Redcar & Cleveland Borough Council v AB & Ors

C (“C”) was born in 2017 at James Cook university hospital (“JCUH”). He was born at 34 weeks gestation by Emergency Caesarean section due to problems with the umbilical cord. His mother is “mother” and his father is “father”. C was the parents’ first child.

At 16 weeks into the pregnancy, a scan revealed that C had a cleft lip, alongside heart and kidney abnormalities. When C was born, the following specific issues were noted by the hospital:

Due to C’s cleft lip and palate, he was started on naso-gastric tube feeding soon after birth.

Within a week of being born, he then underwent urgent surgery to address his imperforate anus (Footnote: ⁴). Because of his complex needs, he was transferred to the Royal Victoria Infirmary (“RVI”) for further treatment before being transferred to the Freeman Hospital. At 6 weeks of age, C underwent cardiac surgery before being discharged home into the care of his parents.

Because of C’s difficulties and complications, his first year of life was not an easy one. It was characterised by a high level of medical interventions and operations:

Thereafter, C received additional medical attention to deal with his ongoing birth related issues as well as interventions to address issues raised directly by the parents:

Because of the constellation of issues with C’s health, he had been the subject of extensive genetic investigations, which failed to identify a known genetic diagnosis.

The mother has a diagnosis of epilepsy. In April 2018 the mother raised concern about C suffering from seizures. The seizure activity has been reported over time to consist of vacant episodes, drops and occasional convulsions. Some of the reported seizure activity has been recorded on video by the mother and shown to medical professionals. As a result, some of that observed footage has been considered to most likely represent seizure activity. Whilst it is difficult to be clear whether the medical records represent incidents of in-person independently observed seizure activity, or reporting by the mother, there is reference to a physiotherapist documenting two episodes of witnessed episodes where C has become vacant.

The parents second child, D, was born on 08.04.2022. He was delivered by way of emergency caesarean section at 36 weeks gestation. Although there were some initial concerns expressed in respect of hypospadias, D did not suffer from the same complex issues as his brother.

However, during the first 8 months of his life, whilst in the care of the parents, a Court appointed expert has noted an “excessive number of overall attendances for review, rare and worrying symptoms of disease, unusual response to medication and over interpretation of symptoms “. (Footnote: ⁷)

A referral was received by the Local Authority on 01.12.2022 from Dr W at Great North Children’s Hospital. Dr W is a gastroenterologist who had recent care of C.

The specific concerns being raised by Dr W will be explored in fuller detail later within this judgment. However, a summary of those concerns can be extracted from page 4 of his report dated 11.12.22:

Those wider concerns appear to have crystallised following an incident on 22.11.2022. On that occasion it is alleged that the mother has engaged in falsification of gastric aspirates:

Following that referral, a strategy meeting took place on 02.12.2022. At that strategy meeting the following is recorded (Footnote: ⁸):

Dr W was not at that initial strategy meeting; it is clear from the minutes of that meeting that Dr W’s concerns are simply being rehearsed to those present. Nor was Dr V present, C’s lead paediatrician from JCH. However, a second strategy meeting then took place on 07.12.22. Both Dr W and Dr V were in attendance at that meeting. It is clear from those minutes that whilst some wider issues are being raised from professionals about exaggerated symptoms, the focus of the meeting comes from Dr W’s concerns around the presentation of syringes which contained feculent material (Footnote: ⁹), two occasions when a feeding tube has been snapped (Footnote: ¹⁰), reported but unobserved excessive vomiting, reported by unobserved diarrhoea and that the mother has “consistently provided false information about various Medical Professionals”.

The local authority issued proceedings on 14.12.2023. The application was made on an urgent basis; the application itself explaining that the precipitating concerns relate to risk of Factitious or Induced Illness, including a recent concern that the concerns have escalated and that the respondent mother has perpetrated and act of deception to amplify the needs of C. The application goes on to explain that the parents are not aware of the child protection enquiries or the intention to issue proceedings and seek to abridge notice to 2 hours before the urgent hearing.

The matter came before HHJ Brown on 14.12.2022. Understandably, Judge Brown was concerned about the issue of notice to the parents, indicating that the parents must be served with the application, be given the opportunity to take legal advice and proper notice of the hearing before the matter could be fairly heard. The case was adjourned to 15.12.22 on the basis that the parents would go and stay with maternal grandparents overnight, who would also supervise any parental contact.

On 15.12.2022 the matter came before HHJ Cains. It was agreed that the children would go and stay with paternal grandparents, underpinned by an Interim Care Order and subject to a contract of expectations.

Following a number of case management hearings, the case came back before HHJ Matthews KC on 10.02.23. At that hearing the Court approved the instruction of the following experts:

The case was listed for a fact finding before me on 05.06.2023 with a time estimate of 10 days and a final hearing on 08.08.2022, time estimate 4 days.

As is usually the case in complex proceedings such as these, the papers are voluminous.

I have read the core bundle and supplementary “Section K” bundle. I have also been referred to various documents within a primary medical bundle and a Newcastle medical bundle. I have been greatly assisted by the advocates taking me to the relevant documents within the medical bundles upon which they seek to rely, as well as a full medical chronology directed to be prepared as part of these proceedings.

I have, over the course of 10 days, heard evidence from the following witnesses:

In addition, I have seen a further statement prepared by the father during the course of the hearing along with associated questions and responses from Dr Salvestrini.

Having heard all of the evidence in the case, I adjourned to allow for written submissions to be prepared. I have received those documents from all of the parties. The case then returned on 27.06.2023 to allow the parties to speak to their submissions, having at that stage had sight of the documents prepared by the other parties.

This judgment was then prepared to be formally handed down on 07.07.2023.

Following the close of evidence, the LA prepared an amended document setting out the findings sought. I am grateful for them having done so as it has allowed the other parties, in particular those representing the mother, to focus their submissions.

I attach to this judgment, as Annex A, the findings that the LA invites me to make. The original document included annotations to assist me in identifying how the findings have changed since the close of the evidence. The attached document does not include those annotations.

The findings sought against the mother fall into 4 categories, with associated pleadings in respect of harm/risk of harm:

Whilst not minimising any of the concerns raised by the various medical professionals and local authority, a) to c) above are set out on a basis of an ascending degree of seriousness, where allegations of exaggerated/misreported symptoms then escalate to physical interference in medical interventions.

I am again grateful to Ms Thomas KC and Ms MacLynn KC for setting out the legal principles which apply specifically to fact finding hearings of this nature. As Ms MacLynn KC notes within her submissions, the relevant law is settled. However, principles and guidance to be applied in respect of allegations which involve Fabricated or Induced Illness, continue to be finessed. In particular, there have been a number of recent cases heard in the High Court, where I can turn to for particular assistance.

It is not my intention to repeat verbatim within the body of this judgment the case law that I have considered and applied. To do so would simply make this judgment unwieldy. However, the principles are important and fundamental to how I approach my consideration of the evidence. To that end, I attach as Annex B a document which sets out the legal framework submitted by Ms Thomas KC and Ms MacLynn KC. I should add that Ms MacLynn also refers me to some guidance which has recently been given by Pool J in a recent FII case, in respect of good practice to be followed by Trusts faced with issues such as these.

Whilst wanting to avoid repetition, there are some principles that are so fundamental to the Court’s decision-making process, that they ought to be explicitly set out within the body of this judgment. They are as follows:

I am very alive to the fact that this judgment will be considered by individuals who have varying cognitive abilities and varying degrees of the understanding of medical jargon and points of reference. The evidence in cases of this type is complex and complicated. I will not be repeating the contents of the written statements, reports, notes, and live evidence that I have considered. To do would be disproportionate. However, I am setting out the parts of the evidence that I consider relevant to my decision-making process. If I do not mention an aspect of the evidence before me, it is not that I have ignored it or failed to consider it. Rather, I have focused instead on those elements of the evidence which has directly assisted me in reaching the decision that I have.

There is always a risk that the ability to discern the Courts reasoning for the decisions it is making, is lost behind a lengthy rehearsal of the medical history and medical evidence. To that end, this judgment will consider each of the headings of findings sought by the Local Authority and set out an analysis of the medical evidence that I have heard about each of those findings sought. Although I am setting out the evidence for each finding in a linear manner, I am considering each of the findings alongside the others as part of an analysis of the wider canvass. I am not considering each finding sought in isolation. To do so would risk blinding myself to the broader landscape of evidence that I have heard.

