A Local Authority v M & Ors

The expert witnesses called by the Official Solicitor, whose evidence was accepted by the local authority, were Dr Carpenter, Professor Williamson, Dr Beck and Mr McKinstrie.

Dr Carpenter is an Honorary Consultant Psychiatrist, having for many years worked as a consultant for adults and children with learning difficulties. Throughout his career he has pursued a special interest in autism, on which he has taught widely. He was a contributor to the guidelines drawn by NICE (the National Institute for Health and Clinical Excellence) on: "Autism; recognition, referral, diagnosis and management of adults on the autistic spectrum." In her closing submissions filed today, E attacked the NICE guidelines on the grounds that they recommend not the most effective medical remedy but only the cheapest. Dr Carpenter was asked to prepare a full chronology of M's medical history, including all complimentary treatments, and provide an opinion as to whether past medical and complimentary medical treatments, investigations and assessments had been in his best interests. In a supplementary report he was asked to advise as to M's capacity.

Professor Williamson is a consultant surgeon at Hammersmith Hospital. He has some 45 years' experience as a gastrointestinal surgeon. He has held a number of posts, including Director of Surgery at the Royal Postgraduate Medical School at the University of London and also President of the Royal Society of Medicine. He was asked to focus on the gastrointestinal aspects of the case, including whether M requires a restrictive diet or dietary supplements.

Dr Beck is a consultant clinical and forensic psychologist at the Royal Maudsley Hospital. She was instructed to assess, inter alia, M's relationship with his parents, the family's relationship with the local authority and risk issues and the impact of those relationships on M's best interests, whether E exaggerates or falsifies M's medical symptoms and, if so, what psychological factors have given rise to this and how it impinges upon M's best interests, whether E poses any risk to M, the specific effect on M's best interests of E's detailed instructions, her biomedical supplements, therapies, medical investigations and assessments, the risks, if any, to M's development if he lives or does not live with his parents and if control over welfare decisions are restored to his mother, and the level of contact with his family in the event that he does not live with them.

Mr Keith McKinstrie is a social worker with very considerable experience in disability services. He is currently employed by Sheffield City Council as a service manager for adults with learning disabilities. In addition, he works as an independent social worker providing reports for the Court of Protection and delivers training lectures and leads service development on social work and social care issues, and, in particular, the personalisation of social care and implications of this for local authorities. He was asked to address a series of questions concerning M's residence, care, contact and the issue of biomedical supplements and medical treatments and investigations.

All four of these witnesses were extensively criticised by E in the course of the case for one reason or another and, in particular, were the subject of a prolonged and vitriolic attack in her closing submissions. In particular, it was alleged that each had tailored their evidence to fit the agendas of the local authority and the Official Solicitor. I therefore record immediately that I found all four witnesses to be wholly reliable and professional. I reject the accusation that they have given false testimony at the behest of the local authority and the Official Solicitor. The summary transcripts of Dr Beck's and Mr McKinstrie's interviews made by E and A, based on their clandestine recordings, do not, in my view, disclose any significant errors or omissions in their reports, nor undermine their reliability.

E and A instructed three experts: Dr Gwen Adshead, Dr Kenneth Aitkin and Mr Paul Shattock. I have already described the unsatisfactory circumstances in which the last two came to be instructed.

Dr Gwen Adshead is a psychiatrist with long and well known experience in the field of forensic psychiatry. For 18 years she has been a consultant psychotherapist at Broadmoor Hospital. Amongst her areas of special interest is factitious disorder imposed on others, previously known as factitious and induced illness or Munchausen's syndrome by proxy.

Dr Aitkin is a consultant clinical psychologist and neuropsychologist with a lifelong interest in autism, in which he has taught and published widely. Amongst his special interest is the use of alternative treatments in the management of autism.

Paul Shattock is a pharmacist, having acquired a degree in that subject in 1966. He was also for many years a senior lecturer in pharmacy at the University of Sunderland. He is the chairman of organisations called Communities for Autistic People and Education and Services for People with Autism, which provide residential care and support for over 200 people with autism in the northeast of England. He states in his curriculum vitae that he has an autistic child himself and has dedicated most of his career to helping people with autism, receiving the OBE in 1999. He has published widely in a number of books and over 50 articles on many aspects of autism, including the use of gluten and casein free diets. He has devised a programme called the Sunderland Protocol, a strategy for testing the effectiveness of different nutritional interventions on children with autism.

Dr Adshead was another reliable and professional witness. As for Dr Aitkin and Mr Shattock, while I accept that the views that they expressed were genuine, I was concerned at times as to their qualifications to opine on some of the matters about which they gave evidence.

Dr W has been the family GP since 2007. Until he went into the witness box, he has managed to maintain a good working relationship with E and A. He has achieved this by adopting an approach that was tolerant and sympathetic to E's concerns and on more than one occasion acceded to her requests to arrange testing for M when his own clinical judgment might have led him to conclude that such testing was unnecessary. He described this approach in evidence as "practising defensively". In some respects, therefore, he was acting in a fashion that could be regarded as typical of an older style family GP. In his evidence he was taken through the list of conditions which E asserted M had suffered from and he excluded a considerable number. In their final submissions filed on the morning of the judgment, E and A expressed a degree of disillusionment with Dr W and said that they were considering their position as to whether or not he should remain their GP. I record that I consider that Dr W has acted in this difficult case in a responsible manner bearing in mind the very difficult circumstances in which he was operating. As a witness, I found him truthful and humane.

The last group of witnesses about whom I wish to make specific mention before turning to the evidence are the three alternative medical practitioners called by E and A: Shelley Birkett-Eyles, Dr Julu and Ms Haywood. Mrs Birkett-Eyles is an occupational therapist and Director of Hemispheres Movement for Learning Limited, a private occupational therapy practice specialising in the assessment and treatment of children and young adults with learning and developmental difficulties. She has seen M on several occasions since 2010 and, amongst other things, ran a training day at X College on the topic of sensory processing. Dr Peter Julu describes himself as a specialist autonomic neurophysiologist and consultant physician. Juliet Haywood is a nutritional therapist who has been advising E on M's diet for the past four years.

My impression of Mrs Birkett-Eyles was that she was a responsible practitioner working within the proper confines of her particular field, although, as will be clear later, the reliability of her opinion as to treatments given to M was challenged by Dr Carpenter. I was more concerned about the evidence given by Dr Julu and Ms Haywood.

Dr Julu told the court in oral evidence that his field of interest is not yet part of mainstream medical training in England and that he is the only autonomic neurophysiologist in Europe. I was not satisfied from his evidence that his purported specialism is a legitimate field of medicine and, again, the reliability of his assessments and treatment recommendations for M were challenged by Dr Carpenter. In her supplemental closing submissions filed this morning, E said that the lack of knowledge amongst those challenging Dr Julu's evidence is "startling, as it is easily accessible on the internet."

Ms Haywood, whose professional qualification is a diploma from the College of National Nutrition, has played a major role in advising E in recent years. The papers contain a number of emails passing between E and Ms Haywood and it is clear from reading them that there are others which have not been disclosed. I am satisfied that in the course of her involvement with the family Ms Haywood has given advice that went well beyond her expertise. One glaring example was Lyme disease when, on her advice, given after seeing a photograph of a mark on M's leg, E sent urine samples abroad for further testing. Subsequently, Ms Haywood confidently expressed an opinion on the interpretation of the results of those tests. She has no chemistry or other qualification that equips her to do so. I was also concerned that Ms Haywood had prescribed the dietary protocol for M without seeing him and with no independent knowledge of his medical history, content to rely solely on what she was told by E; for example, that M had a chronic gut disorder. In contrast to Mr Shattock's Sunderland Protocol, which recommends the systematic testing of diets and supplements individually, Ms Haywood was content to prescribe a dietary programme without testing each individual component separately. She did not agree with the NICE guidelines as to the impact of diet on autism. She had forthright views on many things, saying, for example, at one point that she did not like Cancer Research UK. I was left with a profound anxiety about Ms Haywood's influence on E and her role in the treatment that M has received.

There was one other matter which gave rise to concern about this part of the evidence. None of the three witnesses had received any training on the Mental Capacity Act 2005 and it was clear from their evidence that none of them had given proper consideration to the question whether M had capacity to consent to their assessments or the treatment they were prescribing. The family GP, Dr W, also admitted in his oral evidence that he only made a detailed study of the Act and the Code of Practice when he was told that he would be giving evidence in this case, and he identified a number of learning points about the Mental Capacity Act arising out of his involvement in these proceedings. Mr Bagchi reminded me in his closing submissions of the concerns expressed in the House of Lords' Select Committee on the Mental Capacity Act 2005 Post-Legislative Scrutiny Report on the implementation of the Act, dated 30th March 2014, about the general lack of awareness by the general public and professionals of the principles and workings of the legislation. This case has highlighted the urgent need for all health professionals, including those practising in alternative and complimentary medicine, to familiarise themselves with the Act so that they can apply its principles and procedures when they treat a person who lacks capacity, as most of them will at some point.

M's diagnosis is a matter of some controversy. E gives the following summary of what she claims to be the diagnosis:

Dr Khouja in his report for the first Court of Protection proceedings concluded that M has autistic spectrum disorder, with a mild to moderate learning disability. In his evidence in these proceedings Dr Carpenter was in broad agreement, giving a diagnosis of childhood autism, but thought that his learning disability was in the severe to moderate range.

Dr Carpenter also considered the various other diagnoses that had been suggested over the years. I shall review his observations about the physical diagnoses later, but at this stage I record his comment on the diagnosis of "regressive autism" which was mentioned at various points in M's history and is still cited by his parents as part of the diagnosis. Dr Carpenter points out that there is no such formal diagnosis in the international classification systems, although it is a term often used informally to describe the regression that can occur at about aged 16 to 20 months. He noted that it was mentioned as a diagnosis by the Royal Free Hospital in March 2001 and concluded that this was a reasonable statement having regard to the history supplied by the parents. Dr Carpenter stated that about 25% of children with autism have a history of regression which has over the years been attributed to a variety of external causes, including at one stage the MMR vaccination. Dr Carpenter says that no single external cause has been identified to explain this common regression, which may be a consequence of normal maturation within the brain and in most cases does not indicate an external brain insult. Dr Carpenter noted that there had been different accounts of M's development in the first two years of life and, in particular, the date on which he was perceived as deteriorating. I shall recount his assessment of the history in more detail later. Assuming the account of his normal development, followed by a dramatic regression is true, Dr Carpenter describes regressive autism as "an informal, unofficial subcategory", which fits the picture. He adds, however, that the contemporaneous notes show no such regression, although there was a lack of progress.

