A Local Authority v MA & Ors

These proceedings concern 5 children. I will use the names generally used within the family. They are T, V, Z, Y, and X. The proceedings were instituted by the local authority on 13^th May 2025 following T’s admission to [A Hospital] on the evening of 27^th April after he became acutely unwell and began to fit at home. He was found to have a profoundly high plasma sodium concentration (hypernatraemia) at 235 mmol/L. T was six weeks old and Dr M, Consultant in Paediatric Critical Care at [B Hospital], summarised the situation in his report in this way: “[T]’s condition is consistent with the exogenous administration of sodium chloride (common salt). He is clearly too young to feed himself. Therefore any sodium chloride (salt) which has been given to him has been done by another person.” Dr P at [A Hospital] put it more graphically on 27^th April. None of the doctors had seen such a high level of salt before. T was at risk of dying.

T lived with his parents in a home shared with his 2 paternal uncles and aunts and their children. The other children who are parties to the proceedings are his cousins. Proceedings were instituted in relation to all of the children and consolidated by agreement at the first Case Management Hearing on 5^th June. On the 27^th April, T was 6 weeks old, V was 12 weeks old, Z, Y and X were 11, 8 and 7 years old. The children were placed in foster care following the police imposing bail conditions on all of the adults not to have unsupervised contact with children. I made Interim Care Orders. Everyone in the family has been co-operative and understood the seriousness of the matter. The paternal grandparents live in a bungalow at the rear of the property and use the house so they have also been joined as parties to the proceedings. Everyone is represented, mostly by leading counsel. There are 2 guardians for the children.

The case was timetabled to this fact finding hearing. I have a bundle which includes the factual evidence, disclosure of material from the police and expert evidence. It also includes parenting assessments, which may need updating depending on the findings made. The bundle exceeds 40,000 pages including downloads from electronic devices. I have not read all of the phone downloads but I have considered those that were referred to in their full context. In addition to the written evidence, I have heard oral evidence from Dr Coulthard, Dr Ward, Dr P, AC, DC FT, DC LG, from T’s maternal grandparents and aunt, from a cousin of T’s father and from the 8 adults who are parties to the proceedings. The parents’ and grandparents’ first names are used most of the time to avoid confusion. No disrespect is intended. That will also assist with anonymisation of the judgment. In some of the written documents T’s parents are referred to as mum and dad or the parents so, in this judgment, mum or dad means MA and BF, T’s parents.

I am very grateful to the parties and their legal representatives for all their work in this case and for keeping focused on the issues. I had a comprehensive opening note, chronology and reading list, and helpful submissions. Counsel made written submissions shortly before Christmas and this judgment has been handed down as soon as we were able to reconvene after holidays. A lot of work had to be done in a short time once the downloads from the family’s electronic devices were provided. To assist the witness timetable and the advocates, it was agreed that some witnesses would give evidence or be cross examined out of turn, as it were. A number of facts are agreed so it has not been necessary for every witness to give evidence. There are a few issues about the exact words used with the medical staff in the first few days but they do not go to the issues and it would have been disproportionate to hear evidence and make findings about that.

For the sake of completeness, I should say that we have been assisted by interpreters. They were only needed for the more complex evidence as the parties generally speak good English. An intermediary was recommended for the paternal grandmother but it proved difficult to find one. She has some emotional difficulties which impact upon her cognitive and attentional abilities making it difficult at times for her to respond immediately to questions in a concise manner, with her also often appearing to get lost in her thoughts. Her solicitor has been very helpful and she has provided support in court.

There is no dispute that T suffered significant harm as a result of drinking formula milk contaminated with salt. The issue is who caused it. There is no dispute that the other children have all been affected by the consequences of their actions. There is inevitably some duplication in the documents so, where possible, I take the original source. I deal only with matters relevant to my decision.

The local authority initially sought the following findings –

Following the conclusion of the evidence on 18^th December, findings were no longer sought against the aunts and uncles or the grandparents. The local authority sought a finding that MA caused T’s hypernatraemia by adding significant quantities of salt to the tubs of Cow and Gate milk from which he was fed. The local authority sought additional findings against MA and BF that they dishonestly colluded with each other after T’s admission to hospital to prevent discovery of MA as the perpetrator of T’s injuries by the police and the Court, by the following:

Colluding between the 28^th April and the 2^nd May that BF should falsely assert to the police in his second interview and to the Court that MA had told him on the 26^th April of her concern that the formula in the tub of Cow and Gate milk AJT/9 was gritty or different from normal.

On or around the 13^th May 2025, after the police had undertaken their forensic examination of the cupboard where T’s formula was kept, planting a trail of salt in that cupboard in an attempt to falsely infer that one or more of DF, CM, EM, FF, GM and GF had contaminated T’s formula tubs with salt.

Both MA and BF lied to the treating doctors and the police in their interviews by suggesting that other than a sore throat, T was in reasonable health on the morning of the 27^th April and that neither had any concern for him despite the fact that both knew that he had not taken any feeds at all overnight nor had he had a wet nappy.

In closing submissions, the local authority invited me to consider finding that MA had been poisoning T over a long period of time.

The local authority put together plans for the older children to return to the care of their parents and the police were very helpful in varying the bail conditions. However, MA asked the court to find that EM was to blame for T’s injuries so her son could not return to her care until now. I find that MA caused her own son significant harm and then, with the assistance of BF, caused great harm to the rest of the family by not being honest. In my judgment, EM showed nothing but kindness to T and his parents and she did not harm T. V needs to be reunited with his mother as soon as possible.

There is no dispute about the law in this case and there is no dispute about the medical evidence or the cause of T’s injuries. The law is not complex and not all counsel have referred me to it in their submissions. I accept the submissions of those who have. The local authority bears the burden of proof on the balance of probabilities. MA bears the burden of proof to the same standard in relation to the findings she seeks. I have been rightly reminded that I must survey a wide canvas and consider all of the evidence in relation to all of the other evidence. I must form a clear assessment of the credibility and reliability of the witnesses. The evidence of the parents is of the utmost importance. I must remember, following R v Lucas [1981] QB 720 that witnesses may lie for all sorts of reasons such as fear, panic, misplaced loyalty and the fact that a witness has lied about one matter does not mean that they have lied about everything.

I do not need to consider the submissions about who is in the pool or on the list of possible perpetrators because I find that the only person likely to have caused the injuries to T is his mother. His father has subsequently colluded with her to try to shift the blame elsewhere. The volume of papers in this case is vast and I have read and heard a lot of evidence but it all leads to one conclusion.

Counsel for BF rightly submits that the wide canvas includes the family dynamics, the father’s broken engagement, the relationship between him and MA, and him as a husband and father. The truth about the family dynamics and the broken engagement which I will come onto are that by the time T’s parents married, this was a supportive and welcoming family for whom the broken engagement was not an issue. The relationship between the parents was poor and BF was showing himself to be a poor husband and father.

The family lived in [the address]. MA and T had been staying with her parents not far away from 4^th to 22^nd April and she returned to the paternal family home on 22^nd April. A few days later, T became unwell. I have a transcript of the 999 call made by BF, T’s father, shortly after 8pm on 27^th April. The initial sentence, we think, should be “today”. He said T’s “not been drinking milk for days. He’s started to shake. His body started shaking. He’s got a bit of a temperature as well….he’s just not responsive to be fair with you”. In response to questions from the emergency operator, he said “he’s just constantly shaking, just shaking, shivering and shaking…. His lips are swollen, like I try and give him some milk but he’s, his lips are tremoring, his body’s tremoring, his legs.” He said T was not alert. The operator continued the conversation until the ambulance arrived.

The ambulance crew arrived at 20.12. Their record states “Crew met at door by family and led into sitting room where they were told to wait for the PT [patient] to be brought to them. Crew explained urgency to see PT and he was brought down in mother's arms and laid flat on the sofa for initial assessment. PT had good tone, no obvious increased WOB, and on immediate exposure appeared globally mottled. Parents present throughout and agreed to all assessment and for crew to access medical records. HxPc - PT has 1/7 hx of non-productive cough. Today has had significantly reduced fluid intake, with reduced urine output. At approx 1945 this evening, PT has been noted to have 3 x tonic / clonic seizure episodes, lasting approximately 90-120 seconds.” T had 2 further clonic seizures in their presence and was hypoglycaemic. He was taken to hospital.

The history given by the parents to the hospital was that T had been well but that evening he was working hard to breathe and started having seizures. Seizures continued at the hospital, medication was administered and a number of tests were carried out. Dr P notes at K164 record this information gathered from MA and BF: “Noticed coughing and reduced feeds today, no other concerns, started fitting at home, ambulance called, breast, EBM’ formula fed.”Later on, the term “seizures” was used. MA said in her evidence that she got that word from the paramedics. When providing more detail to the doctors at [B Hospital] the next day, (L870) MA did not describe any difficulties until the Sunday afternoon. She tried breast milk but T only fed for 5 to 10 minutes. She tried bottle feeding and then at 17.30 – 18.00 he was “shaking, shiver like, arms mostly”. She wrapped him up, he was fine for 10 – 15 minutes, then started shaking in his lower body and legs so they called 999.

At hospital, T was stabilised and transferred to PICU. The treating clinicians also consulted Paediatrics at [B Hospital]. The consensus was that extrinsic salt administration was the only likely cause for T’s symptoms. The notes include a comment that the salt level was “so high, none of us has ever seen anything like it, including PICU”. The action plan records that there was no compatible medical explanation identified, and presentation was deemed inconsistent with illness such as meningitis. Clinical opinion indicated that sodium elevation was most likely due to an external source, either via contaminated feeds or deliberate administration. The severity of the presentation necessitated immediate transfer to [B Hospital] PICU. He needed dialysis. He remained there until he was returned to [A Hospital] on 25^th May. The hospital notes tell me how much care and treatment he needed from the team of doctors, nurses, physiotherapists and dieticians over many weeks.