I have already indicated the health difficulties which C suffered from birth. They were complex in nature requiring a significant level of medical intervention. As a result, there were a number of treating clinicians who were involved in C’s care over the years. Various chronologies have been prepared within these proceedings, including a full medical chronology prepared as a result of a Court direction. However, for the purposes of a chronology of issues identified by the treating clinicians, I am greatly assisted by a detailed but specific chronology prepared by Dr V, consultant paediatrician. That chronology was prepared as part of a report dated 13.12.2022. Dr V has been involved in C’s care following a referral letter dated 4^th May 2018, albeit I was told that it was likely that Dr V had met C on ward at some stage earlier than that. That chronology prepared by Dr V has been an invaluable tool in piecing together the issues raised over a number of years.

Between 2018 and 2022, C’s mother has exaggerated, misrepresented, or fabricated his symptoms when speaking to medical professionals as follows;

Exaggerating and misreporting the frequency of epileptic seizures observed in C

I start by setting out the chronology from Dr V (Footnote: ¹²):

There then followed a history of the mother regularly reporting incidents of vacant, falling and convulsive episodes. The mother was being asked to try to record incidents on her phone so that medical professionals could understand what was being reported. On 12^th August 2019 film footage was reviewed by the paediatric epilepsy nursing team. The footage captured part of the seizure that led to hospital admission on 29^th July 2019. It was agreed that C still had some awareness and were not typical of generalised tonic clonic seizure, but it was agreed that it appeared to be a seizure, possibly focal, and if prolonged he would need buccal Midazolam. Dr V notes in her chronology:

Dr V notes that if C was having frequent seizures, then at least some of the seizure activity would be seen at school. On 20^th November 2019 epilepsy nurses met with school staff. The school reported that they did not think that C fell more frequently than other children and did not think that they were seeing seizure activity. They described an episode where C seemed to lose concentration and his mother had said that she thought that was a seizure.

However, on 26^th February 2020, school staff did provide a description of behaviour which Dr V believed was in keeping with C having epileptic seizures.

The mother continued to report frequent episodes of seizure activity. The concern was growing that, whilst Dr V indicates that there was evidence of some seizure activity, if it had been as frequent as reported by mother, she would have thought there would been wider reporting.

On 11^th November 2021 a professionals meeting was held. The mother was receiving assistance from Baby Hospice at that stage, who did not report seeing any seizure activity. They had raised some concerns which appeared to have then resulted in the professionals meeting taking place (Footnote: ¹⁴). A number of concerns were raised at that stage in respect of the mother’s reporting of a number of issues. One of those issues was in respect of seizure activity. However, Dr V and a speciality epilepsy nurse, both described film footage of C that they had seen which was in keeping with epileptic seizures. The concern expressed, was that based on the frequency of reports from the mother, the episodes would be expected to be seen in different locations.

It was at that stage that concern was being raised in respect of over-reporting by the mother. It was agreed that epilepsy treatment would not be escalated further unless there was substantive evidence of epilepsy seizure, seen on film footage or witnessed by a professional.

A meeting was arranged to be held between Dr V, Dr T (consultant paediatrician) and the parents. The purpose of this meeting was to discuss the concerns being raised by professionals that the mother was not always accurately representing issues to health professionals. By all accounts that meeting appeared to be a positive meeting and, as I will consider later in this judgment, led to the mother telling me that as a result she reflected on what she ought to be informing professionals about.

Dr V’s report in respect of epilepsy concludes with the following (Footnote: ¹⁵):

I heard evidence from Dr V as part of the fact-finding hearing. She told me that she thought that she had a good working relationship with the mother. She confirmed her view that she thought the other was a very anxious person, particularly when it came to C’s health. She reinforced her view that C had probably previously had seizures indicative of epilepsy. Her concern was around the frequency of the episodes as being reported by the mother. She recognised that there were a number of medical professionals involved with C, which may cause some element of confusion for the mother in terms of information being received from different sources. However, she remained of the view that the mother had over reported incidents of seizure activity. That over reporting, she told me, ran the risk of C receiving medication which he did not need.

She told me that the reason the professionals meeting in November 2021 was convened was because of growing concerns that the frequency of reporting by the mother was not being independently verified. As she told me in her oral evidence:

It was telling for Dr V that, following the meeting between herself, Dr T and the parents in February 2022, the reporting of seizure activity significantly reduced.

I found Dr V to be a helpful and measured witness. She was clear in her views in respect of there previously being an accurate diagnosis of epilepsy. She was balanced and fair in so far as her acceptance as to the difficulties for the mother in being provided with complex medical views from a number of different sources. However, she remained clear in her view that episodes of seizure activity had been over reported by the mother and that at times his medication may have been increased (or trialled) unnecessarily, if his mother’s reporting was inaccurate (Footnote: ¹⁶).

Exaggerating and misreporting the extent of C’s behavioural difficulties when in the care of others, which was not observed by the relevant professionals

On 25^th May 2021 C was reviewed by Dr Q, Consultant community paediatrician. The mother was in attendance. The reason for referral to community paediatric clinic was set as being due to:

A letter was prepared following that consultation which includes the following: (Footnote: ¹⁷)

It is fair to say that the mother went on to describe her own experiences with C, which included physically aggressive behaviours.

Those comments were fed back to Baby Hospice. I have seen a number of emails sent by ZW to Dr V, raising concern in respect of the way that the mother was reporting issues about C. In particular, reference was made to the absence of any seizure activity and that the mother’s descriptions of C’s behaviour to Dr Q, were not in accordance with how they would have described him. (Footnote: ¹⁸).

Within her written evidence, ZW said the following:

I heard from ZW in oral evidence. She maintained those matters set out within her statement. She told me:

That oral evidence reflected the concerns set out in her witness statement; that there was a concern that information given by workers at Baby Hospice would be misrepresented. As a result, Baby Hospice would try to ensure that more than one member of staff interacted with the mother.

ZW described having a conversation with the mother about what had been reported to Dr Q. Although ZW could not say whether a member of staff might have referred to C as “wild” as part of a conversation with the mother, she confirmed that there was certainly no record of such a conversation. She told me that even if there had of been a passing comment about C being “wild”, that was not how the mother had conveyed information to Dr Q.

ZW also told me of her concern that there was a tendency for the mother to portray C in a negative way. Even when C was being described in a positive way, the mother was reported to bring the conversation back to a focus on the negative.

It was the ongoing concerns being raised by Baby Hospice which was one of the primary reasons for the professionals meeting convening in November 2021.

Informing professionals that C either has autism or is on the spectrum

On 21^st December 2021, the mother had a telephone clinic appointment with Dr Q (Footnote: ²⁰). One of the concerns had been that C had been referred to the community child health clinic because of reports around his development, in particular in respect of regulation of emotions and behaviour modulation and behaviours. The reasons for that referral had been set out more fully in the letter from the appointment with Dr Q on 25^th May 2021, which had led to concerns being expressed by Baby Hospice and the subsequent professionals meeting in November 2021. The following is recorded within the letter arising from that appointment:

On 21^st November 2022, C was at hospital at the RVI. On that day a conversation took place between the mother and DN, following a ward round. DN is a paediatric dietician and her role with C was to assess his nutritional status during admission.

DN says that the mother told her multiple times that C had autism (Footnote: ²¹). When pressed as to whether he had an official diagnosis, the mother confirmed that he did not, but believed that he is on the spectrum.

In her oral evidence DN told me:

DN was clear in her evidence that the mother had told her that C had autism, and that she had said that to her on a number of occasions. It was only when DN challenged the mother as to a formal diagnosis, that the mother told her that there was not a formal diagnosis but that she believed he exhibited symptoms consistent with being on the autistic spectrum.

Exaggerating and misreporting the extent of C’s breathlessness and fatigue, leading to cardiological investigations. The mother also reported having obtained a wheelchair which was manifestly unnecessary for C by late 2022.

It is clear from the medical evidence that C has ongoing significant issues in respect of his heart functioning. That is an issue that has been in existence since birth and is ongoing.