As for the other elements of the diagnosis that pertained to impairment of the brain or mind as quoted by E, Dr Carpenter stated that the phrase "pervasive developmental delay" was a more general term used at the time of Dr Baird's assessment in 1992 and should not be seen as an alternative diagnosis. Furthermore, he dismisses the use of the phrase "severe somatic and pragmatic language and communication disorder" as adding anything to the diagnosis since there is no evidence that he has communication difficulties going beyond those to be expected in someone with childhood autism. Dr Carpenter bluntly concludes that M has childhood autism and that anything else should be seen as a euphemism.

An assessment of capacity was carried out by Dr Khouja in the earlier proceedings and reviewed by Dr Carpenter in these proceedings. They reached similar conclusions. Dr Carpenter's impression from meeting with M, the accounts of the staff and the past assessments is that he has been very well trained to do things through rote learning. It is, however, much less clear whether he understands what he is doing and why or when to use what he has learned. Dr Carpenter considers that his apparent low level of understanding is masked by his rote learned skills. With some things M is clear, for example, when he refuses things, but Dr Carpenter finds it telling that lengthy work with advocacy and speech and language therapist has still only enabled them to establish some basic understanding. Frankly, Dr Carpenter has severe doubts that he can reliably communicate any complex decision.

This is one aspect of the case where there is no substantial disagreement. It is not disputed that he lacks mental capacity to litigate these proceedings, to make decisions relating to his residence and his contact with others or as to his medical treatment, nor is it disputed that he lacks mental capacity to make decisions relating to his dietary or nutritional needs or to have biomedical supplements or engage in medical therapies. Dr Khouja concluded that he was able to make a decision from a list of options presented to him in relation to choices of food, diet and activities and also whether to go home for weekend visits. Dr Carpenter accepted that he had the capacity with regard to food but not other activities or weekend visits. However, decisions as to activities involving an assessment of risks and consequences and decisions about going home are, in Dr Carpenter's phrase, "fraught with value-laden issues." Both Dr Khouja and Dr Carpenter thought that, in those areas where M had capacity, he should be actively supported and given the opportunity to make choices in accordance with the underlying principles of the Mental Capacity Act. Both experts identified his communication difficulties as a significant feature. Dr Carpenter identified:

All parties were keen that I should have the opportunity to meet M, and I was pleased to do so. It is often valuable for a judge to meet the person who is the subject of Court of Protection proceedings, although it is important that such meetings should not be used as a way of obtaining the evidence.

I met M in the presence of his advocate on 25th June at W House, the establishment recently opened by C Limited, the owners of his current residential home, N House. As stated above, W House is much closer to the family home and, therefore, to the family and social network and activities with which M is familiar. E and A are anxious that M should move to W House as soon as possible, and indeed sought to argue in the course of the hearing that this move should take place immediately. For different reasons, the other parties are opposed to an immediate move; the local authority because of concerns that E was becoming too close to the manager of W House, and the Official Solicitor because of advice from Mr McKinstrie that the move should not occur until a significant number of the other residents have already moved in, before a full complement of staff have been recruited and trained, routines established and teething problems overcome and a rigorous care plan produced in conjunction with C Limited for the approval of the court.

My meeting with M lasted about 30 minutes. At his choice, it started in the downstairs lounge. M seemed happy and relaxed. His ability to speak was limited but, with his advocate's assistance, using communication tools, including pictures, he was able to tell me about his journey to W House and that he liked certain sports and computing. From photographs he pointed out and named members of his family and other residents and support workers at N House. Later, when we went into the garden, M spent some time on the trampoline, which he plainly enjoyed. My abiding impression of M is of a warm and friendly young man who clearly enjoys life. I can well understand why his family feel so strongly about him and want to do whatever they can to ensure that he gets the most out of life. It is manifestly right that everything should be done to bring this about, for example, by helping him to access a wide range of activities, as he has done in the past when living at home.

The local authority asserts that E has stated that M is suffering from numerous conditions, the overwhelming majority of which are not true, and has subjected M to unnecessary tests and interventions and/or lied about his illnesses or tests.

In analysing the evidence about an assessment of the case, I shall focus on a few specific examples of instances in which it is alleged that E has given a false account of M's medical condition.

The issue of M's reaction to the MMR vaccination and whether it was the cause of his autism lies at the heart of this case. E and A insist that M had a devastating reaction to the MMR, that his autistic traits date from that time and that this provides clear evidence in support for the Wakefield theory. On the other hand, it is alleged by the Official Solicitor, in particular, but also supported by the local authority, that E and A have fabricated the account of M's reaction to the vaccine and thereby falsely sought to establish a link between the vaccine and his autism.

As I stated more than once during the hearing, this case is not an inquiry into whether there is a link between the MMR vaccine and autism. The relevance of this issue is whether the account given by E, in particular, of M's reaction to the MMR, is true. Nonetheless, it is necessary to outline briefly the expert evidence that I have received about the possibilities of a link.

I have already described the history of the controversy in the summary above. The prevailing medical view is as set out information published by the World Health Organisation - actually produced by E in the hearing - which states that:

Dr Carpenter reached the conclusion in his report that the diagnosis of M's autism as having been induced by the MMR vaccine is inconsistent with the independent contemporary evidence and, therefore, not viable. He notes that M's parents did not link his apparent regression to the MMR injection until after the publication of Dr Wakefield's paper in 1998. Dr Carpenter has carried out, as requested, a full analysis of the medical records and found that the first account of M deteriorating immediately after the MMR vaccination was not given until 2001. E's subsequent accounts of M's reaction to the vaccination - of a child developing normally prior to the vaccination and thereupon having seizures, screaming fits and declining into a vegetative state for six months - is incompatible with the other records. There is no mention of adverse effects or any reference to a bad MMR reaction in the GP records. Dr Carpenter notes that a few months after the MMR, the GP records show M being described as hyperactive, which Dr Carpenter points out is inconsistent with the account of his being in a vegetative state. When a change of GP took place a few months later, there was no note of any recent adverse event being recounted to the new doctor. If M had been in a severely regressed state at this time, Dr Carpenter would have expected this to have been mentioned to the new GP. Furthermore, 21 months after the MMR, when giving a detailed account of his development to Dr Baird, no mention was made by the parents of any deleterious reaction to the MMR. On the contrary, their account concentrated on an earlier deterioration after an illness at age 10 months - seven months before the MMR was administered. In cross-examination by E, Dr Carpenter said that any adverse reaction to the MMR vaccination which had caused a regression in M's development would have been recorded in his 24 month developmental check and it was not. What was recorded was not regression, but a lack of progress.

After the allegation of an adverse reaction to MMR was eventually recorded in 2001, it became more dramatic in subsequent accounts. Thus, in 2001 the description was: "Distressed after injection. Had fever. Eyes glazed, dilated and fixed." E's account became more florid over time, with references to screaming, jolting, spasming and a persistent vegetative state. In her final statement she said that: "M died within six hours of the MMR." In the witness box she gave a full account of the events on the day on which the MMR was administered and M's reaction to it. E acknowledges in her final statement that she uses certain words and phrases in her own particular way. For example, for her the phrase "vegetative state" means "slipping in and out of consciousness, not responding and appearing lifeless." And her use of the word "died" to describe what happened to M means "stopped breathing and lost consciousness". For E, her use of these words and phrases is as valid as the way in which they are used by medical professionals.

For some time E has alleged that part of M's medical record is missing. The inference that she invited the court to draw was that pages had been deliberately removed to conceal contemporaneous records of his reaction to the MMR. It is now clear that no part of the records have been removed. One page of the records was missing and copies produced by E and A, but the original record was intact. I am not going to speculate on the reason why the copies produced by E and A are incomplete.

If M had an experienced an extreme reaction to the vaccine, as now alleged, it is inconceivable that E and A would not have sought medical advice and thereafter told all doctors and other medical practitioners about what had happened. As I put it to E in the course of the hearing, there are only three possible explanations for what has happened. The first is that E did give the account to Dr Baird and all the other practitioners at every appointment, but each of them has negligently failed to record it. The second is that she gave an account but all the practitioners have chosen not to include it in their records. That is what E maintains has happened, alleging that the whole of the medical profession is deliberately concealing the truth about the MMR vaccine. The third is that E has fabricated, or at least grossly exaggerated, her account.

Mass negligence can obviously be discounted. In my judgment, it is also completely fanciful that the whole of the medical establishment had decided to act deceitfully in the way alleged by E. I therefore conclude that the account given by E as to M's reaction to the MMR is fabricated.

For the purpose of this case, it is unnecessary to make any finding as to why it has been fabricated. It is unnecessary to explore whether E truly believes that M reacted in the way she now alleges. It is notable that A also, apparently, adheres to the same account, although he is noticeably more reticent in his evidence about it. The key point for the purposes of this case is that E has fabricated her account of a crucial aspect of M's medical history and thereafter relied on this false account to direct the course of his future treatment.

As recounted above, part of M's diagnosis as expressed by E is that M has autistic enterocolitis, or leaky gut syndrome. Just as this case is not an inquiry into whether there is a link between the MMR vaccine and autism, so also it is not an inquiry into whether there is a form of colitis associated with autism. I note, however, that in his report Dr Carpenter advised that autistic enterocolitis is not a recognised condition. It was put forward by Dr Wakefield, and is now discredited and withdrawn by The Lancet paper, and no independent peer review paper has been published subsequently to confirm the findings of colitis in autism. Professor Williamson described autistic enterocolitis as "a controversial entity".

E has repeatedly stated that M was diagnosed with enterocolitis at the Royal Free Hospital in 2001. In his report, Dr Carpenter observed that, if this is the case, then it must have occurred at an examination that is not contained in the Royal Free records and not communicated to the GP. He was unable to find any evidence in the papers disclosed to him to support the parents ever having been given a formal diagnosis of enterocolitis. The Royal Free tested for gluten free sensitivity and bowel inflammation but found no evidence of any anomaly other than constipation.

Professor Williamson also noted that, unlike some patients seen by Dr Wakefield and his colleagues, M was not given the label of autistic enterocolitis. In his careful analysis of the relevant medical records, Professor Williamson found no evidence to support an organic disease of the gastrointestinal tract in M, with the sole exception that, according to the doctors at the Royal Free who saw M in 2001-2, when they were reporting accounts given by his carers, M's bowel habit had alternated between diarrhoea and constipation. Professor Williamson noted that M had had none of the typical symptoms of inflammatory bowel disease. In his evidence, Mr Shattock disagreed, suggesting that constipation was a symptom associated with gut disorders seen in persons with autism. On this point, I was concerned that Mr Shattock was speaking outside his sphere of expertise, but it is of little consequence so far as this hearing is concerned.

