A Local Authority v Mrs H (Mother to V) & Ors

This is a fact finding hearing with respect to a little girl, R, who died in May 2023 when she was only nine months old. When she collapsed, she was being cared for at the home of a childminder. The conclusion of the post mortem was that she had died as a result of a recent cranio-cervical injury. It also identified signs of earlier injury.

This fact finding hearing is necessary to determine public law applications concerning the children of three families. This is because the timeframe provided by the medical evidence encompasses a period when R was cared for by several people. The medical evidence suggested that the timing for the most recent injury was such that it could not have happened in the care of the parents, and the timing for the oldest that it must have done. She was cared for full time by her mother (with the help of grandparents) from her birth until her mother went back to work on 9^th May 2023. When the grandparents abruptly left on 9^th May the parents arranged for R to be cared for by a newly acquired friend on 11^th, 12^th, 15^th, 18^th, 22^nd and 23^rd May. This was always intended as a temporary measure only whilst a permanent arrangement was sought. The mother then identified someone who she thought would be a suitable childminder by looking online for childcare locally. This childminder cared for R on 16^th, 17^th and 24^th May.

For the purpose of this fact finding hearing I will refer to R’s parents as the parents and/or mother and father, the person who was the temporary carer on days between 10^th and 23^rd May as K, and the childminder who cared for R on 16^th, 17^th and 24^th May as Mrs O. I will also be referring to her husband, Mr. O, within this judgment.

The parents came over to this country in the early 2020’s. They are married and R was born here. The mother has a visa which entitles her to live here for a period of five years. Both parents are graduates, the father working as an accountant and the mother in information technology.

When R was born, the mother’s parents came over to this country for a few months to help, and when they left the father’s parents arrived. The home they lived in was cramped with the four adults and R living in just two rooms. The parents’ relationship was tense, not least because the relationship between the mother and her parents in law was poor. In early May, following a row between them the father decided that his parents should leave, and they did so almost without any warning. This left the parents without childcare which was very difficult for the mother who had only just arranged to go back to work.

Just before the father’s parents left (and before anyone knew how quickly that was going to happen) they met and struck up a conversation with K who they met in a park. She came from the very part of the family’s country of origin in South Asia that they did. She was alone in this country having left her husband and children behind whilst she started a new job and looked for accommodation to allow them to join her. She was under pressure because the visa she had obtained for her son was just about to run out.

The paternal grandparents put K in touch with the mother and father. The father offered to help her with accommodation and in booking cheap flights for her family to come here. He also asked her if she would step in when his parents suddenly went back to the family’s country of origin leaving the mother without any childcare. There has been a question mark as to whether or not K was to be paid for this, with K stating that she only ever intended to give her services for free.

K visited the parents’ home on 10^th May 2023 for the first time to see how the mother cared for R and to be told of her routines. All were happy with how things went and so she started to work for them the following day. As I said earlier, K looked after R on 11^th and 12^th May. 13^th May was a weekend and K went over to the home for a few hours. She did the same on 14^th. K had no family or friends here and she was glad of the company. During the course of that week R was said to be well.

On 14^th May K told the parents that she had work commitments that week (previously she had been engaged in training and this was the first time she was being offered some shifts as a care worker). Therefore, the parents needed to find alternative childcare. The mother made enquiries of the Health Visitor who signposted her to a childminding website. On that website the mother identified a Mrs O who lived locally and looked after a number of children as well as having three of her own. The parents were attracted to her as a possible childminder because she was of the same nationality by origin. Having moved here so recently, the parents understandably felt reassured at the thought of someone whose background was familiar. The parents took R to visit Mrs. O on 14^th May in the evening. K went along too. The meeting was short, but the parents and Mrs. O were content to proceed with the arrangement.

R thus went to the O household for the first time on 16^th May. There were a lot of things to take as the mother wished to make all of R’s food, and equipment such as bottles, clothes, nappies and the like. Parents of young children would not be surprised to hear that one or two things were forgotten when R was picked up. All seemed to be well when R came home that night; at least there is no report of anything being wrong.

R went to the childminder again on 17^th May, being picked up and dropped off by the father. When she came home on the evening of 17^th May, the mother said she was not well. She vomited and appeared to be listless (the mother used the word ‘dull’). At 22.27hrs the father called 999 who in turn called an ambulance to go to the home. The paramedics were there in fifteen minutes. The transcript of the 999 call records the father telling the operator that R was vomiting continuously and that she was not active and not responding. His description also suggested retching when nothing was in her stomach. The paramedics checked R but did not find anything seriously wrong and gave the parents advice about giving her Calpol and settling her to sleep. She was thought to have a minor illness or infection.

The next day, 18^th May, R was cared for by K whilst the parents went to work. K said that R was not her usual self, crying more, and not settling. She did not take all of her food or milk. Later in the evening the mother told K she wondered whether R had picked up something from the floor and put it in her mouth which had made her ill.

On 19^th May the mother worked from home and K went to help her there. K said that R seemed tired but she was fine because her mother was there. On 20^th May the parents took R to hospital, (with K accompanying them), because the mother was worried about her. The father said he thought the mother was being unduly anxious. At the hospital the history that was recorded was that R had been unwell for four days with diarrhoea and vomiting but no fevers. She was said to be more sleepy than usual but easy to rouse. The examination was normal and the doctor considered she had a mild gastroenteritis.

21^st May was a Sunday and K went over to the home and spent time with the family. K, the mother and R went to a place of worship locally. K says that R was not quite herself that day, crying and wanting her mother to carry her. She seemed uncomfortable. On 22^nd May, for the first time since 18^th May, K cared for R alone. There is some dispute about how R was that day. K said that she was told R had not slept well the night before, and described R as only seeming to want to sleep and not to eat. She ate some of her breakfast and cried more loudly than usual although she did not vomit. She said the mother phoned many times that day and, oddly she thought, asked her to check that R was breathing. Whilst the mother agrees that R did not sleep well on the night of 21^st, she said the day when she asked K to check on her breathing was on 18^th May, when she was clearly not well. There is some support for what the mother says in the contemporary text messages.

On 23^rd May K looked after R again and said she appeared back to normal. She said that at 4pm R ‘pooed everywhere’ but did not describe this as being diarrhoea. Indeed, she did not describe witnessing R as having diarrhoea at any stage on any day that she cared for R or was present in the home.

On 23^rd May K told the mother she could not look after R the following day because she was required to go to work by her new employers (on the basis of whose sponsorship K had obtained her visa). The mother therefore sent Mrs O a text asking if she could look after R the following day. Mrs O said yes.

The evidence as to how R was on the morning of 24^th May is in dispute. The mother and father say that she was well. Mrs. O gives inconsistent accounts as to how D was on the morning of 24th May; the most recent account in her statement was that R was listless and not her usual self. There is a wealth of evidence about this which can be gleaned from contemporary messages as well as the evidence of third parties. I will return to this later.

At 12.58pm Mrs. O left home with one child who she had to deliver to nursery. She left Mr. O in charge of R and several other children who she says were sleeping. She was out until just before 3pm. CCTV cameras from the other side of the road record the time she went in and out of the house that day. The camera records that Mrs O parked her car outside the house and went in. Six minutes later she is recorded as coming out of the house (having changed her clothes) with R in a car seat, taking her to hospital. When they arrived at hospital before 15.13pm R was found to be not breathing. Cardiopulmonary resuscitation was started but it was not possible to revive her, and she was declared dead.

Following the death Mrs O and her husband were arrested on suspicion of murder. They were both interviewed on 25^th and 26^th May. The parents were interviewed under caution for the first time on 27^th May.

The police were not alerted to the fact that K had cared for R on the days I have set out above until after the findings of the post mortem that there had been earlier injuries. The parents gave this information when they were interviewed in June 2024. K was then arrested and interviewed under caution in July 2024. Mr. and Mrs. O were further interviewed in November 2024.

At the start of the police investigation the focus was very much upon Mr. and Mrs. O because R had collapsed whilst she was being cared for in their home. The history that they recorded was that R was well when she was taken by her father to their home on the morning of 24^th May. The preliminary findings at post mortem on 2^nd June 2023 were that she had sustained bilateral subdural haemorrhage. Enterovirus had been found on a rectal swab, and so the differential diagnosis at that stage was either infection or head trauma. Further investigations were ordered.

The results of the further medical investigations were not available for many months. In May 2024 Professor Mangham reported that he had identified a number of rib fractures visible microscopically. In a few of these fractures he identified a cellular response (in addition to fibrinoid material), which led him to conclude that they were likely to have occurred between about 36 hours and 4 days prior to death. This was followed by a report from the neuropathologist, Dr. du Plessis that there were older injuries identified in the brain. As a result, the local authority took proceedings with respect to V, the parents’ second child, who had been born in April 2024. She was removed from their care.

At a child protection medical there was concern that V may have bruising to her back. An application was made for an interim care order, and she was removed from her parents and placed in foster care although she had been with them for six weeks. A child protection medical raised concerns that she had bruising to her back. Following Dr. Ward’s report within these proceedings it became apparent that this was likely to be what is often described as a Mongolian blue spot.

The local authority then decided to initiate proceedings in relation to Mr. and Mrs. O’s three children, and K’s two children. The proceedings have been consolidated for the purposes of this fact-finding hearing.

The medical experts in this case suggest that R sustained injuries on at least two and probably three occasions. Cases in which it is alleged that an infant has died as a result of abusive head trauma are not uncommon in the family and criminal courts, but this case is particularly challenging because the outcome of the post mortem (which involved a neuropathologist, a histopathologist, an ophthalmic pathologist, a paediatric pathologist and a forensic pathologist) suggested that R was injured at times when different people were caring for her.

On any view it is unlikely that a child would be injured by shaking in two unconnected households. For this reason, second opinions across the range of disciplines were sought in the family proceedings. Additionally clinical experts, namely a Consultant Paediatrician and a Consultant Neurosurgeon were instructed to assist the court by reference to the symptoms that R displayed in the days and weeks leading up to and including her death.

There has been no major disagreement between any of the experts but there have been some subtle differences which have illuminated the difficulty in (a) identifying injuries which are visible pathologically and not radiologically and (b) being precise about timing. Further, the addition of clinical expertise has been invaluable.

Although the attendance of medical experts to give oral evidence has been increasingly viewed as not being necessary for the court to determine a case justly I have no hesitation in saying that the attendance of so many experts to give oral evidence has been invaluable here where the future and safety of seven children of three separate families is at stake, and the case so unusual. The explanations they each gave to the court during the course of their oral evidence has allowed me to understand their views somewhat better, and how to approach the very difficult issue of timing, particularly where the findings upon which they are based are small, subtle and sometimes not fully understood.

The local authority refined the findings that it sought during the course of the hearing and after the evidence had finished. The final position is that it seeks findings that R received traumatic brain and spinal injuries, injuries to her eyes and optic nerves and also fractures to her ribs. It is submitted that the injuries were caused on more than one occasion, by shaking with or without impact. It is alleged that the fatal injury occurred on 24^th May and must have been caused by the actions of either the father or of Mr. or Mrs. O. It is alleged that there was a further episode of injury which occurred roughly 2 to 7 days before she died and that the perpetrator must have been the father. This event must have caused the healing rib fractures as seen by Professor Mangham. Finally, the local authority submits that R sustained an older injury which must again have been caused by the father.

The local authority further pleads that the perpetrator(s) of the injuries has not told the truth about what happened and failed to seek medical attention for R. Some of the other carers must have known what happened to R and hidden, colluded or lied about it. Further they failed to protect R by telling the professionals what had happened.

The local authority also seeks findings that the parents’ relationship was violent and abusive, which placed R and now V at risk of suffering significant harm. The local authority submits that the father was violent to the mother on many occasions including when she was pregnant with R. In April 2022 he is said to have thrown a mixing bowl at her cutting her elbow. In June 2022 (when she was very heavily pregnant) he is said to have been violent to her on several occasions. The violence included grabbing her hair and shaking her, hitting her on the nose on several occasions, punching her in the stomach, and pushing her into a wall. The father is alleged to have said to the mother that he did not care that she was pregnant and did not want the baby, that he threatened to kill her, and that he took a knife out and held it to his own throat. In July 2022 the father is alleged to have hit the mother with a slipper and said that the unborn baby was not his.