The evidential basis of the exaggeration and misreporting as pleaded seems to come from the evidence of Dr S and Professor X.

Dr S saw C in a cardiac clinic on 4^th October 2022. His typed note is dated 03.11.2022. It appears that Dr S saw C for an urgent echocardiogram as part of his pre-assessment for his upcoming procedure under gastroenterology at the RVI. It seems that the urgent review was instigated by the mother. Within that note of the clinic, Dr S says the following:

Following tests, including an echocardiogram, C’s cardiac status was considered normal.

Professor X is a Professor of Paediatrics and Neonatology. On 15^th November 2022 the mother had an appointment with Professor X. The letter from that appointment sets out the following:

I have not noted any reference to the grandparents being present at that appointment; the reference at the start of the letter is to the mother being in attendance with C and D.

Of relevance in respect of my consideration of the broader canvas is this reference:

On examination by Professor X, C’s presentations were no worse than had been seen previously.

In respect of the reference by mother to a wheelchair, the evidence is clear that occupational therapy had initially assessed C as benefitting from postural support. However, apart from the reference within Professor X’s notes, I have not been taken to any other medical reference which suggests that the mother was routinely, or at all beyond her concession in oral evidence, using the wheelchair as a form of mobility for C.

Exaggerating and misreporting C’s vomiting as being frequent during November 2022 which was not then witnessed during the hospital admission from 18 to 23 November 2022

The admission in November 2022 was aimed at trying to understand, through observation, the reports the mother was making in respect of C’s ongoing vomiting.

From emails contained within the bundle, it is clear that between 7^th and 9^th November 2022, there has been a high level of contact between the mother and medical professionals in respect of concerns she has with feeding generally and vomiting specifically.

During that correspondence between medical professionals, Dr W says on 07.11.2022 (Footnote: ²²):

I was told by Dr W in oral evidence that he had been concerned with the reports provided by the mother previously, in respect of C’s intolerances to feeds, which had reportedly resulted in vomiting. Within his report Dr W notes that the mother had previously provided a history whereby the mother was reporting that C was vomiting twice a day, sometimes more, and that the vomiting gets worse when his gastrostomy is clamped (Footnote: ²³).

The decision was made on 10.11.2022 for C’s admission for observation. As DN noted (Footnote: ²⁴):

C was admitted for observation on 18^th November 2022. The mother was telling medical professionals on admission that C had been suffering from intermittent vomiting over the past few weeks and that he is regularly sick but has days when not vomiting (Footnote: ²⁵). When a dietetics assessment was undertaken on admission, the mother informed PQ (Footnote: ²⁶) that C tends to vomit 3-4 times per week, more often after 12pm and that there is no pattern to the vomits.

C remained on ward until the 23^rd November 2023. During that time there was no unusual observed vomiting. The mother was clearly aware that there had been no observations of unusual vomiting. Of significance, on 23.11.22 the mother tells DN that she wants her to speak to maternal grandmother. When asked why, the mother says:

The next day, on the 24^th November 2023, the mother reports that C had vomited 4 times that night but had kept it in his mouth and swallowed it back down. It was for that reason that there was no evidence of C having vomited. I have been unable to find a reference at any point before that reference whereby it has ever been reported, by mother to professionals or within the family, that C has vomited in his mouth and swallowed it back down.

Exaggerating and misreporting C’s diarrhoea as persistent and severe between 18 and 23 November 2022

The mother had historically raised concerns in respect of C suffering from persistent diarrhoea. One of the reasons for C’s admission on 18^th November 2022 was to understand the reports of chronic diarrhoea (Footnote: ²⁸). Dr W told me in oral evidence that the reason for the admission was to look at the symptoms of diarrhoea and vomiting that had been reported by the mother. From the medical notes it seems clear that there had been an earlier admission on 14^th October 2022, where diarrhoea had been observed (Footnote: ²⁹).

On admission to hospital on the 18^th November 2023, the mother reported that stools vary in frequency from 3-10 times a day. Dr W suggested at one point in his evidence that the mother was reporting that C was having stools 10 time a day, every day. I cannot see any reference to the mother having said that C has stools 10 times a day, every day. Even from Dr W’s own chronology, the frequency is set:

On admission the mother was unable to answer what she would class as “normal” for C. She confirmed that C had multiple stools overnight, usually from 3am and can have 3 stools until waking in the morning.

During his admission on the 18^th November 2023, the medical records indicate that the stools observed were mainly of a “paste” consistency. No diarrhoea was observed on the admission.

Misrepresenting C’s gastrological symptoms to professionals and maintaining that he would become unwell if his gastric aspirates were not drained, and his dressing needed to be changed, on a more frequent basis than suggested by independent observations

There are many references within the medical records of the mother reporting issues in respect of C’s presentation, if his aspirates were not drained. It seems that one of the main reasons why free drainage lasted as long as it did, was because of the mother’s reporting of concerns. In particular, in 2021 the mother reported that C was unable to tolerate clamping of the drainage tube and would “sniff and vomit”. The medical notes also record the mother reporting that when the gastrostomy drainage tubes become blocked (thereby creating a scenario similar to clamping), that C would sniff and vomit. On 21^st November 2022 the mother tells medical professionals that “if gastrostomy is clamped, C starts sniffing and then will retch and vomit. Mum reports only vomit if gastrostomy is blocked” (Footnote: ³¹). On that same occasion, the following is noted:

There is no reference within the papers of C attending a clinic with Professor X when he was retching due to not being attached to his gastrostomy bag. There is no reference to Professor X giving any advice on clamping. In his evidence to me, Professor X told me that he would not give advice in respect of clamping as it was outside of his area of expertise. He indicated that, even if he had, then he would have noted that he had given that advice.

It is not clear to me whether the mother was maintaining that C was retching and sniffing at the appointment with Professor X. The focus in her evidence seemed to be on the issue with the bag and what was said by Professor X, rather than the impact on C in terms of retching and sniffing.

Whilst admitted between 18^th November and 23^rd November 2022, clamping the gastrostomy was tested. There are no observations within the medical notes of any adverse impact upon C. He is described at playing and there being no retching or vomiting (Footnote: ³²).

At the professionals meeting on 11^th November 2021, one of the issues raised was in respect of the mother reporting to Baby Hospice that C’s gastrostomy site dressing needed changing 4 times a day. ZW told me in evidence:

The paediatric nurses at the professionals meeting on 11^th November 2021 confirmed that it is quite common to change dressings on a daily basis, but that none of the team have suggested that it needs to happen 4 times a day. SR, the consultant paediatric surgical registrar, confirmed that she had not advised the mother to change the dressing 4 times a day.

Exaggeration and misreporting of C’s pain responses and requesting analgesia as a result, overnight on 22 November 2022

This finding appears to rely on a reference within the medical notes about the mother asking for a further 5mls of melatonin on 22.11.2022 due to C being unsettled. There is no reference to any other analgesic. There is reference to C in fact remaining unsettled for 1 hour and the mother reporting that C was complaining of a “hurt tummy”.

The other reference within the medical bundle appears to be in respect of a request on 23.11.2022 (Footnote: ³³) for paracetamol and melatonin. The mother is reporting that C is complaining that his stomach is hurting. Although C was not complaining of any pain, he is described as “clinging to mum, and appeared tired… did appear to be darker under the eyes”.

The finding appears to have been sought on the basis of the inclusion within Dr W’s report as one of the identifiable problems being:

Exaggeration of the number of times that C’s tube had become dislodged or removed, saying that it was on 7 occasions between April and November 2018. The notes show the tube becoming dislodged on 3 occasions in 2018, and one occasion in May 2019.

I heard evidence from DST about what the mother had told her about C’s tube becoming dislodged or removed. DST is the Clinical lead paediatric dietician at South Tees NHS Trust.

Although DST had provided a statement to the Court, she was also the author of a letter to C’s GP, dated 29.11.2018 (Footnote: ³⁴). Within that letter, DST describes a review with C and his mother. During that review, DST states that the mother told her that C had pulled out 7 feeding tubes since April 2018 and that Newcastle are thinking about placing a surgical jejunostomy as he will be less likely to pull that out. Whilst there are incidents recorded of C pulling out his feeding tube on 3 occasions, he does not appear to have done so on 7 occasions. The mother did not seek to persuade me that the correct number was 7, rather than 3.