Throughout the hearing, E insisted that M had been given the diagnosis of autistic enterocolitis or leaky gut syndrome and alleged that some of the Royal Free medical records must be missing. I reject that assertion. I find that not even the Royal Free team, who at that time were leading the way and postulating the link between autism and a form of colitis, found any evidence in 2001 of significant gut disorder in M. In his case no diagnosis of autistic enterocolitis or leaky gut syndrome was ever made.

I therefore find that on this point E has, again, given a false account of part of M's medical history and thereafter relied on this false account to direct the course of his future treatment, in particular with regard to diet and nutritional supplements.

The clear evidence of Dr W, the family GP, was that M did not have Lyme disease. Although he was not instructed as an expert witness, it is significant that Dr W's clinical practice has included experience in rural areas where he has come across cases of this condition, which is caused by a tick bite. He advised that it is a diagnosis based on biochemical testing in the context of the overall clinical picture. I therefore conclude that he has the expertise to give a definitive opinion as to whether M was suffering from it, and I accept his evidence that M was not.

E, on the other hand, did not accept Dr W's view and persisted in obsessively pursuing her theory that M was suffering from this disease. Her unshakeable view was based initially on two newspaper reports of women who were diagnosed with the disease that had gone undetected for some time. She thought the mark on M's leg had been caused by just such a bite. Her fears were stoked by comments from Ms Haywood, speaking about a matter in which she was completely unqualified, who warned that testing carried out by British laboratories was inadequate. At her suggestion, E therefore insisted that samples be sent abroad. The results suggested that one marker consistent with, though not diagnostic of, Lyme disease was present in one sample. On this basis E maintained that M had indeed had that condition and continued to include it in summaries of his health history. For example, when he was admitted to hospital in August 2013 for the dental extraction, E said that he "had tested positive for Lyme disease".

I accept Dr W's evidence. M did not have Lyme disease. This is yet another example of E giving a false account of M's medical history. In this regard she was supported by Ms Haywood, who showed no doubt in the witness box about her ability to express an opinion about Lyme disease without having any appropriate qualifications.

On 21st June 2012, E took M to the family dentist’s surgery suffering from pain. The regular dentist, DC, was not at work, so M was examined by a locum, Ms Malik, who works regularly at the surgery. Ms Malik had not originally been scheduled to give evidence at the hearing before me but was located at the last minute and duly called by the Official Solicitor.

Ms Malik's computerised record of the examination stated that M had complained of pain and that E had been informed by his support worker that he had not been eating well on the previous day. On examination she found slight tenderness in tooth upper left 6. An x-ray was taken and revealed that he had an area of periapical infection. Ms Malik was shown the x-rays in the witness box and confirmed the diagnosis. The records indicate that she told E that M needed to be assessed urgently for extraction or root canal treatment under general anaesthetic and that E said that she would like to monitor it for now as M was unable to have a local anaesthetic. The records further indicate that Ms Malik offered antibiotics for M, but E declined. Ms Malik said that she had told E to make a further appointment to see DC when he returned to the surgery.

It is E's case that Ms Malik has given a false account of this examination. E says there was no mention of any periapical infection or abscess, but instead Ms Malik had told her that there was a problem with M's sinuses. She denies that there was any talk of root canal treatment or extraction or that antibiotics were offered. E put this version to Ms Malik in oral evidence, who emphatically stood by her evidence: she had not mentioned sinuses.

Two days later after M was examined by Ms Malik, E called an out of hours doctor about M because he had pain and facial puffiness. When M was examined by the doctor, E reported that he had been seen by a dentist who, according to the doctor’s record, said he had sinusitis. In court, E denied using the word "sinusitis" but said that she had told the doctor that the dentist had said there was a problem with his sinuses. According to the doctor's note, on examination the doctor did not detect any definite tenderness in the sinuses, but after E said that M would not definitely say if there was tenderness, the doctor recorded the diagnosis as "likely sinusitis" and prescribed antibiotics. When M returned to X College and Z House on the Monday after Ms Malik's examination, a diagram was provided (now at page N202 in the bundles) showing the sinuses and recording that the x-rays taken on 21st June had indicated no tooth or gum infection or decay, no nerve irritation, but swelling of the sinuses and pressure from a ruptured wisdom tooth. This was completely at odds with what Ms Malik said she had advised E. On 27th July 2012, M was seen by a different dentist at a surgery close to Z House. On examination nothing untoward was detected. It seems likely, as suggested in evidence by Ms Malik, that the antibiotics prescribed by the out of hours doctor on 23rd June temporarily alleviated the symptoms. E requested that no radiographs be taken at the examination on 27th July. In oral evidence, Ms Malik told the court that a clinician would need to see x-rays to diagnose the presence of abscesses.

In due course, on 23rd May 2013 - some 11 months after Ms Malik's examination - E took M to a different surgery not far from the family home called The Tooth Fairy Holistic Centre, where x-rays confirmed the presence of periapical areas in upper left 6 and 7, indicating the presence of abscesses - confirmed by a surgeon to whom M was then referred and who then subsequently extracted the teeth under general anaesthetic.

E's case is that Ms Malik is lying about her examination on 21st June 2012 and that she somehow altered the communication on the computer record. I completely reject that submission. I found Ms Malik to be an utterly truthful and a reliable witness. At one stage in the hearing, E suggested that the records had been falsified and Ms Malik had lied to the court because DC was concerned about his surgery being sued for negligence. For that reason, DC was called by the Official Solicitor, although in the event E did not put it to him that he had falsified the records. When DC gave evidence, he described Ms Malik as an excellent clinician to whom he had entrusted his patients as locum for many years. I accept Ms Malik’s account of the examination and what she said to E. Amongst the many revealing details is her note that E had told her that M could not have a local anaesthetic. It has been E's case that she is allergic to local anaesthetics following an incident when she was younger, for which there was no independent evidence, and that this has been inherited by M. Ms Malik's note, therefore, contains something that E must have told her.

It follows that this is yet another example of E giving a false account of part of M's medical history and thereafter relying on this false account to direct the course of his future treatment.

In this instance, it is possible to trace the consequences for M of this fabricated account. In ignoring Ms Malik's advice, failing to make an urgent appointment with DC on his return, taking M to another dentist, failing to give a full or accurate account to that other dentist and expressly declining further x-rays which would have been likely to reveal the abscesses, E was solely responsible for allowing M's infected mouth to go untreated for over a year, thereby condemning him to further pain and suffering as the area of infection gradually got worse. Throughout the period of 14 months between Ms Malik's examination and the eventual surgery to extract teeth, M suffered pain, repeatedly described by E, which Ms Malik advised in evidence was probably caused by the abscesses. Meanwhile, as I find, E pursued other increasingly extreme theories for the causes of M's pain, none of which has any basis in fact, at a time when she knew or ought to have known that the cause of the trouble was the dental infection which she was concealing.

On any view, this was deplorable and dangerous behaviour. M was and is a highly vulnerable young man, totally incapable of communicating his needs. E was his deputy and carer. He was dependent on her. She failed to protect him and acted in a way that was plainly contrary to his interests.

The history shows other examples where E gave descriptions of M's health, notably to KH, but also to others, for which there was no independent supporting evidence. These include that M had lost sensation in his hands and feet; that he was suffering from an adverse effect to electromagnetic energies; that he had been diagnosed with what appeared to be brain seizures; that his urinary system had shut down; that he was finding it difficult to walk very far; that M's immune and nervous system were down; that he had tumours in his gum sockets; that he had been diagnosed with chronic blood poisoning; that he had a black shadow sitting on his left sinuses that he had black gunge oozing from every orifice. Other diagnoses put forward by E and dismissed by Dr Carpenter were: rheumatoid arthritis; heavy metal poisoning (based again on an isolated test result when such a diagnosis turns on repeated elevated levels); and a defective blood brain barrier. I share Dr Carpenter's astonishment at reading E's account of how M had attended a cranial osteopathy appointment which:

Many of these were repeated, along with others, in the document entitled, "Overview of M's health" which E attached to the application at the start of these proceedings seeking the summary dismissal of the local authority's application. I find that these were all false, or at least grossly exaggerated accounts of M's symptoms. During the period June 2012 to September 2013, when this crescendo of false and exaggerated reporting took place, M was subjected to a large number of different tests, examinations and assessments, a number of which were invasive and all of which took up his time which would have been better occupied elsewhere.

It is unnecessary to go into these or other examples in any greater detail. The local authority's case on this aspect is plainly proved. I find that E has stated that M is suffering from numerous conditions, the overwhelming majority of which are not true, and has subjected M to unnecessary tests and interventions, and/or lied about his illnesses or tests.

Relying on the professional view of Dr Beck, supported by Dr Adshead, it is asserted by the local authority that this amounts to factitious disorder imposed on others. I shall return to this assertion at the end of the judgment. Before doing so, it is appropriate to consider the other findings sought by the local authority.

The local authority alleges that one aspect of E's control of M's life is over his diet and supplements. This is linked to its allegation that E has exposed him to unnecessary alternative treatments and therapies.

Autistic spectrum disorder has generated a vast medical, scientific and other literature, much of it on the subject of alternative and complimentary treatments. Once again, it is important to emphasize that this case is not an inquiry into the efficacy of diets, supplements and alternative treatments and therapies, either generally or specifically for people with autism. The issue to be determined in these proceedings is whether E has acted in M's best interests by insisting that he is placed on a strict diet, that he receives a range of daily supplements and undergoes a range of treatments and therapies. It is right, however, that I should outline briefly the evidence put before me as to the efficacy of diets, supplements, treatments and therapies given to M at E's behest.

As stated above, E distinguishes between "mainstream medical" opinion and "mainstream autism" opinion. In her view, each is equally valid. That view is plainly shared by others and the validity claimed for alternative treatments and therapies is not confined to autism, but extends to many other diseases and health abnormalities. In the case of autism, however, the popularity of such treatments seems to be greater because, as Dr Carpenter observes, there is no "cure". The only approach that has consistently worked, according to Dr Carpenter, is concentrating on education and training and improving skills. There is, therefore, a greater incentive for people - in particular, parents facing the arduous task of managing an autistic child - to search for anything that might help. As this case demonstrates, there are plenty of people offering help. Whether what they are offering is truly helpful is debatable. Dr Carpenter in oral evidence observed that no medical treatment has been identified that stands up to scrutiny and most of the evidence of the impact or therapies is anecdotal rather than robust, double-blind research science.