In October 2022 the father is alleged to have smashed R’s cot. In August 2023 the father is said to have beaten the mother and hit her head against a wall and on another occasion to hit her head on the door, grabbing her face and scratching it too. In November 2023 the father is said to have hit her with a slipper causing bruising and also grabbed her face causing her to be injured. By this stage the mother was pregnant with V. In May 2024 the father is alleged to have punched the mother in the back. After V was born, this violence is said to have continued, with the father punching the mother in the head when she was breastfeeding V.

The father is alleged to be coercive and controlling, and to look through the mother’s phone and her bank statements.

The local authority also alleges that the mother was violent to the father, in that she threw a glass at his head, and threw a mobile phone against the wall. She is said to have slapped the father on one occasion in October 2022.

The local authority also point to messages passing between the parents in April 2023 and even more particularly on significant dates such as 18^th and 19^th May, which show a high level of conflict, and where the mother asked the father ‘not to shout any more, it is scaring the baby….she is getting scared when we fight each other’.

The mother agrees that the relationship between herself and the father was abusive and controlling and lays the blame for this at his door. She says that the father was a risk to her and R because of this and remains a risk to her and V. She takes issue with some of the allegations, most particularly that she told anyone that the father had punched her in the stomach and/or that she had told anyone he had done so.

The father denies that he was violent or controlling to the mother and alleges that it was she who was abusive and controlling to him, and that she has made up allegations against him. He denies that he or the mother pose a risk of significant emotional and physical harm to V.

The local authority submit that there are issues with the credibility of all the adults, and that at times they all lied. All must know more than they are letting on.

Although the lay parties all accept that R suffered injuries, each of them denies having caused any of them or having been aware that anyone else had done so. Each of them denies failing to protect her or failing to seek prompt medical attention. They have each, through counsel, explored the timing of all of the injuries. Counsel for the parents have invited the court to find that the oldest identified injuries cannot be identified as abusive.

The parents submit that R’s fatal injury was caused by Mr. or Mrs. O, and also that one or other of them shook her on 17^th May.

K’s case is that she did not cause any of the injuries and that she should be exonerated. She states that she was never concerned about the care that she saw the parents (most particularly the mother) give to R.

Mr. and Mrs. O both invite the court to find that the parents were responsible for causing all of the injuries. Ms. Meachin KC and her team for Mrs. O and Mr. Howe KC and his team for Mr O submit that there was serious domestic violence in the parents’ relationship about which the parents (particularly the father) lied, that the parents and K conspired to hide evidence from the court by deleting messages and lying to the police about K’s involvement (and in K’s case, failing to assist the police at all), and that the parents lied repeatedly about R’s condition (and indeed more widely about a number of things). They say that the oldest injury could only have been perpetrated by one or other of the parents, that the medical evidence for the interim injury strongly favours it having happened at a time when only one or both of the parents were caring for R and therefore, because it is extremely unlikely that there are two unconnected perpetrators of injuries that I should also find that the fatal injury was caused by one or other of the parents before R was dropped off at the home of Mr. and Mrs. O on the morning of 24^th May.

Ms. Meachin KC and Mr. Howe KC submit that the ‘wider canvas’ evidence shows a strong contrast between Mr. and Mrs. O (who own their own home, have good jobs, and about whom there is no record of violence or abuse) and that of the parents, and that also points to the strong likelihood of R being injured in the parental home.

I heard evidence from Professor Mangham, Mr. Jayamohan, Professor Al-Sarraj and Dr. du Plessis (together), Dr. Malcomson and Dr. McPartland (together), Dr. Ward, Dr. Leadbeatter and Dr. Jeffrey. I also heard evidence from a doctor who saw R on 20^th May, two doctors who spoke to Mrs. O at hospital on 24^th May, a matron who also spoke to her there, K, Mr. O, the mother, the father and Mrs. O, in that order.

I also read all of the documents in the bundle. I watched the interviews of the parents and Mr. and Mrs. O and K, and have returned to them in the course of this judgment. I have also watched CCTV footage and body worn camera videos which are extensive. I have also returned to look at them again in the course of writing this judgment and after reading the final written submissions of all of the parties.

The summary of relevant principles set out by Baker J (as he then was) in Re JS [2012] EWHC 1370(Fam)still provides very helpful guidance for judges in fact finding hearings. The burden of proof lies with the body or individual who makes the allegation. The standard of proof that must be applied, both as to the making of a finding and as to the identification of a perpetrator is the balance of probability. Findings of fact must be based on evidence, including inferences that can be properly drawn from the evidence, and not on suspicion or speculation. Evidence must not be evaluated in separate compartments, and a judge must have regard to the relevance of each piece of evidence in the context of all the other evidence, and to exercise an overview of all of it before coming to conclusions.

The role of the court and that of experts is distinct. As Charles J stated almost twenty years ago in A County Council & K, D, & L [2005] EWHC 144 (Fam); [2005] 1 FLR 851, it is the court that is in the position to weigh up expert evidence against the other evidence. There may be cases where a judge comes to a conclusion that is at variance from that of the experts.

Factored into every case which concerns a disputed aetiology giving rise to significant harm must be consideration as to whether the cause is unknown (Re R (Care Proceedings: Causation) [2011] EWHC 1715; and R v Henderson and Others [2010] EWCA Crim 1219). The court must guard against the temptation to believe that it is always possible to identify the cause of injury to a child.

There is no ‘pseudo burden’ on a parent, or any obligation to prove the truth of an alternative case by way of a defence and the failure by that party to establish the alternative case on the balance of probabilities does not of itself prove the local authority’s case; Re X (No 3) [2015] EWHC 3651 (Fam) and Re Y (No 3) [2016] EWHC 503 (Fam), Wolverhampton City Council v JA and Ors [2017] EWFC 62.

In Re A (No. 2)(Children: Findings of Fact) [2020] 1 FLR 755, Peter Jackson LJ said this at paragraph [100]:

“The questions for every fact-finder are What, When, Where, Who, and Why? Their significance and difficulty varies from case to case. Some answers will be obvious while other questions can be extremely hard or even unanswerable. Sometimes a question may not need answering at all. At all events the questions come in no set order and each enquiry will suggest its own starting point. It will no doubt find apparently solid ground and progress from there, but conclusions can only ever be provisional until they have been checked against each other so as to arrive at a coherent outcome. At each stage, regard is had to the inherent probabilities and improbabilities surrounding what are inevitably abnormal circumstances”.

The proper approach to the identification of a perpetrator has been set out in a number of recent authorities. In Re A (Children) (Pool of Perpetrators) [2022] EWCA Civ 1348 King LJ, with reference to Re B (Children: Uncertain Perpetrator [2019] EWCA Civ 575, [2019] 2 FLR 211 made clear that the proper approach to be applied remains as set out by Peter Jackson LJ:

“[49]….The court should first consider whether there is a 'list' of people who had the opportunity to cause the injury. It should then consider whether it can identify the actual perpetrator on the balance of probability and should seek, but not strain, to do so: Re D (Children) [2009] EWCA Civ 472 at [12]. Only if it cannot identify the perpetrator to the civil standard of proof should it go on to ask in respect of those on the list: "Is there a likelihood or real possibility that A or B or C was the perpetrator or a perpetrator of the inflicted injuries?" Only if there is should A or B or C be placed into the 'pool'.”

In Re H (Children: Uncertain Perpetrator: Lies) [2024] EWCA Civ 1261 Peter Jackson LJ said this at paragraphs [20-23]:

“[20] Lies, where they are admitted or alleged, will form just one part of the overall evidence in family proceedings. The underlying purpose of the Lucas direction is to ensure that proven lies are assessed with a sense of proportion. In relation to welfare, it has been said that they should not be allowed to hijack the case (Re Y [2013] EWCA Civ 1337 per Macur LJ at [7(4)]) and, as I put it in Re K (Children: Placement Orders) [2020] EWCA (Civ) 1503, [2021] 2 FLR 275, [2022] 4 WLR at [29], that the link between lies and welfare must be spelled out.

[21] The same discipline applies to fact-finding. The court's view of a witness's overall credibility and reliability will naturally contribute to its evaluation of whether it can accept their evidence on the critical issues. If it concludes that lies have been told, it will consider what weight, if any, should be given to that aspect of the matter, after due consideration of any explanations that have been offered. That is part of the normal process of sifting and weighing the evidence, and explaining the result. The family courts encounter many forms of bad behaviour and they are used to assessing their true significance for the issue in hand. There is no special rule of evidence for lies.

[22]I would therefore make one observation about the description of good practice in Re A, B and C. At [58(iii)] it is said that the court should seek to identify the basis on which it can be determined that the only explanation for the lie(s) is guilt. That draws on the slightly different jury direction in the Crown Court Compendium at 16-3, which requires that a lie is only capable of supporting other evidence against a defendant if the jury are sure that it was not told for a reason advanced by or on behalf of the defendant, or for some other reason arising from the evidence, which does not point to the defendant's guilt.”

It must also be borne in mind that discrepancies and inconsistencies in evidence can arise in ways that are not sinister or a result of bad faith, see Lancashire County Council v C, M, and F (Children: Fact Finding Hearing) [2014] EWFC 3:

“in cases where repeated accounts are given of events surrounding injury and death, the court must think carefully about the significance or otherwise of any reported discrepancies.  They may arise for a number of reasons.  One possibility is of course that they are lies designed to hide culpability.  Another is that they are lies told for other reasons.  Further possibilities include faulty recollection or confusion at times of stress or when the importance of accuracy is not fully appreciated, or there may be inaccuracy or mistake in the record-keeping or recollection of the person hearing and relaying the account.  The possible effects of delay and repeated questioning upon memory should also be considered, as should the effect on one person of hearing accounts given by others.  As memory fades, a desire to iron out wrinkles may not be unnatural – a process that might inelegantly be described as ‘story-creep’ without any inference of bad faith. These words echo the words of Leggatt J in Gestmin SGPS v Credit Suisse (UK) Ltd [2013] EWHC 3560 as to the fallibility of human recollection, and the limitations of memory”.

In J (A Child) [2015] EWCA Civ 222 Aikens LJ stated that:

“The formulation of "Threshold" issues and proposed findings of fact must be done with the utmost care and precision.   The distinction between a fact and evidence alleged to prove a fact is fundamental and must be recognised. The document must identify the relevant facts which are sought to be proved. It can be cross-referenced to evidence relied on to prove the facts asserted but should not contain mere allegations ("he appears to have lied" etc.)”.

The medical evidence in this case is complex and very detailed. The summary that follows does not attempt to include everything (it simply would not be possible to do so) although I make it clear that I have read all the reports and the notes of the oral evidence with care, along with the written submissions from all of the parties which set out those parts of the evidence about which they ask me to take particular note. The picture emerging from the medical evidence evolved during the investigation and the hearing.

After R’s death, Dr. Amanda Jeffrey, Consultant Forensic Pathologist, was instructed by the police to carry out the post mortem. This was conducted about ten days after the death, together with Dr. Bamber, Consultant Paediatric and Perinatal Pathologist. As part of this, other specialist pathologists were also instructed to carry out examinations of the brain and spinal cord, the eyes and bones. These experts were Dr. du Plessis, Consultant Neuropathologist, Dr. McPartland, Consultant Ophthalmic Pathologist and Professor Mangham, Consultant Histopathologist.

The findings were of multi-compartmental subdural haemorrhage of at least two different ages, recent subarachnoid haemorrhage, and spinal haemorrhage. There were also retinal haemorrhages and small rib fractures. The conclusion of Dr. Jeffrey and Dr. Bamber was that R had died as a result of a craniocervical injury.