The discharge summary from [B Hospital] [L406] on 28^th May, confirms the diagnosis and summarises the treatment thus far and the plan for further treatment, some of it invasive. The diagnosis was

Dry gangrene to left foot

Right femoral DVT

The police and Trading Standards acted quickly once they were contacted by the hospital. DC FT has been extremely helpful in providing information and liaising with the Family Court. She has co-ordinated the provision of the disclosure from the police. I have the interviews and the phone downloads in particular. In her oral evidence, DC FT said she would chase the lab for an update of page G3004, in relation to the fingerprint on the milk container and she explained the misunderstanding about EM and FF’s phones. FF was asked about the wrong phone. They were re-interviewed by the police following the discovery of EM’s fingerprint on milk tub FLA/3 and the phone downloads. The update on the finger print was provided a few days later. DC FT confirmed that she has reviewed all the messages etc on EM’s phone but the 700 voice notes on FF’s phone have not yet been translated. We received further phone downloads during the hearing.

There is no dispute about the evidence from the police or Trading Standards in relation to the formula milk. The manufacturers of the milk also provided evidence. The salt in the 2 tubs of formula seized from the home were contaminated with salt. Tests on other tubs of formula from the 2 supermarkets where the formula was purchased confirmed that they were salt free. This was not a contaminated batch.

DC FT gave oral evidence to update the court. She said she was not aware of a big family discussion in October 2025 about what happened to T. The family all remain on bail. A charging decision won’t be made for some time because of the enquiries still to be carried out. She told the court about the 27th October police interview with EM where she asked her about a conversation in the house about a trail of salt. EM said she thought that they were released by the police on 2nd May, then after a few days, T’s mum came into the house and said she saw a trail of salt. EM saw it too. I will come back to the details of the trail of salt but the questions for the police witnesses were about the chain of evidence. DC FT said it came to her attention when she attended one of the family court hearings. She went back to the scenes of crime photos, looked at the exhibit and spoke to DC LG and said it was likely he would have to provide a statement.

DC LG in his 25th May statement lists the exhibits he removed from the house and in his 25th November statement, he provides more details. In oral evidence, he said that he was one of the officers who seized exhibits from the home. He has seen the photographs that were taken at the home. G2145, G2146, G2147 and G2148 are accurate representations of what he saw. He remembers going to the address. He did not notice any trail of salt in the cupboard. A further statement was provided by a scenes of crime officer.

Cross examined on behalf of MA, DC LG said the photograph at C180 shows a round tub and a black item behind it. He does not think he lifted the tub up but he did move items around to see the exhibits. He did not see any loose powder. He was instructed to look for salt and he did a general search for baby milk powder. The SOCO looked at everything before he did and moved things around to photograph them and then DC LG went in to seize the items.

Cross examined for CM and then DF, he said he was looking for things that might be salt or baby milk powder. Shown various photographs, including G2297, he said he did not pick up that container. He can’t say if anyone else did. That is the container which MA says the salt was under, although her account has varied.

More than one family member referred to GF saying the police would have seen the salt if it had been there when they searched the house. From the police evidence, I am satisfied that they searched the cupboard and moved things around. GF is right. If there had been salt in that cupboard, the police would probably have seen it. I will come back to the salt trail when I consider the parties’ evidence.

AC is a digital forensic examiner with the police and in her statement, she details searches on mobile phone LEG3 and explains the terms she used. LEG 3 is EM’s phone. The user had searched google for “kill mice with salt”, “babe boy dies with salt poisoning” and The Standard newspaper’s website in relation to a boy who was salt poisoned. Her statement explains how she analyses data and then says (with her reasons) that “the data suggests that the google search relating to "babe boy dies with salt poisoning" has been visited within the timeline between 07/12/2021 10:12 and 08/12/2021 10:51. This is also supported by the google EI timestamp of 07/12/2021 10:21 found within the URL of the google search. In addition to that news article is the next entry within the database table (https://www.standard.co.uk/news/uk/couple-poisoned-boy-salt-solihull-birmingham- arthur-labinjo-hughes-b959346.html?amp.) The news article subject relates to the google search and based of the potential sequential pattern of the favicons database, this suggests the article has been potentially visited between the dates of 07/12/2021 10:21 - 08/12/2021 10:51. Shortly after the “kill mice with salt” search in May 2023, the “cambridgeshire.jgpestcontrol.co.uk" webpage was visited. That explains the reason for that search about salt poisoning.

In her oral evidence, AC explained the timescales for when the searches were undertaken and the methodology and reliability of her work. Google searches can update an older search to a new date though. For the 2 google URLs, it also contains code unique to google. The EI number refers to a recording by google so it’s an encoded date which she uncodes. That number suggests one search was in 2021. The news article was in 2022. It is not the exact time. She is aware that DC FT asked EM about this in her interview and it appears from her evidence and that of DC FT that DC FT misunderstood what AC said.

Cross examined on behalf of EM, she said that, going back over the favicons, she was able to cross reference 2 of the tables of information. One of them was URLs and she has dates for them, then you have the UID and another tab with the UID and time stamp. At G3022, she overlays the data to see where they fit. She could identify the EI number. That corroborates the 7^th December 2021 date. There could be deletions so she cannot say she is completely certain but that is the most likely date. In relation to the 24^th April, there would have been an update from google, she can’t say what it was. She told FF’s counsel that the “kill mice with salt” page coincides with access to the pest control website on how to get rid of mice so that is a contextual link.

Looking at those searches, I do not find they tell me anything more than that the searcher, which I now know could have been FF or EM but was probably FF, would have acquired some knowledge of the dangers of salt. I will consider the police interviews and phone downloads when I assess the evidence from the family.

Dr P, paediatric consultant at [A Hospital], took charge of the case when T was admitted on 27^th April and he spoke to the police about his concerns. He explained how serious it was. The baby had been given a lot of salt and might die. He alerted the police to the fact that they needed to start an investigation.

In his oral evidence, Dr P said that Dr Q and Dr R handed over to him. It was brief. T had a seizure. He thinks the parents arrived about the time he did. He went through the timeline again. The key points were that they had established that T had been exposed to a large amount of salt and they wanted to explore what the salt exposure event was. His initial questions in resus would have been about exploring the day before. MA readily answered the questions. There would have been multiple conversations. He gave them a warning that the police were coming to see them. He had a long discussion with MA. He almost certainly told MA that T had a high mortality risk. She was appropriately distressed. There were also brief updates all through the evening. There would have been other people in the room. He thinks mum and dad were there from resus to the CT scan then in [the ward], it was mostly mum. He said later that he had not had any worrying vibes from T’s parents although he was surprised when dad wanted to leave after the CT scan. He thought that was a bit odd. He knew grandmother as she works at the hospital and he was not worried by her presentation either. He had no concerns about them after the 2^nd admission. He does not recollect anything being said about a trail of salt in the cupboard.

Cross examined on behalf of BF, he said, they became concerned T had been given a high level of salt so they contacted the police. They had discussions with different levels of police officer as the evening went on. His concern was that the salt levels in T’s blood could not be caused by anything other than salt poisoning. At N722, he was telling the police so they could go and tie up everything up at the home.

He was referred to Dr Q’s note. He said, Mum gave a history that T was previously well over the last couple of days but coughing. His recollection is it was just that day. A further comment refers to a few days. Others were speaking to mum and he was concentrating on treatment. Dr P was told he was well during the day. In his long discussion with mum, she said C and G, some ready made formula, occasional expressed breast milk, put to breast, and gripe water. Boiled water, sterilising liquid. He does not think she told him about the grittiness of the formula. It was clearly a busy situation and I accept slightly different things are likely to have been said over the time they were all there.

Dr M, Consultant in Paediatric Critical Care at [B Hospital], provided reports on 9^th May. T was still on a ventilator and his sodium levels were slowly reducing. He was on peritoneal dialysis. Other causes were considered but his opinion was that “[T’s] condition is consistent with exogenous administration of sodium chloride (common salt). He is clearly too young to feed himself. Therefore any sodium chloride (salt) which has been given to him has been done by another person.” That is accepted by everyone.

Dr Malcolm Coulthard, consultant paediatric nephrologist, and Dr Kathryn Ward, consultant paediatrician, were jointly instructed to provide expert opinions for the court. Dr Coulthard provided a clear report and explanations of any medical terms. He was not able to give a long term prognosis for T’s brain development. He sets out the reasons for his conclusions. He provided a further report on receiving additional information. He has also provided details of his communications with the officer in the case. There was a misunderstanding about whether he had permission from the parties to talk to her but, having seen the details of their communications, I am satisfied that his evidence is not tainted.

Dr Coulthard “reached a firm conclusion that [T] was bottle fed with milk that had been made up from a tub of milk formula that had been contaminated with salt.” Like the treating clinicians, he had never seen such a high concentration of sodium. He carried out a thorough analysis of the scientific evidence and of the known factual evidence and concluded that “The pattern of intermittently feeding [T] from the breast, and with milk contaminated with salt, could explain how it was that he presented both with an encephalopathic picture, and with biomechanical evidence that he had been precipitated into kidney failure at least a day prior to arriving in hospital. I cannot think of any other possible explanations.” He thought “it most likely that the 3rd feed on 24^th April was the first contaminated one that [T] was offered.” Taking the mother’s account of the feeds, he worked out the likely build up of contaminated feeds over the next 3 days.

For his second report, Dr Coulthard had the benefit of the Public Analyst Scientific Services’ analysis of the tub of formula milk powder known to be contaminated (exhibit AJT/9) and of another tub recovered from a wheelie bin at the family home (FLA/3). He also looked at and tasted powders from other containers from the home and an untainted tub of Cow and Gate formula. He explained some errors in the PASS report. He found that “FLA/3 was a fine light yellowish powder that had a strong salty taste, and felt very slightly gritty compared to a newly purchased tin of Cow & Gate formula…. AJT/9 was a fine light yellowish powder that had a strong salty taste, and felt very slightly gritty compared to a newly purchased tin of Cow & Gate formula.” In his opinion, “Both the tub of C&G powder seized from the family bedroom, and the tub discarded in the wheelie bin, tasted markedly salty, likely the discarded one more so, and both felt slightly grittier than the newly opened tub purchased today. The cooking salt purchased from the [grocery] store felt slightly more gritty than the salt from the salt shaker or the jar from the shelf, and was probably less finely milled. It appears likely that both tubs of C&G powder seized from the bedroom and the wheelie bin were contaminated with salt purchased in bulk from the [grocery] shop.” I know that was usually purchased for the family by the paternal grandfather. Everyone knew where it was kept in the home.