Dr Aitkin is a proponent of the use of alternative treatments in cases of autism. He contended that there are no standard approaches to the treatment of all individuals with autism. There are a number of accepted processes, depending on the clinical presentation, but no agreed prescriptive evidence-based approach that is universally endorsed. He stated that a large number of clinical conditions requiring specific approaches to treatment have been identified as affecting some groups of people with autism. Mr Shattock is another proponent of alternative treatments who, through the Sunderland Protocol, had developed a strategy for determining the effectiveness of individual treatments.

In his closing submissions, Mr Bagchi observed that many people with no relevant mental impairment undergo quasi-medical therapies or take nutritional supplements because they hope and believe that it may promote their health and well-being, even if conventional medical science cannot establish the effectiveness of the treatment. Those people are able to weigh up the advantages and disadvantages of such products and therapies and make free choices about their own health. Even if there may be limited physical benefits of such therapies, there may be a beneficial psychological effect in terms of a person's sense of well-being. Clinicians speak openly of the placebo effect of certain treatments. Mr Bagchi submitted, however, that the position in relation to a mentally incapacitated person is quite different. A person like M, without the mental capacity to make his own decisions about health care or diet, is unable to weigh up the advantages and disadvantages of any particular therapy or supplement. He is reliant upon others to decide whether he should be given the treatment in his best interests by family members, clinicians and, where appointed, a deputy. It can be accepted that in this context “best interests” may take account of factors other than clinical or medical benefit - as observed by Baroness Hale in the Aintree case (supra). There must, however, be a clear benefit.

Dr Carpenter observed that most of the dietary and nutritional therapies given to M are ones that he has experienced with other patients over the years. He has not objected to them being used in most cases. He also observes that E appears to have normally sought professional help when using therapies; that she has not devised treatment protocols without advice. He adds, however, that he found little evidence that E carried out what he would expect a best interests decision-maker to do when using non-conventional therapies for an adult who does not have capacity to choose for himself: namely, (a) draw in as wide a range of advisors as possible, and (b) ensure that the therapists are fully aware of the medical history. Dr Carpenter is very concerned that the therapists in this case were not given copies of any diagnostic reports but were, rather, given accounts of how the MMR vaccine had induced a vegetative state and a diagnosis of enterocolitis, which was not supported by any contemporaneous medical records.

Dr Carpenter also criticises E for failing to question the reason and purpose of any of the therapies or interventions used or seek unbiased evidence about their effectiveness. He is concerned at the lack of evidence that E looked at the arguments against therapies, as well as the arguments for. He is concerned at the apparent inadequacy of some of the assessments prior to starting therapy. He is also concerned at the apparent lack of monitoring of the effects of therapies. He notes that, despite the lack of evidence that any of the supplements work, the number and manner of taking them has been allowed to grow so that they now seemingly dominate M’s life and care regime. It is the quantity and intensity of the supplements given to M that causes concern for Dr Carpenter rather than any single supplement.

For a number of years, until his placement at N House, M was on a gluten and casein free diet. The efficacy of this diet for people with autism is a matter of controversy. Dr Carpenter quoted the guidelines issued by NICE in 2013, which he helped to draft, which recommended against the use of exclusion diets such as gluten or casein free diets for the management of core features of autism in children and young people. He cites research published by "Research Autism", which he described as a generally respected organisation that attempts to review the evidence of main treatments and interventions in an unbiased manner and which concluded:

A different opinion was expressed by several witnesses called by E and A. Mr Shattock said that excluding gluten and casein from the diet had been reported as leading to measurable improvements in a high proportion of subjects, though in some instances the improvements were minor and not worth the effort, cost or possible disruption to life. Those reports are, however, based on the impression of parents and carers rather than any scientific analysis. Mr Shattock conceded that the benefits of the diet are clinically unproven and frankly acknowledged in his report that, had he been on the NICE committee himself, he would not have been able to disagree with the negative conclusion as to the use of such diets for people with autism. Dr Aitkin said that in general there are several reasons why such a diet might be considered as part of a management approach in an individual with an autism diagnosis and not merely used as a placebo. He cited research that suggested that such a diet is safe if properly adhered to and that there is some limited evidence of benefit. Some individuals with autism showed improvements on such a diet, for reasons other than a casein or gluten free intolerance. Again, however, the evidence of such improvements is the subject observations of parents and carers rather than any clinical or scientific analysis. Ms Haywood, however, was clear that there is now overwhelming evidence about how much autistic people benefit from a gluten free diet.

In M's case, there is no clear evidence that being on a GFCF diet is beneficial. The notes of the Royal Free Hospital recorded on 18th March 2001 that E had tried M on such a diet, but by January 2002 the hospital was recording that “he remains on a normal diet as there were no improvements in his behaviour or bowel habits on a gluten and dairy free diet” and there is no evidence that the Royal Free made any subsequent recommendation that he be put back on that diet. The diet was subsequently reintroduced unilaterally by E without positive medical approval. Professor Williamson regards it as a "telling fact" that, since M became resident at N House, he has remained in good physical health despite eating a normal diet, free of any restrictions and devoid of any of the numerous supplements that he had previously been obliged to take. On the contrary, he is eating well and gaining weight. When Professor Williamson saw him, he thought that he looked in excellent physical shape. Professor Williamson advised that, if M can stay well after a restricted diet, vitamins and minerals, it provides “strong evidence to suggest that they are unnecessary."

For Dr Carpenter the key feature was that the reason given for M being on a diet - that he had a diagnosis of enterocolitis - was fallacious. In those circumstances there was no good reason for his diet being restricted in this way. It seems plain that those who advised E about the diet, in particular Ms Haywood, assumed that the diagnosis of enterocolitis given by E was correct. The concern about the insistence of the diet in this case was, therefore, not so much about the use of the diet per se, (which is plainly not uncommon amongst people with autism, notwithstanding the clear view expressed in the NICE guidelines), but, rather, the fabricated diagnosis which led to the diet being imposed.

If the only alternative treatment therapy provided to M had been the GFCF diet, there would be relatively little concern. But it was not. Rather, it was one of a multitude of treatments given. In her final statement, E described M as an:

Dr Carpenter quotes the NICE guidelines again as not recommending the use of such supplements for the treatment of the core symptoms of autism in adults. He notes that: “Research Autism” observed the evidence of nutritional supplements being untested or incapable of being proved and, therefore, it was not a treatment that they could recommend. Dr Carpenter notes, however, that most of the supplements appeared to have no known toxic overdose limit. He acknowledged that he is not an expert, although he expresses concern in general about how over the years the number of supplements delivered to M has increased dramatically and how the rigidity of instructions given for the supply of the supplements produces what he describes as unnecessary behaviour and choice restrictions of M.

I accept Dr Carpenter's opinion on this point. There is no evidence that the supplements caused physical harm, but I am not persuaded that there is any reliable evidence that they cause any benefit. The important issue is the manner and the quantity in which they were prescribed, without proper objective analysis, to a young man who lacked capacity to make decisions about whether or not to take them.

This approach to supplements was replicated with other treatments and therapies. By and large, it is the sheer range and number of the treatments and their indiscriminate use on an incapacitated person that gives rise to concern, rather than the risk of any harm befalling the individual. I accept Dr Carpenter's evidence that there is no evidence that cranial osteopathy, rheumatology, colloidal silver or homeopathy generally are clinically beneficial. In the case of some treatments, they may have been harmful. I accept, for example, Dr Carpenter's evidence that there may be concern about the use of auditory integration therapy. He quoted NICE as finding no good evidence that such therapy works. Research Autism quoted research evidence to say that such therapy was not helpful in improving perceptions of autism, although it may be of limited use in the help with sensory problems. Dr Carpenter was concerned, however, that people with hearing loss or infection or damage to the inner ear should not be treated in this way. Dr Carpenter observed that, for M, who has recurrent ear problems, such therapy was potentially dangerous. Equally, he was concerned about the use of oxygen therapy. In his report, his concern was about the use of hyperbaric oxygen therapy, which is associated with risks to ear and teeth, and would have been potentially risky to M. Throughout the hearing, E stated that the oxygen therapy had not been hyperbaric, although I note in her final statement E said at paragraph 245 that M “uses a hyperbaric oxygen chamber for health reasons." The main concerns about oxygen therapy in M's case were, first, the sheer degree of interference with the life of an incapacitated adult required to have oxygen administered to him for up to six hours a day and, second, the question of the theoretical process for the therapy provided by Dr Julu - neurodevelopmental dystautonomia - which is not mentioned in any international classification known to Dr Carpenter.

I accept Dr Carpenter's opinion that there is no evidence that any of these treatments were individually beneficial for M and that collectively they were intrusive and contrary to his best interests. M's life was increasingly dominated by the programme of treatment to the exclusion of other activities. I find that E has implemented a programme of diet, supplements and treatments and therapies indiscriminately, with no analysis as to whether they are for M's benefit, and on a scale that has been oppressive and contrary to his interests. She has exercised total control of this aspect of M's life.

I stress, again, that I am not making any definitive findings on the efficacy of alternative treatments generally. That is not the subject of these proceedings, which are about M. I do, however, find that: (1) there is no reliable evidence that the alternative treatments given to M have had any positive impact on people with autism generally or M in particular and (2) the approach to prescribing alternative treatments to and assessing the impact of such treatments on people with autism in general and M in particular has lacked the rigor and responsibility usually associated with conventional medicine.

This demonstrates the fallacy of E's belief that there are two parallel approaches to the diagnosis and treatment of autism - "mainstream medical" and "mainstream autism" - each of which is equally valid. The evidence in this hearing has demonstrated clearly that there is one approach - the clinical approach advocated by Dr Carpenter - that is methodical, rigorous and valid, and other approaches advocated by a number of other practitioners, for which there is no evidence of any positive impact and which (in this case at least) have been followed with insufficient rigor. Whilst each treatment may be harmless, they may, if imposed collectively and indiscriminately, be unduly restrictive and contrary to the patient's interests. These disadvantages are compounded when, as in several instances in this case, insufficient consideration is given by the practitioners to the question of whether a mentally-incapacitated patient has consented to or wishes to have the treatment.

The local authority asserts that E has exercised an unacceptable level of control over M during his periods in residential care and subsequently, and that she is unable to work with the local authority social workers and residential home staff. E and A deny the allegations of excessive control, assert that E is a devoted mother who has at all times acted in the best interests of her son, and complain that the local authority has relentlessly pursued its own agenda of seeking to remove M from their care, enlisting the support of residential home staff to that end. It is convenient to consider the evidence on these issues together. The local authority claim that its evidence disclosed a pattern, with each placement having a honeymoon period at the start, followed by a deterioration as the staff struggled to cope with E's demands and her insistence on controlling every aspect of M's life. The parents responded by claiming that the true pattern was staff at all the homes were acting under the pressure of the local authority to fit in with their overriding agenda.

