X (Factitious Disorder)

These public law proceedings were issued on 12 June 2019. They concern X who was born on [a date in] 2019, and is now just under 2 years old. Since birth, she has been separated from her mother (“M”); for a few weeks, under a s20 voluntary placement with maternal relatives, and from 16 July 2019 in foster care. It is unconscionable that it has taken the best part of 2 years, the whole of this young girl’s life, to bring this matter to court for a final decision as to her future.

The LA seeks (i) threshold findings and (ii) approval of a Care Plan for permanence of placement outside the birth family. The Guardian supports the LA’s position.

M accepts that the threshold is met, but disputes some of the findings sought which are relevant to the welfare stage and have therefore formed part of my inquiry. She seeks reunification with X on a staged return basis or, alternatively, she would submit to a s38(6) residential placement for further assessment with a view to consideration of reunification thereafter.

The father (“F”) does not have parental responsibility. He has played no part in X ’s life, nor does he intend to do so in the future. He actively supports the plan for adoption. He indicated at the IRH that he did not intend to attend the hearing, and would prefer not to give oral evidence, although he has filed written evidence. No party sought to compel him to do so.

M has been profoundly deaf since birth. In 2006 she had a right ear cochlear implant which is powered by rechargeable batteries. She cannot necessarily hear and understand

She has a number of long-standing physical and mental health conditions:

In addition, in about 2007 (as M says, and the medical records confirm), she started presenting with light headedness, headaches, nausea and vomiting. In 2011, she was admitted to NN Hospital with symptoms of vomiting and dizziness. Testing established an issue around cortisol levels and suspected adrenal insufficiency. According to M, she was told that she was suffering from Addison’s disease, and believed that she was formally diagnosed with Addison’s. She cannot recall exactly who told her so, although she was being treated at the time by Dr G and Dr H. As a result, she was prescribed with medication and trained in injection of hydrocortisone. She was told to look out for signs of Addison’s crisis including light-headedness, dizziness, fatigue, reduced consciousness, headaches, and nausea (which I shall refer to hereafter as “Addisonian symptoms”). Thereafter, M told A&E, treating clinicians and GPs that she had been diagnosed with Addison’s, and she received treatment accordingly. Medical records show multiple crises and admissions to hospital at which M complained of Addisonian symptoms.

It is clear from the extensive medical records that treating clinicians (whether specialists in the field or not) told M repeatedly that she had Addison’s. I was told by Dr I (a SJE consultant endocrinologist) that the term “Addison’s” appears to have been used as shorthand for adrenal insufficiency. Dr I told me that in fact there was never a formal Addison’s diagnosis and described the references in the records to Addison’s as a process by which a word or phrase from the early days came to be misinterpreted to provide what appeared to be an accepted diagnosis. I am satisfied that from about 2011 to early 2021, M authentically believed that she had Addison’s. She was told as much by clinicians. Her medical records suggested she had Addison’s, or at the very least indicated partial adrenal insufficiency, which was loosely, and inaccurately, described as Addison’s; inaccurately because Addison’s is a condition where the adrenal glands are damaged and unable to produce the necessary cortisol, whereas adrenal insufficiency more commonly involves under-stimulation of the adrenal glands.

Until further tests carried out by Dr I in January 2021, it was accordingly understood by M, clinicians, the court, legal professionals, instructed experts, the LA, and the Guardian that M had had Addison’s disease for many years. In fact, it has become clear

The LA, M and the child were all represented by leading and junior counsel. F was represented by junior counsel on the first day of the hearing. Given his support of the LA’s position, F sought to be excused from attending the duration of the hearing or being represented throughout. This had been flagged up at the IRH and was not opposed by the other parties. Accordingly, he played no part in the trial.

An Intermediary report dated 5 April 2021 recommended a BSL interpreter for M, but she preferred to use the services of lip speakers, who also acted as Intermediaries, to assist her. In total, five lip speakers performed these roles in relay during the two weeks because of the exhausting nature of the process. Regular breaks were taken. M had access to a dedicated computer in court which allowed her to see the lip speakers at all times

The hearing took place on a hybrid basis. M, and most counsel, attended in person. The majority of the evidence was given remotely; only M and one social worker gave evidence in the courtroom. The hearing proceeded relatively smoothly, with occasional frustrating technical hitches; I am very grateful to the almost herculean efforts of the staff at the local Family Court who managed, and resolved, all technical issues. The bundles totalled about 15,000 pages, which included voluminous medical records. Counsel were of invaluable assistance and no stone was left unturned. Helpfully, they prepared an agreed Note on the law, which is well-established and uncontroversial, and which I have largely replicated in this judgment.

Shortly before the IRH, which took place one week prior to the final hearing, the parties became aware of an allegation of an indecent nature by one of M’s older children, A (aged 16) against another of her children B (aged 19). Although neither A nor B is a subject of these proceedings, the information was of potential relevance given that it was understood A intends shortly to move in and live with M, although M in her evidence said that A was in two minds about this. That in turn raised concerns on the part of the LA about the consequences for X were she to be returned to the care of M, and possibly find herself in the same household as an alleged abuser from her own family. Given that the incident purportedly took place while both older children were living with M, it also raised question marks about M’s ability to protect X. At the IRH, there was no documentation in relation to the allegation and I made directions for further disclosure including against the police. The possibility of having to adjourn the trial was mentioned, in order to allow for a proper investigation of the allegation.

Upon receipt of the relevant disclosure, it became apparent that the allegation is historic and tied in with previous allegations that A had been involved in acts of abuse perpetrated by his father (M’s former husband and not the father of X). B is ambivalent about pursuing it. The police intend to take no further action and are treating A as a victim, not a perpetrator. The LA expressly disavows any reliance upon this matter, seeking no findings, nor inviting me to take it into account. All parties agreed that there should be no adjournment for further investigation.

M is 37 years old. She was born in NN to parents who separated when she was 18 months old. She moved with her mother and sister to MM when she was about 8 years old. She explains in her written evidence that she had a very difficult relationship with her mother, who found it difficult to manage her. For 2 or 3 years she was placed in a children’s home, after which she moved to live with her father in OO.

M has a history of criminal activity and involvement with the police. Between 1999 and 2018 she received multiple convictions for property related offences, public order offences, police/courts/prison offences and miscellaneous matters.

In 2000 M met Mr R. M became pregnant with their son A. Before his birth in September 2001, M separated from Mr R and moved back to MM to be near her mother. Mr R did not maintain contact. M had other relationships and B was born in March 2005 as a result of a fleeting liaison with another man, Mr Q. M and Mr R resumed a relationship after B’s birth and the family settled in MM before moving back to LL in 2009. B was treated as a child of the family by Mr R. They married in 2009 and had C (born in April 2010), D (born in October 2011) and E (born in October 2013).

Children’s services in LL initially became involved due to M’s frequent attendances at hospital, serious welfare issues about the children (for example, A had been seeing eating from a rubbish bin), alleged domestic abuse between the parents witnessed by the children, and violence allegedly perpetrated by Mr R on A.

D was born 3 weeks premature in NN General Hospital. He had a number of significant and complex medical problems. He had frequent desaturations in oxygen and feeding difficulties. He required mechanical support for his breathing. He remained in hospital for about 9 months, during which period he was moved between hospitals (including to PP Children’s Hospital and QQ Children’s Hospital). While in hospital he was almost wholly cared for by M. He was finally discharged home on 30 July 2012 with a high level of support from care workers.

D, according to M, deteriorated shortly after his discharge, and was readmitted to LL hospital on 2 August 2012. The LA in LL, increasingly concerned about M’s behaviour while D was being treated, issued care proceedings on 3 August 2012.

On 26 July 2013 HHJ Richardson QC, who dealt with all substantive hearings, handed down judgment after a 12-day court fixture, which included 3 ½ days of oral evidence from M. It needs to be read in full. It contains a series of damning findings against M in terms of her conduct, and her veracity as a witness. I propose to summarise some of the core findings, conscious that in so doing I cannot do justice to the highly critical tenor of the judgment;

For some time, the LA considered placement of A and B with the maternal grandmother in MM and a regime of trial weekend contact with her was put in place. The plan was suspended due to the LA’s concerns that the maternal grandmother was not being open and honest with them. A number of fact-finding allegations by the LA against the maternal grandmother were determined by HHJ Richardson QC on 28 January 2014. Again, and by way of summary only:

On 6 March 2014, as proceedings continued in respect of the other children, the judge made further significant findings:

Other judgments were given during the proceedings on discrete matters including interim care orders. The common theme throughout is findings strongly adverse to M. Ultimately, and without hesitation, the judge concluded that the threshold criteria were met and separation of the children from their parents was necessary and proportionate. The children were separately placed, and their current status is as follows:

I pause to take stock and note that this catalogue of findings against M were of the utmost gravity, concluding that she was guilty of a very high degree of harmful, cruel, and neglectful parenting. Although they were made 7 years ago, I must take them fully into account and consider, within the context of all the circumstances, whether M has demonstrated change in her behaviour in the intervening period and, if so, to what degree.