In cross examination on behalf of the mother, it was suggested that DST had misheard the mother saying “several” rather than “seven” or that her note was incorrect. Under expert cross examination DST resisted the urge to conceded that it might be a mistake. The following exchange took place:

Despite discussions with the mother and the importance of accurate reporting having been emphasised to her in November 2021, she has continued to over report and misrepresent symptoms.

The professionals meeting, convened to consider concerns being raised about the mother’s reporting, took place on 11^th November 2021. Following that meeting, a meeting was then arranged on 2^nd February 2022 between the mother, the father, Dr V and Dr T. A letter was produced as a result and sent to the parents (Footnote: ³⁵). That letter starts out by reiterating that a professionals meeting had taken place and that a number of positives had been identified in respect of C’s care. However, it goes on to set out some of the issues that had been discussed at the 2^nd February meeting. In summary:

In her oral evidence, Dr V indicated that following that meeting there had been a reduction in the number of reports of seizure activity. Dr V saw that as a real positive coming out of the 2^nd February 2022 meeting.

However, the finding is sought on the basis that I make findings about over reporting and misrepresentation of symptoms following that meeting. For example, whilst the LA accept that there was a subsequent reduction in reports around seizures, they say there remained issues around vomiting and diarrhoea, resulting in the admission on 18^th November 2022.

The mother has hindered C’s feeding development as a result of her over presentation of symptoms, limiting his oral solid food intake,

Within her report, Dr Salvestrini opines the following (Footnote: ³⁶):

In reference to the suggestion that the mother has hindered his progression for effective oral intake by asking him to spit out his food, I am alive to the advice that the mother was being given. By letter of 13^th June 2022 Dr V was advising the mother that C should avoid swallowing food because it could block his NG drain (Footnote: ³⁷). Likewise, on 27^th May 2022 the mother was being told that if he swallows solid food this may block the drainage tube and cause C pain and discomfort. Thin watery foods could be swallowed if supervised but anything else he should be encouraged to spit out (Footnote: ³⁸).

However, whilst there may be an argument around what information the mother was being provided with and whether it was reasonable to act in the way that she did, there is still a need to consider how C found himself in that medical situation in the first place.

Dr Salvestrini continues within her report:

The picture in so far as C’s feeding plan is concerned, is not clear. C was a child with a series of complex issues, some of which, at various times, became the priority. When I look at the medical records what is clear is that C’s move to jejunal feeding was influenced by what the mother was reporting to medical professionals in respect of his vomiting. But even that point is not straight forward as Dr Salvestrini also raises an element of concern over the decision making that took place which resulted in the procedure. She says the following in her report:

In essence, Dr Salvestrini opines that even if what the mother was reporting was accurate, there were other interventions that could have been trialled before the decision was made to move to jejunal feeding.

I pause there to reflect that treating clinicians are in a very difficult position. They are doing their best, in often extreme circumstances, to do what is right for the patient in front of them. To that end, they often rely on information being provided by caregivers because that is where the primary source of information comes from. It is an expectation that the information being provided is accurate and true. I doubt that those in the medical profession start from a position of doubt and/or suspicion.

The mother has tampered with C’s gastrojejunal tube causing it to become dislodged:

Between April and 11 November 2018, C’s GJ tube was dislodged on three occasions which are not accepted by the clinical team or expert evidence to have happened accidentally.

In her report Dr Salvestrini notes that C allegedly pulled out his GJET tube on 3 different occasions, in June, October and November. The fact that the GJET tubes were pulled out on those occasions is not disputed by the mother. It is how they were pulled out which is disputed.

The GJET is a particular type of port which is designed to mitigate the possibility of it being pulled out accidently. As well as having two ports for gastric drainage and jejunal feeding, there is also a 3^rd port. The sole purpose of that third port is for the inflation of a balloon that sits just beyond the tract and acts as an anchor to prevent the tube being pulled out.

To inflate the balloon, 5ml of water is syringed into the third port which then inflates the balloon. When inflating the balloon, you are unable to see the inflation because it sits inside the patient’s body.

I was told that the inflation would have been undertaken by a care giver at home, having been shown how to do it. However, should the GJET be removed, reinsertion would require medical intervention.

Within her written report, Dr Salvestrini opines (Footnote: ³⁹):

In her oral evidence, Dr Salvestrini maintained that accidental removal, in her clinical experience, was very unlikely. She went so far as to say:

In cross examination Ms MacLynn KC attempted to persuade Dr Salvestrini that there was a possibility that C could have done it himself, by falling and having the tube caught or some other mechanism. Dr Salvestrini replied:

Dr Salvestrini was clear in her view as to the likelihood of being able to pull out a fully inflated balloon from a healthy tract. She told me:

However, given how firm Dr Salvestrini was in her views, I was surprised to note that at no point is there reference within the medical notes to any clinician raising concern or alarm that the GJET had been pulled out accidentally. The only concern was that further intervention was required to prevent any further accidental dislodgement. The concern in respect of potential GJET tampering is raised for the first time by Dr W on 7^th December 2022 (strategy meeting). Nor is there any reference within the medical notes to any clinician contemporary to any of the dislodgements, raising any concern about damage/bleeding to the tract site.

On 20 May 2019, the mother reported that C had fallen backwards and pulled his GJ out. This is not considered to be credible by medical professionals.

As above, Dr Salvestrini’s view is that it is unlikely that the GJET could have been pulled out accidentally. However, this finding is slightly different, in that the medical note for the hospital presentation refers to a history given by the mother that C had hold of the tube then moved backwards, pulling it out (Footnote: ⁴⁰). Dr Salvestrini was clear in her evidence that she could not see how the force could be generated by a child moving/falling backwards, so that the balloon could be dislodged.

However, as above, the history of the admission from 21.05.2019 does not indicate any concern being raised by any professional in respect of what the mother was describing to them, or any concern in respect of the site itself.

On 22 November 2022 the mother contaminated a bag containing gastric aspirate from C’s stomach, by adding feculent matter to the fluid and informing Dr W that she had drawn the contents from the stomach.

As indicated above, it is this incident which led to Dr W making the referral and, seemingly, moving from a position of perplexing presentation to suspected fabricated or induced illness.

There are different sources of evidence for the incident, with varying degrees of clarity. The local authority suggest that the Court’s clearest evidence comes from the nurse, NN. Her written evidence sets out the following:

In her oral evidence she provided further detail:

It seems on NN’s account, she left a nappy and 2 syringes in the sluice for medical examination. One of those syringes contained the aspirate from the used bag (light brown fluid, flecks of black). The other syringe contained fluid which was tinged pink and cloudier than it had appeared in the bag attached to C.

An addendum note by Dr Y on 22.11.22 refers to (Footnote: ⁴¹):

Dr Y’s note from the next day, 23.11.2022, refers to the gastronomy bag on 23^rd November being “75mls yellow clear translucent liquid. No bits”.

In his evidence, Dr Y told me that he could remember NN telling him that she had syringed out the contents of the gastronomy bag and had left them in the sluice to review. In his oral evidence he said the following:

Dr W’s written statement dated 19.04.2023 indicates that he recalls only one syringe (Footnote: ⁴²). He says that he had a conversation with the mother who told him that the content of the syringe was the content of the gastronomy bag. He says at paragraph 10:

I take Dr W to be referring to the contents of the bag which is attached to C, and not the used bag from which the gastric sample had been taken.

There is no mention in his statement to the two syringes identified by NN by Dr Y or within his own earlier report. In his report dated 11^th December 2022 (Footnote: ⁴³), Dr W describes the following:

Unfortunately, I found Dr W’s oral evidence to be confusing on this issue. He seemed to accept that, contrary to his statement, there were two syringes. It was put to him that NN had identified two syringes and that Dr Y had told me that the contents were identical. He was specifically asked if both syringes had sediment in them to which he replied:

However, there seemed to be some confusion from Dr W as to when an aspirate sample he observed as pale yellow and clear, had been taken. It seemed that Dr W was confusing a sample taken earlier in the morning from that which had been taken from C’s attached bag by NN at the time she had taken the sample from the used bag.