The evidence from Y House staff was that they found E controlling and difficult throughout M's time there. CS, the manager of the home when M arrived, described how E was very demanding and tense throughout the whole process of moving M into the property, and thereafter would purchase all his food, provide a detailed weekly menu, check the food cupboards every week, provide cleaning and laundry products, with guidance on how to use them, supply a large box of supplements and alternative remedies to be given to M and leave a large number of Post-it notes in M's room and the kitchen giving further instructions. On a weekly basis, the home would receive an email setting out E's concerns and raising issues about M's care. Any failure to follow the guidelines would lead to a phone call and further work. Dealing with these issues was extremely time consuming, to an extent that they came to dominate the staff's work. CS had never previously been expected to communicate with family members to this extent.

On one occasion, when E had not received immediate attention because CS and his colleague, PL, who was M's key worker, had been attending to another patient's medication in a locked cupboard, E, according to CS, started screaming and shouting outside the cupboard in the hearing of M and other residents. As a result, she was asked to leave the property. When cross-examining CS, E implied, without expressly asserting, that CS and PL had acted improperly in some way by administering medication to a resident in that way. E's behaviour, according to CS, affected the mood of the staff. In the end, CS found the difficulties of managing her and the parents of another resident - in fact, the couple who E called in evidence at this hearing - impossible and decided to leave the job.

The evidence of the staff at Y House was that, once E had been appointed M’s deputy by the Court of Protection, she used this position to assert even greater control. Staff felt that the deputyship was impeding M's choices in a number of ways, including diet, clothing and social activities. RR, the agency's operations manager, spoke of how E had been unhappy that M was expected to do activities with some of the other less able residents. She objected when staff used the word "peers" to describe the other residents, explaining that in an email to RR dated 19th April 2011, quoting the dictionary definition of "peers" and adding that: “we usually do ignore 'ignorance' as knowing no better" and asking her to arrange a training session to enlighten staff on this matter. As stated above, a major issue at Y House arose over the parents refusing to allow M to be registered with a local GP. PL said in evidence that all residents in any care home require a local GP so that they can access the local services that are channelled through NHS referrals. PL, who took over as acting manager, was particularly concerned that M was being denied his own voice, for example, in the question of whether he should have a local GP. He said in evidence that he is a believer in the importance of advocacy for people with learning disabilities and had, therefore, referred M to an advocacy service. He said he felt that M needed an advocate because his life was being controlled by E and he needed to have his own voice. In cross-examination of PL, E suggested that the purpose was not to give the service users a choice but, rather, to take the voice away from the parents and family members. PL did not accept that this was so. He said that he wanted to help M to live his life to the full.

The evidence from staff at Z House was that relationships deteriorated after a relatively cordial start. CH, who took over as manager during the course of M's time at the home, described how difficult it was working with E as deputy. Information had to be passed through E rather than directly to the local authority. CH was unhappy at this restriction. In cross-examination, E put it to CH that she had never mentioned her deputyship to him. He disagreed. It was his evidence that every aspect of M's life was under E's control. The amount of documentation provided by E, setting out guidelines to be followed, was more than CH had ever experienced. CH felt that this was unduly restrictive of M's life. For example, whereas other residents could choose what they ate, M did not have that opportunity. Instructions were given as to the contents of the drawer in his room. He had so many supplements that they had to be stored in their own cupboard. Health reports were provided every week. Sometimes CH would receive a long email from E which he would read carefully. He said that it became quite difficult for him to manage and still give time for the other residents and staff. Staff found E difficult and said that when she visited it was like treading on eggshells. They felt threatened and anxious. Other residents also resented the long hours that E was present at the property, and at their request a policy was drawn up which set down fixed visiting times.

KH was a junior member of staff who was a classroom assistant at X College and was allocated to work with M at Z House in the last few months. CH said that KH had a great relationship with M. KH confirmed that staff and other residents had felt anxious about E's presence and he described how M would also be at his most anxious when his mother was there. He thought that he had a good relationship with E and A and described how E had offered him a job helping to look after M at home. KH described how on one occasion he had heard M say "Mummy ruined my life." Given M's communication difficulties, I do not draw any conclusions from that evidence. KH said that he found E intimidating and said that on one occasion she had said to him that she knew he would not mess with her "because Z College have learnt" and that she would sue the local authority.

According to the staff at Z House and the local authority evidence, the placement had finally come to an end when the staff refused to comply with E's direction to give more pain relief medication than the recommended maximum, whereupon E took M home. E denied that she had made such a request and claimed that her decision to remove M had been made because of concerns that his health was not being attended to properly at the home. After M left, KH was sufficiently concerned about him that he rang every week to check on his health. He has given a detailed account of his conversations with E during these calls in written notes and stood by this account in oral evidence. In cross-examination, he denied that he had been trying to give evidence against E to impress his employers. In his evidence, E suggested to him that it was he who had raised the possibility that M might have cancer because he, KH, had been tested for a bowel problem. KH said that no such conversation had ever taken place. He reiterated that it was E who told him that the dentist had found a tumour. He also stood by his note which recorded that E had asked him to arrange an autograph book for M from everyone at X College and Z House to sign and that she had said "so, if he doesn't pull through, it's something he can take to the grave."

The evidence from the staff at N House was that E and A found it very difficult accepting the restrictions placed on them after M had been removed from their care following the order of 6th March 2014. AA, the owner of the agency that runs the home, recorded in his statement that, whilst A had remained focused on spending time with his son, E had become increasingly demanding and challenging during the visits. E and A secretly recorded some of their sessions at N House. AA was alarmed that this had happened. He was very concerned that staff had not been asked and that there was a risk that the confidentiality of other residents might have been compromised. Matters came to a head when a visit was terminated early because of the way, it was alleged, that E had treated a junior member of staff - AR - who had been asked to supervise a contact session and to make notes about it. E told the solicitor then acting for her, in an email that she has voluntarily disclosed to the court, that they could not have chosen someone more insulting and offensive if they had tried. Thereafter, AA refused to permit the parents' contact to take place at the property.

In her statement, AR described E as being patronising and rude to staff and how she verbally pushed A out of the way when he attempted to talk to staff. Most of the time when she had been supervising visits had been spent by E asking questions. In cross-examination, E accused AR of spending most of the time during the visits on the phone. AR did not accept that this was so. On one occasion, AR had been sitting in her car outside the home when E and A approached her unexpectedly. They had arrived and were unable to get into the home. In her oral evidence, AR said that she felt very intimidated on this occasion, in particular by E. She described how they had banged on the window of her car. She described in detail what E and A had asked and what she had done to try to get someone who was on duty to see them. E put it to her that she had fabricated her account in order to fit the local authority's agenda. She denied that this was so.

AA's evidence was that, generally, M was doing very well at N House. His parents, however, accused the staff there of neglecting him and said that, because of the ill-treatment and poor diet he was then being allowed, he had put on weight and his health had deteriorated. A GP local to N House, with whom he has been registered, has seen him during this hearing and reports that, although he has put on weight, he remains in the healthy weight range. In cross-examination by E, AA denied that he was making the situation look rosy to justify the decision to remove M from home, or that he had tailored his evidence out of a desire to maintain his commercial relationship with the local authority. He accepted, however, that he had identified as a potential issue that other residents had moved in and were causing a noise that may have an adverse effect on M.

The evidence from the local authority social workers was that E was uniquely challenging and difficult. JR told the court that this was the longest-running and most expensive case in the experience of this authority's adult services team. It was for that reason that two senior members of staff had been assigned to this case after MS withdrew because of the complaint made by E and A. The local authority had statutory duties in respect of M and it was in carrying out those duties that the social workers came into conflict with E. JR said that it was her preferred approach to work with families to support young people for whom they have statutory responsibilities. E put it to JR that, since the outcome of the judicial review proceedings, the local authority has pursued a vendetta against them. JR denied that this was so.

LG described how she had checked out the complaints made by E about the quality of care at Y House and found that they were unjustified. It was suggested that it was naive of her to trust the home staff. LG disagreed. There had been a process undertaken before the contract had been approved by the local authority, as commissioning body, to check to see if there were any safeguarding issues. The CQC reports about the unit are publicly available. LG corroborated the evidence given by several others that E had used her deputyship to restrict the local authority access to information. That was what she had been told by staff at Y House and was also her own experience. LG conceded that sometimes there might be a small element of truth in some of E's complaints, but they were exaggerated out of all proportion.

It is LG's evidence that, after M was removed from Z House, she sent emails to E on several occasions but received no reply. She visited on two occasions, was denied access on the first occasion but saw M on the second, when he seemed in good health. It has been E's case that she did not receive the emails. She endeavoured to argue that the reason had been because of the way her address had been written at the top of the email.

Following the incident which led to the cessation of contact at N House, the local authority put in place protocols setting out the basis upon which contact could take place. JR said that she had done this because of the escalating problems with E's behaviour at N House and in order to try to make arrangements which would enable contact to take place. She rejected the suggestion that the wording of the protocol was inappropriate and designed to cast E in a bad light. The Head of Adult Services, MW, denied that the local authority had an agenda to assert power over the family because it was providing funding for the family. It was his evidence that, with the deputyship, E had adopted the position of wanting to be in total control.

In response to all these allegations by care home staff and the social workers, E, supported by A, asserts that she has done nothing wrong other than fight for her son's best interests in a reasonable way. She asserts that all three residential homes have been neglectful in their care of M in different ways and set out to undermine her relationship with her son. She is particularly critical of Y House, complaining that he acquired fungal infections and ringworm, was unshaven and unwashed and generally unkempt and that his clothes were shrunken and creased and stained. She describes Y House in her final statement as:

In her statement finally filed towards the end of the hearing, E reiterated and expanded her case set out during the hearing and during her questioning of various witnesses: she asserted that the aim of the local authority was “to dehumanise me and render me irrelevant." Various reasons for the challenge to her deputyship were alleged in this statement, including a mutual interest and a tension between the local authority and service providers to conceal service failures; to prevent the involvement of the CQC; to misrepresent M as more able than he is; to enable the local authority to take over decision-making powers in respect of M; to prevent E and A escalating their complaint at the way in which their complaints had been investigated; retribution for the local authority's loss of credibility following the various earlier judicial review proceedings; and various financial reasons, including gaining access to M's benefits.