Dr Ward provided a very comprehensive report. She gives an overview of the possible causes of hypernatraemia and she defers to Dr Coulthard where appropriate on the cause. She said that “If the Court accepts that [the hypernatraemia] was the result of being fed with formula which had been contaminated with salt this would suggest that he was the subject of Fll - fabricated or induced illness.”  In relation to the parents, she observed that “There is no evidence of health seeking behaviour or presentation with recurrent symptoms which would lead to a suspicion of fabricated illness. Furthermore, if the Court accepts that there has been induction of illness as a result of administration of feeds contaminated with salt there are a number of potential perpetrators as all of the adults in the house had access to the tins of formula so that the parents were not the only individuals who could have contaminated the feeds.”

Dr Ward sets out the very serious consequences of salt poisoning including multi organ failure and she agrees with Dr Coulthard that it is difficult to give a long term prognosis. But “in this case the extent of MRI changes and the history of extremely high sodium carries a very high risk of long-term impact on neurological function with risks for possible cerebral palsy impacting on gross motor function and coordination, feeding, speech and language development, cognition, memory and potential neurodiversity such as autism. Early physiotherapy and occupational therapy assessment showed evidence of gross and fine motor delay and speech and language therapy assessment showed some difficulties with oromotor function requiring supplementary tube feeding. [T] will require very careful review as neurological deficit is likely to appear over time as progression of milestones is affected. It will be important to monitor vision as MRI scan showed some changes in the optic tracts.” In summary, “there is a risk of impaired motor, cognitive and communication skills” and “He will continue to require consistent care in a safe environment with ongoing input from a team consisting of paediatrician, orthopaedic and plastic surgeons, support services including physiotherapy, speech and language therapy, occupational therapy, orthotics and prosthetics and dietician. Prognosis will become more apparent with the passage of time and monitoring of general health and development.”

On the likely cause, timing and mechanism of T’s injures, Dr Ward defers to Dr Coulthard and accepts his opinion “that the pattern of mixed breast and salt contaminated feed over a period of more than one day could explain the clinical and biochemical presentation.”

When they gave their oral evidence, each expert stayed within their areas of expertise and deferred to the other where appropriate. Dr Coulthard agreed with Dr Ward’s view that T’s faltering growth was unlikely to be due to hypernatraemia but more likely to be due to not establishing a feeding routine and other matters. He agreed with her list of the likely consequences of hypernatraemia.

Dr Coulthard said, this particular baby presented with fits and extraordinarily high sodium but his particular presentation showed he had been poisoned over a longer period. The reasons is he was predominately breast fed so only some of his feeds were contaminated. This enabled him to excrete salt whilst he was being breastfed.

For his first report, he only had the milk labelled AJT/9. He explained that qualitative analysis asks and answers the question of whether or not the milk powder formula had salt mixed with it and it’s established by looking at the powder under the microscope. You can see clearly salt crystals. Quantitative analysis is asking how much salt. The question he wanted to answer was, if you made up the milk, what was the concentration the baby was exposed to. He explained that the milk powder would have been more shaken up over time. With the concentrations in AJT/9 and FLA/3, and the fact that by the time it reached the lab it would have become more fully mixed, he feels you can’t distinguish between the 2 tubs.

He said that adding Saxa table salt did not alter the texture, there was a subtle colour difference. It was extremely smooth. The sample from the [grocery] shop felt grittier and when he added it to the milk powder, it still felt grittier but it was subtle. Mother, MA, told the police in her interviews (N140) that “I don’t know if it was just me but the texture seemed a bit gritty … I got another box. When I was blending it, there were still gaps … I felt it was crumbling.” He could not see any difference when he used the scoop and levelled it off.

Asked about timing, in his report he says he is certain that T was not first exposed on the day of his presentation. The reasons is that his creatinine was very elevated on admission. That is a blood test which measures kidney function. Creatinine is cleared by the kidneys and if your kidneys stop working that level rises. It takes time to rise and there is a lot of maths behind this. Essentially the level of creatinine T had reached would have likely taken 24 hours. His kidneys would not have been working for at least a day. He drew some graphs with various hypotheses to work out how the salt poisoning would have happened. It was put to him that we are told that the tub FLA/3 had not been used since before 4^th April. He can’t exclude the salt begin given to T before the 4^th April. He can’t exclude other dates either. He can only be clear about the 26^th and 27^th.

On the harm T suffered and the prognosis, Dr Coulthard said that does not have a correlation with the level of salt poisoning. The key factor is how well the hospital managed bringing the salt level down and he thought this was masterful management by the hospital. T’s body was so compromised that he could not properly service his body and get the blood flow to his feet or get oxygen to his brain.

In cross examination for other parties, Dr Coulthard explained his testing of the salt further. What is clear from him, as he said, and from all the evidence is that this was a substantial quantity of salt that was added. A big percentage of the powder was salt. A smallish quantity of salt would make a child generally unwell and a bit miserable but it would not come to a clinic’s attention. If you took a baby who was a bit poorly to a doctor, he does not think they would suspect salt poisoning.

At E136 in his report, he talks about likely behavioural responses and he said that babies do have a powerful sense of taste. There was a tragic accident at a nursery in 1963 which provided useful evidence. Going back to that incident as an example, to a certain extent all the babies did not want to feed but they did. Babies are hungry but they pull away, then because milk is food and water and the drive to drink is huge, they do take enough milk to become very ill. He did not see a clear description of T pulling away or grimacing but there was reluctance to take as much as normal. They know it is due to taste because they have seen salt poisoning in tube fed babies. If T had contaminated milk earlier, he would expect so see him turning away. He explained that obviously there are no tests on how babies respond. He does not think T’s weight chart can help us on the salt exposure.

On behalf of BF, Dr Coulthard was asked how he reconciles his certainty that T was not first exposed to the salt on the day of his presentation and his opinion on how he was exposed to it earlier. He said that T must have been exposed to salt earlier so he had to assess how he was exposed to the levels of salt. If the salt goes up gently you would expect neurological symptoms when he had the kidney failure so it must have needed about 3 feeds. He referred to his graphs on E138 to show when it must have begun. We know T was breast fed before that. He acknowledged that it is speculation but he cannot think of any other explanation. To that extent, I do not think speculation is the right word; he was assessing all the possibilities and reaching a likely explanation. He said it is fairly straightforward to work out how much salt he had. He explained the calculation. He had taken into account the times T was said to be breastfed.

He said that a clear theme from the 1963 paper is that the babies were reluctant to take the feed but there is a danger of over interpreting the data. Examples were given of babies reluctant to feed when given contaminated milk but then keen to feed on uncontaminated milk. Asked about E139 on timing and his charts, Dr Coulthard is saying that what T was given on 26^th was enough to cause acute kidney failure. He can’t have been given the same amount 2 days earlier. It was put that he has a solid foundation for his conclusions. He agreed. At E135, he provides an analysis of how much salt T was fed. His calculation fits with what he has been told about what T was fed which further supports his conclusions as does his analysis at E139. In effect, his conclusions are based on the evidence.

Asked on behalf of CM about the feeds on the 26^th and the 27^th he said, there must have been salt contamination in those feeds. He referred to the creatinine again. Knowing the concentration in the feed tells us how much milk must have been delivered which gives us the confidence to know he must have had that many feeds. The window may have begun earlier but he can’t say that on the biochemistry itself.

Dr Ward confirmed at the start of her oral evidence that her opinion has not changed as a result of reading the further evidence. On timing, she defers to Dr Coulthard but as a clinician, if a child has a problem, feeding is a key diagnostic factor so, if he had not been feeding, that would have implications for the timing of the administration. The tests show there was already an impact on kidney function so that would not happen in a short time.

Looking at her report at E321, where she sets out T’s weight and then on to E322 she says “it is unlikely that hypernatraemia was the cause of faltering growth from early life”. He was gaining weight which is in keeping with a feeding pattern not fully established. She pointed out the problems of not breast feeding for long periods. Clinically that is consistent with the pattern of growth we see. Feeding support was declined. She did not wish to over interpret scenarios put to her. She explained that some babies take ready made formula better. This was a young baby with an unusual feeding routine which was not fully established. She said it’s not uncommon to see a slow steady weight gain. He was 6 weeks old and one would have expected him to settle into a routine but on 25^th April, he had lost weight. Constipation was a transient problem. It could have been related. A difficulty in this case is pinpointing what may have been significant.

Asked about the quality of care T received at [A] and [B] hospitals, she thinks it’s remarkable that he survived. That tells her he was appropriately managed. She has never seen a case with a sodium level above 200. Of the likely long term impact, she reminded us of the organs affected but also the quality of care. She said he has shown central nervous system disfunction. The possible outcome could be cerebral palsy with abnormalities of tone and movement, it could affect the fine motor development. And a big worry is on speech and language development. There are significant risks in terms of neurological development. One can’t exclude the possibility of subtle changes to the kidney and the heart.

Cross examined for the local authority about the expected presentation of a baby who has been given contaminated milk, Dr Ward said she would agree that you would expect a baby to turn away from the bottle at this level of salt, given this baby was a bit fussy anyway. They may vomit. Asked if the court found as a fact that T had been given salty contaminated milk intermittently from birth, could that have contributed to his faltering growth? She said, possibly. One of the difficulties is in establishing what he had been given and the proportion of breast to formula feeds. It may also have affected the quantity of milk he was taking. If he was given the earlier contaminated milk, that would have impacted his growth.

Cross examined for MA, she was referred to the investigation in relation to MA in 2018, when there was said to be an allegation by MA’s younger sister. Dr Ward said she has seen allegations by other people of issues within the family so she would not discount the possibility of adverse childhood experiences.