Dr. du Plessis identified at least two if not three episodes of injury, the oldest being over two weeks old at the time of death and the most recent likely to be very shortly before she died. Dr. McPartland identified at least one episode of injury causing retinal haemorrhages, but stated that there were signs of cellular inflammatory response which suggested some injury which was not less than two or three days old. She stated that this was consistent with one event with this timing or an older injury superimposed with a more recent episode of bleeding shortly before R collapsed. Professor Mangham identified 10 small rib fractures, and possibly another two although these could not be interpreted with confidence. He considered it likely this was caused by CPR. So far as seven of the fractures were concerned there was no sign of a cellular response which meant they could not be aged with any accuracy beyond saying that they could have occurred any time from just before death up to about a week. He considered three of the fractures showed a cellular response, one of which also had a cartilaginous spur. One of those was larger than the others, which made it easier to assess the findings. In his view this fracture and the other two were likely be between about 36 hours and four days old at the time of death. He also found spinal nerve root haemorrhage which was recent (within two days) of death and a sternal fracture which appeared to have occurred in the perimortem period and likely to be caused by CPR chest compressions.

The findings of the post mortem, and the timings in particular were such as to point towards at least two different perpetrators of any injuries to R - if inflicted. The older subdural bleeding was said to be at least 10 days and probably older at the time R died. The first time she was looked after by Mr. and Mrs. O was on 16^th May, eight days before she died. The most recent injuries which were thought to have led to her death were likely to have occurred after the last time that she had been reported to be well. On the basis of the evidence that had been given about the morning of 24^th May, that appeared to be after she was taken to the O’s home. Added to this, the view of Professor Mangham (and to a lesser extent, Dr. McPartland) was that there were intermediate injuries which were likely to have occurred between 17^th and 24^th May, in other words in the period of time when R was not with Mr. and Mrs. O.

The proposition that a child should be injured in two completely different households by people who did not have any significant connection with each other and must have been acting independently of each other is an extremely unlikely one; one which required very careful assessment. For this reason, further experts were instructed in the family proceedings, namely Dr. Leadbeatter (Forensic Pathologist), Dr. Malcomson (Consultant Ophthalmic Pathologist), Dr. Mankad (Neuroradiologist), Dr. Ward (Consultant Paediatrician), Mr. Jayamohan (Consultant Paediatric Neurosurgeon) and Professor Al-Sarraj (Consultant Neuropathologist). On any view this is a lot of experts, but it is important to note that each of the possible perpetrators have other children, who could be at risk if their parents, or one of them, injured and/or fatally injured a nine month old child.

I will set out the evidence of all the witnesses in a little more detail below.

Dr. Jeffrey was the forensic pathologist who was responsible overall for the post mortem examination and report, drawing on the other pathology specialists (Professor Mangham, Dr. du Plessis and Dr. McPartland) for their opinions on the specific findings in the bones, brain and spinal cord, and eyes. She gave the cause of R’s death as craniocervical injury. She found no evidence for any injuries on the external surface of the body and no medical or natural cause of death. There was no evidence of hypoxic ischaemic injury in the organs of the body generally (apart from the brain itself) save for some small signs in the liver. She did not think that the absence of such findings contributed very much to the understanding of the injuries and their timing. In answer to questions from Ms. Hendry KC she said that the post mortem had revealed digestive contents limited to red fluid (rather than any solid food) but that such is individual variability when it comes to digesting food that this did not tell us very much.

Dr. Leadbeatter agreed with Dr. Jeffrey that the cause of R’s death was craniocervical injury. He further agreed that there were no injuries to the external surface of the body save for what he would attribute to resuscitation attempts. He agreed with Dr. Jeffrey’s findings as to the minor degree of bleeding into the lungs and also that this was not of particular significance. As a general paediatric pathologist he deferred to the specialists in relation to their own findings but he drew attention to the controversy surrounding the significance of what can be called microfractures in/of the ribs as identified in this case and others. He was fully able to see what Professor Mangham identified as areas of injury, particularly so far as the larger lesion on the fourth left rib was concerned. He stated that he was aware of the views of other osteoarticular pathologists that such findings might not, in themselves, be outwith the remodelling seen in an area where there is active bone growth. In the absence of knowledge of detailed microscopy of these areas in the ribcages of infants who have died where there is no suspicion of injury he said he would hesitate to say that these changes represent healing of previous injury inflicted with intent. He also stated that, however caused, he considered it difficult to age these changes, particularly because the findings are in a growing area where remodelling typically happens (albeit he did not think what he was seeing represented simple growth alone).

So far as the findings in the head and spine are concerned, he gave a timeframe of 10 to 23 days for the older injury and confirmed there was more recent bleeding. He was prepared to say that the older injury could be as recent as 8 days old although he clearly found this unlikely. As was the case with the other pathologists he emphasised the importance of looking at the clinical evidence in order to estimate timing with respect to the recent event and said that it was his understanding that the majority of infants with fatal injury are symptomatic very shortly after the traumatic event, particularly where that event is inflicted head injury. He said that uncertainty does remain as to how long is the period before symptoms appear. He provided the court and the parties with a case study of an infant who survived following a traumatic event where there was an interval of over two hours before symptoms appeared. He is not aware of any research to suggest that a child who has been the subject of multiple episodes of head trauma would be more prone to injury on a subsequent occasion but emphasised that this does not mean it does not exist.

Like a number of other witnesses he expressed caution about timing injuries from the pathology alone. He stated that it is all the more difficult when there are several episodes of injury so that findings are superimposed upon each other.

Professor Al-Sarraj was instructed in the family proceedings to prepare a report as to the neuropathological findings, timing and aetiology. Dr. du Plessis was instructed by the coroner to conduct the post mortem histological examination of the brain. Given the complexity of the case, they both read each other’s reports and attended to give oral evidence. They both attended on the same day and listened to the evidence of the other. In almost all respects they agreed with each other but there were some differences in their view as to the timing of some of the injuries. In most cases this would be considered very minor but in this one they were of the greatest importance.

Professor Al-Sarraj advised that there was subdural haemorrhage in multiple locations in the brain, with histological evidence of different episodes of bleeding. He also found spinal subdural haemorrhage of different ages, haemorrhage around the spinal nerve roots of different ages, recent subarachnoid haemorrhage and some ischaemic damage to the axons.

Both experts considered that there was neuropathological evidence of injuries of at least two and most likely at least three different ages. Dr. du Plessis gave a timeframe of between 2 weeks and 2 months before death with further evidence of another episode of bleeding a few days (which he suggested as being most likely to be less than a week) before death and a further episode within 48 hours. Professor Al-Sarraj gave a time frame of three episodes 10 days to about 4 weeks before death, 6 to 10 days before death and less than 48 hours respectively. Each of them allowed for the possibility that there were just two episodes of injury, but the oldest of these would still have occurred 10 days or more before death. At the conclusion of their evidence it was clear that both agreed that the middle of the three episodes they identified could have been the time when R was with Mr. and Mrs O on 16^th and 17^th May albeit they differed slightly as to how likely they thought this was on the neuropathological evidence alone. Dr. du Plessis said that it would be a matter for the court to consider the other evidence and how it would sit with the expert opinion.

Professor Al-Sarraj stated that the injuries are all likely to have been caused by acceleration and deceleration of the brain involving hyper-flexion and hyper-extension in a mechanism such as shaking. Both experts agreed that the cause of death was cranio-cervical injury caused by trauma, and with Mr. Jayamohan’s opinion that brain dysfunction was likely to have led to cardiac arrest. Professor Al-Sarraj said that in 15 to 20% of cases they could not find any pathological evidence of bleeding in the brain. From the pathology all that can be said is that the fatal injury had occurred within 48 hours of death, but he and Dr. du Plessis considered their findings about the recent injury were consistent with Mr. Jayamohan’s evidence about the clinical picture. Dr. du Plessis said, in answer to questions from Mr. Vine KC, for K, that bleeding into the nerve roots in the cervical spine was likely to cause quite a bit of pain, and therefore ‘a very irritable child’.

Professor Al-Sarraj gave a general warning about the timing of lesions to the brain saying that all that pathologists can do is to give an estimate as to timing. They cannot pinpoint it to minutes or hours, but only within a window stating the relative likelihood of it occurring at any given point within that. Further, the neuropathological findings must be considered in conjunction with the findings in the eyes and ribs as well as the clinical picture, using the analogy of a jigsaw of which neuropathology is one part. He commented, in response to questions from counsel that we were lucky here to find such consistency between two pathologists because it was apparent at conferences that he attends how the opinions of experts about this around the world differed.

Professor Al-Sarraj and Dr. du Plessis both opined that the most likely cause of the oldest bleeding was trauma involving shaking in the absence of any other explanation, albeit this was not an injury which it was possible to isolate radiologically and few children, thankfully are subject to a post mortem. It is not possible to know whether the older bleeding was accompanied by retinal haemorrhages. The absence of any obvious clinical history must be taken in the context of a lack of a history being a feature of non-accidental injury generally and the possibility that the event was not sufficiently serious to cause significant symptoms. Neither thought that the injury could date back to birth.

Dr. Mankad prepared a report based upon the post mortem scans. His findings were consistent with the findings of the pathologists. He said that the density of the collections was mixed, mostly hyperdense but with some low-density components also noted. There was no evidence of layering or membranes. He was only able to say from his perspective that there was evidence of injury of less than 10 days old. Otherwise, he was not able to say whether this arose from one or more than one episode of head trauma.

Evidence about the findings in R’s eyes came from two pathologists, Dr. McPartland who carried out the post mortem examination and Dr. Malcomson who prepared a report for the family court. Dr. Malcomson found that there were bilateral, numerous, widespread, multi-layer intra-retinal haemorrhages. There was peripapillary intrascleral haemorrhage (PPSH) in the left eye, and bilateral optic nerve sheath haemorrhage (ONSH). All of the eye-related injuries form a recognisable pattern of injury owing to the same causation, namely blunt force head injury. The force required would have been in excess of that achievable in ordinary handling of the child or even in rough play.

The presence of recent haemorrhages is consistent with significant head trauma having occurred at any time up to several days or a few weeks prior to death, including immediately prior to presentation. A period of survival of at least an hour or so prior to death following an episode of head injury is supported by immunohistochemical evidence of focal axonal injury to the retinae although this might have originated in one or more episodes of retinal injury having occurred at any time within the period of up to a small number of days (probably substantially less than 7 days) prior to the death. He considered it unlikely that the eye injuries in this case, most associated with severe/fatal injury at post mortem had occurred substantively before the day of presentation without significant adverse neurological effects. Optic nerve haemorrhage is associated with severe injury to the head. In his view it is eminently plausible that a head injury event had occurred within hours of presentation and caused death. It is reasonable to suggest that the acute pathological effects of the latest implied head injury event were superimposed on earlier injuries of lesser extent but it is now not possible to separate the histopathological effect of the various events of head injury in the eyes by morphological means alone.

In his oral evidence, Dr. Malcomson said that the eye pathology on its own was not capable of telling us whether there was more than one episode of injury. There could be two or three, or even more but he could not be definitive from the perspective of his own specialism. Some of the findings required there to be a survival time of at least a few hours between the time some injury occurred and death. Acute inflammatory cells were present to a greater degree than chronic cells which suggests an episode of injury which is probably less than a week old at the time of death, albeit it is difficult to be precise. He said that there was at least one shake at least two to three days prior to death, probably less than a week, and that he could not exclude another shake within minutes or hours of death. The superimposition of findings, particularly of acute bleeding make it difficult to separate from previous incidents. However, he made it clear during the course of his evidence that it is very difficult to give precise timings about these incidents, stating at one point ‘these are extremely subtle changes which with the experience we have, and deciding whether or not you can just about detect an increase [in inflammatory response], just a few cells here and there, some of them are clustering which shows we are seeing a real effect in the eye’ and that ‘we are at the limit of what we can achieve through eye pathology alone’. He was cautious to avoid being prescriptive about timing and said on more than one occasion that eye findings must not be taken alone and must be taken into consideration with other findings, clinical and neuropathological. He did not say that the eye pathology excluded episodes of trauma happening on 17^th and then 24^th May 2023 although he preferred a shorter timeframe than 7 days for the non-acute injuries.

He accepted that there was a broad temporal correlation between the findings of Professor Mangham and the eye pathology but said that was as far as it could go.

Dr. McPartland listened to the evidence of Dr. Malcomson and gave evidence afterwards. She agreed with the views that he expressed.