After the case finished, M spent time with her father and then resumed living with Mr R between May and August 2014. In September 2014 she left NN and moved back to the MM area. Her relationship with Mr R ended. She drank to excess. She had relationships with abusive partners, including Mr P and then F. Between 2014 and 2019 there were 26 domestic abuse police referrals, including 13 as between M and F. She continued to engage in criminal activity, including being convicted on 30 May 2016 of harassment of Mr P, and on 7 June 2016 for assaults on a constable for which she received an 18-week suspended imprisonment sentence. She and Mr P attempted reconciliation before final separation in 2017.

In 2016, M alleged that she was raped in Turkey by a Turkish man. She reported this allegation to police in England who took no action due to (i) lack of evidence and (ii) the alleged offence having taken place abroad. During this period, she also alleged rape by Mr P; again, the police took no action.

In October 2017, M and X started a relationship which was, as they both accept, turbulent and volatile. As I have already mentioned, there were 13 domestic violence referrals during the period of their relationship; the records indicated that both parties behaved violently. Police reports refer to the parents being heavily intoxicated at callouts. M in evidence told me that she used to binge drink. In October 2018, M became pregnant with X and the relationship between M and F came to an end. M obtained a non-molestation order against X in November 2018, although the allegations made in those proceedings were disputed in court and never made the subject of findings; the order appears to have been made consensually after an initial without notice hearing. The evidence suggests that M and X have not resumed their relationship, although they have occasionally stayed in contact, and M has been single since.

In the same period, that is to say from the end of 2014 until the end of 2018, M overdosed on about 12 occasions and there was poor compliance with medication. Her chronic behavioural patterns continued. She told her treating mental health team that her symptoms of PTSD and frustration caused her to feel anger and contribute to volatility and turbulence in her relationships. She was offered therapy but between 2015 and early 2019 her engagement with such support was limited and irregular; in reality, she did not commit, and no progress was made as a result. M also failed to be fully open and honest with her mental health treating team:

In this same period M attended at A and E on repeated emergency call-outs presenting with Addisonian symptoms. The records suggest at least 27 such instances; 13 occasions with vomiting, nausea, and headaches, and 14 with unconsciousness or reduced consciousness. This was a continuation of some 22 such Addisonian presentations which had taken place between 2009 and 2014.

In respect of unconsciousness, or unresponsiveness, the records paint a picture of clinical doubt about whether the presentation was genuine. To pick out a handful of examples, which are echoed many times elsewhere:

It is clear to me from all I have read and heard, and not substantially disputed by M, that her lifestyle and relationships continued to be chaotic, abusive, and marked by abnormal behaviour from 2014 until late 2018 or early 2019. She continued to be unable to cope and function appropriately, and her maladaptive behavioural patterns were, as Ms K (the SJE consultant psychologist) explained to me, dysfunctional coping mechanisms triggered by extreme anxiety and stress.

Given the history, it is unsurprising that on 4 April 2019 a pre-birth parenting assessment by the relevant LA expressed concern about M’s mental health, her relationships characterised by domestic violence, and the findings from previous proceedings. Her capacity to change remained in doubt, as was her ability to understand and appreciate the wider impact of her mental health, domestic violence, and exaggerated illness. The assessment did not recommend X remaining in the care of M following birth.

Fairly swiftly, the LA started to form a brighter picture of M’s abilities. The first social work statement dated 21 May 2019 (2 days after birth) said “M has some significant health issues including Addison’s disease” and that “she accepts the majority of the concerns that were raised regarding her parenting by children’s services”. M seemed reflective, acknowledging past mistakes, and believed that her young age when having children had been a negative factor, as had been the abusive relationship with her husband. 5 years had passed. She had separated from F, her home conditions were well maintained, and she felt able to cope. This improving picture set the tone for a number of months.

From, I judge, late 2018 until early 2020 it is clear from the evidence, and was readily accepted by the LA in its opening written presentation, that M made concerted efforts to effect and demonstrate change in her functioning. This process started during pregnancy. She showed signs of progress. I consider that was partly because of having exited a string of abusive relationships, partly because of the sheer joy of having a new baby and partly because of a real desire to try and find a way to keep her baby. In addition, she obtained a job at a pub which clearly increased her sense of worth and self-esteem. There is no doubt in my mind that M’s intentions were genuine. Upon birth, the hospital praised her care of X. She underwent therapy and completed parenting and domestic violence programmes. I note that on 23 October 2019 a hair strand test showed no excessive levels of alcohol between April 2019 and October 2019. She was far more open with social services and other professionals. I was told by the Health Visitor, Ms U, that both before and after birth M was positive about the birth, eager to learn, and engaged with X’s needs. Ms U observed M with X in a supervised context on 9 occasions between birth and March 2020 and found the interaction to be good. In February 2020, a referral was made to Ms V, an Early Years Practitioner, particularly in respect of feeding. She told me that M engaged with her and was eager to learn, albeit such learning had to take place online because of the pandemic. The then social worker, Ms W, praised M’s attitude, willingness to cooperate, receptiveness to advice and generally open demeanour. The current social worker, Ms Y, spoke in similar terms. It was clear to me that the LA formed a more favourable impression of M during the year than perhaps anybody had expected, although it has to be recalled that all M’s undoubtedly warm and loving interaction with X took place with a high degree of support and assistance. The fact that, as Dr I reported, her thyroid tests stabilised toward the end of 2018 demonstrating, for the first time,

The picture, it should be said, was not perfect. We now know from the evidence that M was continuing to experience flashbacks and nightmares at this time, which in turn indicated a continuation of her PTSD, yet she did not share this relevant information with mental health services.

After birth, X was initially accommodated with the maternal aunt and her husband under a s20 agreement with M. Sadly the aunt’s husband suffered a stroke and they were no longer able to care for X. As a result, she moved into foster care in July 2019 and has remained with the same foster carer ever since. She is unquestionably happy and settled, and her principal secure attachment is with the foster carer. As another example of M’s changed approach, she established a good relationship with the foster carer.

Supervised contact with M was initially set at 5 times per week for several hours while X was placed with the maternal aunt. That reduced in duration to 2-hour sessions (still supervised) after the move into foster care, a function of resources rather than any particular concern about M’s behaviour. As a result of the onset of the Covid pandemic, and consequent lockdowns and tier restrictions, it altered to remote contact only from March 2020 to July 2020, during which time M was able to connect only by mobile phone; it seems to me that, for reasons beyond anyone’s control, this must have been unsatisfactory and greatly dispiriting for M, as well as stressful. In July 2020, restrictions were eased sufficiently to permit supervised face to face contact once more, albeit for short periods of time (about 1 ½ hours) and only once per week. I have great sympathy for M, whose contact is now a pale imitation of how it started through no fault of her own. Notwithstanding all these challenges, M has been fully committed to contact throughout, never missing a session.

In general, the observations of contact have been reasonably positive. I was shown some touching and happy videos and photographs of M and X together, and heard evidence about warm interaction. The aspect to which I will return is the need, commented on by the LA’s witnesses, for M to be advised repeatedly about basic care elements such as feeding, playing, and sleeping. M, I was told, was receptive to advice and wanted to engage with it, but she was unable to implement it, or to appreciate X’s cues, and as a result she would have to be prompted time and time again with the same advice. Ms K told me that M would have genuinely wanted to act on the advice, but her deep-rooted anxiety disorder “gets in the way”.