Cross examined on behalf of CM on T’s likely feeding response, she was reminded of Dr Coulthard’s opinion that T must have been consuming contaminated feeds on 26^th and 27^th April and may have received them earlier. She agreed with that as a clinician. He also said that the fact T’s kidneys were not working properly pointed to an accumulated delivery of salt. She agreed with that. She said, the clinical presentation would depend on the quantity and over what time period. Dr Coulthard in his calculations on AJT/9, gives us the concentration of salt. She said she had no doubt that the feed would have been excessively salty and that would have been apparent to a baby of that age. At E136, Dr Coulthard gives an opinion T’s likely presentation, pulling away etc. He says virtually all infants would display that. She agrees with that.

Dr Ward thinks the behaviours T was likely to show probably would have been obvious. Even a first time carer would interpret this as difficult feeding or a feeding problem. The sort of response that she and Dr Coulthard have described are such that a carer would question whether there was something wrong with the milk. It is not uncommon for carers to change formula. In this case, I have a mother who, on her own account, thought there was something wrong with the milk but carried on using it.

There was no challenge to the accuracy of the medical evidence from the treating clinicians or from the jointly instructed experts. They all gave reasoned explanations for their opinions based on their own expertise and clinical experience and published literature and I accept their evidence. I also know that this milk was not contaminated before it was purchased. The seal was intact when MA opened it. I am satisfied that T was poisoned with salt added to the tub purchased on 22^nd April and that that poisoning probably took place from at least 24^th April. Having heard the evidence from and about the family, the local authority rightly no longer seeks findings against T’s grandparents or aunts and uncles.

Nothing of concern was known about the family prior to the events which led to the proceedings. They were not known to children’s services. The health visitor records for T include observations such as this in March - “Appropriate interaction seen at this contact. Infant clean and well presented. No professional concerns about parental capacity to meet infant’s needs. Good eye contact and interaction observed between mother and [T] and responding positively to his cues when wanting to be held following weight review, mother cuddled him. Mother very attentive with handling [T] gently and appropriately and spoke with warmth and affection about his development and spoke with soft tones….. Visit undertaken in the living room which was warm, clean, uncluttered and well furnished. Family living with paternal grandparents and extended family and no financial concerns raised. Family have lots of support and maternal grandparents live nearby and reported to be supportive and see often.”  There was a slight concern on 2^nd April about T’s weight gain and his appointment for a jaundice review was missed. Mother was breastfeeding and using formula milk. No concerns were raised at the home visit on 25^th April and appropriate warmth and sensitivity were observed. But T had lost weight. The health practitioner discussed a referral to the weight clinic which MA agreed to. She was there for 45 minutes, they discussed feeding, MA said T had lots of wet nappies, and there were no concerns about MA’s wellbeing. I now know that MA had contacted Cow and Gate on 25^th April concerned about the texture of the milk yet she did not mention this to the health practitioner, nor did she tell her that she was lonely or unsupported. I will come back to that.

Both T’s mother and V’s mother were seen routinely by maternity services and there were no safeguarding concerns or concerns by the health visitor about the parental care. Both babies were breast and bottle fed and needed some support with feeding. V’s weight dropped to the 9^th centile and on 21^st March, the health visitor advocated a referral to the infant feeding team. This was declined by his parents but the health visitor referred to them as being despondent. On 7^th April, V’s mother said that bottle feeding had improved. I note that the foster carer for V also found that he was experiencing feeding difficulties and he was referred to the acute paediatrician on 14^th May. It seems he had tongue tie.

There is a note in T’s medical records that suggests the health care services could have explored better the roles of the different family members, the relationship dynamics and how family members supported each other. I think that was with the benefit of hindsight and I do not think there was a lack of family support. I have parenting assessments for all 3 couples and kinship assessments of alternative family members. There is a lot of support within this family.

In relation to the older children within the household, there were no safeguarding concerns and they were not known to children’s social care. Their school attendance was good. The parenting assessment of CM and DF is positive. There was background information from schools, medical reports and positive contact reports to inform this assessment. They appeared to have a close and loving relationship with the children and the children have positive sibling relationships. There was a concern that the children have been raised to be highly dependant on their parents but that can easily be addressed. In the addendum assessment, they shared concerns about other family members and confirmed that they will work with the local authority. The local authority would plainly not have needed to become involved with them but for the injuries to T.

The assessment of EM and FF contains many positives. V had some feeding difficulties. Family time is positive and they are able to meet V’s emotional needs. However, their insight into the serious harm suffered by T was lacking and there was a concern about their ability to prioritise V’s welfare over familial loyalty. If I find that they are not likely to have caused harm to T, parenting work was likely to be needed. I do not think they lack insight now. They have read and heard the evidence and I have seen that they know the risk T’s parents pose. They are loving parents and the local authority would plainly not have needed to become involved with them but for the injuries to T.

The assessments of MA and BF were positive, subject to the outcome of this fact finding hearing. They have been consistently attentive and caring during family time. The assessor did not know about the difficulties in their relationship, their dishonesty or that MA poisoned T.

MA seeks to blame EM for poisoning T and she and BF also suggested that it could have been CM so I have heard a great deal of evidence about the relationships between the adults in the family around the time MA and BF became engaged. Their case seems to be that CM bore a grudge on behalf of her cousin to whom BF was engaged when he started going out with MA or that EM was jealous of MA and T. When they started going out, MA knew that BF was already engaged. His brothers had each married a cousin and BF had gone to [A Country] and exchanged rings with JK, another cousin to all of them. Breaking the engagement affected his fiancé but also the financial situation of the wider family in [A Country]. However, by the time he married MA on [a date in October] 2023 and she moved into the family home, she was made welcome and the past was forgotten.

In their early statements, the paternal family members kept largely to factual matters but in their later statements they had to respond to allegations by MA and BF. Even when she had to respond to BF’s claims of her statement on the wedding day, CM was reluctant to be critical of him and she said he had made a mistake.

Everyone in the family agrees that the breaking of the first engagement and plan to marry MA caused some problems within the wider family. In his 31^st October statement, BF gives the impression that him breaking off the first engagement caused a lot of financial damage to JK’s family to whom CM and EM were close, implying that was a motive for them to harm T. He also said “[CM] helped me dress and get ready for my wedding. There was only [CM] and I in the room and she said to me – ‘I will never forgive you for what you have done.’ We were at home and she was talking about her disgust that I had let [JK] down and not doing what our family expected. No one else was around when she said this to me, but I have never forgotten her words on my wedding day.” That seems to be the first time he has mentioned something he had never forgotten and it is contradicted by all the other evidence I have about CM and EM. EM knew about the relationship for a long time before other members of the family because she did beauty treatments for MA so she could have caused trouble years ago if she wanted to. CM welcomed MA from the start so I cannot see how BF would know what she was referring to if she had said that on his wedding day. In his first statement for these proceedings, BF said that everyone welcomed MA to the family and he implied that the broken engagement was long forgotten. His story has changed over time to support his wife’s efforts to blame someone else for poisoning T. I have heard how busy everyone was on the day of the wedding. CM had her own children to prepare as well as supporting MA. She did not have an opportunity to say she would never forgive him. There was nothing for her to forgive, in any event. BF has made that up in an effort to imply she had a grievance against him.

MN, a second cousin of BF, provided a statement to the police and gave oral evidence. He said that, on 27^th April, he had lunch with BF and another friend; BF did not talk about T or MA. He was the best man at the wedding and he spoke positively about the couple and the wider paternal family. He did not know of any issues between MA and BF. Asked about 27^th April, the two of them and another friend went out to a restaurant. BF did not tell him that that evening, he was due to take MA out. There was no discussion about her or T. He thought BF was a loving father but I got the impression they were not that close and he did not see him with T. I note that he said BF was very happy on the day he got married and BF did not say to him that one of his sisters in law had said she would never forgive him. BF’s accounts about this have varied but no-one else’s has in relation to the wedding day being a happy occasion all round.

I have read and heard a great deal of evidence about the first meeting between the two families at [a restaurant]; even those who were not present have described how badly it went. PQ, maternal grandfather, found the men welcoming and friendly and said the family seemed to get on well and MA was positive about them and he said his wife found CM and EM welcoming and friendly when they met them in 2023. The problem was GM, T’s paternal grandmother.

RS, maternal grandmother, found GM cold and distant at their first meeting and, at the second meeting in a restaurant, GM declared that she had been upset at BF’s decision to marry MA. Then, at the end of the meal, GM suddenly hugged RS and declared, "we are friends now". RS was confused by the very sudden shift of attitude in a short period of time. She said in her statement that GM has not apologised or provided a sufficient explanation for her behaviour. But she appeared to happily partake in the festivities of the wedding and has displayed a warm demeanour since.  In her statement for the police, RS was very positive about both parents and their care of T. BF had visited every day when MA was staying with them and he was a doting father.

In their oral evidence, PQ and RS expanded on their statements. PQ said that his wife returned from that first meeting upset because she felt ignored. His wife told MA. She said BF was a good man and they would lead their own lives. They met up again and the family apologised. RS said that after that first meeting, she went for a walk with MA and OT and said are you sure you want to marry into this family. MA said GM would come round. MA was happy and it is her life, she assured her mother BF is a good lad. The daughters in law called her and apologised. They had a second meeting. RS did not know he had been previously engaged until later. By the time of the wedding, everyone seemed happy. It seems to me that, if she had been told earlier about the broken engagement and its ramifications, she might have understood GM’s reaction better. Both of MA’s parents seemed to me honest and straightforward caring parents. They had raised their concerns, there was an apology and everyone moved on. RS was positive about GM in cross examination and the relationship has greatly improved. They had both been involved in the wedding festivities. CM and EM had been chatty and friendly and welcoming from the start.

PQ spoke warmly of BF and of his daughter. BF is very nice and respects him. He said MA talks to him but mostly she confides in her mother. She has a good relationship with her sister, OT, and he thinks she probably confides in her. They were obviously delighted to be grandparents and RS said MA was over the moon to be pregnant and when T was born. MA has not confided in her mother about any difficulties in the relationship with BF, she thought she seemed happy. BF visited daily, he could have stayed if he wanted to. They described similar feeding routines of breast and formula milk. MA made the feeds even if others fed T. T fed well. PQ saw no signs anything was wrong with T.