Professor Mangham conducted a post mortem examination of R’s ribcage. He found what he considered to be 10 small fractures at the back of the ribs where they join the spine (both on the left and the right) and two possible fractures at the front. All the fractures are small which, he warned meant that they can be difficult to interpret. Three of these fractures demonstrate what he considered to be was a cellular response, meaning that they occurred before 24th May. He stated that the very earliest that a cellular response can be seen in an infant is about 12 hours (what he described as a ‘plumping up’ of the cells), becoming clearer between 24 and 36 hours. These fractures were the 3^rd right rib (posterior), and the second and fourth left ribs, also posterior. So far as 3R and 2L are concerned Dr. Mangham said he could not rule out the possibility that the cellular response related to normal growth and tissue remodelling, but he considered this was less likely for 4L. 4L is slightly larger than the other fractures and he saw not only a clear cellular response around the site of the lesion itself but also a cartilaginous spur which is caused, he stated by blocked access of normal physeal resorption. He said that the appearance suggests that this fracture occurred between 36 hours and 4 days before death.

In his oral evidence he said that it was extremely unlikely that the fracture occurred within 24 hours of death, albeit he said it was not impossible. He did consider 12 hours was impossible. At the other end of the age range, he said that 7 days was beyond what one would expect as he would expect to have seen a high level of resolution. Here, for example there were no osteoblast cells and he could not see any signs of a fracture that was as much as six days old.

Professor Mangham said that there was a vigorous dispute as to whether the lesions such as seen in this case actually represent genuine fractures. Professor McCarthy whose evidence had been accepted by Keehan J in a different case took issue as to whether they represent fractures, and experts such as Professor Freemont and Dr. Leadbeatter accept they represent micro injuries but question whether these can arise in normal handling. There is no perfect ‘control group’ of children whose bones are examined in this way when trauma is not suspected. Professor Mangham pointed out that Dr. Leadbeatter is a general pathologist and as such he will not see the same volume of cases involving the pathology of bones as he does.

It was apparent to me when reading and listening to this evidence that the understanding of the significance of lesions such as this is still developing. They are by their nature, very small, and interpretation as to their timing and causation relies on subtle changes from what is considered normal. Whilst Professor Mangham has clear views that they are fractures which must have happened outside normal handling, he was also very willing to acknowledge that different views existed. He was more sceptical about the position of Professor McCarthy in that he disputed whether the lesions existed at all, than about Professor Leadbeatter and Professor Freemont who accepted they existed but queried what they signified.

Mr. Jayamohan noted that there was evidence, from a clinical perspective, that would support two episodes of trauma, namely on 17^th May and 24^th May. He stated that if R was well in the morning of 24^th May when she was at the childminder’s house, the event that led to her collapse is most likely to have happened after that, being a shaking or shaking type injury. He does not believe that a child could have sustained these injuries then deteriorated to a point of cardiorespiratory arrest with a period of normality between the injury and the collapse.

Mr. Jayamohan also said that the history of R being unwell for a few days following 17^th May would fit clinically with an earlier shaking injury, although he fully accepts that the pathological findings are of an older episode (more than two weeks before death) and another possible episode a few days but less than a week before death.

Having discussed the issues with the neuropathologists at the experts’ meeting, Mr. Jayamohan’s opinion is that R’s collapse was very sudden and that the findings are in keeping with anoxia leading to death rather than a period of hypoxia. A longer period of hypoxia would normally be associated with a swollen brain and evidence of hypoxic-ischaemic injury which can be seen pathologically. The mechanism for sudden anoxia in the light of the pathological findings is of trauma to the brainstem caused when the area is stretched, for example by a shaking injury. He stated he had also seen an injury in a child who was wrongly put into a car seat and was then involved in a car accident.

He made clear in his oral evidence that the sort of findings in R are not the usual sort that are seen in a severe shaking case, which would normally involve a hypoxic ischaemic injury to the brain, leading to the child having a high pitched cry, breathing abnormalities and deterioration. Here there was a very rapid stopping of blood flow to the brain. He was very clear in his view that R could not have suffered her brain injury before a time when she was considered to have been well, stating ‘I cannot envisage from all the knowledge I have of how a child who has had such a substantial injury could have been well that morning’ if it had already happened. Although he acknowledged that, if the pathological evidence of an injury before the childminder looked after R was right, this would mean her suffering injuries by two different and unrelated carers, he did not think that could change his medical view. He said that there was no evidence clinically of an earlier episode although of course that does not mean it had not happened.

As a clinician, Mr. Jayamohan was focussed on the history, not only in relation to 24^th May but also the period after 17^th when she was reported as being unwell and presented for medical treatment. Whilst the symptoms that were described were somewhat non-specific and could be associated with more common conditions such as enterovirus (which was found on a post mortem rectal swab), it was his view that they were also consistent with a shaking event on 17^th May, followed by R recovering to the extent that she was well enough to go back to the childminder on 24^th.

Mr Jayamohan said this was one of, if not the most challenging case he had ever dealt with. In an expert who has reported on over 1000 cases this is very striking.

Dr. Ward prepared two reports, one dealing with R and one with V, specifically as to whether a mark found at the child protection medical could be considered a bruise. Dr. Ward does not believe that there is reliable evidence that it was a bruise and so that aspect of the case has fallen away.

Looking at the clinical picture, and with her experience as a paediatrician dealing with child protection cases, Dr. Ward stated that she was in agreement with the views of Mr. Jayamohan in particular about the likely timing of the fatal injury (if that is what it was) to R. She emphasised that current research does not support the concept of a lucid interval between an injury of such severity as to cause death and the child’s collapse. She said, however, that it is important to be cautious because of the risk of a cyclical argument whereby there is no evidence of such a phenomenon as a lucid interval because nobody accepts that there is such a thing. In cases of acute head trauma there is often no history or at best a very imprecise one. Nonetheless, she was of the view that the traumatic event that caused R’s death most probably occurred in the middle of the day on 24^th May as opposed to the morning.

She did note that the traditional literature would say that it would be very uncommon to cause a rib fracture by CPR, but that CPR is more commonly being done now by putting hands around the chest and using the thumbs rather than the old method of using fingers alone (and not holding the chest). She said that people do not record the method they have used and suggested that there has been an increase in the number of fractures thought to have been associated with CPR. Sternum fractures (there was one here) have been associated with CPR in children.

Dr. Ward was asked about the mother’s evidence that R returned from the O home on 17^th May with a mark on her face, and said that (depending on the reliability of that evidence) a bruise in a pre-mobile child is not something that can be ignored, as it can be what she describes as a ‘sentinel feature’ and indicative of some occult injury. At this point R was an early mobile child but unexplained bruising (if that is what it was) should normally be investigated. The symptoms that she displayed upon return from the O home are consistent with a head injury, but also with enterovirus which complicates the picture (as could a worsening of her condition on 20^th May). She did say that vomiting would more often be associated with a head injury than diarrhoea (as opposed to enterovirus). She noted from her experience that R’s parents did not seem to be what she described as ‘super anxious’, with the level of consultations with the medical professionals being within a normal range. Therefore, the level of parental concern about R as demonstrated by their actions on 17^th May and afterwards was notable.

Dr. Ward stated that the descriptions of R’s breathing were somewhat non-specific and she did not think it was associated with a fatal head injury.

The expert evidence available in this case is of the highest quality, from experts who are well known nationally as well as, I believe, internationally. I am very grateful to all those who have contributed to this very difficult case. In order to avoid this judgment becoming excessively long I have avoided setting out all of the detail of the findings and conclusions as opposed to the overarching views as to timing, the reasons behind that, and causation.

There is a remarkable amount of agreement between the experts on most matters. I say remarkable because Professor Al-Sarraj’s comment about the differences of opinion between neuropathologists seen by him at conferences did not surprise me. Cases involving alleged abusive head trauma are difficult for a variety of reasons and scientific knowledge and understanding is developing all the time. The findings in each area of expertise also broadly fit together.

All of the experts concur that R died of cranio-cervical injury. Although Dr. Leadbeatter preferred not to use the term ‘shaking’ to describe the mechanism, all the experts agreed that there is no identifiable natural or medical cause to account for the findings of recent subdural, subarachnoid, spinal and retinal haemorrhage, together with her collapse and death on the afternoon of 24^th May. The pathological evidence could not pinpoint the timing of the terminal injury to less than about 24 hours (or even 48), but all the experts stated that it is the clinical evidence which is most important in determining this. The pathologists were all clearly conversant with the research and other evidence to the effect that the gap between a child who is injured so severely that it leads to death is likely to be very short in a case where there is no substantial evidence of brain swelling or gradually rising intracranial pressure. Further, Professor Al-Sarraj and Dr. Malcomson considered that it would be difficult to imagine a child behaving normally after sustaining the sort of bleeding into the brain, eyes and spine that they had seen.

Dr. Ward pointed out the need for caution in cases of this type where there is a risk of a circular process, in other words if experts state that there is no such thing as a lucid interval where there is a sudden collapse and death, then it will never be recognised in cases where the history given by caregivers cannot be relied upon. Nonetheless, she too was of the clear view that a lucid interval, or lucid type interval was unlikely. Mr. Jayamohan’s evidence about this was unequivocal. He found it very difficult to accept that R could have presented in any way normally (including drinking, eating and interacting) after suffering the injury which caused her death. His view was that she is likely to have stopped breathing almost immediately, because of the lack of any real signs of hypoxic ischaemic injury or brain swelling.

In all the circumstances the overwhelming weight of the medical evidence is that, based on the accounts of R’s behaviour given at the time, the interval between fatal injury and death is likely to have been very short and certainly whilst she was at the O home. The clinical experts were taken to the account of R’s presentation on the morning of 24^th May which is given by Mrs. O in her statement for this court but did not accept that even this account was consistent with R having sustained an injury before she arrived that morning.

I then turn to the older injury(ies). All of the experts stated that it was not possible to know how many episodes there were. Dr. du Plessis and Professor Al-Sarraj favoured there being at least two previous occasions although did not rule out the possibility of there being only one. If there was only one, they each believed that it occurred at least 10 days before. Dr. du Plessis thought it was older than 14 days, Professor Al-Sarraj put the nearest date at 10 days. I note that Dr. Leadbeatter was prepared to countenance 8 days but with no great enthusiasm. The signs of old injury that were visible pathologically were of scarring, which was not visible radiologically. It is not possible, from the aging of the retinal haemorrhages, to say whether bleeding in the subdural space was accompanied by retinal haemorrhages or indeed from the histopathology, any rib fractures. There is no material in the medical records or other evidence to point to a clinical episode which could have been caused by a head injury. None of the relevant experts could think of any other cause of subdural bleeding which led to the scarring identified other than some sort of trauma.

The eye pathology was of at least some injury which showed signs of healing which could have been present in conjunction with fresh haemorrhage. Both Dr. Malcomson and Dr. McPartland favoured timing that was just a few days old rather than a week for these injuries because of the ratio of acute to chronic inflammatory cells, but they did not rule out the older injuries being as much as 7 days old. The retinal haemorrhages were very extensive, and taken together with the evidence of fresh subdural bleeding, the likelihood was that some of the retinal haemorrhage was sustained in an incident shortly before R collapsed. Any retinal haemorrhages older than 10 or 14 days would have resolved.

Taking the findings from the eyes, brain and spine together, the medical evidence strongly supports there being not less than three episodes, one of 10 days or more which is only evidenced by the subdural findings which are of scarring, one intermediate episode of somewhere between about 36 hours and probably less than 7 days, and one episode which happened shortly before collapse and death.

The evidence from Professor Mangham as to three of the ten fractures that he identified, namely that they showed evidence of healing consistent with injury dating somewhere between 36 hours and 4 days of death fits with the evidence relating to the eyes which favoured just two or three days rather than as long as 7 for the intermediate episode and that of Dr. du Plessis who preferred a period of less than 7 days. This timing evidence is less firmly based than the evidence of the oldest and most recent injury, because Dr. du Plessis and the eye experts do not rule out an episode having occurred 7 days before death, and the evidence of timing of the rib injuries has to be looked in the light of the current concern about the aetiology of these in the absence of there being a suitable control group. Also, several of the experts including Dr. Leadbeatter warned against placing too much weight on specific timings where the injuries are so small and in an area where remodelling is to be expected as part of normal development.