A parenting assessment by Ms W dated 10 September 2019 identified the good progress since the previous proceedings, including better interaction with medical professionals, positive reports from hospital staff, engagement with the LA, and pleasing interaction with X during contact. M appeared to have accepted the previous findings, had attended 6 sessions of CBT and 6 sessions of Integrative Psychological Therapy, and had completed the freedom programme and Safe 4 Life Programme. Nevertheless, M continued to require ongoing support. It was noted that there was evidence in the past of M not coping when under stress and experiencing “profound issues within her life which have impacted upon her emotional state and her ability to meet the needs of her older children….At times of stress and crisis within her life her parenting capacity has

Accordingly, the LA considered that M and X should be placed for 6 weeks in a mother and baby unit. That contemplated residential assessment was opposed by the then Guardian, given the strong findings made in the previous set of proceedings. The Guardian considered the proposal to be premature and over optimistic, and that updated expert evidence from Ms K, who had reported in the first set of proceedings, should be sought. It also seems that not all the previous papers were available. At a case management hearing on 30 September 2019, the court agreed, noting the complexities of the case. The Recorder refused to sanction a plan involving a residential assessment at that stage, and approved the Guardian’s Part 25 application. As time passed, and the scope of expert evidence (initially positive about a residential unit) broadened, the recommendation of the LA for a residential assessment was put on ice, until unfolding events in 2020 meant that it was abandoned altogether. M herself did not make a s38(6) application after the September 2019 hearing, and no such residential assessment has ever taken place. On M’s behalf it is said that there was a missed opportunity at the end of 2019, a window within which round the clock supervision and assessment might have provided the necessary level of observation and support enabling the court to identify needs and contemplate a bespoke rehabilitation plan. I understand M’s frustration, but I am not at all surprised by the Recorder’s decision given the very high level of poor, even cruel, conduct perpetrated by M as found by HHJ Richardson QC previously; an assessment of the sort contemplated needed the firm foundations of expert evidence. As it happens, and with hindsight, a residential assessment would have proceeded on a false basis, namely that M had Addison’s, and would therefore not have explored all the issues which have been canvassed before me arising out of the nondiagnosis and consequential impact on an analysis of her mental health.

It is, at this point, right to record from M’s perspective how initial optimism gradually declined. She had done much right, working meaningfully to re-establish her parenting abilities with X. But events thwarted her. The initial placement of X with her sister changed, through force of circumstances, to foster care. Contact reduced. The LA’s plan for a residential assessment was rejected by the court. Further expert evidence was commissioned. The onset of the pandemic brought a total cessation of face-to-face contact which impacted M’s ability to nurture her bonds with X, and her attempts to prove her parenting skills. Work with professionals did not cease but was conducted largely remotely which no doubt diminished its scope and effectiveness. M herself was required to shield. As I will refer to below, her contact with her older daughter, B, was suspended, again for reasons outside her control. I consider that these misfortunes, not of her doing, will undoubtedly have generated great anxiety and uncertainty in her, and it seems to me that they must have contributed to the re-emergence of M’s previous chaotic behavioural patterns from early 2020 onwards.

It is unnecessary to chart the glacially slow progress of the legal proceedings, largely caused by what appears to have been a piecemeal, and sequential, approach to obtaining expert evidence, and disclosure of medical records. I do not doubt the complexity of the issues involved, but nobody could seriously dispute that this prolonged litigation runs contrary to good practice, mandated time limits, and the best interests of a child who needs finalisation so that her future path is clearly set forth. Even by the time of my first involvement in the case, one week before the final hearing, it was touch and go whether it would be ready for trial. Fortunately, and in no small part due to the considerable efforts of all counsel in the case, the case was ready to, and did, proceed.

Until late 2019 M was having 4 times a year contact with her older daughter B. On or about 16 November 2019, M posted on B’s Facebook page a message (which she swiftly removed) that she (M) was not in a good place and nobody cared for her, which must have been deeply upsetting for B. From 18 November 2019, it was intended that B should receive therapeutic trauma intervention from Barnardo’s. The view of Barnardo’s, supported by social services, was that contact between M and B should cease so as to allow therapy the best possible chance of success. I heard from B’s social worker, Ms Z, and, although the chronology was a little confused, it became clear that on a number of occasions between late 2019 and June 2020 (but not thereafter), and contrary to express advice from social services, M regularly contacted B directly or via her father, MGF. I acknowledge (i) that for M suspension of contact with B was distressing and (ii) since June 2020 she has not contacted B, but by ignoring social work advice she did not act in an appropriately child centred way, particularly given the gravity of the findings made in 2013/2014.

On 25 February 2020 in the early hours M called 999, complaining of shortness of breath, headache and feeling “spaced out”. On an ambulance attending at M’s property, she was unconscious. M remained in hospital until 28 February 2020. Dr N (M’s treating endocrinologist) confirmed that M’s admission was a result of having an Addison’s crisis (blood tests did not show the admission as alcohol related, although the paramedics had suggested this as a possibility and M herself said she had drunk 23 pints of lager at a pub that evening). This was the first such episode since February 2019 and heralded a reversion to the patterns previously apparent.

A number of further such incidents have taken place (I note that sometimes M called 111 and the nature of the call led to an upgrade to 999):

M, as she accepted in evidence, has a history of addiction to medication and the medical records show dependency dating back to 2009. A graphic medical note dated 9 August 2016 records M “on occasion kicking off in custody” as her zopiclone was withdrawn. That addiction, or at the very least high dependency, has continued to the present day. GP records show that M from October 2020 onwards sought, against GP advice, on at least 8 occasions, additional, and stronger dosages of anti-depressant, painkilling and sleeping pill medication, in particular zopiclone. M accepted this history, but told me that she is now weaning herself off it; her next review is in 2 weeks.

In part because of these events, the LA’s position evolved. By September 2020 they had abandoned all notion of a residential assessment and had moved towards a plan for adoption.

Finally, and for completeness, a further toxicology report established no evidence of either cannabis use or excessive alcohol use by M between September 2020 and March 2021.

Because of the evolving circumstances, I propose to record the written expert evidence in chronological order, thus dovetailing it with the chronology of events set out above

Professor J, consultant psychiatrist, prepared a psychiatric assessment dated 12 December 2019; he was instructed in place of the expert from the previous proceedings who was no longer available. His assessment was largely based on M’s self-reporting; he had limited access to medical records. He concluded:

Ms K, consultant clinical psychologist, reported on 16 December 2019 that:

It is, in my view, important to record that, notwithstanding the note of optimism in the reports of both Professor J and Ms K as to the progress of M, they each tempered such optimism with caution as to the risk of relapse and the need to treat a residential assessment as very much a first step. Further, neither Professor J nor Ms K had had

Dr L, consultant paediatrician, in a report dated 30 December 2019 reviewed the medical records of M to consider whether the abnormal illness behaviour had continued. He concluded that:

It was then discovered that these three experts had only had sight of GP records. An order was made on 4 February 2020 for hospital records to be obtained and disclosed to the experts.

The addendum reports of Professor J dated 10 February 2020 and 19 May 2020, after receipt of the further medical records, concluded:

The addendum report of Ms K dated 1 June 2020 was rather more cautious than her first report:

Dr I, a consultant endocrinologist, reported on 23 August 2020:

Dr I arranged for more tests to be carried out in order to confirm, or otherwise, Addison’s disease. By letters dated 13 January 2021 and 29 January 2021, he confirmed that the tests revealed M did not have Addison’s disease or any other form of adrenal insufficiency. He then provided answers to two sets of questions put by the parties jointly which concluded, in summary:

Inevitably, a forensic retroscope had to be applied to all the previously obtained evidence in the light of this new finding. Accordingly, Ms K and Professor J were asked to update their reports in the light of the updated Addison’s evidence, and all the records which then were available, including historic medical records, police, and ambulance disclosure; essentially the material which was before me at trial

On 6 April 2021 Ms K reported:

Professor J ’s update is dated 14 April 2021. Crucially, he concluded that on balance the mother suffers from the previously identified diagnoses and also with SSD and FD. He reports there is considerable overlap between the two; the primary emphasis with SSD is that the symptoms reported by the sufferer are genuinely experienced even if they have no organic basis, and appear to be derived as a response to stress and as a defence to psychological distress. He said:

It is notable how the written expert evidence of Professor J and Ms K evolved over time, becoming much more pessimistic and ultimately reaching conclusions which are firmly negative about M’s capacity for change, her parenting abilities, and her ability to safeguard X. There are main two reasons for this; first, the receipt of all relevant disclosure, including hospital, police and ambulance service records, and second, the events of 2020 demonstrating a regression by M to familiar and ingrained behaviour patterns.

I was struck by the warmth expressed by the experts towards M. They were balanced, fair and understanding of M’s situation. I detected no animosity; on the contrary, they were empathetic and insightful. Each was very even-handed and I unhesitatingly accept their evidence.