When evaluating the evidence at this point I cannot avoid having regard to the way in which E cross-examined the various witnesses. At times I found her manner towards the witnesses intimidating, in particular to the junior members of staff, such as AR and KH, but also towards CH and, indeed, JR. During her cross-examination of JR, in particular, E became increasingly strident and angry, accusing her, for example, of violating her deputyship behind her back, using M as a pawn to get at E over the last three years and of getting to know him better so that she could, in E's phrase - "kidnap him”. JR calmly denied all the increasingly extreme allegations put to her by E.

In contrast, E adopted a different tone while examining MS, the social worker allocated to the case in the first few months after M went to Z College. MS was a notably assured witness who was not at all intimidated by being cross-examined by E. She rejected the suggestion that she had been motivated against E and A because her husband had been passed over for promotion in favour of A. She described how E had become angry with her. E then became agitated, accusing her of telling lie after lie. MS remained calm. She denied that she had been pursuing any agenda or that she had retaliated against E after a complaint against her had been made. In her final statement, E described MS as "a very nasty, incompetent and unprofessional person." In her supplemental closing submissions filed this morning, E asserts that, "The social workers' obsession is to punish me" and adds that "they seem to take a sick pleasure doing so."

In assessing the witness evidence, I take into account that not every relationship between E and a professional is fraught with difficulty identified by the local authority. Although there has been little evidence about it, I am satisfied that the relationship between E and the staff at X College was mostly better than her relationship with the social workers and care staff. In her final statement, E says that she and A both had "an exceptional working relationship with everyone throughout M's 13 years of specialist education." Another example is their relationship with the family GP, Dr W. Having heard Dr W in oral evidence, it is clear to me that his relationship with E was more subtle and nuanced. He had no concerns from his own experience that M was coming to harm in her care and he appreciated the great challenge facing any parent looking after an autistic child. He was critical of E's inaccurate use of medical terminology when describing M's symptoms, and he adopted what he described, as I have already said, as a defensive approach. So far as I can see, whilst he tried on a number of occasions to dissuade E from taking a certain course, there was no occasion when he challenged her outright on any issue that mattered. As a result, they maintained a relatively good relationship. The local authority and the Official Solicitor submit that the reason for E and A's reluctance to agree to M having a local GP when he was living at Y House was because they found Dr W to be emollient and unchallenging. E has also been on excellent terms with a number of alternative practitioners, but I am satisfied that is because they have not challenged her but rather tended to support her uncritically, reinforcing her beliefs and in some cases feeding her anxieties and prejudices.

I also take into account, importantly, that all parents who, after caring for a disabled child for many years decide that he should move into residential care, must find the transition very difficult. It is not surprising, having had no dealings with social services at any stage in their lives, that the involvement with the local authority in 2007 and onwards has required E and A to make adjustments. Many people who are obliged to seek the assistance of social services find it irksome and bureaucratic. At home the young person will have received devoted personal attention. He will have been the main focus of his parents' lives. They will have done everything within their power to give him whatever he needed in his best interests. It is inevitable that, however well run a residential home, the move into residential care will involve making compromises. The quality of care will not be quite the same, the attention will never be quite as personal and there will not be quite the sense of devotion that a parent can give. Such a move will be very difficult, particularly in the case of a home catering for disabled adults, each of whom will have different and special needs.

I do not doubt the devotion which E and A feel for their son. In some ways his life at home was far richer than could possibly be achieved in any care setting. The range of activities arranged for him was plainly very stimulating and beneficial. I am sure that in some respects the quality of care given to M at the three residential homes was inferior to that he received at home. In such circumstances, it is only to be expected that parents may complain about some aspects of the care offered to their beloved son. A degree of criticism would not be surprising and, indeed, would be expected, but the level of complaint and criticism, in particular of Y House, goes far beyond what might normally be expected and far beyond what is supported by most of the evidence, in particular the evidence of LG, a very experienced local authority senior social worker, whose evidence I accept. I find that the level of criticism made by E and A is grossly disproportionate and unjustified.

I should record one minor point on which it is appropriate to criticise JR, arising out of the instruction of Dr Delamont. He prepared a report at an early stage of the proceedings and it was the local authority's case that this had been at the instigation of the parents. E and A denied that this was so, and when an inquiry was made of Dr Delamont, who did not give oral evidence, he replied that the request had come from JR. JR subsequently apologised for misleading the court and the parents on this and explained in a further statement that she had forgotten about a conversation with Dr Delamont. I accept her apology and her explanation. I do not find that she was deliberately concealing information from the court. In any event, this is a relatively unimportant detail in the wide-ranging issues in this case.

Having heard a number of witnesses, I am now in a position to form a clear view as to what has happened with regard to these issues. Without exception, I accept the evidence of the social workers and care staff. Where their evidence conflicts with that given by E, I prefer their evidence and reject that given by E, and indeed A. I find that E has not told the truth about a large number of matters. For example, I find that she has grossly exaggerated the deficiencies in the standards of care at Y House. I am sure that they were not perfect, and no doubt some care staff were better than others, but the picture painted by E in her evidence is completely distorted and inaccurate. I find that she repeatedly referred to her deputyship in dealing with social workers and staff, including when speaking to CH, in order to impose her will. I find that staff and some residents at Y House, Z House and N House have found her difficult and intimidating.

I accept KH as a witness of truth as to his accounts of dealings with E and, in particular, his accounts of phone conversations after M was removed from Z House. E and A assert that KH has a tendency to elaborate and sensationalise situations. I exonerate him from this charge. I found KH to be a careful and truthful witness who was plainly motivated only by concern for M. I accept his evidence as to the content of his phone calls with E in the months after M left Z House. As those phone calls demonstrate, it is in fact E who has a tendency to elaborate and sensationalise situations. After the conclusion of the evidence, E sought to introduce extracts from her diary which, although alluded to in the course of the hearing, had not been disclosed, which purported to support her account of her dealings with KH. I do not accept that these extracts from the diary, if genuine, undermine the reliability of KH's evidence. I accept AR's accounts of how she found E's behaviour difficult and threatening at N House.

I reject E's account that she never received the emails sent by LG after M was removed from Z House. There are a number of email exchanges in the papers - see, for example, at N600 to 618 - in which her email address has been written in exactly the same way as in the emails to which LG referred and to which E has responded. E's explanation about this was wholly implausible and I have found it to be untrue. I found that she did receive these emails and chose not to respond. I find that E has a fanatical desire to maintain control over her son's life and there is little she will not do to achieve it. I find that E has restricted the access of professionals to M, for example, by seeking to prevent the staff at Y House from speaking to the local authority social workers, by scuppering the proposal that he should have an advocate and by refusing to allow him to be registered with a GP local to Y House. E’s practice is to look for professionals and others who are biddable and compliant and then use them for her own ends. She bombards professionals with written instructions and emails in order to get her own way. If challenged, she will threaten and intimidate and, if that does not work, she will launch a professional complaint.

Furthermore, E’s attitude to professionals led her to secretly record conversations with a number of those instructed in this case, including Dr Beck, Dr Adshead and Mr McKinstrie. All were highly critical of her acting in this way. Dr Adshead described this as a symptom of a state of mind associated with mistrust and antagonism. Dr Beck said that this level of mistrust was an element of E's narcissistic personality disorder. Mr McKinstrie described it as "highly unethical". He added that to record a conversation that he had had with M was more than unethical. As Mr Bagchi observed in closing submissions, E:

Moreover, I find that E has grossly abused her position as deputy, to control M's life and to restrict the roles of the professionals. Indeed, I find that this was the very reason why she sought to be appointed deputy in the first place - as her application asked to be appointed his "lifelong custodian" and specifically asked the court to decide that “lifelong advocacy is also included in this role unless otherwise delegated by me." She expressly said in the application that she wanted to be able to take decisions "without the influence of external pressures or distractions". This is completely contrary to the underlying purpose of deputyship under the 2005 Act, as described in the Code of Practice and previously reported cases.

I reject the parents' case that the local authority has been motivated by a desire for revenge after the outcome of the judicial review proceedings, or by a desire to get control of M and his money. The social workers have not been vindictive, nor malicious, nor cruel, nor vengeful, nor callous. They have tried to do their job, meeting the local authority's statutory responsibilities to M, in the most difficult circumstances, caused entirely by E's completely unreasonable behaviour. In 35 years of family law and in the Court of Protection, dealing with many hundreds of families, I have rarely, if ever, come across someone who is so difficult to work with, who presents so many challenges to hard working professionals and who takes up so much of their valuable time and resources.

I therefore make the findings sought by the local authority: that E controls all aspects of M's life and does not allow him to develop his independence, restricts access to M and information about M and is unable to work with professionals. In closing submissions, Mr Bagchi submitted that this degree of control was unnecessary, unreasonable and constituted a suppressing effect on M's life. I agree.

I therefore return to the question of whether this is a case of factitious disorder imposed on others.

Dr Adshead provided some background information about this disorder. She advised that it is not a diagnosis of an illness from which people "suffer". The term is, rather, used to describe highly abnormal behaviours in relation to health care professionals, demonstrated by a person who has responsibility for another person. To date, such abnormal behaviours have been most commonly described in mothers who have care of dependent children, but they have also been seen in nurses and in those who have care of the elderly and other vulnerable adults. In essence, the key feature of the disorder is that the person who has care giving responsibility elicits professional health care in one of the following abnormal ways.

Dr Adshead advised that abnormal behaviour of types (1) and (2) is probably common and may go undetected. The commonest forms of abnormal behaviour are giving exaggerated or false accounts of symptoms. There is, obviously, an overlap of those mothers who have unusual levels of health anxiety, who tend to misinterpret any symptoms as a sign of dangerous illness. Abnormal behaviour of types (3) and (4) are probably less common and are detected by clinicians who are familiar with some of the recent presentations in the literature. Detecting these behaviours is, however, often extremely difficult. The commonest presentation is by a mother of a young child with limited verbal ability. Perpetrators are not typical of criminal offenders in general or even other maltreating parents. They often have features of good mental health and physical health and no previous contact with the criminal law. Dr Adshead stresses that it is important to emphasize that perpetrators do not "have" factitious disorder; they are exhibiting behaviours which may or may not be associated with a psychiatric diagnosis. In one study half the mothers were recognised as showing abnormal illness behaviour on their own account and slightly over half were diagnosed with having a borderline personality disorder. However, a substantial sub-group had no underlying psychiatric diagnosis and it is important to emphasize that there is no direct connection between any psychiatric diagnosis and this behaviour. There is little published evidence available on the treatment of perpetrators. They tend to deny any such behaviour and disclosure and acceptance usually takes place over time in the context of support and therapy. If there is an identifiable mental disorder, then treatment of this probably increases the chance of an ongoing relationship with the child. However, it has been described by Dr David Jones, the well known child psychiatrist, that abnormal illness behaviour by proxy is a bad prognostic sign in terms of family reunification.