RS said MA was coping really well, she had always been someone who interacted well with everyone and that did not change when T was born. T was fine feeding. If MA had had any concerns about T, she would have mentioned it. And she did not pick up on any issues. When MA left, RS cleaned out the cupboards, told MA she had left her milk, there was only enough for one feed so should she bin it? MA agreed.

Counsel for the guardian pressed the maternal grandparents on whether MA had been low or confided in them about problems. They were clear that MA was a happy, smiley mother, not low or tearful and she did not say she felt lonely at BF’s house. She did not say she was fed up with BF or he went out on his own. They struck me as a supportive family and I think they would have tried to persuade MA to stay with them if they had been worried about her.

Both maternal grandparents thought initially that the formula was a bad batch from Cow and Gate, but now it has come to their knowledge that somebody tampered with the milk. They do chat about who it could be. She has mentioned it could be one of the daughters in law, it’s more like a female act. RS did not want to make allegations, nor did PQ, but her feeling is that it was CM or EM. My view is that is what MA wanted them to think when she told them about EM’s baby going in and out of hospital and when they were told about CM’s alleged comment to BF on the wedding day.

OT, MA’s sister, said MA was very happy after T was born, a bit tired but nothing out of the ordinary. She did not say she was down or struggling. She did not know MA had been in touch with Cow and Gate. She did not notice any difficulties when she did see T feeding. She does not recall MA mentioning any difficulties. MA did not mention colic or ask for any advice. She spoke to a midwife shortly after she left. She saw BF during that period. She received a text on 25^th April from MA asking her to check if the box of formula she left there was grainy or powdery. OT said she threw a box away but when she opened it this morning, it was more smooth. It was sitting on the countertop where they usually throw away things, she looked inside to see if it should go back in the cabinet and it was almost empty. On 26^th April, she texted MA to ask how T was (G1329). MA said “he’s good, he’s been constipated and not really drinking his milk but I think he’s just let it out.” She explained that she was vaguely aware that T was not drinking his milk, then when he went back to [the address], she asked how he was.

OT told counsel for the guardians that she kept an eye out on MA (in case she was tired, say) but she did not see anything. MA did not say she was low. She did not say she was going to stay with them because she was lonely at BF’s or that he did not take her out. OT had not seen anything of concern and she seemed happy about the paternal family.

That is the wider background. Far from showing that there was any hostility to MA in the paternal family, I am satisfied that she was made very welcome. CM and EM have a strong supportive friendship but they were willing to include MA in that. She preferred to keep a distance. She had hoped that she and BF would have their own home after their marriage and they had not planned to start a family so soon. I do not think life has turned out as she hoped. I now know from the messages between them that there were problems in their relationship and that he was not a supportive husband. I will come back to that.

The parties have each filed a number of statements and some accounts have varied. The first statements lacked detail. Later statements are made with the benefit of seeing other evidence. I find the arrest details and police interviews and statements which were closer to the events and less tailored to each party’s position of more help. MA and BF did not criticise other members of the family until later. The only

MA and GM were spoken to at the hospital on 27^th April. MA explained that T was fed a mixture of breastmilk and formula.

Members of the family made statements, largely about the Saturday, and they were interviewed by the police about the wider picture once the police received the forensic report about the salt in tub AJT/9. BF was interviewed at 16.35 on 28^th April. He was not good on the details of the milk or the bottle making and sterilising. It has become clear that he did very little. He did the supermarket food shop and his father popped into the [grocery] shop and bought salt for cooking. He had bought a new tub of formula (AJT/9) when he picked MA up from her parents on 22^nd April. He spoke positively of the family relationships but seemed awkward when asked about MA going to stay with her family. He did not have much to do with the feeding and bottles and he was vague on where the formula was kept and about the tub that was thrown out. He thought MA was over protective of T. He came across as an enthusiastic but not very hands on father. He googled salt poisoning after the doctor told them about it because he did not know what it was. He said his wife had not done anything and nor had his family. He spoke positively about everyone in the family.

BF did not know about the half full Cow and Gate tub in the black bin in the garden. BF was interviewed again on 2^nd May at 11.57. He said he did not put salt in the Cow and Gate formula. He said they bought it in Tesco at [a place] on Tuesday 22^nd.

MA was interviewed on 28^th April at 18.30. She said that T had not drunk much milk on the Thursday (the 24^th), she told the health visitor he was constipated, then on the Sunday he was not drinking much, he drank some breast milk. She gave the details of his feeds. When he started shaking, they called 111. She had been concerned about the Cow and Gate formula being gritty and she had messaged the company on WhatsApp about it. She had asked BF to buy a new box of formula but she was using the old tub, breast milk and ready made milk. She had no idea how the salt had got into the tub but suggested a bad batch in manufacturing. She thought they had bought it in Tesco on the Tuesday.

In her second interview at 13.25 on 2^nd May, MA said she did not put anything in the Cow and Gate formula, she and her husband had bought it on Tuesday 22^nd in Tesco, she unsealed the container when she first used it on the Tuesday, he was breastfed overnight and she next made up a bottle at about 3ish on the Wednesday afternoon, the formula seemed fine then, the next feed was fine, Thursday morning he was breastfed, then she was sore so he was bottle fed, she thinks she noticed the formula was a little bit gritty on the Thursday (24^th). The formula was in the kitchen cupboard. She described him being constipated but he was taking the formula milk, he was breastfed overnight, on the Friday he took the bottle. That was the day the health visitor came round and MA did not say anything to her about the formula milk. On Saturday, T took the formula, although he was spitting it out when her sister tried to feed him, he was breastfed overnight and was fine, he did not seem to take all the formula on Sunday, he began to be unwell from about 5/5.30 and that is when they called 999. She asked her husband to get another tub of formula in Asda. She then took the previous tub upstairs to the bedroom because she was going to throw it away. That seems an odd thing to do.

MA described positive relationships with everyone in the family. She was asked about her relationship with BF because she had been suggesting he was not doing enough to help and he was not there enough. The police explained that salt had been found in the formula tub labelled as AJT/9. She said she had not done it and she could not think of anyone else in the house who would want to harm T. She said everyone was really nice and she was happy in the house. She had not asked anyone to buy salt.

MA and BF were both asked about the phone messages between them on 9^th April. She had said “I’m beginning to think you really hate me” and they were like 2 strangers sharing a room. His first explanation was that it was because he was a bit lazy then he said it was because he had been having a conversation with another girl but they had sorted it out. He said that was nothing to do with why she went to stay with her mum. I doubt that. MA said she sent the messages because he was not around that much. “He’s a great dad when he is around…” She comes across as feeling he was not supportive enough.

GM, T’s paternal grandmother, was interviewed and gave the impression that she got on well with MA. GF (paternal grandfather) was interviewed on 2^nd May at 12.25. He said he didn’t know who put salt in the milk. He had brought T’s father back from the hospital when MA stayed there. It was not clear why. In his oral evidence, GF explained that he thought it would be useful for BF to go home and get his own car, not that BF bothered to go back to the hospital for hours. He confirmed he did the shopping, including buying salt. He had not researched salt poisoning.

DF and FF were each interviewed on 2^nd May. They did not know who put salt in the formula. In their statements, they both said they were at work on the Saturday. DF spoke positively of the relationship between T’s parents and of MA within the family. He had no concerns about T’s parents. He knew a bit about the babies’ formulas.

EM was interviewed on 2^nd May at 15.42. She described the Sunday afternoon. She said she did not know who put the salt in the formula. She was asked if she had ever researched poisoning and she said, No. She said she got on with MA and BF. She said sometimes she had picked up T’s formula and moved it to get hers but she had never opened it. She corrected that after a discussion with her solicitor to explain she had made a bottle that Sunday in case they needed it at the hospital. My view is that her fingerprint subsequently found on the side of the milk tub FLA/3 is consistent with her moving the tub.

CM was interviewed at 17.50 on 2^nd May. She spoke positively of MA as a mother. Her description of the household gave me the impression that the families led separate lives within the home or did activities together as and when they wished to. There had been an argument between her and BF about the cost of the shopping but that was soon resolved. She said she had not tampered with the formula. In her earlier statement, she described taking the children to the park, MA was invited, coming home, organising tea and then at 7.55pm she got a call from BF asking her to go upstairs as T was unwell. She said she took the “Nazar off”. That is a [cultural] ritual performed either when someone is unwell or afterwards. Once or twice, removing the evil eye was referred to. T was asleep but breathing heavily and she thought they should call the GP. Then EM came up, T started shaking and she told BF to call an ambulance. I now know they were not given the whole story about how long T had not fed or how unwell he was. The messages between her and BF told a different picture about how unwell T was and how long it had been since he had a wet nappy.

The older children were ABE interviewed in July. They were not able to help.

The family were largely supportive of each other initially. But MA and BF have since tried to move the focus away from them onto other family members. They have made false allegations against CM and EM.

They also went back to the house at least 3 times in May and MA laid a trail of salt in the kitchen cupboard and tried to implicate someone else. Their accounts have varied about what they saw, when and who they told. On one occasion MA said she told no-one, on another just her mother in law was present. EM and FF were asked about the salt trail when they were re-interviewed by the police in October and FF suggested BF and MA may have done it suspiciously. He was right. MA and BF’s accounts have varied as to the location of the salt, when they first saw it and who they told when. In her oral evidence, MA said, she saw the salt trail 3 times, the first time was when she took a photo of it. She thinks she was in the kitchen alone and everyone else was next door. They were all in the house on both occasions she saw the salt. The others would have known when she told them. Her account changed in cross examination. She said she did not tell anyone the first time she saw the salt but the second time she told BF.

In reply to questions on behalf of DF, she said the first time she saw the salt she was alone and she took the photograph attached to her statement. That was 13^th May. There were other family members in the house. She was going to tell them. Pressed on this, she said she does not know why she did not tell them. She told BF and showed him the photograph. He was shocked but they did not go and look at it. Her answers did not make sense. She said they had gone there to collect things, then said they were in a rush. They were there to collect bottles but then she forgot about them. The 2^nd visit was 2 days later to go and talk to them. It was also to pick up things. FF and her father in law were in the kitchen, the girls were in the conservatory. Then she said DF came in. But he was at work. Then she went a third time to tell her mother in law. She accepted that her 30^th June statement is the first time it was mentioned in the case. She said more in her 22^nd August statement and it reads as though she told them on 13^th May. In her November statement, she gives a different account of who was present when she found the salt trail. She said she can’t remember the exact timings. It was pointed out to her that in his statement, BF makes the same mistakes about when he saw the salt and who was present. They had plainly colluded.