Dr I told me that for about 2 decades, until she became pregnant with X, M was not taking her thyroxin medication regularly as prescribed. That is objectively verifiable from the blood tests in the medical records. But failure to take thyroxin, or irregular and chaotic taking of thyroxin, would not have caused any of the Addisonian symptoms with which M has presented over a number of years, such as dizziness, vomiting, headaches and unconsciousness. Poor adherence to thyroxin might lead to gradual, chronic symptoms including weight change, loss of body hair and skin coarsening but would not trigger a crisis such as those apparently experienced by M and which is consistent with Addison’s. He told me that since M became pregnant in 2018, she has complied with her thyroxin tablet taking requirements. Accordingly, on any view, irregular or missed thyroxin medication cannot have contributed to any Addisonian symptoms since 2018.

He told me that usually a patient who is chaotic with taking one form of medication is chaotic also with another form of medication. In this case, he was asked whether M would have been uncompliant with inhaler use for asthma and agreed that was likely to be the case.

The initial investigations into adrenal insufficiency arose due to M presenting with symptoms including dizziness, headaches and collapses from about 2007 onwards. The doctors then did Short Syncathen Tests in 2011 which were “sub-optimal” and produced, to Dr I ’s mind, unreliable results. This was possibly because M was pregnant at the time and perhaps also because the use of inhalers is incompatible with a reliable test result.

There was never a formal diagnosis of Addison’s, but M was repeatedly told by clinicians of various disciplines that she had Addison’s, and received advice on hydrocortisone emergency injections. Leading counsel for M referred to a number of medical notes from 2011 onwards referring to Addison’s, and a reference to Addison’s in the expert psychiatric report of Dr O from the earlier set of proceedings. Dr I felt this was a catch-all phrase used by medical staff to describe adrenal insufficiency which had been partially diagnosed in 2011. It was therefore, according to Dr I, entirely reasonable for M, since 2011, to have believed that she had Addison’s and to tell clinicians and other medical staff accordingly.

As a result, she has been taking hydrocortisone steroids by injection since about 2011 for a condition which, it now transpires, she never had. However, there were no side effects of the treatment and in particular it would definitely not have contributed to the multiple presentations with dizziness, headaches and unconsciousness or semiconsciousness.

He said categorically that there were no organic reasons for the multiple Addisonian presentations over many years. Thus, she did not have Addison’s but nevertheless presented frequently with Addison’s symptoms, and crisis occurrences. He described M’s case as very unusual.

He felt that for M to have said she has Addison’s would not have been factitious because she genuinely, and reasonably, believed it, having been told repeatedly that she had Addison’s. But the symptoms which she presented with were not in fact referable to adrenal crisis because his tests confirm that she never had it. Thus, in the absence of organic explanation, those symptoms are consistent with factitious illness. That said, he fairly pointed out that although he has knowledge and experience of factitious illness, it is not within his area of expertise.

Ms K has a particularly helpful perspective as she saw, and reported on, M in 2012 and can therefore comment on M’s trajectory. She told me that in 2019 M was strikingly different, and showed much progress. She was more stable and coherent, showing a genuine willingness to change, and clearly devoted to her child.

What matters, however, in this case is not her intentions but how her emotions intervene and compromise those intentions. The crux is that she finds it difficult to manage and contain her stress levels. Since the end of 2019, her underlying maladaptive behaviour patterns have re-emerged. They had never gone away but had been better managed during 2019 for whatever reason. But from early 2020 all the old patterns of behaviour resurfaced as her anxiety was triggered. She felt that a number of factors may have had an impact; X moving into foster care, the fear of losing her, the court’s refusal to sanction a residential assessment, the ongoing expert evidence, the onset of the pandemic and the consequential impact on contact with X.

She told me that M’s deep-rooted behaviour remains. When her intense and acute anxiety is triggered it leads to negative behavioural patterns; she finds herself at the mercy of her emotions. Her Addisonian symptoms are likely to have been genuine but psychosomatic, triggered by ingrained anxiety.

She confirmed to me that she had viewed the possibility of a residential assessment in late 2019 as an opportunity for 24-hour observation and supervision to assess M’s capacity and her needs. But as time has gone by that opportunity is no longer there. It is too late. X is older and has consolidated her attachments. To remove this child into a residential assessment with M, who she has seen little of since March 2020 would be, she felt, very damaging. M is still struggling, and she cannot recommend it any longer without evidence of real change on M’s part. She went so far as to say she is 100% against it.

She agreed with the suggestion that there is a real risk that M may form relationships with abusive partners, and not be fully open about the consequences thereof.

She felt that the prospects of successful therapy are remote because M has such chronic and deep-seated issues. Therapy itself would be stressful and could trigger maladaptive behaviour. Very deep and wide-ranging therapy would take at least a year to make meaningful progress, perhaps more, which she felt was not within X’s timescale and in any event, she thought it would not be likely to be successful.

The observations at contact of repetitious advice being given did not surprise Ms K. She was confident that M would try to implement it, but her efforts would be compromised by her behavioural issues.

Overall, she has made some progress since the previous proceedings. But the 2020 episodes have demonstrated again how deep-seated and structural her anxiety disorder is. The flurry of incidents show that the pre-existing conditions are still there and the potential hazards for this child are unabated. M remains “all at sea” and has not managed to go further than “not doing more badly”.

Professor J told me that in 2019 M presented with apparent insight into her behavioural patterns, and for that reason he supported a residential assessment. However, having now seen all the medical records, he said that despite that apparent insight, and despite a considerable amount of therapy, the past behavioural motivations and patterns have re-emerged; put simply, therapy has not worked and the apparent insight is to be regarded as highly questionable. The evidence of multiple admissions to hospital, and attendances at her GP’s, is highly significant. To address her deep-rooted issues, and bring about meaningful change, would require highly intensive, one to one bespoke therapy for a minimum of 3 years. There is no guarantee that such deep therapy would be successful; indeed, he felt that to be unlikely. He tended to the view that her unconscious motivations are probably not capable of remedy.

He was confident that M did indeed experience, to a degree, Addisonian symptoms which he attributed to SSD. They are somatic in that the symptoms are, in part, genuine, and driven by her underlying motivations and anxiety.

He also considered that there is an element of FD in that M exaggerates symptoms as an attention seeking device. He felt that in particular her multiple presentations at hospital with unconsciousness, lacking any organic physical or neurological explanation, were likely to be exaggerated. He was referred, for example, to an attendance at A and E on 2 August 2018 when the hospital note records that she was

“likely not truly unconscious” and simply left hospital without any apparent difficulty, and agreed that to be illustrative of a particular, entrenched behavioural pattern. Additionally, he referred to ongoing overuse of medication as entrenched attention seeking behaviour, and addiction to medication in itself would represent a risk to both mother and child. Now that M knows she does not have Addison’s, he considers it likely that her SSD and FD will manifest themselves through other symptoms.

The combination of previous FII to the older children, together with M’s ongoing and unresolved SSD and FD, makes it more likely (as the research shows) that X would herself be at risk of FII if returned to M’s care. He also felt that the fact of a return would in itself be a high stressor for M.

Finally, his view was firmly that a residential assessment now would be unlikely to enable M to make sufficient progress to a point where consideration could be given to a return of X to her care.

Miss Z (social worker) explained to me about a number of occasions from late 2019 to June 2020 when, despite advice to the contrary, M contacted B who was then embarking on therapy provided by Barnardo’s, in circumstances where Barnardo’s considered that such contact should be suspended for the duration of the therapy. She said, and I accept, that although this must have been disappointing for M, she should not have continued to communicate with B.

X’s health visitor, Ms U , who observed interaction between M and X on 9 occasions up to March 2020, was generally complimentary about M, her willingness to engage and cooperate, her warmth towards X, her interest in X’s development and her obvious commitment to her daughter. Of particular note, I felt, was her description of how M would be advised about aspects of basis care (feeding, putting X down to sleep, playing with her), welcome that advice and yet be unable to implement it regularly. Nobody suggests she ignored the advice. It had to be given to her on repeated occasions because she was simply unable to absorb and act on it. Repeated advice was given by way of prompts on the same issues. This particular aspect struck me as a very concrete example of how M’s behavioural patterns affect her.

Ms V, an Early Years Practitioner to whom M was referred in February 2020, was only able to provide assistance and support to M remotely because of the national lockdown. Her witness statement summed up her evidence in which she said that M attended all sessions (remotely) and “appeared to engage well with me and appeared eager to learn”.

