been diagnosed). The tenor of the evidence from Dr Allemaddine was that the clotting effectiveness might improve with a resolution of factor IX and his system maturing. Further, Professor Saggar noted that often where there have been injuries children are treated with greater care.

128. Dr Cleghorn conceded that given the clotting issues it would be possible for the bruises on the cheek to have been caused by rolling onto the dummy.

129. Finding – The LA must satisfy me on the balance of probabilities that the bruises are non – accidental. It is certainly possible that they are. However, it is also possible that they were inflicted in other ways – the changing table and the dummy or in some other way. I am not satisfied on the balance of probabilities that these are non-accidental bruises. Brain Injury

130. It has been very difficult for the experts to reach a considered view on the brain injuries. Dr Allameddine’s evidence clearly altered the perspectives of both Dr Oates and Mr Jalloh.

131. All experts accepted, as do I, that bleeding in the brain (both contusions and sub arachnoid haemorrhages) can occur at the time of birth. This might be as a result of a traumatic birth eg a shoulder dystocia or even during a normal birth. The process of birth is itself traumatic.

132. The consensus of the evidence was that due to the clotting issues it is likely that Z would be more susceptible to suffer bleeding. Dr Oates hypothesised that if there was bleeding at birth, the clotting disorder might result in ongoing seepage which could have caused the CE which all experts accepted was an unusual birth injury. There was further force in this hypothesis because there was limited amount of bleeding to otherwise explain the CE. It also means that the diffusion and brightness of the CT scans would not be accurate. They were described as being “ null and void ”.

133. Dr Oates and Mr Jalloh in their oral evidence said it was difficult to say it was not birth related. Mr Jalloh said that if there was an ongoing bleed related to trauma then that was more likely to produce CE. He also said that at under two weeks of age, what was seen on the scans could reasonably be considered to be birth related.

134. However, Mr Jalloh also considered that the injuries could be a result of shaking or impact. However, there are few signs of shaking in such a young baby – limited bleeding – more might have been expected with the greater propensity to bleed; there was no skull fracture or evidence of impact and no swelling to the skull. Clavicle Fracture

135. This needs to be considered alongside the brain injuries because for Dr Oates this was a sticking point, given the evidence of the healing process and his estimate of the timing of the injury which would have been when Z was at least 5 days old – in his opinion the fracture was 10 days old or less. It therefore impacts on whether the injury is birth related which may then affect the likelihood of the brain injuries being birth related given the uncertainties in the expert evidence.

136. The LA relies on the evidence of Dr Oates as to the timing of the injury and the fact that if the Court accepts that evidence, the injury cannot be birth related. It also relies on the evidence of the midwife’s records and statement which record that there was a normal delivery. Further the LA suggests that the parents have invented this explanation, only after the expert reports were available.

137. Mother and father have put forward an explanation that this injury was likely to have been caused at birth. Mother set out in her 1 st July statement what happened at the birth; this was further explained by father, that he was asked to pull out Z and was given a pair of gloves. Although their evidence post dates the expert reports it is consistent but not identical. Both parents seemed genuinely shocked by the process. It may have contributed to their unwillingness to remain in hospital where they felt they had not been well cared for. The MGM was also present at the birth and she confirms what is said by the parents. She also reports the midwife inspecting the shoulder several times following the birth.

138. Clavicle fractures do occur at birth; they are the most common birth related fracture. Dr Oates accepted that timing a fracture was an imprecise exercise and he could not be definite. Dr Cleghorn said there was no clinical evidence to support a birth fracture or to exclude it. Prior to the final hearing, none of the experts considered the parents’ account in any detail. Dr Oates accepted in oral evidence that the mechanism described by father could account for the fracture. Findings about the Birth

139. Father’s evidence was graphic and, in my view, credible. I thought the detail about the baby being “slimy and gross ” sounded like a true experience. His account of being thrown blue gloves also appeared to be his honest account of what happened. I accept that by the time he says he was pulling Z out the head had been born so he was able to pull by the shoulders. I also accept the MGM’s account that the midwife was checking Z’s shoulder and then seemed relieved that it appeared to be all right.

140. There is nothing in the midwife’s notes to support this account. However, her evidence is untested. The father’s team have been very clear that they wanted her to be available for cross – examination. It is for the LA to disprove a reasonable explanation and she is clearly a key primary witness. The medical evidence explaining why she could not attend is not adequate and was produced at the last minute.