On 27^th October, EM and FF were re-interviewed by the police. EM’s solicitor read out a prepared statement about the searches on her phone in relation to salt poisoning. It said, “I would say I have never searched for this on my phone. My phone is password protected. Only myself and my husband know my password. The kids may sometimes use my phone to watch YouTube if I opened it for them. Other people in the household wouldn't use the phone for a call. I wouldn't have given them my password. I can categorically say I've never searched this term on my phone prior to my arrest for this incident.” "Point 2, 'Exhibit FLA/3 is a tin of Cow & Gate baby formula which was found in the bin at the home address. This tin has a fingerprint which matches that of your client". In respect of this point, I would say this is not the formula I would have used. I said at my first interview that I didn't make up feeds for my nephew and I maintain that, but that doesn't exclude the possibility that living in the same household I could have touched that tin, although I have no specific recollection of doing so".

She replied “No comment” to many of the questions on her solicitor’s advice. At one point in the interview, she said her English was not good and then she said she had read the statements about the milk being gritty. She criticised MA for giving that milk to T. In her oral evidence at times, she had to ask for clarification of some English words although her understanding is generally good. She said they had all got on well. FF now thinks it may have been him using her phone and, in their context, I do not find the searches suspicious. Nor do I find it suspicious that her fingerprint was on the side of a tub which she could have moved in the cupboard to get to other things.

MA and BF do not want the rest of the family to know where they live now because they think one of them harmed T but they repeatedly went back to the house, even staying there for a few days whilst BF asked the others to lie about that. They went there in October to find out why EM and FF were re-interviewed by the police. I think they were trying to get information. Everyone agrees that there was an occasion, probably in October but it could have been earlier, when MA wanted them all to swear on the [holy book] that they had not harmed T. Why MA hesitated, which she agrees she did, does not assist me. But CM asked her some perceptive questions about why she gave T the milk if she thought something was wrong with it and MA could not answer that.

MA’s actions when she thought there was something wrong with the milk were unusual. Earlier in April, she had contacted Cow and Gate about the broken seal in a container of ready made milk so she knew there was a system for dealing with enquiries. She told the police that she sent their customer service line a WhatsApp message about the texture of the milk. From the phone downloads, I know she had an exchange with them from 25^th April at 18.55. She said, “I purchased a box of formula powder, upon opening it I've noticed the consistency isn't powdery it's more so gritty.” She sent them pictures and video clips. In her statements for these proceedings, MA referred to T’s bottles being almost grainy, or to it feeling different. She did not do the obvious thing, taste the milk. She did not ask anyone in the house or the health visitor to look at the formula. Obtaining help from Cow and Gate, she knew from her earlier enquiry would take time. She was also likely to know, from her degree and hope to join the police that they would get the digital material so she was setting up a defence. She did not seem to realize that the manufacturing process would be checked though.

In her oral evidence, MA’s lack of honesty and the difficulties in her relationship with her husband became more obvious. She accepted that she had exaggerated her mother’s response to the [restaurant] incident and that any unpleasantness had been forgotten by the time of the wedding. After the wedding, though, she said BF was still going out with the lads. He is lazy, he was either out or sleeping. He was out with the lads, maybe every day. They went out just the two of them but not that often, maybe once a month. It was more often before they got engaged. When she was university, he would come and see her there. The pregnancy was a surprise. BF was excited, she was a bit more scared….. but the week before T was born, she saw some messages between BF and another girl. She spoke to him briefly and said they would pick up on it after T was born. They did, maybe 2 or 3 weeks later. BF said it was just something that went too far. She said he was going to have to change and she needed to see that. After T’s birth, they went home to BF’s home, it was a small bedroom. She spent a lot of time in her room. She agreed that she was looking after T, coming to terms with his infidelity, living with his parents while he was still going out and doing little to help. She was starting the 40 days. For him to be part of that, she would really need to stay at [the address]. The first week was pretty tough, she was feeling low and pretty overwhelmed. She had decided to mix feed as that is what she had seen her family do. On the day of T’s birth BF bought a tub of formula. That is FLA/3. They had bought the steriliser etc in advance. T was waking up every couple of hours. BF was a heavy sleeper and he thought T was only waking once. She was breastfeeding at night. If T needed a bottle, she would make it. BF never made a bottle. The most he did was change one or two nappies. She agreed she told the police that sometimes he would get up and leave the house with no explanation. It was put that she must have been exhausted. She said she was tired but used to it. She was overwhelmed. She did not talk to anyone about it. On 4^th April she went to her mother’s house. She just wanted to be with her family. Things were not going well at [the address].

She was asked about the messages between them. They included her saying he didn’t care, that he was too busy for her, she was going to her mum’s because she was lonely, she said she felt like two strangers who share a room. It is clear that she was struggling and that her husband did almost nothing. If her actions were to get his attention, she did get it because they have now moved out of the family home and he is being supportive but his loyalty is now misplaced. On 27^th April though when T was seriously ill and she knew it was important to be clear with the doctors about what had happened, she told Dr P the health visitor had had no concerns about T. She had told the police T was normal until 5/5.30 on the Sunday. In her messages to BF, she said T had not had a wet nappy since the previous evening. There is another message in which she said T could not go another night without drinking. She misled the police. She was trying to get BF to come home that afternoon but he just stayed out with his friends. She did not ask anyone else in the family for help because, in my view, she just wanted him to come home. She said in cross examination that she felt lonely, she needed his physical presence. She had felt more settled and warm emotionally at her parents’ house.

It was clear from her evidence, though, that CM and EM were kind and supportive and she could have gone out with the rest of the family but she did not want to. When they got back from the park, CM asked her how T was and she said he was OK. It does her no credit now to suggest they were not supportive or make up stories about EM being jealous. She agreed in cross examination that FF had made an effort to make her feel welcome in the family and he was kind and fun. The trouble was, as she said, that she felt pretty unloved by BF and she bore the entire burden of looking after T. She did not have his attention. She said that she took the tub of milk upstairs a handful of times but she denied it was to mix it out of sight.

When she was cross examined on behalf of the guardians, MA said she did not tell anyone she was feeling tearful and low because she felt inadequate. The first time she told anyone how she had been feeling seems to have been the Liaison and Diversion Service on 2^nd June. They noted that “[MA] had seemed tearful in custody. Difference in presentation noted from initial assessment where she had seemed happy in mood. Referral to PNMH reports vulnerabilities in terms of low mood since the baby's birth, deteriorated in the last two weeks and since arrest. [MA] reports of normal pregnancy, when baby was born, she felt low, tearful, inadequate, not sleeping, and anxious, she reported this lasted for a week. She reported having support from all the family in the household, she reported of baby staying with her at night then in the day baby would go to different family members to help assist her, she reported even the children would hold baby at times but were not left alone… [MA] reports over the past two weeks she has had extended low periods which have worsened since baby was admitted into hospital, she reports of continually feeling tearful since baby has been born, not sleeping due to feeling stressed, which has worsened since baby was admitted into hospital. [MA] reports since baby was born, she has not been eating as frequently due to losing her appetite, she reports since baby has been admitted into hospital, this has worsened. [MA] reports of over analysing and second guessing over the past week and requesting support.” MA kept saying in her evidence as an excuse for some of her actions that she was over thinking but she could not explain what she meant. The simple fact seems to have been that she was lonely. She had been thinking of staying at her mum’s for longer and she was looking on the internet to ask if she could change her address for the health visitor. She wanted her husband’s attention so she went back to his house.

She could not explain why she asked no-one else about the milk or why she did not taste it. The reason is obvious, she knew. She could not explain why she waited so long after the first shiver to get help. She could not explain why she went back to the house in October when she did not trust the family. I think it was all because she knew the truth but was trying to distance herself from it.

Counsel for the guardians asked MA about the bottles she had made up for T and why she did not notice the milk powder level was not going down. On her account of the bottles she made, the tub would have gone down by just under a third. She had no answer to that. She just said she did not do it. But she did. I asked her what she knew about salt. She said she knew it was not good, but she did not know what it would do. She told counsel she knew how important it was not to give a baby anything apart from milk. I don’t think she realized how dangerous salt would be but she did know he should not have been given it.

BF, in his evidence said he was over the moon to be a father and he would do anything for T. He then accepted he was lazy and would get up and go out with his friends. He did not seem to see much wrong with sending a girl flirty messages such as “hi Cutey”. For a man who said he would do anything for his son, he did very little. On 27^th April, he went out with friends when he was meant to be taking his wife out and he ignored her pleas for him to come home. He thought T was an easy baby. I don’t think he would have noticed. He told the police MA went to her mum’s because they wanted to have a party; he knew it was because she was feeling lonely. He did not show any interest in finding out what the health visitor had said on her visit. He knew from the morning of the 27^th that T was not well but he still went out for hours. He ignored the requests from his wife to come home. Once he was home and he saw T shaking, he still did nothing. It was CM and EM who took action. Once they were at the hospital, he went home and did not return for hours.

When he first spoke to the police, BF did not say anything about contaminated milk. He referred to the consistency not being right in his second interview and it was put to him that he was covering for MA. He denied that but that was the beginning of their stories marrying up. His account of the salt trail was adjusted in his statements and then in his oral evidence to fit in with his wife’s. He could not explain why they both left out the same details from their statements but then put them into their evidence. They can’t agree on who was there when they raised it with the family. He initially said there were no problems with the extended family about the broken engagement but then on 31^st October, he made the claim about the alleged comment by CM on his wedding day. Now he thinks CM or EM are capable of harming T.