A photograph was taken of a syringe, as arranged by Dr W and Dr Y. If there were two syringes, it is unclear which syringe was photographed. There are no tests that can be done to confirm the presence of faeces within the syringe. Dr Mecrow indicated that appearance and smell would be diagnostic. Dr W confirmed that he had not smelt the contents of the syringe/s.

C appears to have been on free drainage until the morning of 22^nd November 2022. There is reference within the papers to C being given food up to his admission on 18^th November 2022, albeit the expectation was that he would chew and then spit. It appears that C continued to eat during his admission. There is reference within the nursing observations from 18^th November 2022 that C was eating toast (Footnote: ⁴⁴). In her evidence to me, the mother also indicated that C had continued to be provided with food, albeit she had thought he would be spitting it out. The mother told me that C liked the taste of “pepperami” sticks (a dark meat-based snack) and that he had been chewing on such a snack at a point/s during his admission. There is reference pre-admission to C nibbling on a pepperami (Footnote: ⁴⁵) previously.

Although it was later on 22^nd November 2022 from the gastric aspirate sample being taken and after the initiation of clamping, there is evidence of C not only eating but also swallowing food (Footnote: ⁴⁶). C clearly had the ability to swallow food.

Those findings sought above are the basis upon which the Local Authority invite me to then proceed to consider additional findings which they say then flow as a consequence. I do not intend on setting those additional findings out at this juncture but rather will consider them more widely as I turn to look at the specific findings sought below.

Dr Mecrow provided an extensive report looking at all of the issues raised by medical professionals since C’s birth.

He makes it clear from the outset that there is no test or investigation which, of itself, proves that a child has been a victim of FII. He notes that in his experience very many of the children who fall victim to FII have had a true organic illness or disease to account for at least part of their symptoms:

In respect of C, Dr Mecrow concludes that the abnormalities in symptom reporting have been around the gastrointestinal symptoms of diarrhoea and vomiting. He also raised concerns around the reporting of neurological symptoms of epilepsy but confirmed that he would defer to the opinion of Dr V, who had knowledge of the video recorded incidents said to be seizure activity. In any event, the LA do not seek a finding that C never suffered from epilepsy; preferring instead a finding that the seizures had been exaggerated and misreported in terms of frequency (see above).

Dr Mecrow concludes as follows in respect of C (Footnote: ⁴⁸):

Dr Mecrow’s conclusions in respect of D are as follows (Footnote: ⁴⁹):

In his oral evidence to me, Dr Mecrow stood by the contents of his report. In cross examination on behalf of the mother, he was referred to the evidence that C had continued to suffer from diarrhoea whilst in the care of the paternal grandparents, having been removed from the mother’s care. Dr Mecrow acknowledged that issues of diarrhoea had continued and that it may be linked to issues around medication. However, that did not change his overall opinion. He told me that it was the speed at which previous issues had resolved, which indicated that something had been very different from the care he received now and that he received from his mother.

Ms MacLynn quite properly cross-examined Dr Mecrow in respect of individual elements of the medical evidence, upon which he had relied when forming his opinion. Dr Mecrow told me that he accepted that there may be some explanations for some the issues that had been reported. But it was the whole picture, rather than individual incidents, which must be considered. His evidence to me was that this case involved true and complicated issues that C suffered from birth, with resulting symptoms from those issues and side effects of medication aimed at dealing with those symptoms. However, there was also evidence of over reporting. This was a case, Dr Mecrow told me, that involved a combination of all of those factors.

In respect of D, Dr Mecrow reiterated that he did not think that D had been a victim of FII. His concern was for the future and how presentations might have developed.

I have set out already in my identification of the evidence in support of the findings sought, Dr Salvestrini’s primary views. I do not intend on setting out that evidence again.

However, there is one additional piece of evidence that Dr Silvestrini gave in her oral evidence that has relevance to a more generalised assessment in respect of the mother’s reporting. In connection with gastro issues, Dr Salvestrini was asked about her analysis of the mother’s reporting in respect of episodes of vomiting. She was asked about the mother’s reporting of vomiting and whether she as satisfied that it represented over reporting. She answered:

The mother accepts that she is an anxious parent. In my view, given the circumstances around C’s birth and the complications that have flowed since then, it is unsurprising that she is an anxious mother to both C and then also D. C’s complications have been described within the expert evidence as only being seen in 1/10,000 children.

In her oral evidence to me when asked about D she said:

The mother accepts that she was anxious to get the right help for C but denies intentionally exaggerating, misreporting or over reporting symptoms to get that help. However, in her oral evidence the mother did accept that she does at times struggle to express herself to others and, in her interactions with the father and her own mother, will use figures of speech which could be considered to be exaggeration. Having made that concession, she then denied doing so with professionals.

She told me that following on from the meeting with Dr T and Dr V in February 2022, she realised that she should not report absolutely everything to professionals. She told me that she then “paused” before reporting issues around seizure activity. She accepted in her oral evidence that she may have been reporting seizure activity before that meeting when it was just normal daydreaming behaviour.

She denied exaggerating issues in respect of diarrhoea or vomiting. However, she told me that there may have been some misreporting because of the way that she describes events. For example, she told me that C might have an episode when he is being sick. If he is sick and then is sick shortly afterwards, she would describe that as two episodes of sickness, even though others might consider that a continuation of a single event.

She denied tampering with C’s GJET at all and maintained that it had come out through by accident. She maintained that she had certainly never intentionally pulled a GJET out. She was able to tell me that there had been a dislodgement that had occurred when C had been having a seizure.

She denied categorically putting faecal matter into C’s gastric aspirate during his admission in November 2022.

In respect of the wheelchair, the mother told me that C had been given one, but they had not really used it. He had used it to start with but quickly didn’t like to be in it. She had stopped using it except, she told me, when she was required to use it to get on the bus that collected C. She told me that it was not that he needed it at that point, but rather she was told it was a requirement.

The mother was unclear in her evidence to me in respect of the gastric aspirate allegation. Her accounts as to the circumstances of the removal of the sample from the gastric bag, were inconsistent as between her oral evidence and written evidence. It was entirely clear to me from her written statements what her evidence was in respect of how and by whom the sample had been collected. However, I have been very cautious in my consideration of a lack of clarity from the mother in respect of that allegation. What is clear from the evidence is that the issue of contamination was not initially disclosed to the mother; she was not asked about it nor made aware of the issue until weeks later when the LA issued proceedings. When she was discharged from the hospital with C in her care on 24^th November 2022, if she had not intentionally contaminated the gastric aspirate. I very aware that the finding is not for the mother to disprove, it is for the Local Authority to prove on the evidence before me.

During the course of the hearing, the father filed a statement in respect of his own observations of C pulling out tubes. It surprises me, given the issues in this case have been known for some time, that the evidence was not produced earlier.

In any event, it was not clear to me what incidents the father was describing when he was referring to having seen C with tubes dislodged and whether those were incidents involving the GJET or not. He was certainly not able to assist in respect of timeframes.

In his oral evidence he confirmed what he had said in his written statement dated 10^th February 2023. Within that statement he had said (Footnote: ⁵⁰):

In his oral evidence the father elaborated on that evidence. He told me that it was the terms of speech that she used which were sometimes not in keeping with reality. He told me that if you knew her, then you would know what she meant.

He went on to say to me in oral evidence:

However, the father remained adamant that the mother would never intentionally cause harm to C. As such, he did not believe that she would have intentionally pulled out a GJET. Nor did he believe that she would have put faecal matter into a gastric sample.

I have had the benefit of detailed and well-presented written submissions on behalf of the local authority and the mother. As would be expected in this case, I have also received shorter submissions on behalf of the father and the Children’s Guardian. I am grateful for the eloquent and clear way in which each party has set out their case and arguments. Those written submissions were supplemented by brief oral submissions.

I do not intend on repeating those submissions within this judgment; to do so would double its length.

In summary, the LA invite me to the view that I can rely on the medical evidence as set out above, so that I can make the findings sought to the requisite standard. They remind me that the concerns in respect of the mother are, generally, held by a variety of different professionals from different specialities. I am invited to the view that the evidence I have heard can lead me to the view that this mother is prone to exaggeration. They submit that there are numerous examples of exaggeration within the papers, but that I have also heard the mother exaggerating first hand from the witness box. For example, the mother has during her evidence described C as being “the loudest baby on the neo natal unit”, and that D’s thrush was “the worst the doctor had seen”. It has to be accepted that someone’s thrush will be the worst that a particular doctor has seen, but the Local Authority asks me to consider that evidence within the context of the evidence of exaggeration within the papers.