Ms W was the allocated social worker from April to October 2019 and became team manager in June 2019. She was unstinting in her praise of M at that time. M worked well with her, was reflective and cooperative, even during difficult times which involved X being removed into foster care, changes to contact and an issue about M not being allowed to prepare the feeding bottle because of the findings of the previous proceedings about FII. M, to her credit, has developed a good relationship with the foster carer. The problems started in 2020 with the incidents which I have outlined above. Previous patterns came to the fore once again. During the course of the year, the view of the LA evolved until, by September 2020, adoption was thought to be the preferred option. She told me that she had heard from others about the need for repetitious advice to be given to M and felt that this caused concerns about whether M can provide even basic care.

Ms Y, who took over from Ms W as the allocated social worker, told me that the consideration of family members had been kept under review from the outset. A viability assessment of M’s father, MGF, was carried out, not because he formally put himself forward but because of a chance conversation with M in early February. MGF has been present at some team meetings and is well aware of the proceedings. Ms Y

Ms Y was cross examined, properly so, at length about contact/family times between M and X. She herself observed 6 sessions between October 2019 and March 2020, and 2 sessions in September 2020. She described M’s punctuality, positive interaction and fun with X. Her reservations were that she felt M was not particularly proactive, and required repeated parenting prompts from supervising staff; this echoed what I had been told by others. She said that M was repeatedly given advice, including at regular meetings, and by the foster carer and contact supervisors, but was unable to do so. The repetitious nature of advice, despite all the support, has continued throughout and M has been unable to put it into practice spontaneously. She told me that notwithstanding the LA’s adoption plan, M maintains a good working relationship with social services. I asked her about M’s support network, which M identifies as principally her sister lor, her neighbour, her mother and her father, and which she felt was inadequate to protect X.

I accept all the evidence of these witnesses. They were all fair and thoughtful. They gave credit to M where it was due and were generous to M in the steps she had taken. It is clear that M reacts less well to Ms Y than she did to Ms W, but I reject the suggestion made in cross examination that Ms Y has ever been less than scrupulously fair towards M. There may have been differences of opinion, and occasionally tricky judgment calls surrounding implementation of contact, but I am quite satisfied that Ms Y did her very best to be balanced. She was composed in her evidence, and palpably trying to do her best.

M’s neighbour has known M for 4 years. She is a neighbour and good friend. She told me that M had not told her about the previous court proceedings or findings of FII; she had been told by M that the older children were in care because of the abusive relationship perpetrated by Mr R. She said that M has told her she continues to experience flashbacks and nightmares as a result of the sexual assault in Turkey. She was asked about the 18 August 2020 episode which she described as a mental health crisis. She agreed with counsel that such an event would be very upsetting for X if exposed to it, and it would not be right for X to grow up with such crises. I thought she was obviously honest, kind and a great source of support for M who confides in her to an extent.

M gave evidence for a whole day. I have to say that she created a better impression on me that she did on HHJ Richardson QC in 2013/2014. That is, I believe, because she is in a better place, or at any rate a less bad place, than she was then. She was composed, articulate and polite. She acknowledged much that was put to her about the chaotic events of 2014-2018. I did not get the sense that she was telling me manifest untruths. All that said, I came to the clear view that at times, although not being dishonest, her perception of events was rather different than that portrayed by the evidence; she has persuaded herself of a more positive narrative than the evidence justifies. At times she said “I don’t remember” (commented on by HHJ Richardson QC in the previous proceedings) when, I suspect, questions were too difficult to answer. She was very over optimistic about her ability to parent X and leave behind her mental health issues. I felt also that to an extent she had expunged, or put out of her mind, or minimised some of the terrible events in her life which have led her to where she is now. I do not think she did so deliberately, or as a façade, but more as a protective measure for herself. The reality, it seems to me, must be for her very hard to bear.

Her love for X was palpable in the way she described her beautiful, intelligent, happy little girl. Her eyes lit up when describing her daughter. I was also struck by how she described the job she has had for 2 years or so as a barmaid/waitress in a pub, albeit interrupted by Covid. It gives her evident delight and self-confidence. With this, as with so many other things in her life, the pandemic was a particularly cruel interruption to the genuine progress which she had tentatively embarked upon.

More difficult territory for her was questions about the previous proceedings. She fell back on “I don’t remember” on occasion. She said that she accepted the findings of the previous hearings, that she had been guilty of FII and neglect, that she did not put the children’s needs first and that she had caused them long-term harm. But I am confident that, although her sentiments were at one level genuine, her insight into the consequences of her behaviour was skin deep. Under cross examination by leading counsel for the Guardian, she told me that her memory was poor and she could remember very little before 2017. She was unable to explain why she behaved the way she did (including causing harm directly and indirectly to her children) beyond saying that she was not in a good place. She could not really articulate the effect upon her children of her own actions. She was unable to say whether A has struggled as a result of her own neglect, simply saying that they get on well now. Her communications with B, in particular posting on B’s Facebook page in November 2019 a message that she (i.e M) was not in a good place and nobody cared for her, clearly demonstrate to my mind that she does not truly appreciate the impact of her actions on B. Her acknowledgment of past mistakes was more in form than in substance; a true acceptance that findings were made against her, but a continuing difficultly in accepting how and why those findings have impacted on her children. It is also of note that she has not told members of her support network the full, unvarnished truth about the circumstances of the removal of her older children.

In similar vein, she agreed that the experts’ conclusions about her ongoing SSD and FD are correct and that she has experienced these conditions for a very long time. She confirmed that she continues to have flashbacks and nightmares, particularly about the sexual assault in 2016. She appeared to agree that she requires a great deal of therapy,

It seemed to me that she underestimates the scale of the task ahead for her, and X, if reunification takes place. She said that her mental health issues would not affect X, although she did acknowledge that recurrent admissions to hospital would impact upon her daughter. I sensed she viewed that aspect more in terms of keeping X physically safe, e.g by placing her with a neighbour, without fully considering the extent of the emotional impact on X of being exposed to M’s mental health crises and battles. She expressed optimism about the future, whilst acknowledging she could not predict how her mental health issues would develop.

She was asked about her communications with B at a time when all contact should have ceased to enable B to undergo therapy. It seemed to me that much of what was put to M about these events emanated from B who did not give evidence and, as a troubled young woman, may not be entirely reliable. That said, it was clear from M’s evidence that she did contact B on a number of occasions, including occasionally via her father. Even if she did not seek to discourage her from the therapy, as was suggested to her, the very fact of engaging with B must have been confusing and disruptive and, in my judgment, was inappropriate behaviour on her part given that she was under no illusion about the need to cease contact. The most obviously inappropriate action was to share with B screenshots of abusive messages which she had received from A and his then girlfriend.

M was asked a number of questions about her past relationships. It was clearly demonstrated, as she readily accepted, that there was a pattern with Mr R, Mr P and F of experiencing an abusive relationship yet continuing or resuming that relationship. Thus, she went to live with Mr R for a while after the original proceedings during which they had separated. She alleged rape against Mr P in July 2017 yet continued to stay in touch with him and was the victim of a vicious assault by him in August 2017. X was, she told me, violent, aggressive, and controlling, yet even after obtaining a nonmolestation order she continued to stay in contact with him and she had to accept that she initially concealed subsequent meetings with him (including him attending the prebirth scan) from social services. I felt that this pattern had the hallmarks of dependency.

M accepted that on 16 June 2018 she was pushed down the stairs by F, sustaining a serious head injury, yet described it as an accident to the professionals, including medical staff, social services, and her mental health treating team. It was not until police disclosure for the episode of 10 September 2020 when she revealed the assault; M accepted that she was indeed assaulted and had dishonestly concealed it. Similarly, she had given contradictory accounts about her sexual relationship with F. On 6 February 2018 and 19 May 2018 she told her mental health team that she was in a relationship with him, but not sexually, yet on 13 May 2018 she told the Crisis Centre that she had miscarried F’s baby (which was untrue) and on 18 June 2018 told the mental health team that she had had earlier sex. She was unable satisfactorily to explain why she had given different accounts.

I am also satisfied, as she acknowledged, that she was not fully open with treating mental health professionals, and others in the period up to the end of 2018/early 2019. She repeatedly told them (and indeed others) that her older children were in care as a

M told me that she does not believe she needs constant advice on the basic care requirements of X. She said that she did not think it would be stressful to look after her.

M was willing to enter a residential placement but believes that X can be reunited with her now, safely and securely, perhaps on a phased basis. She told me that she could undertake therapy at the same time. She was confident that the past episodes will not recur and that, even if they did, X can be protected by the support network.