Cross examined on behalf of CM, he agreed that she was welcoming to MA and helped him sort things out with his mother. On the wedding day, he went outside because the cars were there. Then someone said he should get ready because the cars were there. He was waiting for the cameraman in the front room, he needed help getting his outfit on and that was when she said it to him. In his 31^st October witness statement, he says it was just one sentence, not a wider conversation. He does not mention this was in the front room. He does not think it was unusual for his sister in law to be helping him to get ready. Now he has seen DF’s statement and picture of DF helping him but he says DF was just doing that for the picture. He was rather argumentative with counsel. I noticed more than once in his evidence that BF became irritable if he did not like the questions. I also noticed that he was vague on details but quick to correct any counsel who got a detail wrong in their questions so he plainly knows the details when it suits him.

He said CM was there and said it and he was shocked but he brushed it off. He says he told CM her opinion does not matter. He has apparently never forgotten it but he told no-one and no-one saw any signs of upset on the day. It was put that this “memory” came from a conversation with his wife and he was being untruthful to try to suggest someone else did this. He agreed CM was chatty and welcoming and a contented person. He did not think CM was jealous, she was friendly to MA and was excited about the baby. I find that there is no reason why CM would have said anything to BF as he alleges. It goes against all the evidence I have about her, including from BF and MA. He did not mention it before because it did not happen. I prefer CM’s evidence that she did not help him get ready and she did not say she would never forgive him.

I have already referred to the changing recollections of MA and BF about the salt trail in the cupboard. It must have been obvious to BF that his wife planted it there but he went along with it and altered his accounts to fit in with hers.

BF did not accept in cross examination that his relationship with MA was under stress. It plainly was. He thought it was unfair when he was criticised for flicking through pictures on snapchat when his son was so ill on the 27^th April. That just tells me what his priorities were. When cross examined on behalf of the guardians, he played down the messages which show he and his wife were not getting on. He said he did not visit his wife and son at her parents every day because he was working as much as possible but he told the police he was relaxing and out with friends.

He is trying to support his wife by saying she told him the milk was clumpy or gritty but he could not explain why he did not tell her in his messages on 27^th April to tell the police about it. He did remind her to tell them about the gripe water and the Infacol. My view is that is because that was all he knew about. Where he actually knows about something his memory and ability to give details are very good.

BF’s lack of support for his wife and son at the hospital on 27^th shows how selfish he was. He had not altered his life at all since his marriage or following the birth of his son. He had already delayed coming home from his outing with friends, he delayed getting help after T’s first shake and then he left the hospital because he needed his own space. He referred to “me time”. He went to a friend’s house and then he was on various websites, including looking at pictures of women. Rather belatedly, he is now supporting his wife, probably out of misplaced loyalty and guilt for his past failings. It began between his first police interview when he said he bought the new tub of formula on the 27^th because the old one was finished and the second interview when he said his wife had told him about the consistency not being right.

I do not need to set out the evidence of the rest of the family in detail. They all agree that the initial meeting at the [restaurant] went badly but by the time of the wedding, everyone was happy and MA was welcomed to the family. I got the impression she was well liked. FF and DF knew their brother was immature, lazy and selfish but they tried not to be too critical. FF spoke warmly of CM. He said, she did everything for him before he was married. When her kids were born, there was a good feeling. She had his back. She was chatty, polite, loving. She was attentive to MA’s needs. She’s a wife, mother, part-time teaching assistant. She was busy and she seemed happy. He did not think she was jealous of T. CM was part of the efforts to see BF and MA able to get married. She was part of the wedding preparations. He saw a happy joyful day. Everyone in the family gave similar evidence about how lovely CM is.

No-one described any jealousy or hostility towards MA. CM, in her evidence, described how her own children have been affected but she is still distressed by what happened to T. She wishes they had gone to the park with her that day and she might have seen and taken T to the hospital. She was not told about any of the problems earlier in the day or about the shaking before she was called upstairs. There was an attempt in cross examination on behalf of MA and BF to suggest she was close to JK and her family and that she and EM were close and excluded MA. A similar approach was taken with EM. I have seen nothing but welcoming sisters in law. That comes from their actions, their messages and from MA and BF before they decided to try to divert attention to them. EM kept secret BF and MA’s relationship at their request for some time. Had she been hostile to MA, she could have caused trouble for them years ago. It was put to EM in cross examination on behalf of MA that she had too much pride in her baby. I am not sure how a parent could have too much pride in their baby but the implication seems to have been that she did not like T getting attention. I don’t think that is right. I saw no jealousy or hostility from EM. FF and DF had stronger views about their brother breaking his engagement and its effects on the family in [A Country] but no-one is suggesting now that either of them harmed T. They hoped he would be happy with MA. Nobody wanted to harm T.

I heard evidence from the paternal grandparents. They were clearly shocked and upset by some of the evidence they had heard. I think they were trying to cling on to the idea that this was faulty milk. They are very close and supportive of the whole family. They were supportive of MA going to stay with her family but pleased when she got back. Everything I know about this family tells me how loving and caring they are. Had they known of MA’s struggles or realized how little BF was doing to support her, they would have tried to help.

There is no dispute that T was poisoned with salt which was added to his formula milk. He might have died. Plainly he suffered significant harm. All of the other children in the family were at risk of harm and have suffered emotional harm as a consequence of the actions of whoever put the salt in the milk powder. The perpetrator has then tried to blame others and added to the harm caused to everyone in the family.

I remind myself that the evidence of the parents and the rest of the family is of the utmost importance and that witnesses may lie for all sorts of reasons. I have already made some observations about the witnesses. I do not think anyone has lied in this case except MA and BF. They have tried to create a picture of a long held grudge against them and their marriage as a reason for harming their son. All of the evidence from the wider family on both sides and their own clear evidence in their early statements tells me that the broken engagement was long forgotten and the family were supportive. There was one disagreement between BF and CM about the shopping bill but that was soon resolved. In so far as it is relevant, BF seemed to be rather ungracious considering how much CM did for him and his wife.

It is submitted on behalf of BF that the family all chose to present a united front and pretend that the broken engagement was not as significant as it really was. He seems to be saying they are still not being honest about that. I reject that submission. In addition to their statements and oral evidence, I have descriptions of everyone’s conduct over the last 2 years. BF’s brothers do not have a high opinion of his behaviour but it is not said that they have harmed T. All of the grandparents had moved on and were supportive of the couple. CM and EM showed MA and T nothing but kindness. There is nothing in any of the evidence, including endless electronic messages, to contradict that. BF avoids addressing his own failings as a husband and father and is colluding with his wife to blame someone else for the harm she caused to their son, although he seems to concede that his case amounts to no more than being suspicious about EM.

It is also said on BF’s behalf that there is no evidence that MA told him she was the perpetrator of the harm to T. In my judgment, he would have known within days that no-one else put salt in T’s milk but he has stood by her throughout and supported her efforts to blame someone else.

I heard a great deal of evidence about the first meeting in the [restaurant]. In my judgment, the relevance of it is that it shows that MA and BF are willing to be dishonest. They went out together despite his engagement to JK and he asked EM not to tell anyone. BF broke his engagement and this distressed his mother. If both grandmothers had known the truth, that first meeting might have gone differently. MA exaggerated to BF her mother’s response to GM’s hostility, presumably so he would make an effort to bring his mother round. BF is lazy and selfish, that was apparent from everyone’s evidence including his own, so MA exaggerated what her mother said to get him to do something. It is clear that GM apologised and everyone was very happy when the wedding took place. She was clearly very fond of MA by the time T was born and she was the one who sensed that MA would benefit from going to stay with her mother at the start of April. There was an unkindness in MA and BF. They were both rather dismissive of JK and her family and they showed no acknowledgement of the upset they had caused by the way he handled the situation. But, from all the evidence, I am satisfied that within the immediate family, any hostility to the marriage or to MA had gone by the time of the wedding and everyone made MA welcome. In turn, they welcomed T’s arrival. There was no motive for anyone to harm T. Their unkindness has continued throughout this case because their actions have kept the other children apart from their parents.

MA said more than once during her evidence that she may have been overthinking, not that it was very clear what she meant. If she was telling the truth when she said she did not harm T, she was actually underthinking at the end of April. She did not take the obvious steps of asking the other mothers or the health visitor about the milk, of tasting the milk or of questioning why the tub was always full of powder. That is because she was not telling the truth.

The only conclusion I can reach is that MA had a plan to get her husband’s attention by making her son ill and then to say it was the milk. She did not seem to have anticipated how quickly the police and Trading Standards would ascertain that it was not faulty milk. The time frame in which the salt was added to the milk was short. As the men within the family work fairly long hours and their wives did the cooking and spent more time in the kitchen, it was unlikely to have been one of the men or grandmother. That narrowed the list of people MA could try to implicate. CM was busy with her children and she worked part-time and EM was busy with V. MA fuelled suspicions by leading others to believe that EM was jealous of her and by implying that she was struggling with parenting. Some parents are more anxious than others but, instead of being supportive to EM, MA was critical of her. When MA was at her parent’s house, EM was kindly asking how T was. If anything, MA seemed to be jealous of the bond between CM and EM although they tried to include her. She preferred to keep her distance but then blamed them for it, particularly EM. Then BF invented the story that CM told him on his wedding day that she would never forgive him, the implication being for marrying MA instead of their cousin. This apparently was to be her motive for poisoning T.

The problem for both parents is that they were clear at the start that the family were supportive. In the early police interviews, MA was positive about EM. Only later did she try to blame her. The extended family on both sides were positive about all the relationships, apart from that initial meeting. There is nothing in any of the messages to show hostility to MA or T.

I have already made some observations on the evidence about the salt trail and visits to the home. MA and BF kept going to the family home despite saying they thought someone there had harmed their baby and, allegedly being so worried that they don’t want the others to know where they live now. They were very keen to go and find out why EM and FF were re-arrested in October. The charade of asking everyone to swear on the [holy book] was an excuse to go to the house; whether MA hesitated is not significant.

There was no evidence against CM beyond the fact that she did the cooking and used salt. The more evidence I heard, the more obvious it was that she is a good mother, sister, aunt and friend to everyone in the family. Her prompt actions on the day helped to save T’s life. She welcomed MA from the start, on the wedding day she helped with the bride’s preparations, and she showed MA nothing but kindness. Her children are plainly fond of T and, on the Saturday, they invited MA and T to go out with them. If MA felt lonely, that was because of BF and not the rest of the family.