The lay evidence falls into several different categories, namely the wider canvas evidence with respect to all the parties concerned, the evidence surrounding the times when R may have suffered injuries, the evidence about R’s presentation throughout her short life, and the accounts given by all the adults at various times, including what they said in their contemporaneous messages, what they said to medical and other professionals contemporaneously and after the event, and what they have said in their police interviews, witness statements for these proceedings, and their oral evidence.

In every single case it is vital for a judge to look at all the evidence, expert and non-expert, and to consider all of that in the light of everything else. Here this task could not be more important. For the most part, in this case and elsewhere, evidence given by witnesses close to the time of events is very valuable and needs to be scrutinised with care.

The first of the parties to give evidence was K, followed by Mr. O, the mother, the father and then Mrs. O. This was not the order which was originally intended but a number of individuals contracted Covid during the early part of the hearing and the witnesses changed about as a result. Whilst illness and some other matters put pressure on the court timetable, I made it clear that if more time was needed, for example, for Mrs. O’s evidence which was completed on the last day of the trial, it would be found. In the event that was not necessary as counsel kept to the times that they had put forward on the witness template.

K came across as a gentle and good natured individual who was somewhat isolated as she had only recently arrived in the country in 2023. She had obtained a visa to come here as a care worker and was in the course of training. She was living alone and apart from her family (who were shortly to join her) at the time she met the parents. She and the parents only met on about 9^th May but they identified with each other quickly because they came from the same area of their country of origin, and none of them had had time to make friends or contacts in the area they lived in the UK. K appeared to be very fond of R and had nothing bad to say about the parents. She thought that R was provided with a good standard of care and told me how the parents repeatedly told her that if only she was looking after R on 24^th May, she would not have died.

Mr. O was a guarded witness and apart from one notable occasion when he appeared to become suddenly angry when questioned by Ms Branigan KC, controlled. Many people who had been responsible for the care of a child just before she collapsed and died (as was the history given by both Mr. and Mrs O) would have repeatedly asked themselves whether they ought to have noticed anything wrong earlier, but neither Mr. O or his wife gave the impression of having done this. Mr. O said he had not asked his wife what had happened when (according to their account) he had gone upstairs leaving her alone with R.

There is bodycam footage of the police entering the O family home on the evening that R had died. Whilst he was quite entitled to ask for their names and numbers first of all, and it was not surprising he was worried about his own children, he appeared very guarded in his dealings with them. He did not volunteer that he had been on his own with R immediately before she was found to have collapsed.

Mrs. O, who gave evidence last, was, even more than her husband, inconsistent and evasive. I found her evidence on matters which were both central and peripheral to the issues in this case to be very unsatisfactory.

By contrast I found the mother to be straightforward and much more reliable than either Mr. or Mrs O. Her oral evidence was broadly consistent with earlier evidence she has given to this court and the police, with what was said by others and also contemporaneous records. I acknowledge that she has not been truthful about everything (for example by maintaining to Mrs. O that she was attending interviews and had not secured a job) but I did not think this undermined her overall credibility on the issues that were central to this case.

Finally, I found the father to be intense and argumentative. He found it difficult to acknowledge any other perspective than his own, and blamed the mother for matters which he bore responsibility himself. I thought he was much more credible when being asked about matters which related to R.

I will explain the reasons for these observations about the parties in the course of my assessment of the evidence below.

I am asked to find that the relationship between the parents was (and continues to be) violent and toxic. The allegations of domestic violence are very serious, including that the father was violent and abusive to the mother when she was pregnant, and also said that he did not want the baby, and, on one occasion, that it was not his. They include an allegation that he banged or smashed R’s cot, and that the parents’ relationship was in a very poor state in May 2023, including on potentially important dates such as 17^th and 18^th May. There are numerous messages between the parents in which the mother castigates the father for shouting and also suggests that she becomes angry when he shouts at her. There is also evidence of a very poor relationship between the mother and the father’s parents and that there was such a serious argument on 9^th May 2023 that it led to them leaving the home that very night and flying out of the country to their home the following morning. If I make the findings sought that is relevant evidence relating to the propensity of the father in particular to be violent, but also the mother, and the environment in which R was living.

In those circumstance I propose to consider the issue of domestic abuse between the parents first. It is an important part of the wider canvas, and an allegation with respect to the threshold criteria for V in its own right. The evidence in relation to this comes from the parents as well as the records of police call-outs, medical records, and messages.

The mother gave evidence at length, both about the abuse she said she had suffered from the father and his parents, and also about all of the events concerning R. Although there were times when she was very distressed, she maintained her composure throughout, never becoming angry or flustered.

The mother has given numerous accounts of all these events to different people at different times, in her police evidence and her written and oral evidence to the court. She was cross examined closely over several hours by counsel representing not only the local authority, but also Mrs O, Mr. O, K and the Guardian. Throughout all of it I found it notable how consistent the various accounts are with each other and with the evidence of others. This does not mean that every account was identical, nor would I expect that. I noted how the mother was prepared to accept evidence which did not support her case at times or put her in a good light, and appeared balanced and thoughtful.

The mother explained that most of the arguments between her and the father surrounded his parents and the fact that they did not approve of her. She described him as being caught in the middle, and unable to stand up to them. She maintained throughout that she was unwilling to accept the treatment he meted out to her, and/or the treatment the paternal grandparents were telling him that she deserved, that she would argue back and stand up for herself.

She further maintained that they both made an effort not to shout or argue in front of R after she was born, because they were aware of the effect of this on her. There is no doubt that the mother was aware of the effect on R because she brought it up in messages, for example on 18^th May. She said that there was no abusive behaviour in front of R but that they carried on their arguments via WhatsApp. There is some support for the contention that they could restrain themselves from abusive behaviour if they had to, for K said she was not witness to this despite spending a lot of time with the family between 10^th and 24^th May.

The mother’s account of the domestic abuse she said she had suffered was clear and cogent. Only one aspect was puzzling because it was in contrast to the rest of what she said, and that was what she said about the father hitting her in the stomach whilst pregnant. She said this to different professionals more than once but said to the court that she could not recall the father doing this although she said he threatened to. She said that if she had she would have been worried about the unborn baby and gone to hospital. Either this was an example of her exaggerating an account of violence to the professionals at the time or minimising violence later.

The father presented as a more intense, argumentative and excitable character than the mother. He presented as emotionally immature. He readily agreed that he was inclined to speak loudly so as to give the impression that he was shouting. He denied all the allegations of violence and abuse made against him by the mother and said that it was she who was controlling of him and critical and disrespectful of his parents.

When deconstructed, the father’s allegations of coercive control against the mother did not rely on much more than his feeling resentful that the mother did not agree to his being able to do such things as going to the country where he was born to see a terminally ill relative, and that she in turn resented the lack of time he spent at home. At the same time as objecting to her placing emotional pressure on him not to do things he wanted, he appeared not to appreciate the fact that making threats of suicide to her was also a kind of manipulation, and serious manipulation at that. He maintained his account that the mother had thrown a glass at him and that she had called his mother a bitch.

The more questions the father was asked about his relationship with the mother, the more answers he gave which suggested he found it difficult to see his wife’s point of view about things, or to pause and reflect on his own behaviour. Whenever he was asked what he might be able to do to change his own behaviour he gave answers which suggested he thought he did not need to do anything at all. He really placed the responsibility for all their arguments upon her. He denied any mental health problems even though he said he had tried to end his life by swallowing poison before they came to England and had made many suggestions since that time that he would do it again. He repeatedly said that his wife was trying to make him agree with things that he could not, being the sort of person who must stand by the truth. Why his wife would make such detailed allegations against him, and stick to them, was something he could not explain.

There are extensive records of call-outs made by each of the parties to the police, and evidence that the police recorded injuries on the mother which corroborated what she said. She sought support from the police and, when she was pregnant, from the midwife. She has maintained that she was the victim of domestic abuse whilst being fully aware as to the consequences of it for this enquiry. I note that the father made threats of suicide in some of the messages, and also that he tried to poison himself before the parties came to live in this country. I did not believe his denials that he was violent to the mother, or that she invented allegations against him. He accepts that he banged R’s cot in temper albeit he minimised this. In my judgement, the mother was a reliable and credible witness and I accept what she said. I find that the father was violent and abusive to the mother on the occasions pleaded by the local authority, including when the mother was pregnant with R. I also find that he was violent and abusive to the mother also when she was pregnant with V, and also after V was born. I do not find that she was violent to him by throwing a glass or a mobile phone, but that he has made these allegations to try and undermine what she has said about him.

The local authority case is that the mother has minimised the father’s violence. I think she was worried about telling the court that he had punched her in the stomach lest it be thought that she had failed to seek medical attention for R, but many less credible witnesses would have denied this outright. The evidence as to whether the father actually hit her when she was breastfeeding V or afterwards is more muddled and I accept what the mother says about that.

Subject to those points, I do not consider that this mother has tried to hide or minimise the father’s violence to her. On the contrary, she called the police when she was frightened, told the midwife, and gave extensive evidence about it to this court. The allegations she has made and stood by are very serious, and indeed the question of whether or not the father threatened to punch her in the stomach, or actually did so, do not add a great deal to the whole. The fact that domestic violence was not always recorded on the forms when she sought medical attention for herself or R does not lead me to believe that she has tried to cover anything up. This is plainly not the case. Whether or not she should have left him and sought refuge for herself and R is a different point, but I must bear in mind how difficult were her circumstances, being in a country which is foreign to her and without friends and family.

There were fewer calls to the police about violence once R was born, although this may be because of the presence of grandparents for a lengthy period of time. Counsel for Mr. and Mrs. O understandably submit that the angry argument that the parents clearly had by text on 18^th and 19^th May is bound to have continued when they got home. The messages (which the mother cannot have expected anyone to see) refer to fighting but many people use this term to refer to verbal arguments as well as physical ones. There are no specific references to anything physical. K was around quite a lot during that period of time and she said she did not see the parents getting angry with each other, which shows that they were able to control themselves when necessary. Neither of the parents have been slow to call the police in the past, the mother particularly if she had become frightened, but she did not call them out then. The level of love and care that she has shown for R at all times leads me to believe that she would have called the police if she thought that R had been hurt, or was at risk of such.

The mother and father came over to the UK to try and make a better life for themselves and their children. Obtaining a student visa was the platform for that. In order to try and achieve their dream they borrowed money from family (specifically the paternal grandparents) and put this towards the costs of visas and accommodation. The mother was already two months pregnant when she arrived which placed pressure on them. Rented accommodation was hard to find and very expensive. Thus, it was that they first lived in one room and then in two rooms with a bathroom and small kitchen. The maternal grandparents came over to help the mother first, and then after they left, the paternal grandparents. All the adults shared these two rooms so it was very cramped. The father juggled two or three jobs to try and make ends meet. I do not doubt that the circumstances were very stressful for the family and that the father found it difficult to find himself responsible for supporting his wife and child as well as paying back loans he owed to his parents. He is obviously very worried about his parents’ opinions and found their criticism of the mother difficult.

Therefore, the family was under very considerable financial pressure and pressure at home after the paternal grandparents arrived because the relationship between them and the mother was bad. The mother was keen to return to work and it was originally intended that the paternal grandparents would care for R for as long as they were here. That option was abruptly not available when they left on 9^th May, the very day that the mother had started a new job. There was suddenly no childcare so that the family budget was going to have to stretch to paying for it.

The contemporaneous messages and other evidence shows that the mother attended all her ante-natal appointments and that there is evidence that she contacted the health visitor and GP regularly but not at a level which might be considered excessive. The mother appears to have followed advice from professionals about taking R out to Sure Start, and there were no suggestions from professionals that she was not well fed or cared for.

The messages sent by the mother to Mrs. O and others would appear to demonstrate great attention to R’s care. The mother provided her with specially cooked food including things such as cooked pear, beetroot and dhal, which she got up very early in the morning to prepare on the days R went to the childminder. Her messages to Mrs. O show attention to detail about her daughter’s care, almost to a fault. She found it very difficult to leave her to go to work, texting both K and then Mrs. O at regular intervals to find out what R was eating and how she was getting on. She wanted to have a video to see her playing at Mrs. O’s house. Poignantly, the bags she packed for R to go to Mrs. O’s house on the day she died have been opened and photographed. They are very carefully and neatly packed with a change of clothing, nappies, bottles, indeed anything that R could possibly have needed. These are small points but they speak to a high standard of care and show that R was very precious, and much loved.