She believes she can cope with her mental health now. I felt that she does not really think that she now has an issue. Curiously, she said that one way for her of mitigating mental health issues would be by relying on X, using her as a distraction which struck me as likely to amount to a burden on X to grow up with the knowledge that she is an emotional crutch for M.

Ultimately, I came to the view that her measured performance in the witness box was carried out with courage, fortitude, and a true desire to prove that she is capable of looking after X. But she lacks true insight into her past actions or a realistic appreciation of what her needs are, and accordingly whether she can provide X with safe and stable parenting.

The Guardian’s report is comprehensive. She gave her oral evidence eminently fairly, focussing on matters from the point of view of X. She was thoughtful and clear. She was present throughout the hearing and listened to all the evidence. She said as follows:

The principles are not in dispute. So far as relevant to the present case, I summarise them as follows:

The chronology of events, as I have found it to be, largely speaks for itself. The findings made in 2013/2014 were followed by a continuous pattern of maladaptive behaviour until the end of 2018 when under no circumstances could M realistically have been capable of bringing up a child. Her deeply entrenched behaviour, negative and destructive, continued unabated. During 2019 she was clearly much improved before she regressed to depressingly familiar patterns in early 2020. It seems to me, and I so find, that, taking the start of the public law proceedings as the relevant date, the s31 threshold are clearly met.

I do not consider it necessary to go through each and every one of the findings sought by the LA, many of which are accepted by M, but I record that I accept all the findings sought in the Local Authority’s schedule for threshold purposes save for the following amendments

First, and uncontroversially, the findings made by HHJ Richardson QC bind me and the parties. His judgments must be taken in the round, and I do not intend to incant each and every determination he made, but the main findings were:

Second, and linked to those findings, M has experienced, and continues to experience, FD which may have started as long ago as 1999, a date which I take from a medical record of 13 April 1999 which said “she often manipulates the family into taking her to casualty for minor limb injuries….”, and certainly since 2007 when she first started presenting with Addisonian symptoms. She has sought attention by fabricating, or exaggerating, medical symptoms.

Third, I am satisfied that M did not deliberately falsify a condition of Addison’s, but the symptoms of which she complained were a product of SSD (headaches, nausea, vomiting and nausea) and FD (unconsciousness and unresponsiveness):

Fourth, I accept the clear expert evidence, particularly of Professor J , that a combination of (i) earlier findings of FII to the children and exaggeration by M of her own medical symptoms (FD) and (ii) M’s ongoing SSD and FD, indicates a significant risk that X would be subject to FII if returned to M’s care. The research demonstrates that this inter-generational impact is a very real possibility. The consequences would be deeply damaging and harmful. One potential cause of such stress (among many others) would be X returning to her care. In other words, and sadly, the very act of rehabilitation of X with M would likely trigger highly negative responses of FII in M’s treatment of X, and FD in herself.

Fifth, I accept that for approximately 1 year, from about February 2019 to March 2020, no presentations by M with Addisonian symptoms took place. That was during a time when M showed definite signs of improvement. She had undertaken therapy and domestic abuse programmes. She was single and not in an abusive relationship. She had started a job. She was generally cooperative with the LA, although her conduct in this respect was not faultless as demonstrated by her failure to abide by advice not to contact B. However, and despite the therapy, education, counselling, and very high level of support, from March 2020 she lapsed back into a pattern of presenting with Addisonian symptoms, as well as high levels of emotional and mental health instability, including suicidal ideation and dependency on medication. In short, she had not made sufficient progress to be protected from the re-emergence of her multiple issues. I find it to be likely that such episodes will be regularly repeated in one form or another, and carry a high risk of exposing X to physical and emotional harm.

Sixth, M continued to be involved in volatile and abusive relationships from 2014 until late 2018, in particular with Mr P and F. I consider on the basis of all the evidence, including that of Ms K , that there is a real risk of M in the future forming one or more dysfunctional relationships with an abusive partner, thereby placing her under the sort of stresses which in the past have repeatedly triggered her negative behavioural patterns to which X would be exposed. Further, I am satisfied that should M enter into an abusive relationship of this nature, she would be likely to conceal, or minimise, its damaging patterns from professionals, and would be disinclined to seek help.

Seventh, M continued to engage in a significant level of criminal activity on numerous occasions until 2018.

Eighth, I am satisfied that between 2015 and 2018 M was not open and transparent with her mental health treating team and other professionals, particularly (i) minimising her relationship with F, and its abusive characterisation, and (ii) minimising the findings made in 2013/2014 that she had subjected D and B to FII and had neglected all the children’s emotional needs, instead casting herself as a victim of domestic abuse. In addition, in this period she did not engage fully or properly with mental health services, undertaking some work but repeatedly disengaging.

Ninth, although M has committed to contact and fully engaged with it, she requires repeated advice prompts for basic caring involving feeding, sleeping, and playing, even

Tenth, M has been diagnosed with various mental health conditions including depression, anxiety, PTSD and Emotionally Unstable Personality Traits. She remains subject to, and in the grip of, these conditions. It clear that her emotional functioning and moods continue to be heavily impacted by her mental health and personality traits. She continues to experience flashbacks and nightmares which have been ongoing since 2016. She has poor distress tolerance and lacks healthy coping mechanisms when faced with stress. She remains addicted to, or at least heavily dependent upon, painkilling medication including zopiclone; such addictions represents, as Professor J said and I accept, a risk factor for both M and X. Exposure to these ongoing conditions would expose X to harm.

Eleventh, in my judgment, although M says that she accepts the findings made by HHJ Richardson QC, her comprehension of why she acted as she did, and the far-reaching emotional consequences upon her children as a result, remains superficial at best. On 7 October 2015, 4 November 2015, and 9 May 2018 the records show M struggling to accept why the older children were removed from her care. Her failure to appreciate the consequences of her interaction with B in late 2019/early 2020, and her lack of understanding about the impact on A of her past actions, are further indications of lack of insight, which in turn is a risk to X.

Finally, in my judgment and based on all the above, X is likely to suffer significant harm, and such harm is attributable to the care which would be likely to be given to her by M, not being what it would be reasonable to expect a parent to give her.

I repeat that M made obvious progress for about a year. But sadly, it did not prove to be enduring, despite all the support and treatment on offer. The very fact that M relapsed or, to put it another way, her harmful behavioural patterns re-emerged, demonstrates why X is incapable of being protected by M. With all the assistance and support of various services from 2014 onwards, M has sadly been unable to demonstrate lasting and permanent capacity for change such as to enable her to care for X both physically and emotionally.

The duty of the LA to assess family members/connected persons and the legal basis for this was summarised by Cobb J in Re H (Care and Adoption: Assessment of wider family)[2019] EWFC 10 at paragraphs 1-32. Local Authorities have a duty to undertake assessments in order to ensure that the reasonable placement options are properly before the court, but that duty is not limitless.

As to the timing of assessments, and challenges thereto, Mr Justice Keehan said in L & Ors [2017] EWHC 2081at paragraph 12:

“The message has to go out loud and clear that these very late challenges to viability assessments, or the very late identification of family member will only be countenanced by the Family Court if there is exceptionally good reason as to why they have not hitherto come forward, and the assessment of them does not have an adverse effect upon the timetable for determining the future of the children. As it is, these proceedings will not be concluded within twenty-six weeks. That is regrettable. But, it is my duty, and it is the welfare best interests of the children that these proceedings are determined, whatever the outcome, as soon as ever possible.

MGF has no meaningful relationship with X, having seen her briefly at hospital after birth, and on a couple of occasions when M involved him in remote contact. I accept the evidence of Ms Y that he and the wider family generally were kept in mind throughout as part of an “ongoing conversation”. He attended family network and care planning meetings. He has known of the plan for adoption since at least October 2020. MGF has never formally put himself forward as a potential carer. He emerged late in the day as a result of a conversation between himself and M in February (which M passed on to Ms Y) in which he indicated a wish to be considered as a carer for X. The LA rightly carried out a stage 1 viability assessment which was completed on 8 March 2021, followed by a stage 2 assessment dated 19 March 2021. For some reason MGF was not made aware by the LA of the negative outcome until during the first week of the hearing and did not receive a hard copy of the assessment until 23 April. I was told that he disagreed with the conclusion. I invited him to come to court on 27 April to explain his position. He was initially content to participate, including by giving evidence, that same day, but I suggested he should return to court remotely on 29 April so as to have time to prepare and, if he so wished, to secure legal advice.