In terms of exaggeration and misreporting, the Local authority invites me to look not at single incidents, but rather take a broader view of all of the evidence, to consider the wider canvass.

In respect of tampering with the GJET, the local authority invites me to consider the clear evidence from Dr Salvestrini. They remind me that Dr Salvestrini firmly maintained that that a child of C’s age could not pull the device out himself. They remind me that Dr Salvestrini does not accept the mechanisms described by the mother. To that end, they invite me to the conclusion that the dislodging of the GJET must have been caused by the mother, presumably intentionally.

The local authority reminds me of Dr W’s clear evidence in respect of his belief that the contents of the gastric aspirate appeared to be feculent. His position is described as a “strong stance”. Whilst it is accepted that Dr W identified 2 syringes, and that they both had sediment in them, they remind me that Dr W’s view was that the contents did not have the appearance of food.

It is submitted on the mother’s behalf that, bluntly, the evidence does not support a finding that the mother deliberately contaminated C’s gastric bag on 22^nd November 2022. I am reminded about the discrepancies within the evidence of Dr W, Dr Y, and NN. I am reminded about the sequence of events that is set out by NN in respect of taking aspirate samples from both the used bag, as well as the bag still attached to C. It is submitted that the evidence suggests that there were two syringes, taken from both bags, which contained similar looking particulate material. It is further submitted that Dr W’s comparison of the syringed samples and the bag attached to C at the time of the ward round is flawed, in that there were a number of hours passed between samples being taken and observation of the attached bag.

Whilst Ms MacLynn KC acknowledges Dr Salvestrini opinion in respect of it being unlikely that a GJET could accidentally dislodge, she quite properly notes Dr Salvestrini’s most recent email evidence that:

Ms MacLynn invites me to look to the broader canvass of evidence. In looking at the broader canvass of evidence before me, Ms MacLynn invites me to consider what is missing from that canvass. In particular, there is no concern raised at any point in respect of the dislodgement. The only concern seemingly expressed is not about how the balloon could have been dislodged, but rather what could be done to stop it happening again in the future.

Regardless as to my findings in respect of misreporting or exaggeration of gastric symptoms, I am invited to consider what I know about this mother and consider that alongside the medical evidence when determining whether the Local Authority have proved that this mother has deliberately tampered with the GJET.

I am invited to consider the circumstances surrounding mother’s reporting of vomiting and diarrhoea in the lead up to his admission on 18^th November 2022. I am reminded that the term diarrhoea has a specific medical meaning which is not a definition generally understood by a lay person; it is not unusual for a parent to refer to loose stools as diarrhoea. In particular, I am asked to consider that there is evidence of diarrhoea within the care of the grandparents, once removed from the mother. I am also asked to consider whether the cessation of the reported vomiting is as a result of the passage of time between the mother’s report and C’s admission. I am reminded that Dr V had opined that it was possible that C had in fact been vomiting prior to his admission but that his symptoms were resolving (Footnote: ⁵¹), something which Dr Mecrow seemed to accept as a possibility in his oral evidence.

I am asked to consider that the assertion that the mother discouraged or prevented C from eating and swallowing food against advice is incorrect. In a wider sense I am asked to reject the assertion that the mother misrepresented C’s gastrological symptoms to professionals.

Ms MacLynn submits that whilst the mother may have inadvertently misreported the extent of C’s vomiting, the Court cannot say that this in itself led to C suffering significant harm. That point is echoed throughout the submissions; even if I make findings in respect of exaggeration and/or misreporting, how does that equate to C suffering significant harm?

I am asked to be careful about placing too much weight on a direct comparison between C’s presentation in the mother’s care and in the care of the paternal grandparents. Ms MacLynn submits that the comparison would only be fair if the circumstances were the same under both sets of carers. Ms MacLynn submits that they are not. Specifically, there has been a change of plan from gastric to oral feeding with a resolution of the lengthy jejunal feeding that had been taking place in mother’s care. Further, there has been a change in medication once in the paternal grandparents care which may have had an impact on any vomiting and/or diarrhoea observed in the mother’s care.

Finally, Ms MacLynn asks me to consider the mother’s own circumstances and cognitive abilities as I survey the wider canvass of evidence before me. I am reminded of the evidence provided by Dr Ollis in respect of his assessment of the mother and warned against holding the mother to a harsher standard than other parents, in light of her learning difficulties.

Ms MacLynn submits that the evidence before the Court falls significantly short of establishing fabricated illness. At worst, she says, the mother has unwittingly exaggerated or misreported some of C’s symptoms as a result of her anxiety and cognitive functioning issues.

In her short document, Ms McKie notes that no findings are being sought against the father, that he had no concerns in respect of the mother’s care of the children and that he was “shell shocked” once he had been made aware of professionals concerns.

I am grateful to the Children’s Guardian and Ms Boothroyd for making general observations on the evidence that I have heard. Too often Children’s Guardian’s take a position of neutrality when submissions are appropriate as to the quality or otherwise of the evidence.

Ms Boothroyd notes some of the concessions made by the mother in respect of exaggeration to family, in terms of her use of speech. She also notes the mother’s acceptance that since the meeting with Dr T and Dr V in February 2022, her approach to reporting seizure activity had changed as she took the time to think carefully about incidents before reporting them.

Ms Boothroyd acknowledges the evidence from the experts, in particular from Dr Salvestrini, as to the likelihood of a balloon being dislodged from a healthy tract. She also notes that none of the clinicians involved at the time raised any concern in respect of the dislodgments. Ms Boothroyd also notes the lack of evidence in the contemporaneous notes of any trauma to the tract at the time, and an absence of evidence in respect of the state of balloon inflation.

Ms Boothroyd notes some of the difficulties with the evidence in respect of the allegation that the mother intentionally contaminated the gastric aspirate, including the difficulty presented to the Court where there is no forensic test that can be undertaken to ascertain whether the contents were feculent. Ms Boothroyd notes that the contents of the syringe/s were not smelt by any clinician and that the evidence suggested that if C had eaten something then it would be present within the gastric bag if he was on free drainage.

I have taken a considerable amount of time to consider all of the evidence before me. I have analysed the source of the medical opinion upon which the local authority relies, but have then considered that medical opinion having regard to the specific circumstances that the mother found herself in following the birth of C, and subsequently D. In essence, I have not restricted my view to the concerns as expressed by the medical professionals, but have looked at the wider canvas of evidence which has been made available to me.

There is clear evidence on the papers, and within the oral evidence provided by the mother and father, that the mother in this case has a tendency to exaggerate. Whilst the mother says that her exaggerated figures of speech are only used with family members, it became clear to me that, even in her evidence to me, she has a tendency to use exaggerated phrases when describing scenarios.

I have therefore looked carefully at what evidence there is within the papers that the mother’s tendency to exaggerate has filtered into her interactions with professionals. One allegation of exaggeration involves the mother’s comments made to DST. DST has recorded the mother as saying that C’s tube has been dislodged 7 times. DST rejected the suggestion that she could have misheard “several” times, albeit was willing to concede that she couldn’t be 100% sure.

I found DST’s evidence to be compelling. She told me about the process in which she takes notes and enters them into the system. On balance, I accept DST’s evidence that the mother did in fact tell her that the tube had been dislodged 7 times. In accepting DST’s evidence, I am left with a question as to whether the mother saying 7 times was an exaggeration or a simple mistake. It is hard to see how such a specific mistake could be made. There is no suggestion within the note that the mother was making an estimate or guess. There is no suggestion within the note that the mother was suggesting it was around 7 times.

On balance I am satisfied that not only did the mother say that the tube had been dislodged 7 times, but that in so saying she was exaggerating the frequency of dislodgement.

I am satisfied on balance that the exaggeration was not an inadvertent exaggeration, it is an example of the mother’s tendency to exaggerate not being confined to conversations with family members but extending to the professionals with whom she was interacting with.

That example highlights the difficulty raised by Dr Mecrow in cases where exaggeration is being suggested; there is often a truth at the centre of the assertion and the difficulty is unpicking whether what is said goes beyond that core truth.