There is no evidence that the father was ever rough or violent with R herself. There is a photograph of him with her a day or two before she died and he looks happy and proud of her. There are medical notes which show the paternal grandparents being bonded with R too, which would appear to show that the paternal hostility to the mother did not extend to R. There are one or two messages which have been referred to by counsel for Mr. and Mrs. O with the father saying things such as ‘kick her out of bed’, but they were explained. I thought the evidence that the father gave about R, particularly when cross examined by Ms Meachin KC for Mrs O and Mr Howe KC for Mr. O, was qualitatively different from the evidence he gave about domestic abuse, and much more credible.

Neither of them have made allegations of domestic abuse against the other and there are no call-outs to the police or anyone else in relation to this family. Mr. and Mrs O are both fully employed and own their own home. They do not appear to have any financial worries. Leaving aside the number of children that Mrs. O looked after, the house is not overcrowded.

Mrs. O plainly looked after the children of professional people, particularly doctors. No doubt this was because her house was so close to the hospital. Apart from one or two issues those parents appear to be very pleased with the care that their children were being provided.

On the other hand there is evidence of tension between Mr. and Mrs. O which was not admitted by either of them. The messages show that Mrs. O sometimes left children to be cared for by Mr. O and that on occasion he complained about that and the fact that she sometimes disappeared and he did not know where she was. Mrs. O was in a relationship with at least one other man during May 2023 and on 24^th she was out of the house for two hours leaving Mr. O with four children under the age of 3 on his day off. Many partners would have been incensed by this behaviour but Mr. O portrayed this as being no problem at all. The phone records show that Mrs O frequently blocked Mr. O on her phone (albeit she gave an explanation for this), and counsel for the parents have pointed out that photographs of the upstairs of the house appear to show them using separate bedrooms.

Mrs O seemed to lack a sense of responsibility, especially for the fact that she was breaking the law by caring for children without being registered or indeed caring for more children than would have been permitted if she was. Most people would think it was very hard to care for four children under the age of three. She brushed away questions about it by saying that this was something for the parents to decide about. Equally she brushed away any suggestion that the lengthy period of time she spent on video calls on the morning of 24^th May distracted her from caring for the children.

I thought that both Mr. and Mrs O minimised the difficulties in their relationship and the work involved in caring for so many young children to a very significant degree.

I also had considerable concerns about the wider credibility of both Mrs and Mr. O. Of course the fact that a witness lies about one matter does not mean they are lying about everything but I did not believe the evidence given by Mrs. O in relation to such things as whether they told the parents that R would sleep upstairs when she was there, whether they told the parents they had baby monitors in the house, that she did not actually interact much with her friend on video on 24^th, amongst other things.

K was new to this country too, and was finding it hard to get suitable accommodation for herself and her family. She was dependent on her newly acquired job for her visa, and was anxious that her husband and children could join her in England in June 2023. There is no indication that she had any significant family problems, or that her own children are anything other than well cared for. She presented as a warm and gentle person who had been happy to spend time with people from a culture that was familiar to her.

In the written documents provided to me by counsel there have been various submissions as to which point I should start in considering what has happened in this case. Of course I have to start somewhere, but in assessing the evidence in relation to particular events or issues I am fully aware of all the other evidence.

I have already set out that the evidence suggests that R was taken to routine medical appointments and that attention was sought for her in circumstances that were appropriate. Dr. Ward said that the number of referrals by the parents to professionals for R was within a normal range, not too much or too little. There were no concerns about her presentation or development of note, save for matters such as head shape. There are one or two entries about the mother not wanting to pick her up but to let her lie flat, but these do not seem significant.

There is no entry in any of the health records that corresponds to an episode of what is said to be the oldest sign of head injury (at the very highest there is a reference to the mother telling the health visitor on 24.1.23 that R had been unsettled since her grandparents left and a report of a cold in April 2023), and no reference in any of the messages passing between any family members to suggest R was showing any relevant symptoms in the period.

There is no account or record of R being anything but well between the cold (19.4.23) and 17^th May 2023 when the ambulance was called, save for what Mr. and Mrs O have said about R’s breathing. Mr. O said that he witnessed R breathing heavily on one occasion on 16^th May, and Mrs O stated that she informed the father about this verbally when he came to pick R up. K said that in the first week she met her R was well. The parents said R was well on 16^th save for having a dripping nose which the mother thought was caused by her having cold juice.

On 17^th May at 22.27hrs the parents called an ambulance, saying that R was not well. There is a transcript of the 999 call in which the father states that R was not responding as normal and vomiting. The paramedics recorded that she was off her food and vomiting. They examined her but thought that her observations were in the normal range. The parents were given advice. The mother sent a message to Mrs. O at 19.29hrs that night saying that R became ‘dull’ today and cried after reaching home and seeing her. A minute later she sent a message saying that R vomited twice and slept after getting home. A series of messages follow in which the mother asked her whether R had been in the sun, and after an exchange of messages about food and then, at 19.49hrs ‘Whenever u leave her in the garden pls hold her n sit she is not comfortable in sitting properly she falls to the side or back she didn’t get that stability to sit on her own’, then ‘I make her to sit then only she sits after sometime she will fall’.

The following day the mother and K say that R was not well. K said R was vomiting and the parents told her about summoning the paramedics the previous night and that R did not sleep well. This all fits with the other evidence, including the messages that the mother sent to Mrs. O asking her if R had vomited at her house the day before. She also said that the parents had told her that R had diarrhoea but that she did not see this during the course of the week.

The evidence about R’s presentation on the following days, namely 19^th to 23^rd May inclusive comes from the mother, K, the father, and the contemporaneous records including messages.

K stated that on 19^th the mother worked from home and R was better, particularly because she seemed happier when her mother was there, but she was still tired. She said she did not remember if R was vomiting on 19^th but she said she was not surprised about the visit to the hospital on 20^th because R had not been well for a few days. On 21^st she was better albeit not her normal self, and she wanted to be carried by her mother all the time. On 22^nd May, K said that R seemed to be sleeping a lot, indeed she did not want to do much else, and her mother called more often. She also said that when she told the mother R was sleeping so much the mother asked her to check that she was breathing. By 23^rd May R was said to be better.

In giving her account K did not have the benefit of having given her account to anyone between the relevant events and June 2024 when she was interviewed by the police. She had no messages save for some that had been saved on the phones of her own family, because she deleted messages from the parents.

K’s evidence fitted with the evidence of the mother and the phone and other records save for what she said about 22^nd May. The mother’s case is that she asked her about R’s breathing on 18^th, and this is supported by a contemporaneous text message.

There is a record of a call from the mother to the GP on 19^th May which states that R had been vomiting after taking milk for two days, and that she was feeding less. She was better than the previous two days. On 20^th May the family attended the hospital. Here the doctor (who gave oral evidence) recorded that there was a four day history of diarrhoea and vomiting without fever. He thought it was gastroenteritis.

All the witnesses agreed that R was better on 23^rd May.

Another important issue is whether or not R had a mark on her face when she returned on 17^th May. The first written record of this is when the mother sent a message to Mrs O at 10.51am on 24^th May, saying ‘Becoz she is not stable to sit on her own she falls to one side also…I can see something she hit on her face last time but only a little red’. I have already set out the messages that the mother sent to Mrs O on the evening of 17^th about R’s ability to sit. The mother’s case is that she noticed a mark on R’s face, on the left hand side around the cheek, when she came back home on 17^th. She said that she also noticed what looked like two grey lines, which she described as nerves, on the same side, closer to the edge of her eye. She gave context to it by saying, during cross examination, that she had first noticed it when changing R’s dress. I note that this is very similar to what she said in her third police interview in June 2024. She said she mentioned this to her husband on 17^th when he came home but it had disappeared once R had had her bath. She said he pressed his finger on her cheek but R had not responded, so that he did not think there was anything wrong. The mother recalled this in her oral evidence and I note that it is also what the father told the police in his first interview on 27^th May. The mother told the police on 27^th May that the father had told her there was no need to mention the mark to the paramedics on 17^th.

On 24^th May there is no record from the messages that any of the adults were saying that R was not well when she went to Mrs. O in the morning. That has been the consistent evidence of the parents too, throughout their interviews and statements. The nurse who spoke to Mrs. O when she was at hospital on the afternoon of 24^th records Mrs O as saying that R was fine, playing and eating and drinking normally when she arrived at her house in the morning. The doctor she spoke to at around the same time records very much the same thing. Mrs. O accepts that she said something to the effect that R was fine but denied that she said she was playing. Both nurse and doctor gave evidence to the court about this. Although neither of them any longer had an independent recollection of it, they each thought it likely they had written down what they were told, subject to a few different words here and there. Mrs. O’s evidence in her police interview that day was very similar to what is recorded by the doctor and nurse, namely that R was well when she arrived that morning. So, for that matter was the account given by Mr. O when he was interviewed the following morning.

Mrs. O said in her first police interview that she noticed on 16^th May that R had odd breathing, demonstrating her drawing in breath quickly. In her second interview she demonstrated rolling her eyes back. Mr. O said that he saw R breathing like this once on 17^th May and then again on 24^th May when Mrs. O was out, and that he had told his wife about it. Mrs. O stated that she had told the father about this, something he denied. The mother also denied being told anything about it.

Mrs. O gave a rather different account as to how R was on arrival at her house on 24^th May in her statement filed in April 2025 and her oral evidence. In this she states that R appeared very fatigued, tired, which was unusual. She said that she did not demonstrate the joyful, playful behaviour that the other children did. Her evidence about how much R ate that day had also evolved, so that she said that R did not either eat or drink much at all, and demonstrated that she had had to hold her own hand around R’s when she held the melon (something not mentioned earlier).

It was only on 23^rd May that K told the parents that she would not be able to look after R the following day. The mother sent Mrs O a message at 22.03 that night asking her if she could care for R the following day. Only one minute later Mrs O replied, saying yes.

The mother said she got up very early on the morning of 24^th to make lunch for herself and the father and also to prepare R’s food which was all home made. The parents left home together with R. The mother was dropped off to catch a bus. This seems to have been in something of a hurry as she texted the father at 8.42am saying that she was sorry that she had not waited to fit the car seat as she was worried she was going to miss the bus. The father dropped R off at the O household. Sometime later he returned to drop off R’s bottle which had been left behind in the car. He left this outside the door rather than go into the house. He said that R had clung onto his lapel when he dropped her off and he did not want to unsettle her by coming into the house again.

Mr. O went out for the early part of the morning. During the course of the day Mrs. O spent considerable periods of time in video contact with a man which whom she was having a relationship (S), albeit she says that the video was simply on for much of the time and she was engaged in looking after all of the children. Mr. O came back and at about midday she and the children had lunch. Mr. O says that he also had lunch, sitting on the stairs.

By one o’clock when she went out there were six children under the age of three being cared for at the home, one of whom was Mr. and Mrs. O’s own son.

CCTV footage shows that at 12.58, Mrs O went out to take one of the children, Z, to nursery. The phone records show her making a number of calls as she drove, including to her husband and also to S. After she dropped Z at nursery she went to collect a folder from college. After that she went to the shops (CCTV times that at 14.18). Call logs show Mr. O ringing her at 14.49, and her ringing him at 14.51. At 14.51 the logs show Mrs. O ringing X, who is the father of one of the children. He was the one who was asked to collect Mr and Mrs. O’s other children who were at school with his own child. At 14.52 and 14.53 Mrs O phoned the school, presumably to say that their children would be collected by X.

At 14.54 the CCTV records Mrs O as arriving at home, parking outside the house, going up the path quickly and going into the house. At 14.55 her call records state that she rang 111 although she did not speak to anyone and says that she was told to wait in a queue etc. At 15.00.45 the CCTV records her as coming out of the house, in different clothes with R in the car seat and she drives away. She is recorded as arriving at the desk at hospital at 15.18 and there was a code blue call to resuscitation.