Although MGF, who did not in fact obtain legal advice or representation, did not formulate it as such, I treat him as having applied for a further assessment to reconsider the existing negative viability assessment. I must consider (i) whether he is a realistic possible carer and (ii) whether it is in X’s interests for a further assessment to be carried out.

On 29 April MGF attended remotely and expressed a willingness to give evidence and be asked questions by counsel. He told me that hadn’t read any of the documents in these proceedings. He had read the judgments from the previous proceedings, but it was clear that he did not accept the conclusion that M had deliberately caused harm to D and B by interfering with their medical care and treatment. He told me that he thought such issues were misunderstood. He also seemed to me to have a jaundiced view of the Local Authority, an outlook which he shares with other family members. He said that they all regard M as having been vilified and victimised by the LA. In particular, he felt that Ms Y had been biased and inaccurate. His belief is that M is an experienced and accomplished mother, and that she does not pose any risk to X. In answer to questions from me, he felt sure that he would be able to prevent M from seeing X if that was required. After he gave his evidence, the following day he asked to attend remotely again for a short time to sum up his position which I readily agreed to.

I thought MGF was straightforward, frank, and honest in his evidence and subsequent submissions. He clearly wants the best for M and X. However, in my view he minimised to a very significant degree the damning findings against M from the previous proceedings and is over optimistic about M’s progress since then. He has not seen, and is therefore not aware of, the welter of documents in these proceedings, particularly the expert reports. He cannot, and does not, have a full insight into M’s ongoing issues, and X’s needs. He was ruled out as being a carer of the older children and age (he is 67) is now somewhat against him. I also felt that, although he is a robust and strong personality, he would have great difficulty in protecting X from M if that is what is required. M is herself a strong personality. He does not think she poses a risk, and I judge that the pressure to allow M into X’s life, were she accommodated with him, would be hard to resist.

I have come to the clear conclusion that (i) he put himself forward very late in the day and, as a result, if his application is granted there will be additional delay, (ii) further delay would be manifestly contrary to X ’s interests and (iii) he does not have a realistic prospect of securing a positive assessment nor is there any realistic prospect of the court, some weeks or months down the line, determining that X should be placed with him. I accordingly reject his application.

Once the court is satisfied that the threshold criteria are met, it must then go on to consider whether it is in the child’s best interests to be made subject of a care order. When the court is deciding whether to make a care order it is required to consider the permanence provisions of the care plan for the child. In considering the care plan, the court must consider how it deals with the impact on the child of any harm that s/he has suffered or is likely to suffer, the child's current and future needs (including those needs arising out of that impact), and the way in which the long term plan would meet the child's current and future needs.

Where the court is considering an application for a care order which involves approval of a care plan of placement for adoption, the court should carry out its balancing exercise by reference to both welfare checklists in s1(3) CA 1989 and s1(4) ACA 2002, always bearing in mind that the child’s welfare is the court’s paramount consideration; Re C (Appeal from Care and Placement Orders)[2014] 2 FLR 131. The court must also consider, as mandated by both Acts, the “no order” principle and the general principle any delay in determining the question about a child's upbringing is likely to prejudice the welfare of the child. The court will only make a placement order if it is justified having given paramount consideration to the child's welfare “throughout his or her life” (section 1(2) of the Children and Adoption Act 2002. The court must have regard to the checklist set out in section 1(4) of the Act.

I have well in mind the famous words of Hedley J about standards of parenting in Re L (Care: Threshold Criteria) [2007] 1 FLR 2050:

“Society must be willing to tolerate very diverse standards of parenting, including the eccentric, the barely adequate and the inconsistent. It follows too that children will inevitably have both very different experiences of parenting and very unequal consequences flowing from it. It means that some children will experience disadvantage and harm, whilst others flourish in atmospheres of loving security and emotional stability. These are the consequences of our fallible humanity and it is not the provenance of the State to spare children all the consequences of defective parenting.

In any event, it simply could not be done.’

When the court is considering the child's welfare it must carry out a welfare evaluation of which set of arrangements for the child's future care are in his or her best interests; Re G (A Child)[2013] EWCA Civ 965. In carrying out that welfare evaluation, the court must consider the Article 6 and Article 8 rights of each of the parties. Where there is a conflict or tension between the Article 6 or 8 rights of a parent or carer on the one hand, and of a child on the other, it is the rights of the child which prevail Yousef v The Netherlands [2003] 1 FLR 2010.

The court should contemplate separation of a child from its parents only if satisfied that it is necessary and proportionate to do so. Before making an adoption order in such a case, the court must be satisfied that there is no practical way of the authorities (or others) providing the requisite assistance and support.

However, there is no presumption that a child will be brought up by his or her natural family. The arrangements for the child fall to be determined by affording paramount consideration to the child's welfare throughout his or her life in a manner which is proportionate and compatible with the need to respect any Article 8 rights engage; Re W (A Child)[2016] EWCA Civ 793.

The words “nothing else will do” do not represent a short cut. In Re M-H [2014] EWCA Civ 1396Macur LJ said:

When determining the welfare stage of the hearing process, the court must consider the realistic placement options (Re B-S (Children) [2013] EWCA Civ 1146) and do so by globally analysing those options in a holistic and rigorous evaluation rather than taking a linear approach.

Where a care order is in force, s21(3) ACA 2002 provides that the court may only make a placement order if, in the case of each parent, the court is satisfied that the parent consents to the child being placed for adoption with any prospective adopters who may be chosen by the local authority and has not withdrawn the consent, or that the parent's consent should be dispensed with. The court cannot dispense with the consent of any parent or guardian of a child to the child being placed for adoption or to the making of an adoption order in respect of the child, unless the court is satisfied that the parent or guardian cannot be found or is incapable of giving consent or the welfare of the child requires the consent to be dispensed with; CM v Blackburn with Darwen Borough Council (supra).

In relation to dispensing with consent, Wall LJ said in Re P (Placement Orders: Parental Consent) [2008] EWCA Civ 535,[2008] 2 FLR 625at 126:

“Section 52(1) is concerned with adoption – the making of either a placement order or an adoption order – and what therefore has to be shown is that the child's welfare “requires” adoption as opposed to something short of adoption. A child's circumstances may “require” statutory intervention, perhaps may even “require” the indefinite or long-term removal of the child from the family and his or her placement with strangers but that is not to say that the same circumstances will necessarily “require” that the child be adopted. They may or they may not. The question, at the end of the day, is whether what is “required” is adoption.”

“Required” in this context means the connotation of the imperative. It is what is demanded rather than what is merely optional or reasonable or desirable. It is a stringent and demanding test. The court should begin with a preference for the less interventionist rather than the more interventionist approach. This should be considered to be in the better interests of children unless there are cogent reasons to the contrary (Re O (Care or Supervision Order) [1996] 2 FLR 755 at 760.

There are material differences between adoption and long-term fostering in terms of what they offer by way of security; Re V (Children) [2014] 1 FLR 1009 at 95-96.

I acknowledge that M loves X dearly and wants nothing more than to be able to care for her. She undoubtedly made progress in 2019, and despite the setbacks in 2020 she is in a better place than she was in 2018. That said, Ms K describes her as no better than

“not doing more badly”. Many of the issues and patterns of behaviour demonstrated in the earlier proceedings, and which continued unabated until 2018, have re-emerged in 2020 and led to repeated crises. They are very ingrained. She continues to experience deep-rooted psychological issues which prevent her from functioning to a level which would enable her to care for her child. Her PTSD, characterised by recurring nightmares and flashbacks, is ongoing. She continues to lack insight into past events, and her own behaviour which led to the removal of her older children. Her SSD and FD, coupled with past FII in respect of her older children, present a clear and present risk of FII by M to X if rehabilitated to M. M is unable to provide basic care without very considerable support and prompting, despite extensive oversight and support. A return to M’s embedded behavioural patterns would be unthinkable for X and, sadly, that is what has happened over the past year. Medical crises, abusive relationships, impulsive overdoses, chaotic adherence to medication, FII/SSD/FD, drinking and criminality are never far from the surface. M has shown herself unable to find appropriate coping mechanisms to address stress and anxiety and I have no confidence that she will be able to do so in the future. Nor, given the history, do I consider that M would be open, transparent, and honest with professionals about such recurring events; she has consistently shown, when under stress, a capacity to minimise and conceal which in turn would jeopardise X’s safety. Absent such meaningful change, X would be placed in an intolerable situation, at risk of grave physical and emotional harm. M would quite simply be overwhelmed. Indeed, a return of X to M would by itself operate as a significant additional stressor in M’s life and thereby increase the risks to X. In short, the better presentation in 2019 is not nearly sufficient by itself to offset all the maladaptive behaviour present in M for most of her life until 2018, and repeated throughout 2020.