Another allegation of broader exaggeration is in respect of the mother’s reporting of C’s behaviours which she said had been observed by Baby Hospice. I have a clear note, as referred to above, as to the what the mother was relaying to Dr Q on 25^th May 2021. It was not suggested by the mother that the recording was wrong in respect of what she had said. Instead, the mother suggests that she had been told by a worker at Baby Hospice that there were concerns about his behaviour.

Having heard evidence directly from ZW I am satisfied that the concerns being raised by the mother, as then reported to Dr Q as having originated from Baby Hospice, were on balance exaggerated by the mother. Even if the mother is right that she had spoken to a worker who had made some comments about C being “wild”, that does not tally with the description given by the mother to Dr Q of C displaying challenging behaviour, being fairly wild and aggressive. Again, there may be some truth at the core of what the mother was saying to Dr Q; the mother may well have been told by a worker that C had been wild in a session/s. However, I am satisfied that the mother has taken that core truth and has then exaggerated it to professionals. I am mindful that it was that specific disconnect between what the mother was saying to Dr Q and their own observations of C, that caused Baby Hospice to initiate the raising of concerns which led to the professionals meeting in November 2021.

Another example of exaggeration relied upon by the Local Authority is in respect of the mother telling DN on 21^st November 2022, that C had autism. In her evidence DN was clear that the mother had told her on a number of occasions that C had autism. It was only when DN probed that assertion that the mother then indicated that he did not have a formal diagnosis of autism, but that she believed he presented with traits consistent with being on the autistic spectrum. I accept DN’s evidence that the mother told her on numerous occasions that C had autism. He plainly did not have a diagnosis of autism. But more than that, discussions around autism had been had with the mother with Dr Q on 21^st December 2021 where it was highlighted that both the mother and professionals do not feel that there is evidence currently to support an autism assessment.

It may be that the mother was growing increasingly concerned about C’s behaviours by November 2022, although the evidence seems to suggest that his behaviours were getting better rather than worse. Even if they were getting worse, the mother had again taken that core truth, and relayed that core truth as an exaggerated fact. On balance, having accepted DN’s evidence, I find that the mother has exaggerated issues around C’s behaviours resulting in her misreporting to DN that C has autism.

Finally, there is an incident whereby the mother is reporting to Baby Hospice that C’s dressing needed to be changed 4 X per day. I deal with the evidential basis for that at paragraph 90 and 91 above. The mother told me in evidence that she had simply told Baby Hospice that it needed to be changed if it got wet. The evidence from Baby Hospice is clear and specific. I do not accept the mothers assertion that she was talking about it being wet, rather than a frequency of 4 X a day. It is, in my judgment, another example of the mother exaggerating to professionals in respect of C’s needs.

Those are a number of clear examples that I am satisfied, on balance, represent situations where the mother has exaggerated C’s circumstances/presentations to professionals. I do not accept the mother’s suggestion that any exaggerated terms of speech she may use, is confined solely to her interactions with family.

Having considered the wide canvass of evidence before me, I am satisfied that the mother has a general tendency to exaggerate, to both family members and professionals.

That does not mean, of course, that the mother’s tendency to exaggerate including in her interactions with professionals, means she has exaggerated as specifically pleaded by the local authority. Just because I have found that the mother has exaggerated to professionals does not mean that she has exaggerated everything.

I turn then to the specific allegations.

The mother accepts in hindsight that she may have been misreporting incidents of seizure activity prior to February 2022. Whilst she says that the seizure activity was already reducing at the time of her meeting with Dr T and Dr V, she accepts that following that meeting she took time to properly consider suspected seizure activity before then reporting it. She told me that she realised that some of the incidents were simply occasions of daydreaming.

When I consider not only the mother’s evidence, but also that from Dr V and Dr Mecrow, I am satisfied that the mother has over reported the frequency of seizure activity, up to February 2022. I am satisfied that on the basis of Dr V’s evidence, there was underlying seizure activity which had been independently verified. That was the core of truth. That truth being relayed to the mother, that C had been diagnosed with epilepsy, simply heightened the anxiety that the mother was already experiencing in respect of C’s underlying health problems. I am satisfied on the evidence that the mother’s anxiety manifested itself into the mother alerting professionals as to any presentations that she thought might be unusual. In doing so she would tell professionals that she thought he was having seizure episodes. In my judgment she was not fabricating symptoms or episodes. Instead, she was exaggerating and misreporting symptoms, without stopping to consider that many of the episodes may simply be normal behaviour. That would result in medical intervention, including hospital visits. Those interventions would occur because clinicians had to rely on what the mother was telling them, especially when he had an underlying diagnosis.

I accept the submission made by Ms MacLynn that it is difficult to determine what medication might have changed if the mother had not misreported the instances of seizure activity, especially where there was a genuine diagnosis that had been made on independently verified video footage. Whilst concern is raised by Dr V as to increases of the medication that C has received, I am unable on balance to say that his underlying diagnosis did not require the medication he had received. I have my suspicions that his medication has, at times, been increased inappropriately on the basis of the mother’s misreporting. I accept Dr V’s suggestion that it could be argued that it has (Footnote: ⁵²). However, suspicion is not enough.

What I am clear about is that the mother’s misreporting resulted in C being subjected to frequent medical interventions, which he did not require. He was placed at risk of requiring more significant medication, which may have adversely impacted upon his health.

I have already dealt with this allegation above. I confirm that I make the finding as pleaded.

Again, I have already dealt with these finding above. I confirm that I make the finding as pleaded.

The mother told me that she and grandparents had been on holiday and that they noticed some issues with C. Those issues were in respect of C becoming tired easily and wanting to be carried more frequently than he normally would. It is not clear to me when that holiday was, but I note that there was correspondence from C’s neurodisability consultant on 22.09.2022 when C was specifically witnessed walking and running around the consultation room, opting to do so most of the time.

This came at a stage when C was due to be admitted for a gastroenterology procedure on 10.10.2022 (Footnote: ⁵³). This was no doubt a time of high anxiety for the mother. The appointment with Dr Z on 04.10.2022 had been arranged urgently because of the upcoming gastroenterology procedure.

There is nothing within the note, or medical evidence more generally, to suggest that the mother was only talking about a short period of time when on holiday. A period of holiday is not mentioned at all.

Again, in my judgment this is likely to be an exaggeration of a core truth. It may be that the mother had noticed an occasion when C had been feeling tired or had been sweaty. However, the way she then conveyed it to the medical professional, in a setting which was specifically looking at whether there might be issues with his heart which may impact upon his upcoming surgery, was exaggerated. I am unable to say whether the mother’s reporting resulted in the echocardiogram taking place; it may be that one would have been undertaken regardless of the mother’s reporting. However, it certainly ensured that an echocardiogram would take place.

In his appointment with Dr X on 15.11.2022, the mother again is reporting C to not be as fast when running and asking to be picked up a lot. Again, it is not clear to me whether the mother is still referring to the period of holiday, but no holiday is mentioned. She refers to C not now walking to the shop and asking to be carried. This is at a time when C is fast approaching his admission, arranged by Dr W, to get an understanding of how C is presenting in light of the mother’s reporting. Dr X can see no reason for the mother’s reported symptom of increased tiredness. In her telephone conversation with Dr V on 10.11.2022, the mother made no mention about concerns she had with C’s tiredness and mobility.

As above, I find that the mother was exaggerating C’s symptoms at a time of acute anxiety.

It was during the conversation that the mother had with Professor X that the issue of the wheelchair was raised. When I go to the notes (Footnote: ⁵⁴) from Professor X I note:

The finding sought suggests that the mother was not only reporting that she had a wheelchair, but that it was being used unnecessarily in November 2022. On that note from Professor X alone, the evidence does not support a finding that the mother was using the wheelchair for C in November 2022. She did report that she had a wheelchair, in my view as a way to stress her exaggerated concern. However, I am content that the first part of the finding accurately deals with the mother’s exaggeration at that time without the need for reference to the wheelchair.

There are a number of references to the mother reporting frequent vomiting at the beginning of November 2022. The mother accepts that she was reporting frequent vomiting. On 7^th November 2022, the mother is reporting that C has been vomiting for the last 6 days.