If it was established that E has exaggerated M's condition and/or made false claims about illnesses that he does not have and/or given him medication that was unnecessary and/or obstructed a normal relationship with health care professionals, Dr Beck and Dr Adshead both concluded that it would then follow that factitious disorder imposed on other people has taken place. Both Dr. Beck and Dr. Adshead observed that the degree of contradiction between E’s claims and the medical records record indicates a pattern of abnormal illness behaviour which seems to have escalated in the last few years. The nature of the diagnoses put forward are couched in increasingly dramatic narrative terms but are not supported with corroborative medical evidence.

Dr Beck believes that the underlying driver for the mother's factitious disorder is that she is suffering from narcissistic personality disorder. Dr Adshead agrees with Dr Beck that there are significant features of personality disorder in E's presentation, mainly narcissistic and histrionic features, and, in addition, Dr Adshead suspects that she may have some feature of an emotionally unstable personality disorder. As a psychiatrist, Dr Adshead reported that she had seen no evidence that E suffers from a severe mental illness. Dr Beck and Dr Adshead both thought that M's health care and his identity as an illness sufferer is a key part of his mother's relationship with him and that M's health status clearly dominates that relationship. Dr Beck expressed the view that the mother's desire to find other people to blame appeared to serve functions for her. First, it distracts from her own shame (self-imposed) and, secondly, it draws attention to her and her own needs. Dr Beck concluded her first report by observing that, whilst she did not doubt that E loves her son, she does not believe that she is capable of putting his needs above her own.

Dr Adshead advised that, if the facts are proven that support the accounts of factitious disorder imposed on another, together with a diagnosis of personality disorder, this provokes questions of further future risk and how the relationship between carer and a dependent other should be managed in the future. In her experience, the risk of harm to the dependent other is real, especially if the carer has no insight, although the nature of the harm may not necessarily be severe or dangerous. Having seen there is a real risk, it should be fairly clear that the risk can be managed if E is prevented from being the person responsible for M's care. Once a carer is removed from the role of a carer, there is usually no danger in the carer and the dependent other spending time together. Dr Adshead advises, however, that in such circumstances there must be a proper health care plan put in place, overseen by a senior health care professional. It is Dr Beck's recommendation that all of M's health needs hereafter should be overseen by the local authority. Dr Beck agreed that there would be the real risk of an emotional mental and physical nature were M to return to live with E. She also believed that M's access to opportunities to make choices and grow as an individual would be curtailed.

I accept the opinion evidence given by Dr Beck and Dr Adshead. I find that E's behaviour amounts to factitious disorder imposed on others. It was suggested by E in the course of the hearing, relying on material available on the internet, that the diagnosis was made without justification, as a means of attacking mothers of children with autism with a view to removing them from their care. I have no reason to believe that there is any basis for this assertion, but it certainly does not apply in this case. I am sure that the diagnosis of factitious disorder in this case is valid.

Whilst it would be desirable to make final orders and bring these proceedings to an end, I have concluded that that outcome is not possible at this stage. The course I propose to take is to make further interim orders and list the matter for review once the parties have had a chance to digest my findings on a date in the week of 8th September, in London, to be fixed by the Clerk of the Rules in consultation with counsel's clerks, with a time estimate of two hours. In view of the complexity of this case, further interim orders may then be required postponing the final decisions to a later date.

In making decisions as to M's future, I remind myself again that I must have regard to the principle that such decisions must be made in M's best interests and I must apply s.4 of the Act in so far as it is relevant to this case. I must have regard to M's wishes and feelings, to his beliefs, to the beliefs and values that would be likely to influence his decision. In view of his limited capacity as analyzed above, I accept Mr McKinstrie's opinion that it would be unwise to form any opinion as to his wishes based on a single remark or when he has been encouraged to express particular views. What is known is that he has not expressed a consistent wish as to where he wishes to live in the future. I accept that family life is important to him, as is the aim of helping him to achieve his maximum potential. The court must also have regard to the views of his family. E and A wish their family, culture and values to be respected and for M's right to a family life to be upheld. They ask that as soon as possible M be returned to the family home.

Mr McKinstrie identifies several advantages of a return home. First, M clearly has a longstanding affectionate relationship with his parents and sister and they continue to be important people in his life. Furthermore, each is committed to M and in supporting him in what they consider to be his best interests. The family home is a known environment for M and he has established routines that are familiar to him. Furthermore, if he went home he would be able to access activities in the community that he has previously attended and enjoyed. As Mr McKinstrie recognises, however, these advantages are manifestly outweighed in this case by the disadvantages which flow from my findings. It is inevitable that, were M to return home, he will be subjected to the same regime as before in which his mother sought to reimpose control over all aspects of his life. Furthermore, it is likely that she would continue to misrepresent his state of health and expose him to unnecessary examinations and treatments. It is inconceivable that M could return home unless E demonstrates a fundamental change of attitude.

I accept that A and S are devoted to M and want what is best for him, but I conclude that they are completely under the influence of E as to what should be done, blind to her faults and, therefore, unable to protect M from the risks that would arise were he to return home. As Mr Bagchi observed in closing submissions, A has become so enmeshed in E's view of the past that he has been unable to protect M from his mother in the past and his lack of insights into her difficulties and the risks she may present offers little confidence that he would be able to do so in the future. As for S, it is notable that she has not played any active part in these proceedings until late in the day. I am unclear about S's role and position in this family in recent years. This is a matter which may merit further investigation by the local authority in due course.

As to the alternatives, Mr McKinstrie reaches the clear view that a move to W House is the best option for M. It is a large, detached house with four floors each of which has their own separate living space. There is also a shared communal lounge for the whole house on the second floor. There is capacity for up to 12 residents. The intention is for each floor to have people with similar needs to each other. People with the most complex needs are to be on the first floor, whereas the two bed-sits on the top floor will be available for people with more ability. It is proposed that, were he to move to W House, M would occupy one of those two bed-sits. Within each bed-sit there is a kitchen range, a sofa and a single bathroom to be shared between the two bed-sits. W House is intended to support young people at a transitional stage of their lives. A quarter of the staff are already in post and the rest are being recruited. The plan is to build a permanent staff team so that the property does not have to depend on temporary or agency staff. It is not proposed that W House should be a permanent home. It has been set up with the intention of assessing and assisting young people to maximise their potential to live as independently as possible and then support them to move to live in supported housing or similar in the community.

Mr McKinstrie does not consider that there are benefits for M continuing to live at N House for any longer than the short-term. W House is managed by the same provider as N House and so this would provide some continuity in the approach, care and support. The current staff at W House have spent time at N House and have therefore become familiar with M. W House is more spacious than N House and able to offer M a greater variety of living areas. M spent time at the property and staff at W House and family members have begun the process of building relationships focused on M. Finally, W House is relatively close to the family home and would provide M with the opportunity to renew some of his local activities and contacts, as well as making contact with his family easier.

There are some disadvantages to W House perceived by Mr McKinstrie. It is a larger property, so there would be times when the environment is busy and noisy - a disadvantage to M given his acute perceptual awareness. In addition, W House is a new, untried residential unit and the staff are new and still being recruited. Furthermore, it is not known who the other residents will be and, in particular, there is no other person yet nominated for the second bed-sit on the floor where M will live. The size of the staff group and the number of residents may mean that he is not always supported in a person-centred way as would be desirable. Overall, however, Mr McKinstrie indicated that he thought the benefits of a placement at W House outweighed the risks. The property is intended to support people of his age and ability, the stated ethos is to encourage young people to move on and to be able to live more independently, consistent with the long-term plan for M. The bed-sit property seems particularly ideal for that purpose. It would be a long-term planned placement for M and potentially allow for stability to enable him to move in a further planned way into supported living accommodation within two years. Living at the property would provide him with the option of attending day services that he has attended in the past and revisit past friendships.

In his oral evidence, however, Mr McKinstrie added that M should not move to W House until certain things had been established. First, it was important that a significant number of other residents move into W House first and that a full complement of staff be recruited and trained, routines established and teething problems overcome. In addition, there should be a rigorous care plan approved by the court. None of these steps have yet been achieved so, relying on Mr McKinstrie's oral evidence, the Official Solicitor suggests that it is premature for the court to sanction a move to W House.

In the course of the hearing the local authority, which had initially been very supportive of a move for M to W House, became increasingly concerned about the relationship between E and the manager of the home. In final submissions, Miss Bretherton indicated that the local authority did not support an immediate move but proposed instead that the local authority be given time to explore other options. It is the ardent wish of E and A that M move to W House as quickly as possible.

I have decided that it is too soon for the court to reach a conclusion whether it is in M's interests to move to W House. The next move will undoubtedly be of crucial importance. If it is, indeed, the aim that he should move into a form of supported living - and happily this is one issue on which all parties seem to agree - it is vital that his next residence should be able to equip and prepare him for that move. W House may be the best resource to achieve that and it has the added advantage that it is close to his home so that, if he moves there, contact arrangements will be easier and he will be able to access some of the activities he enjoyed when living at home. But I accept the views of Mr McKinstrie, the Official Solicitor and the local authority that, for different reasons, now is not the right time for such a move.

I have therefore decided that, for the time being, he should continue to reside at N House. I have thought carefully about the strong views of his parents that he should not stay there. Having considered all the evidence, including that of Mr McKinstrie, it seems that it is better for him in the short-term to remain there. Although it is not an ideal place for him, I do not accept that he is suffering harm there and I agree with Mr McKinstrie that a precipitous move to W House will be counterproductive. This placement is intended only as a short-term option while decisions are taken as to where M should live in the medium-term pending a long-term move into supported living, as supported by all parties, it seems.

This court has not been addressed at this hearing on the question whether or not his current placement amounts to a deprivation of liberty. I do not propose to analyze that issue in this judgment. Instead, I shall simply declare that in the interim, in so far as the placement amounts to a deprivation of liberty, the same shall be lawful. In their final submission, E and A asked that the

“DOLS [by which they mean the Deprivation of Liberty Safeguards under Schedule A1 of the 2005 Act] imposed upon M is removed whatever the outcome of these proceedings and with immediate effect as M does not deserve this. It is shameful that this was insisted upon by those who purport to have his best interests otherwise."

I do not understand this submission. The purpose of a declaration that M is being deprived of his liberty is to protect M, not stigmatise him. If necessary, this issue can be revisited at the next hearing.