The timetable required for M to overcome her deeply-rooted issues is, in my judgment, more likely to be a minimum of 3 years (as suggested by Professor J ) rather than 1 year (as suggested by Ms K ); the fact that M’s patterns re-emerged notwithstanding a considerable degree of prior therapeutic intervention in my judgment tends towards the more conservative timescale. The scale of such a task would be enormous, requiring bespoke and intensive one to one therapy. In my judgment, based on the evidence of Professor J and Ms K, it is likely that the outcome would be unsuccessful. I have concluded that M is unable to meet X’s physical and emotional needs, and were X to be returned to her care she would be at risk of significant harm.X is 22 months old and urgently needs resolution, clarity, and a settled future. M, sadly, cannot offer the strong, consistent, and protective parenting which she requires.

Nor do I consider that M’s support network is sufficiently robust to assist M in ensuring X’s safety and wellbeing. None of the identified persons has any real insight into the enormity of M’s difficulties and the reasons for the removal of her older children, in part because M has not been fully transparent about these matters. The family do not have any particular concerns about M, and do not see her as presenting a risk to X; the likelihood is that they would give way to M’s own wishes. Some have issues of their own (M’s mother’s health, her sister’s husband’s health for example). M’s father lives too far away. M does not get on well with her sister. M’s mother was found to have colluded with M in the earlier proceedings. The family have a very negative view of the professionals, with whom they would have to work. It is unrealistic to place upon her friends and family the very considerable burden of protecting X. It also seems to me that the support network is broadly the same as that which she relied upon in 2013/2014, and has turned to since then, without any obvious success in terms of M’s own mental health, shielding her from abusive partners, and protecting the children.

I have carefully considered the suggestion that M and X should undergo a residential assessment for a period of time, although no such placement is currently available. A residential unit, it is submitted, would operate round the clock supervision and support. Therapy could also be part of the programme. Such an approach would afford the opportunity of observing M’s ability to parent X, and provide her with the intense support which she so obviously needs. Essentially, what is suggested is a reprise of the proposal in late 2019. Although I can see the attraction of trying to find a way by which the return of X to her mother’s care can be explored, in my judgment there is no real prospect of such a placement being successful. Given M’s deep-rooted abnormal behaviour patterns, it is likely to break down. Even if it does not formally break down, the prospect of it leading seamlessly to a phased return of X to M seems to me to be very remote. It would be highly disruptive for X, and probably very distressing. M has not had sole care of X at any time since birth and this would be an untested step. Too much uncertainty would lie ahead. Time is not on the side of M or, particularly, X. X’s needs are pressing, and an assessment of this sort, with little prospect of success, would delay yet further a resolution to her future. The expert evidence was clear that it would be highly unlikely to achieve sufficient progress to enable the court to contemplate returning X to her mother. M’s mental health issues will require prolonged, and successful progress, far beyond the timescale of a residential assessment. Ms K and Professor J were firmly against a residential assessment, as was the Guardian, and I agree.

With regret, and notwithstanding all the obvious advantages ofX being brought up by her mother, I conclude that it is simply not possible for that to be achieved in any realistic timescale, whether with the benefit of a residential placement or not. The risks to X are too great. She would not enjoy the stable, coherent, and nurturing environment that she so urgently requires. She would, instead, be exposed to an ingrained chaotic lifestyle, inconsistent parenting, inability on M’s part to protect her and risk of exposure to factitious disorder behaviour.

The possibility of kinship care is not realistic. The LA has considered potential family and friends as carers throughout the proceedings, but none are suitable. The family have been aware in general terms of the progress of the case and there has been plenty of opportunity for possible carers to make themselves available for assessment. M put forward only two options; her sister, who ruled herself out because of her husband’s health, and a friend who did not want to be considered. Only M’s father has put himself forward, albeit late in the day, and the viability assessment is negative. I have ruled against a further assessment.

The preferred course advocated by the LA and the Guardian is adoption; to take such a profound step should only be sanctioned where nothing else will do and it is the best outcome based upon a welfare evaluation of all the circumstances. The obvious disadvantage would be the severing of all ties with M and the biological family, including her half siblings. As against that, it would provide X with certainty, security, and long-term stability in circumstances where a return to M is not realistic or safe. X should be able to achieve a sense of permanence, emotionally and psychologically as well as physically, within an adoptive setting. The Guardian told me that there would be little difficulty in identifying appropriate prospective adoptive parents within a fairly short timeframe, and X would be able to form a secure relationship with them. Further delay in securing a placement would be contrary to her interests. X needs to be able to develop her secure attachments with her long term carer as soon as possible, and in my judgment that can best be achieved within an adoptive setting.

Long term foster care was not advocated by any of the parties, not least because of X’s age. It seems to me that it would not give this child the sense of permanence which is, in my judgment, essential for her wellbeing. She has an immediate need for long term security and stability which long term fostering would not sufficiently provide. M would be able to apply in the future to discharge a care order, which seems to me to be replete with risk and uncertainty for X, whereas an adoption order would be final. A fostering arrangement would leave open the question of contact, in a way which generally does not apply in an adoptive placement; cessation of contact with M in the event of adoption is not, on the evidence of this case, likely to be distressing or damaging for X. In a fostering context, the Local Authority would continue to have a role in X’s life. Fostering does not offer the best all round solution for X, particularly given her age. She needs to develop her attachments and sense of identity. She cries out for a warm, enduring, nurturing attachment with long term permanence and in my view a foster placement would not be the best means of achieving this.

I have carefully weighed up all the various options, considering the advantages and disadvantages of each. In so doing, I have considered all matters holistically and in the round. In the end I conclude that placement for adoption is by some distance the preferred, indeed required, outcome for X. Her welfare is my paramount consideration and in my judgment, adoption is in her best interests. It would give her a sense of permanence, allowing her to settle into the adoptive family to which she will fully belong. Given M’s obvious, and deep-seated difficulties, F’s decision to seek no part in her life, and the lack of a viable alternative family carer, placement within the birth family is sadly not realistic. In particular, M’s abnormal behavioural patterns may re-

I therefore make the threshold findings as outlined above, approve the care plan for adoption, make a placement order and dispense with parental consent as appropriate. Both in written opening, and during oral closing submissions, the LA invited me to make an order for parental responsibility in favour of F so that his consent to a placement order could then be formally dispensed with under s21(3) of the ACA 2002. Without parental responsibility, he does not qualify as a parent for the purposes of giving consent, and therefore no order for dispensing with consent is required. Although presented to me as essentially a procedural step, it would of course require proper consideration within the context of the welfare checklist and is therefore much more than a technicality. As F had not attended during the hearing (other than briefly by counsel at the very start), I invited the parties to contact his legal team and inquire whether he sought an order for parental responsibility. He confirmed by written submissions through counsel that he does not seek such an order. Since he makes no application for parental responsibility, has played no part in X’s life, and M through counsel indicated that she would oppose a parental responsibility order being made, I shall make no such order.

An issue arose about the continuation of contact in the event that I approve the Local Authority’s care plan. The Guardian considers that there should be one further, farewell, contact session. Her view is that X needs the emotional space to prepare for a move from foster care to identified adoptive parents. The Guardian has been assiduous throughout in looking at matters from X’s point of view, but on this issue, and by a narrow margin, I conclude that the Local Authority’s proposal for contact to continue until prospective adopters are identified is to be preferred. It is not clear how long that process will take. There is no evidence that X is being discomfited or disturbed by contact with M. On balance, I consider that it should continue as suggested by leading counsel for the LA in closing.

This will be the bitterest of pills for M to swallow. Nobody can condone or excuse her past actions, but the sad reality of this case is that her behaviour has its origins in mental health problems which can be traced back to her own childhood and have gripped her ever since. I have considerable sympathy for her; mental health illness is a curse. Over time, her behaviour has become ever more ingrained. Stressful events lead to crises which in turn set M back and place her under ever greater stress. It is a vicious circle. Unless and until she fully banishes her mental health demons, or at least finds a way to cope with them, she will be unable to lead a happy and fulfilled life. There are glimmers of hope; a degree of progress for a period in 2019, a job, a life currently without an abusive partner. I sincerely hope that she finds it within herself to embark on the hard journey which she needs to undertake with expert mental health treatment.