141. I have to determine the facts on the balance of probabilities. In the absence of any primary evidence to the contrary and in circumstances where mother, father and the MGM have given written and oral evidence about what happened I prefer their evidence and accept that on the balance of probabilities the father did pull Z out by the shoulder. Wider Canvas

142. The LA seeks to look at the wider canvas and in particular the difficult background of the parents; the stress the parents were under in the days leading up to Z’s admission to hospital and their difficulties in dealing with professionals and accepting advice.

143. It is clear that they were struggling and that there were tensions between them. There is nothing in the texts and messages to suggest that one or other of them told the other about any sort of incident. Finding – Brain Injury and Clavicle

144. All the experts have found this to be a challenging case; none has been certain about the cause of the injuries and both Dr Oates and Mr Jalloh have moderated their views in light of the haematological evidence.

145. I find that with respect to the brain injury it is possible that it occurred as a result of the birth with an extended bleeding time as a result of the clotting disorder. It is also possible that it was a result of some sort of traumatic injury. However, given the evidence before the Court I cannot say that a traumatic inflicted injury is more probable than a birth related injury with an extended bleed. The LA has not therefore proved on the balance of probabilities that this was a non-accidental injury.

146. With regard to the clavicle fracture, I also do not find that this was a non-accidental injury. In making that finding I have taken account of all the evidence but in particular the evidence of the birth, the midwife’s anxiety over the shoulder immediately following birth and the fact that clavicle factures are the most common fractures and can occur even in normal birth. I have not discounted the timing that was proposed by Dr Oates but his evidence was that the timing was not certain nor fixed. I do not find that the LA has proved it is a non – accidental injury. Welfare Threshold – welfare

147. I am satisfied that on the basis of the admissions from both parents, threshold is crossed. In so far as Item 16 is concerned I do find that the parents had a volatile relationship – there were clearly arguments, not just disagreements, that the parents minimised. I also find the incident on 1 st March proved as pleaded. I do not attribute specific fault to either parent. Welfare Checklist

148. In coming to any decision about the welfare of a child the Court must make decisions that are in the child’s best interests. While mother does not seek to have Z in her care, father does.

149. The factors that the court must take into account in coming to a decision are set out in s1 of the Children Act 1989 and in reaching my decision, I have taken them into consideration. It is very clear from the contact notes that father has a good bond with Z and is able to provide him with some basic care. This will be more natural if D is able to supervise and provide father with guidance and boundaries. I am sure that Z will want to have a relationship with both of his parents moving forward and if he cannot live with them then he will want to see them and grow up knowing them and loving them.

150. It is not known yet whether Z will have any issues as a result of his brain injuries, he is too young – he appears to be meeting his developmental milestones. However, he has two neurodivergent parents and may need additional support as he grows up to meet those challenges. He is currently a small baby who needs the adults in his life to make good decisions for him and to help him to grow and be healthy and safe.

151. He has been with D for nearly the whole of his life. Any change to this is potentially harmful to him. He is thriving in her care.

152. Unfortunately, I do not consider that either parent is able to safely care for Z. Mother accepts this. Father does not. He would like to care for him. He has found working with professionals incredibly difficult; even the Guardian found it hard to engage the parents; father is very mistrustful of professionals and constantly challenges their advice. This is likely to put Z at risk.

153. Further, father still has his own mental health issues to manage – he is very vulnerable as was demonstrated during the course of the final hearing. While that was particularly stressful there will be many other stressful times dealing with a young baby and a growing toddler. In my view and on the evidence before the Court including the evidence of the Social Worker, Mr Pokharel father would find it very difficult. He is, on his own admission, using significant amounts of cannabis which would affect both his availability to Z and his ability to care for him.

154. Sadly, although I know father dearly loves his son and believes that he would be better with him, I do not agree. I do not believe Z would be safe in father’s care and I believe he would be exposed to significant harm. Placement

155. I am satisfied that the order that best meets Z’s needs now and in the immediate future is a care order in favour of the LA with contact in accordance with the LA revised plan. Practicalities

156. I have received some corrections and typographical errors which I have accepted. This judgment is being handed down in this format on Tuesday 10 th June 2025. HHJ Lindsey George 16 th May 2025. Approved following comments from counsel 10 th June 2025