So far as contact is concerned, I note that, following the difficulties that arose at N House, arrangements were varied so that contact now takes place once a week for four hours at W House and a further session for two hours within the community near to N House at weekends. Mr McKinstrie noted, and I agree, that it is clear that, since contact moved away from N House, it has been a less intense and more constructive experience for all concerned. There continue to be tensions, but they are at a lower level and supervisors have been able to manage things differently by having an external focus to the contact. I agree with Mr McKinstrie that it would be in M's best interests for contact to continue to take place in the community.

As for the future, Mr McKinstrie stresses that E, A and S continue to be significant people for M and it is important and in his best interests to be supported to maintain these relationships. He warned, however, that contact will only continue to be in M's best interests if it is not secondary to or subverted by tensions between E and others. Mr McKinstrie advises that contact should be face to face rather than indirect and there should be a clear understanding between all parties that contact sessions are to allow M and family members to spend time together, that there should not be any discussion during contact of how M is cared for or supported or his health or other issues concerning his future plans. Furthermore, Mr McKinstrie advised that contact should continue to be supervised directly to mitigate any potential risk to him from the arrangements and ensure that the conditions attached to contact visits are followed. Supervision should only be relaxed as a result of a review of arrangements and when there is confidence that all parties are able to maintain the conditions attached to contact. Mr McKinstrie does not at this stage consider that contact should take place at the family home.

On the issue of supervision, Dr Beck expressed a different view. She advised that, if no observer was present at contact and E were allowed contact only on the basis that she was fully compliant with a set of guidelines, Dr Beck thought that E would be much less able to exercise control or protection. She would therefore be interested to see how short periods of unsupervised contact between M and his family worked. She thought that unsupervised contact in a fixed place was less likely to be antagonistic to E. I understand Dr Beck's point but on the issue of supervision I am firmly of the view that Mr McKinstrie is right and that all contact should for the time being remain supervised. Until the next hearing M should continue to have supervised contact with his parents twice a week as he has done in the course of this hearing. I also agree with Mr McKinstrie that the local authority should carry out a risk assessment of all contact arrangements. There should be a contact agreement signed by all parties and a clear process for reporting and monitoring the work of the arrangements.

I turn to the question of deputyship. It is plain from my findings that E has grossly abused her position as deputy, and there is no question of her being reinstated. She is the last person who should be entrusted with that responsibility, and her application to be restored as deputy is refused. The question arises whether there is a need for a deputy to be appointed at all, either for M's personal welfare care or for his property affairs. Both the local authority and the Official Solicitor question the need for any deputy having regard to the legal framework in the Mental Capacity Act and the guidance in the Code of Practice and previous reported cases.

So far as property and affairs are concerned, I agree that a deputy is probably otiose. M's financial affairs are relatively straightforward and can be managed by an appointee. I therefore invite the parties to identify, and if possible agree, an appointee. So far as a personal welfare deputy is concerned, I reiterate what I said in G v E, at paragraph 58, that:

Mr McKinstrie made some sensible suggestions about the practical arrangements for future decision-making in this case. It is important to remove as far as possible the opportunity for misrepresentation by any party. To assist in achieving this, all communications should be formalised and recorded. E and A should be a party to relevant information concerning M and should receive any formal communications that concern him. They should also be included as a matter of course in any formal assessments or reviews of his health and social care needs and in planning for his future, with their views taken into account as part of those processes.

The local authority and the Official Solicitor suggest that Dr W should no longer be M's GP, on the grounds that he has been over-influenced by E and that there is a possible conflict of interest as he remains E's own GP. The issue does not arise for consideration at this stage as M will remain at N House for the time being and should, therefore, remain registered with his current GP. The question of who should be his GP in the event that he returns to a placement nearer to the family home can be decided at a later hearing.

It is unnecessary for the court to make any detailed decisions as to M's health management at this stage. I shall give directions as appropriate for a supplemental report on that issue to be prepared for the next hearing. At this stage I merely give these directions. First, as just stated, I direct that M should continue to be treated by the GP local to N House as necessary. Secondly, I conclude that he should receive a tetanus booster injection if in the opinion of the GP such an injection is in his best interests. His parents are opposed to all vaccinations, but their opposition stems from their erroneous view that his autism is attributable to the MMR and that he is the victim of what E calls "vaccine assault". There is no objective reason why M should not have an updating tetanus inoculation and, if he is going to take part in outdoor activities such as farm visits, there would seem to be every reason why he should have it. If his GP recommends that he has the booster injection, then this court will give its approval. Thirdly, I direct that his diet shall be in accordance with the practice at N House and any recommendations by his GP. I am sure that the staff at N House will allow M an element of choice as to what he eats - that being an issue on which, as Dr Khouja and Dr Carpenter have found, he has limited capacity. I would be grateful if counsel would draw up an order reflecting these directions and submit it to the Clerk of the Rules by 4 p.m. on Thursday 14^th August, with a request that it be forwarded to me.

There are three residual matters that I should mention, about which I am not making orders, at this stage, despite requests from the parties. First, there are ongoing financial issues between the local authority and the parents. Those have not formed a central part of this hearing and I make no findings or orders about them at this stage, but I foresee that they may have to be considered at the next hearing or in due course.

Secondly, E and A seek the lifting of what they call the "gagging clause", namely, the order made at the hearing on 11th March 2014 and subsequently renewed, that they should not publish or disclose any information relating to the proceedings to any person, including any media organisation, save for their legal representatives. For the time being that order will remain in force, but I will in due course hear submissions that any party wishes to make as to the lifting of that provision and as to the lifting as to the confidentiality which attaches to all Court of Protection proceedings unless otherwise ordered, and also as to the imposition of any further injunctions. I remind all parties that the proceedings in the Court of Protection are held in private and information may not be disclosed without the court's permission. I also indicate that I propose that a transcript of this judgment be published in accordance with the President's recent guidance, suitably anonymised to protect M's privacy.

Thirdly, E and A have requested that the court takes steps to recommend an independent inquiry into the use in this country of the Urabe strain of the MMR vaccine. I suspect that part of their aim in this litigation has been to bring about such an inquiry. I do not propose to make any such recommendation, not least because, as I have found, M's case has nothing to do with the MMR vaccine, save in the false accounts given by E. Suffice it to say that nothing has emerged in the course of this case to undermine the prevailing view quoted above that the overall evidence clearly indicates no association between the MMR vaccine and autism.

This court acknowledges the enormous demands placed on anyone who has to care for a disabled child. Even though such carers are motivated by love - and I accept that both E and A love M and are deeply devoted to him - the burdens and strains on them are very great. Every reasonable allowance must be made for the fact that they love their vulnerable son and want the absolute best for him. Every reasonable allowance must be made for the impact of these burdens and strains when assessing allegations about the parents' behaviour. However, having made every reasonable allowance for those factors, I find the behaviour exhibited on many occasions, by E in particular, was wholly unreasonable. I agree with the insightful observation of the independent investigator appointed to consider the parents' complaints in 2010 quoted above. E and A do feel that their mission has meant having to fight every inch of the way, against health and legal services and, more recently, social care services. This has influenced the extent to which they are able to work in partnership with statutory agencies. As they have such clear ideas about all aspects of M's life and believe the conclusions they have reached about him are correct, it is understandable that they have had difficulty in accepting the views of others where they differ from their own. However, their attitude and approach has far exceeded anything that could be considered as reasonable.

E’s friends admire her determination to stop at nothing to get M the care, support and long-term achievement he deserves. Unfortunately, I find that this determination has led her to behave in a devious and destructive way, relentlessly criticising, occasionally bullying, repeatedly complaining about those who do not follow her bidding. Throughout this hearing she has repeatedly accused the local authority of pursuing its own agenda. I find that it is she who has an unshakeable agenda to follow her own course in pursuit of her own beliefs about M's condition and how it should be treated.

E's allegations of multiple conspiracies are a fantasy. It is nonsense to suggest that there has been a conspiracy by large numbers of the medical profession to conceal the truth about the MMR vaccine. It is ridiculous to suggest that the local authority has pursued a vendetta against E and set out to remove M from his family for financial reasons and that the staff at the various residential homes have fallen into line and in some cases perjured themselves under financial pressure from the local authority. It is delusional to suggest that the Official Solicitor has been motivated in this case by an agenda designed to prevent a revival of the claims arising out of the MMR and to that end suborned experts. The tone of these outlandish claims by E has become increasingly more strident as the case progressed, culminating in the documents filed after the conclusion of the hearing in which she expresses outrage at the conduct of the local authority and the Official Solicitor at the hearing on 6th March, in terms that are barely coherent. In their final submissions, E and A have made a number of further attacks on the integrity of the Official Solicitor, all of which I reject. It is unnecessary to go into any further detail. They are wholly misconceived.

The critical facts established in this case can be summarised as follows. M has autistic spectrum disorder. There is no evidence that his autism was caused by the MMR vaccination. His parents' account of an adverse reaction to that vaccination is fabricated. The mother has also given many other false accounts about M's health. He has never had meningitis, autistic enterocolitis, leaky gut syndrome, sensitivity to gluten or casein, disorder of the blood brain barrier, heavy metal poisoning, autonomic dysautonomia (which, in any event, is not recognised in any classification of medical conditions), rheumatoid arthritis or Lyme disease. As a result of E maintaining that he had these and other conditions, she has subjected M to numerous unnecessary tests and interventions. He did have a dental abscess for which E failed to obtain proper treatment and caused him 14 months of unnecessary pain and suffering. E has also insisted that M be subjected to a wholly unnecessary diet and regime of supplements. Through her abuse of her responsibility entrusted to her as M's deputy, she has controlled all aspects of his life, restricted access to him by a number of professionals and proved herself incapable of working with the local authority social workers and many members of the care staff at the various residential homes where M has lived. This behaviour amounts to factitious disorder imposed on another. In addition, E has a combination of personality disorders - a narcissistic personality disorder, histrionic personality disorder and elements of an emotional unstable personality disorder.

Despite her serious conclusions about E's personality, it is Dr Beck's view that these parents have a lot to contribute to their son if they are capable of offering the care and support he needs under the guidance of an overarching programme of care coordinated by the local authority. I agree that they would have an enormous amount to offer their son if they could work in collaboration with the local authority social workers and other professionals in M's best interests. I have not given up hope that this may be achieved. Such an outcome would be manifestly to M's advantage. It will not be achieved, however, unless E and A – in particular, E – can demonstrate a fundamental change of attitude. If this does not happen, this court will have to take permanent steps to restrict their involvement in his life.