Mrs O was therefore out of the house for just under two hours, following which she was in the house for six minutes, then in transit to the hospital for just over 15 minutes.

Body worn camera captured the moment when the police visited Mr. O at home on the evening of 24^th May. Having watched the recording, Mr. O’s attitude towards them can only be described as defensive and unhelpful, something that seems surprising given the fact that a child who had been in his care had died that day. During his evidence he stated that he had previous poor experiences of the police (as a complainant) when he ran his own business.

Mr. O did not volunteer to the police who arrived at his house that night that he had been on his own with R but he did tell them he had been at the house all day. In his first interview he did say he was on his own but said it was for about half an hour. He has always said that the children had all been fed and their nappies changed before Mrs. O left at 12.58 and that none of them needed any care from him whilst she was out. He has also always said that R was asleep all the time, apart from one point when she stirred and opened her eyes. He said he noticed one episode of heavy breathing and told his wife about it. He says that apart from when he was out and eating his lunch he spent all his time upstairs.

He told the police that he had stood in the room where the children were when his wife was out (when he was putting forward half an hour as the timeframe), but said in his oral evidence that he had been sitting on the floor. He said that he did not accept that the timing on the CCTV opposite his home was correct, thinking it was a few minutes out.

Mr. O said that his wife had run to the lavatory as soon as she arrived home, which appeared to be an explanation for the hurry she demonstrated when arriving back at home just before 3pm on 24^th. This was an account given for the first time in his oral evidence.

When Mr. O was interviewed by the police on 25^th May 2024 he denied being involved in any attempts to resuscitate R, stating that it was only after his wife had got home and he had gone upstairs that he was called down when his wife was on the phone to medical services. Almost immediately, and after a short discussion she had decided to take R straight to hospital; to quote what Mr. O said ‘I didn’t really see anything at that point, I’m like physically didn’t witness anything with the child basically. And that’s about it’.

In his written evidence Mr. O stated that he went upstairs when his wife came home and that he only came down again when she called him down because R was unwell. He says he saw her doing chest compressions but did not say that he had been involved. In his oral evidence he also said that he had not done anything for R in the sense of any CPR or resuscitation attempts. In his oral evidence Mr. O said that he had seen his wife doing some CPR with two fingers when she was lying on her mattress and then move R to her car seat, although when pressed upon this at one point by Ms. Branigan KC he suggested he had ‘lost focus’ on what was happening in the sitting room when turning the corner around the stairs.

In her first police interview on 25^th May Mrs. O stated that when she arrived back at the house she had found R lying on her back. She said she was concerned that something was wrong and started to give CPR. She gave a detailed account which included Mr. O being there with her. She said he rubbed her legs and back at her request and that both of them gave her mouth to mouth. In her statement she said she got home and R was making an odd noise. She said that she asked Mr. O to wait with the children while she went to change. Nothing unusual had happened and she then went downstairs. When she did so she tried to wake R and said she could not. She gave a detailed account of trying to revive her, and then said she called Mr. O (who had gone upstairs) down, and had to scream for him. She says she dialled 111 although she thought she had dialled 999.

On her way to hospital Mrs O called the father and told him that R was not breathing.

I found the evidence of both Mr. and Mrs O to be very inconsistent, both as between each other, and also as between their different accounts given at different times. I also found their evidence on crucial facts to be vague and lacking in credibility. I bear in mind that the events of the day were very shocking, and that they were held overnight in the police station and that they will have been worried about their own children who were taken into foster care.

Yet I do not think that these things, or the usual vagaries of memory (by which I mean that nobody remembers things in quite the same way, different things come to mind at different times and memory is affected by hearing what others say) can account for the inconsistencies. The most obvious one is as to whether or not Mr O was involved in performing CPR for R. He told the police that he only came down when his wife was about to leave the house and that he was not involved at all. She told the police that he was there all along, actively helping her with rubbing R and giving mouth to mouth. This is not the sort of thing Mr. O would have forgotten.

I do not accept that Mr. O would genuinely have mistaken being on his own with the children for half an hour when it was in fact two hours. I would not place much weight on the inconsistency as to which children were awake or asleep when Mrs. O left and then came back but it is difficult to believe that all the children were quiet for so long, and that none of them needed anything for all that time when he was alone with them. Indeed, I found all of his evidence about the 2 hours he was on his own with the children to be contrived and I did not believe that all the children were downstairs for that entire period. It is obvious that he was trying to distance himself from any contact with R and trying to minimise the time that he said he spent with her. I consider he fabricated his evidence about Mrs. O running upstairs to go to the bathroom to try and explain why she rushed into the house in the way she did, caught on CCTV.

To the police Mrs. O gave an account of what had happened when she was in the house which would have had to stretch far beyond the six minutes or so that passed between her arriving back and taking R to hospital. Like Mr. O she had not mentioned rushing in to go to the bathroom when she arrived until after he had done so in the witness box. She does not appear to have asked Mr. O what happened to R whilst she was out, nor does he appear to have asked her what happened when he was upstairs.

Further, the account given by Mrs. O as to how R was that day after she arrived at their house has changed. I accept the submission of Ms. Branigan KC, Ms. Bath and Ms. Georges that the most reliable evidence about this is the evidence closest to the time. I accept the evidence of the nurse and doctor at the hospital that Mrs. O referred to R as playing as well as fine during the morning. She obviously had something to eat and drink.

Mrs. O’s much more recent evidence that R was not herself that day seems to me to be designed to try and fit in with the medical evidence that a child who had already been injured to the extent that she would later die was unlikely to have an intervening period when she appeared to be well.

The medical evidence in relation to this event very strongly points to R being subject to an abusive act very shortly before her collapse. This is not just the evidence of Mr. Jayamohan but of all the experts to the extent that their expertise allowed it. The pathology does not allow for the timing of the injuries to be pinpointed to a period of less than 24 hours, but those experts deferred to the clinicians in being able to narrow it further than that. Both Mr. Jayamohan and Dr. Ward clearly advised that current medical thinking is that, in a fatal case such as this, the timing between the abusive event and collapse is very short. The case example produced by Dr. Leadbeatter was very different to the circumstances here.

The experts have not been able to define how many episodes of injury R was subjected to, but there appears to be evidence of at least three, putting everything together. One which caused her death, another one a few days to a week before death, and one probably two weeks or more before.

I have already set out the medical evidence about what I shall call the intermediate injury. The experts do not rule out it being as old as 7 days before death, but putting together the different disciplines, think a period of three or four days more likely. The force of that is in the fact that the evidence from the eye, brain and bone pathology align. I have to put this evidence together with everything else.

I have a very clear account of R being unwell when she was returned home after coming back from Mrs O on the evening of 17^th, having been well when she was delivered there in the morning. The accounts are supported by the contemporaneous material. The parents called an ambulance out that night because they were so worried about her. One very obvious reason for this, in the context of this case, is that she had been shaken when she was being cared for in the O home. Of course, R could have been displaying symptoms of enterovirus, and the paramedics did not pick up any neurological symptoms, but the medical evidence is that symptoms following an episode of shaking can be very non-specific and are commonly mistaken for a minor illness. I think the local authority is wrong to place reliance on the mother’s contemporaneous belief and that of the treating doctors that this was a virus, particularly in the light of the evidence given by both Mr. Jayamohan and Dr. Ward. Viruses are extremely common, occult head injuries are not.

Earlier in this judgment I set out the evidence from the mother about the existence of a mark on R’s face on 17^th. I have thought about this very carefully. It is true that she did not immediately bring it up with Mrs. O but I found the mother’s explanation about this and the mark in general to be compelling. She clearly sent a message about R not being stable when sitting and that care had to be taken lest she should fall over. This supports her explanation for her actions in cross examination, namely that she was trying to find out if something had happened but did not ask directly. Also, she did send a message about the mark on 24^th before anyone was investigating anything (which also mentioned that R might fall over when sitting). Why would she do that if there had been nothing there? It could be a bluff to try and explain something sinister but there was nothing sinister that day to see. The mother also gave an account of the father pressing R’s face as a way of trying to find if she demonstrated a pain reaction, an account which the father himself gave to the police in one of his early interviews. Several times the mother said how much she regretted being persuaded that night, against her better judgement, that R did not really have a mark at all. I make clear I am aware that the mother’s evidence about this mark has varied a bit (for example telling the police that the message she sent on 24^th was sent on 17^th and suggesting that she had told Mrs O about the mark verbally) but I believe this to be within a general margin of error to be expected. Consistency is not about giving identical accounts every time. That also applies to the description given to the appearance and colour of the marks on R’s skin that night. I believe the mother’s evidence about the existence of this mark and that once it had disappeared after the bath she began to doubt herself. The significance of this mark is uncertain, however, because it did not develop into a bruise.

R’s subsequent presentation between 17^th and 24^th May was the subject of intense focus during the course of the hearing, with the parents and K being cross examined about it extensively. In my judgement all the evidence points to R appearing particularly ill on the evening of 17^th May and 18^th May, and then gradually getting better for the whole of that week. I find there is no reliable evidence of any material deterioration in her condition on the intervening days. In the course of any recovery there will be some element of ‘up and down’ along the way. This is consistent with the history given to the doctors on the dates of all three consultations, namely 17^th, 18^th and 20^th May.

I know that K’s evidence suggested that R was unwell on 22^nd May, but after considering what she said together with the surrounding material I do not accept that this was so. If it was, I believe the mother would have sought further medical attention. Apart from what she said about 22^nd itself, her evidence was also of a gradual recovery which included R being clingy to her mother. I note that the first time she gave an account of what happened that week was over a year later, in May 2024, a very long time later. What she said about the mother asking her to check R’s breathing on 22^nd is at odds with the contemporaneous message the mother sent to the father. Further, during the course of cross examination K became quite muddled, saying at one point that the mother had asked her constantly to check R’s breathing and at another that it had happened once. In her statement she said that she thought what the mother had said was odd, but she seemed to resile from this somewhat in her oral evidence. She appeared to change her evidence somewhat depending on who was asking questions. In saying this I wish to emphasise that I do not find that she was being deliberately dishonest, nor did I form the view that she would be prepared to cover up cruelty to a child.

The messages that passed between the parents during this period do show that the parents were arguing during this time and that their relationship was very fraught.

The finding of older injury is a pathological one. If R had had a scan during life this might not have been picked up at all. Both Dr. du Plessis and Professor Al-Sarraj were clearly of the view that this had occurred before 16^th May (i.e. before she was cared for by Mrs O) although Dr. Leadbeatter, a general pathologist, was prepared (with significant reservations) to believe it could beonly 8 days old (which would take it back to 16^th).

None of the experts could think of any cause for this bleeding other than an episode of injury caused by shaking which has not been disclosed. The level of force required is unknown. Babies of this age, very thankfully, hardly ever have scans after a post mortem, so it is really not possible to know how many babies might have signs such as this without anyone ever being aware.

The existence of this injury, outside the timeframe of the care of Mr. and Mrs O, points towards the parents being the source of abusive behaviour towards R, particularly in the light of the father’s capacity for violence. Nonetheless there is no history anywhere of R showing any clinical signs of illness which could be related to such an assault. The mother in this case has shown herself very sensitive to R being out of sorts or unwell, so it is difficult to believe that she would have failed to notice this or act upon any symptoms. Further, the father was hardly ever alone with R. The mother was not alone in the house with R much either, before 9^th May. I have said this before, but the love and attention she gave to her daughter is such that it is hard to envisage her being the perpetrator, failing to seek medical attention, or that she would cover up for anyone else, including the father. If there was an assault, I can only conclude that it led to no symptoms that were noticeable to the mother, who was R’s primary and attentive carer.

One important issue which is relied upon by the local authority, Mr. and Mrs O and the Guardian (but in her case by way of credibility generally) is the agreement between the parents and K to delete messages between them and to avoid telling the police that K had looked after R several times in the two weeks preceding her death. I will turn to look at that next.