EM’s phone was used a few years ago for internet searches in relation to salt which are not suspicious. FF thinks that was probably him and he has a clear memory of searching for rat poison. Her fingerprint on the side of the tub of formula is consistent with moving the tub in the cupboard, not with tampering. EM was not jealous of MA, she was just a slightly anxious first-time mother with a baby with feeding difficulties. She was always supportive of and welcoming to MA, even before her relationship with BF was common knowledge. There was no real evidence against her. There are no messages or other evidence suggesting she was anything other than supportive. EM was also the person who said they should call 999 on the 27^th April. She had nothing to hide. Whoever did the internet searching on her phone about salt would have known how dangerous it is whereas MA did not. I think that is more relevant. MA felt very lonely and she wanted her husband’s attention. She almost killed her son.

MA is the person who poisoned T. Then she and BF tried to blame others. MA described the person who contaminated T’s milk, and then fed him and allowed others to feed him too, as “evil and psychotic”, adding “they are a selfish person, letting people go through this”. I regret that she was describing herself.

The local authority asks me to consider making a finding that T was given milk poisoned with salt for a longer period. They rely on the evidence of the parents who I find unreliable witnesses. I do not have medical evidence to support that. I do not have to decide how MA added salt to the formula milk but it may be that she used the tub FLA/3 as a way of adding salt to the second tub rather than that having been fed to T earlier and already contaminated. In relation to FLA/3, she put that in the wheelie bin after the bin had been emptied on 23^rd April. She could have thrown FLA/3 in the kitchen bin or in the outside bin if she did not want to keep using it as it had been opened for some time but she took it upstairs either to conceal it or to use it. In my judgment, she knew it was contaminated though when she threw it away. I know that she took the other tub up to her room from time to time and it would have been more difficult for anyone else to add salt to the tub in the kitchen without risking detection. But I cannot find on the evidence that she is likely to have poisoned T earlier in April.

The messages to Cow and Gate are concerning because they show the extent of premeditation in MA’s poisoning of her baby and setting up her defence. It may be that T was ill after being given a bottle of ready-made formula with a faulty seal and her exchanges with Cow and Gate about that showed her a way to try to explain away her using contaminated milk later. She was also doing internet searches which show there were feeding problems on 14^th and 15^th April but there is not sufficient evidence for me to find that she was giving T contaminated milk then. I do not think I can find that T was given deliberately contaminated milk before the 24^th April.

The messages to Cow and Gate on 25^th April seeking advice about the formula possibly being gritty were not a genuine enquiry; they were so she could say she had been worried about the milk. I reach that conclusion because she continued to give her baby milk she was supposedly worried about without doing anything to test it. She did not ask 3 experienced mothers in the household about the milk, she did not ask the health visitor, she did not taste it. That was in contrast to when she supposedly found the salt trail in the cupboard later. She knew what was wrong with the milk. MA says she could see that there was something wrong with the formula but [an analyst] studied the mixture and could only see a difference under a microscope. Dr Coulthard said in a blind test with formula contaminated with the coarser salt from the [grocery] shop and with uncontaminated formula, he could only see a subtle difference. I do not accept that she saw a difference. My view is she did not need to test or taste the formula because she knew what was wrong with it. The guardians’ counsel rightly points out that, in contrast to MA allegedly observing a difference in the consistency of the formula, she did not notice that the tub did not get any emptier. If it was anyone other than her adding the salt, my view is she would have mentioned and queried that. She didn’t, because she knew why.

MA and BF were not honest about the state of their relationship. She lied to the police in her first interview when she said their relationship was really good and she was 100% happy with BF. He concedes he was not a hands on father. It was worse than that. He was lazy and selfish and continued to come and go as if he did not have a wife and child to consider. She was disappointed by the fact that they did not have their own home, she had a career plan which had to be put on hold when she fell pregnant unexpectedly and then she had little support from her husband. He was, at the very least chatting to other women and looking at dating websites. They had arguments over messaging platforms, she was trying to get his attention without much success. She went to her parents at the beginning of April because, as she said in her messages “He’s too busy for me ”, “That’s why I’m going to my mums” and “Feeling too lonely”. He only visited there when he could have stayed so she went back to [the address] and then, on 27^th April, he went out with his cousin and did not even bother to go home until it suited him when she was sending desperate messages. I have already referred to their failure to act when T had his first seizure and to their lack of honesty about T’s health and lack of wet nappies on the 27^th. That all increased the harm T suffered.

The collusion between MA and BF from the end of April was done to conceal what she had done and to blame others. There is no other explanation. They seem to think the family should have been more supportive of them but they showed no support for or regard for anyone else. They went to the home 3 times in May, allegedly found a trail of salt in the cupboard, took pictures of it but told no-one, then they went round later and showed it to others. The location of the salt trail has varied in their accounts and BF changed his in his oral evidence to fit in with MA’s. I do not believe them. Her first statement about the salt just had a sentence and later she added to it. The salt was not in that cupboard until MA put it there. It was rather foolish in any event because whoever put salt in the formula would have had to take the tub out of the cupboard and would be unlikely to leave a trail in the cupboard.

When BF was first interviewed by the police, he did not say anything about the formula being gritty but, in his second interview on 2^nd May, he said he was told there was something wrong with the consistency. He was beginning to support her case and that has continued.

In her 19^th November statement, MA makes a number of new criticisms against EM. She says, “After [T] was born [EM] said to me the reason [V] was not drinking his milk is because she was feeding him in the same room as [T] who was in his 40 days. She was so serious about it that I felt bad and kept [T] away. I disregarded it somewhat because [V] was having feeding problems way before [T] was born. But apparently, that is something to do with our culture. I thought it sounded bizarre but she seemed so serious and emotional so that is why I just ended up keeping [T] upstairs most of the time.” I do not believe that. She was making another attempt to cast suspicion on someone else. Both sisters in law were supportive and inclusive.  It was MA’s own choice to spend time away from the family. She also says, wrongly, that the family did not care about T. Then she makes allegations about EM being jealous of the attention paid to T and she says “[EM] would often watch me make [T's] milk, her gaze fixated on what I was doing. There was a look of anger in her eyes that made me very uncomfortable.” She has simply made that up. It contradicts all of her own earlier evidence as well as everyone else’s. If anything, MA was jealous of EM. She describes the support she had from her husband, in comparison to the lack of support she received from BF. The only accounts of the good family relationships which she described to the police which are contradicted by other evidence are those of her relationship with her husband.

Any possible mitigation there might have been for MA’s actions because she did not know how harmful salt would be was lost during the 27^th April. T was not drinking or passing urine. She messaged BF at 16:06:36(UTC+0) to say “He still hasn't wet nappy”, at 16:08: 23(UTC+0) to say, “Last time he wet it was when you changed at last night”, at16:09:15(UTC+0) to say “He can't go another night without drinking what if something happens”, then at 16:09:22(UTC+0) to say “He hasn't drank anything today”. BF still did not come home when she said at 16:12, “just come home and feed him.” When he finally came home, T had more than one seizure before they sought help and they had to be prompted by EM to call 999. At the hospital, she did not tell the doctors the whole story. UTC + 0 is one hour early due to BST.

I regret that I have to find that MA poisoned her baby over 3 days and did nothing about it although he was getting more and more ill. But for CM and EM, she may not have called 999 at all. Their actions, and the medical team led by Dr P, saved T’s life. I find that, at the relevant time, the child T was suffering significant physical harm attributable to the care that his parents were providing to him not being what a reasonable parent would give.

On the 27^th April 2025 at 20.15 [T] was admitted by ambulance to [A Hospital] suffering from encephalopathy with intractable seizures, acute renal injury, impaired cardiovascular functioning and cardiac contractability resulting in hypotension and poor tissue perfusion and multi system failure caused by extreme hypernatraemia which has resulted in significant life altering injuries including but not limited to brain damage and the development of dry gangrene resulting in the amputation of his left foot. [E1-3,E4-6, E119,E134, E139, E327, E328, E337, G281, G459, G803]

The cause of the extreme hypernatraemia was poisoning by sodium chloride (salt). [E119, E134, E139, E336]

At least two of the tubs of powdered Cow and Gate milk formula from which [T] was fed (AJT/9 and FLA/3) were contaminated with significant quantities of salt.[E119, E128 , E218, E220, G450, G457, G795, G1609, G2484, G2489, G2525, G2837,G3097]

The contamination of the tubs of powdered Cow and Gate milk formula from which [T] was fed (AJT/9 and FLA/3) did not occur in the manufacturing, distribution or retail process. [C62-90, G849, G1149-1153, G1154, G1161-1165, G2475, G2487, G2680]

[MA] caused [T’s] hypernatraemia by adding significant quantities of salt to, at least (but not necessarily limited to), the tubs of Cow and Gate formula milk from which he was fed.

[MA] and [BF] dishonestly colluded with each other after [T’s] admission to hospital to prevent discovery of [MA] as the perpetrator of [T’s] injuries by the police and the Court, by the following:

Colluding between the 28^th April and the 2^nd May that [BF] should falsely assert to the police in his second interview and to the Court that [MA] had told him on the 26^th April of her concern that the formula in the tub of Cow and Gate milk AJT/9 was gritty or different from normal.

On or around the 13^th May 2025, after the police had undertaken their forensic examination of the cupboard where [T’s] formula was kept, planting a trail of salt in that cupboard in an attempt to falsely infer that one or more of [DF], [CM], [EM], [FF], [GM] and [GF] had contaminated [T’s] formula tubs with salt.

Both [MA] and [BF] lied to the treating doctors and the police in their interviews by suggesting that other than a sore throat, [T] was in reasonable health on the morning of the 27^th April and that neither had any concern for him despite the fact that both knew that he had not taken any feeds at all overnight nor had he had a wet nappy.

I do not find that EM or anyone else in the family caused harm to T or any of the children. They have all been harmed by MA and BF’s actions.