When K met the paternal grandparents and then the parents, she had not been in this country very long. She was here on a carer’s visa and expecting her family to join her soon. She lived in unsuitable accommodation and was undergoing training for her job. She only really knew one person here, from work, and so she and the parents identified with each other very quickly. The parents urgently needed help with R, and were themselves socially isolated, and K needed help to find accommodation and was isolated too. It was thus that people who hardly knew each other became very close very quickly. Also, they were not close for very long, for shortly after R died, K began to distance herself from the parents. Her husband was anxious not to become involved and so the suggestion that they should all share accommodation was dropped.

There are therefore no obvious ties between K and the parents, or any visible bonds of loyalty. Of course, I must consider whether there is a bond of fear or a pact between them, or any of them that might lead them to cover up something really serious that had happened to R.

When K met the paternal grandparents, even though it was the first time they had met they told K that the mother did not give proper respect to older people, and that she did not listen to or obey them. K said that she did not think too much of this at the time because in the family’s country of origin a certain tension between a spouse and her in-laws was not uncommon.

In broad terms the evidence that K gave about R and the arrangements at the family home was very similar to the evidence that the parents gave. The home was small with only two rooms, and the parents needed to find childcare urgently because the mother had just gone back to work and the grandparents left suddenly. She had absolutely no concerns about the way the parents related to R or how R was cared for; indeed, she said on more than one occasion that she was looked after very well. Although she has now become aware of the arguments between the parents as illustrated by the messages between them, they did not display this in front of her.

K’s evidence was that the parents had asked her to delete all the messages between them, and that of the parents is that it was the other way around. They all agreed that they spent the night of 24^th May together, in shock and distress at what had happened. The mother said that K had asked them to delete messages and in her state of mind she did so having barely thought about it at all. The messages were all on WhatsApp. It is worth pointing out that deletion of messages between two people on this platform can be done in the work of a moment and does not require each message to be deleted individually. I am less clear about the deletion of messages as between K and the father as it appears there may have been some individual messages deleted. That aspect of the evidence is difficult to pin down but I am satisfied nonetheless that it is not evidence of a conspiracy to hide material events.

When the parents were interviewed on 27^th May they did not mention K, and K did not make herself known to anyone in authority, in particular the police. The mother (and father) said that it did not occur to them that K had injured R and so in not saying anything about her they were not aware at all that they were keeping something material from the investigation. When they were questioned it was about what had happened to R at the home of the Os.

The surrounding evidence supports what they say about this. Plainly the focus on the investigation was on the cause of R’s death; that was why Mr. and Mrs O were interviewed straight away and before the parents. Nobody suggested until later that there were earlier injuries. K said that the parents told her that if she had been looking after R none of this would have happened. That makes good sense. I have watched quite extensive recordings of the parents taken when they were at the hospital holding R just after she had been declared dead. The mother can be heard castigating herself for having gone to work that day. Both parents expressed disbelief that R could have stopped breathing when she had been so well that morning. They implored the doctors and police to investigate what had happened to R at the O’s home, suggesting that Mrs. O cannot have been looking after her properly. The mother told the police that they must look at the cameras that they believed were in the house.

There is nothing to suggest that K had any animus against the parents or they her. The parents said, (and this would be entirely understandable) that they were very hurt that K did not come to R’s funeral. There is no evidence of any collusion between the parents and K from any of the messages that pass between the parents themselves; indeed, the messages about K (who they referred to as a sister in accordance with their culture) are entirely unremarkable.

Although the decision not to mention K and to delete the messages is troubling, I have come to the conclusion that they did not do this to hide information about the police inquiry. That would amount to collusion at a high level to suppress information about the death of the child, something which is difficult to countenance, especially from the mother and K. K was for the most part a witness who appeared to be doing her best to help the court. She appeared genuinely fond of R and distressed about what had happened. I thought that she was inclined to try and fill in gaps in her knowledge when she should have acknowledged that she did not know, and in a very human way, to avoid confronting some of her own behaviour but not that she intended to cover up for mistreatment or injury of a child.

I also thought that K’s expressed reasons for distancing herself from the parents in the days after R’s death and then beyond lacked cogency. I can accept that she was nervous of a police investigation because of the reputation of the police in her country of origin, but not to the extent that she made out.

The terms of K’s visa required her not to carry out paid work of any significance save for the employer who sponsored her. She and her husband and children, just like the parents had come here to seek a better life. Although she maintained that she looked after R without payment some of the messages contradict this. In my view she was very worried about her employment and consequent living status and what it might mean for her and her family if it was discovered that she had been working outside of the terms of her visa. She responded to her husband’s suggestion that they should keep away. In my judgement it was she who asked the parents to delete messages and to keep her out of the investigation. The mother did so because she was sensitive to K’s position and I accept that both she and the father did not tell the police about K because they genuinely did not think it was relevant to R’s death.

Balancing all evidence in this case is a very difficult task for reasons that are obvious. No matter how much the evidence points in different directions, it is my task to come to such conclusions that I can, based on everything that I have heard and read. I must stress that I make my findings on the balance of probabilities, no more or less.

I deal with the fatal injury first. I find on the balance of probabilities that R sustained severe shaking injuries which led to her death very shortly before her collapse and when she was in the home of Mr. and Mrs. O. I simply do not accept that she was injured by one of her parents that morning, followed by what can only be described as an extensive lucid interval.

My conclusion is not based simply on the medical evidence, strong as it is. Mr. and Mrs O have both repeatedly lied about what happened that day, to the police and to this court. Those lies go to the very core of the significant events and the only reason that I can think of for them is that they are designed to conceal what really happened. They must each know that R died as a result of an abusive assault. None of the evidence against the parents and K is sufficient to override these compelling factors.

Secondly, I find that it is more likely than not that what has been described as the intermediate injury occurred on 17^th May whilst R was being cared for by Mrs. and/or Mr. O. The pathological evidence points to a more recent date, but I simply do not find support for this in the other evidence which I have set out in detail above. R showed symptoms which were compatible with being shaken on 17^th May after returning from the O household, and was so unwell that her parents called an ambulance. During the course of that week, she got gradually better and then on 24^th was fatally injured. I acknowledge the inherent unlikelihood that people who had only cared for her for three days injuring her on two of them, but the rest of the evidence compels me to find that this is indeed what happened. Because of the nature of the episodes, it is not fully known why perpetrators injure children, and why some children are injured and not others. There must be a variety of factors involved. In their final submissions Mr. Howe KC, Mr. Ward-Prowse and Ms Claridge on behalf of Mr. O referred to an article by Adamsbaum which considers that a child, once shaken, is shaken on further occasions because the shaking stops the child from crying. That is one possibility but there may be others.

As more than one expert warned, it is not possible to be too prescriptive about timing. Professor Al-Sarraj pointed out that the views of different experts will often vary. He himself estimated 6 to 10 days as the time frame for the intermediate injury. The Ophthalmologists preferred a shorter timeframe but did not rule out 7 days. As for the fractures, they are very small and would not be visible radiologically. I do not criticise Professor Mangham who was plainly doing his best to assist the court, but I prefer to heed Dr. Leadbeatter’s caution. There is no reliable control group so as to know whether injuries such as this can be sustained with normal handling. Further, it is very difficult to be sure as to timing when one injury may be imposed upon another, as with the findings in the eye. We do not actually know how many occasions of injury there were on the days R was cared for by Mr and Mrs O; it may not be limited to one on each day.

The fact that Dr. Leadbeatter is a general pathologist does not mean that his evidence is less reliable than a specialist, for these are points which are as well made by an experienced and measured expert who is able to take an overview.

I must then turn to the evidence of the oldest injury. My findings on the other injuries now means this later one now stands by itself and is not capable of being corroborated as another assault by the same person. I am left with signs of bleeding and scarring which is older than 10 days which the radiology cannot clearly corroborate. The father is a man who is capable of serious violence when he becomes angry, but I have not found the mother to be someone who is prepared to cover this up. On the contrary she was a reliable witness about the things that have really mattered and she repeatedly sought assistance for herself and medical advice about her daughter when she was worried.

The father was almost never on his own with R. In order to find that this earlier injury is abusive I must contemplate either that the father did it without anyone noticing in a small house (perhaps when the mother was in the kitchen for a short while) and that there were no following symptoms, or that the mother, despite everything, has injured R herself or covered for the father.

I do not know when this injury occurred, or the level of force that would be necessary. There are no accounts of R suffering anything other than a trivial accident, but there is no evidence about anything else either. I accept the evidence of Dr. du Plessis and Professor Al-Sarraj that R had suffered previous bleeding which appears to be more than 10 days old at the time she died, but I cannot say it is more likely than not that this was the result of an act of abuse. I simply do not know. As has been said in numerous cases, it is not always possible to identify the cause of an injury. That is the situation here.

I must now turn to whether it is possible to identify a perpetrator with respect to the injuries which were inflicted on 24^th and 17^th May. By virtue of my findings about when and where the fatal injuries happened, only Mr. and Mrs O can be on the list of those who may be responsible. As I find that R was well when she was delivered to them on the morning of 24^th only one of them can be responsible for any injuries that occurred that day.

The timing of the phone calls as compared with the timing of the CCTV camera in the minutes preceding Mrs. O arriving back home at just after 14.54 strongly suggests that, contrary to her evidence, Mrs. O made arrangements for her own children to be picked up by another parent at school before she arrived home rather than after. That, together with the phone calls between herself and her husband strongly suggest that she knew perfectly well before she arrived back that something was seriously wrong with R. That would fit with the hurry, the lies that both Mr. and Mrs O told the court about going to the bathroom, and the call to 111 so soon after she arrived back. During his oral evidence Mr. O said he challenged the timing of the CCTV camera and suggested it was a few minutes out.

Both Mr. and Mrs. O have both clearly lied and covered up what happened that day and I cannot rely on the evidence of either of them. Whilst Mrs. O was obviously shocked and tearful when she arrived at hospital with R I have been very struck by the lack of overall responsibility or concern both these adults have shown about a child that died in their home. Mr. Jayamohan’s view was that R probably died very quickly indeed after the assault. That would really take only seconds and could have happened straight away when Mrs. O got back and then led to her ringing 111. It is possible that the reason for the rush back to the house at 3pm was something else which has not been disclosed. I do not know if R was shaken once that day or more than once, albeit any earlier injury must have been less serious than the fatal one. In all the circumstances I am not able to find which one of Mr. or Mrs O injured R save that they both know what has happened and have covered it up.

I also find that R was injured whilst she was being cared for at the home of Mr. and Mrs O on 17^th and before she went home. The likelihood of the father inflicting the injury in the car on the way home is so small that it can safely be discounted. The same is true of the proposition that the mother injured R that night. K was not there at all. Therefore, there is no real possibility that either of the parents or K was responsible. As between Mr. and Mrs. O there is insufficient evidence for me to identify a specific perpetrator on the balance of probabilities. In all the circumstances there remains a real possibility that either one or the other of them was responsible.

I make no findings adverse to K as regards the injuries and so it follows that the threshold criteria are not met in relation to her children.

My findings about the injuries to R mean that the threshold for V is not met on those grounds. Nonetheless, the findings about the father’s violence and abuse and the very toxic relationship between the parents are such as to mean that V is at risk of significant harm in the future.

The father’s behaviour is a cause of very considerable concern. He has assaulted the mother on several occasions and he has also behaved in impulsive ways to himself, for example taking poison and putting a knife to his throat. This combination of both violence and high levels of manipulation is capable of being dangerous particularly for the mother but, by extension, any child. I make it clear I have not reached a concluded view about this but it is something that needs to be taken very seriously. The mother has been prepared to stand up to him and speak out, but she appears enmeshed in the relationship too. Witnessing domestic abuse of this (or any) nature would be very damaging indeed to V in the future, as would having the health and wellbeing of her primary carer adversely affected. The effect on her could be worse than for most children because of the significant disruption she has suffered in her early life.

The parents themselves will have been hugely affected by the trauma of losing R and subsequent events. They will each have to give very careful thought to what they propose for the future.

I will await further submissions as to whether the findings I have made about R mean that their three children are at risk of significant harm in the future.

This has been an extremely complex and sensitive case. I am indebted to all the lawyers who have worked tirelessly to ensure that it was possible to complete this fact finding hearing on time. It has involved an enormous number of documents, some of which only became available very shortly before the hearing. On every level it was a huge task, and I want to thank everyone concerned.