The finding is sought on the basis that the frequent vomiting was not observed when C was admitted. However, the admission took place on 18^th November 2022. On 8^th November 2022 the mother had attended at the Emergency Department, it seems as advised to do so by Dr V. At that appointment she gives an explanation that C has not vomited since 1pm on 7^th November 2022 (Footnote: ⁵⁵). There is then no report of the mother saying that C has vomited from the point of that report to the point of admission; some 10 days later.

In his oral evidence, Dr Mecrow accepted that C may have been ill with a virus which caused the vomiting in early November. On 8^th November 2022 the mother seems to be associating the vomiting with an improper placing of the jejunostomy.

It seems to be accepted by all that during his admission from 18^th November to 24^th November 2022, C was not vomiting frequently. However, that does not prove to the requisite standard that the mother had been exaggerating or misreporting frequent vomiting in early November. Whilst I have already raised my concerns in respect of the mother’s tendency to exaggerate to family members and professionals, that does not mean that every report is exaggerated or misreported.

I am however concerned with an aspect of the mother’s reporting whilst in ward during that admission. On 23^rd November 2022, the mother was clearly becoming concerned that medical professionals did not believe her and thought that she was lying about C’s vomiting. Then, it seems that night (through to the 24^th November 2022), the mother reports that C had been sick 4 times. However, the evidence of his multiple sickness episodes is not available, because the mother informs the medical staff that he had then swallowed the sick back down (Footnote: ⁵⁶) on each occasion. When being asked to account for why he would do so in oral evidence, the mother told me that she thinks that C did it because he wanted to go home. She told me that he knew that if he were to vomit then it would mean that he would have to stay in hospital. On that basis, she told me that she thinks C intentionally swallowed the vomit back down.

I find that an incredible explanation for C swallowing his own vomit. At the time he was 5-year-old, even if he had been able to keep the vomit in his mouth in the process of being sick, I do not find it credible that he would then have the clarity of mind to analyse the consequences of vomit having been discovered in respect to his current admission. I do not accept the suggestion that C was sick and swallowed his vomit on 4 occasions on the night of 23^rd November 2022.

I have considered very carefully whether, on the evidence, this is an incident of fabrication by the mother. Given the concern that the mother had expressed only the day before about her suspicions that people did not believe her about C’s vomiting at home, I can see a situation where the mother might be minded to fabricate the episode. However, on balance, whilst I have my suspicions, the evidence is not before me to prove that this as a complete fabrication. On balance, I am satisfied that C may have retched or coughed that night, which the mother has then exaggerated into 4 separate episodes of being sick.

C had been admitted to hospital on 11.10.2022 with chronic diarrhoea (Footnote: ⁵⁷). Watery, mucousy loose stool had been observed on the following days, with the medical notes confirming on 14^th October 2022, that C was suffering from diarrhoea. That is a clinical note, using the clinical definition of diarrhoea. I must take care not to properly consider whether I should criticise the mother for the use for the word “diarrhoea” when the reality is that different people use that term to define differing looseness of stools.

It seems then that diarrhoea had been a problem for C both before his admission on 18^th November 2022 and following his removal from the mother’s care. The medical evidence was unanimous in the acceptance that one of the side effects of C’s medication was diarrhoea, or loose stools.

There is reference within the medical notes to C having loose stools whilst on admission from 18^th November 2022. On one occasion, that stool is described as (Footnote: ⁵⁸):

I suspect that many parents would consider themselves reasonable in describing that type of stool as diarrhoea. I further suspect that stool described as a “paste” might also be referred to as diarrhoea by many parents. I remind myself that any description the mother is giving at this stage is on the basis that the medical team is able to fully consider and examine C’s stools. This is not an instance where unverifiable reporting is taking place. The mother would know that that her description can be analysed alongside the stool itself.

There seemed to be some confusion in Dr W’s evidence as to the mothers reporting of frequency of stools. When initially answering questions, Dr W seemed to be under the belief that the mother had been saying that C’s stools had been occurring at a frequency of 10 times a day, every day. He had to be taken to his own chronology to clarify the point. Both in that chronology, and within the medical notes, it seems clear that the mother was saying that C’s stools varied in frequency from 3-10 times a day. There is no record as to how often the mother would say that the frequency reached 10 times a day. Although the passing of 10 stools in a 24-hour period seems high, I have not heard any evidence to suggest that such a frequency could not be right, on at least a single episode. Nor am I satisfied that any criticism ought to be directed at the mother for using the term diarrhoea when, in my judgment, the description of the loose stools could reasonably be termed “diarrhoea” by an untrained lay person. I am also mindful that C suffering from diarrhoea is an independently verifiable fact, both before his admission and after.

I am not satisfied that the Local Authority have proven to the requisite standard that the mother’s descriptions on admission were an exaggeration or misreport.

When I consider the mother’s views to clamping within the medical notes, they are all of a negative nature. It appears that it was the mother who caused the clamping to be stopped in 2021 due to her reporting of sniffing and vomiting. Whilst it is right that the mother engaged with the clamping trial whilst on admission from 18^th November 2022, it is clear to me that she was not happy about the clamping being tested. In an act, I find of clear misreporting, the mother informed medical staff that Professor X had told her not to clamp the tube on 15^th November 2022. The context of the mother reporting Professor X telling her that, is important. It comes from a discussion that Dr W was having with the mother on 21.11.2022. Dr W is specifically asking the mother about clamping. It is recorded (Footnote: ⁵⁹):

That report from the mother reads as if Professor X witnessed retching and sniffing and as a result told mother not to clamp because clamping has a negative impact on C.

In his evidence Professor X told me that he would not give advice about clamping as it was outside of his specialty. In any event, advice in respect of an issue like that would make its way to his notes. That advice is not in the notes.

In her evidence, the mother told me that Professor X had told her not to clamp, unless medical advised to do so. That addition in oral evidence does not sit well with the mother reporting concerns about clamping, to medical professionals, if the advice had been simply to clamp if advised to do so by medical professionals. I do not accept the mother’s assertion that Professor X told the mother not to clamp, unless medically advised to do so or otherwise. I accept Professor X’s evidence to me that he would not give that advice for the reasons set out in his statement. I also accept that such advice, in those circumstances, would form part of the detailed note that he then prepared, if it had been given. In my judgment this is an example of the mother misreporting information to create a negative picture around the issue of clamping.

When I consider that misreporting and negativity, alongside the concerns raised by Dr Silvestrani in respect of the clamping in 2021 having ceased as a result of the mother’s reporting, and her opinion that there is a history of misreporting from the mother in respect of vomiting, I am persuaded on balance that the mother has either misreported or exaggerated gastrological symptoms in order to paint a negative picture of the impact on C if clamping were tried.

In so far as the mother’s reporting as to the frequency of the change of dressing, I have already dealt with that above. I confirm that I make the finding as pleaded.

I am able to deal with this finding in brief. I have already set out above the evidential basis upon which I am invited to find this allegation proven to the requisite standard. That evidential basis is lacking. The evidence as set out within the papers does not come close to the Local Authority establishing the exaggeration and/or misreporting as pleaded.

I have already dealt with this finding above. I confirm that I make the finding as pleaded.

I believe this refers to the point that the mother had the meeting with Dr T and Dr V in February 2022. The fact of that meeting and the discussions that took place are accepted and set out above.

The findings I have made so far have referred primarily to incidents prior to February 2022. There are some findings that I have made in respect of exaggeration and/or misreporting since then, in particular in respect of reports of breathlessness and fatigue, ongoing misrepresentation in respect of gastrological symptoms and the reporting of vomiting on ward during his November 2022 admission.

On the basis that this finding refers only to those incidents, then it follows that this allegation is made out to the requisite standard.

I set out above my reasoning for a finding in relation to the mother misrepresenting C’s gastrological symptoms. The consequence of that finding is that the mother’s actions have then played a role in hindering C’s feeding development. However, as I have already indicated, the situation in respect of C’s progress is far from clear. There are concerns expressed within the papers as to whether, in hindsight, alternative medical plans and actions might have been a better plan for C.

I am also concerned to note that even at the point of his admission in November 2022, his feeding plan was far from clear. It seems unfair to me that the mother ought to be criticised specifically for hindering C’s oral solid food intake when the evidence suggests that the mother was being provided with ambiguous advice in terms of solid feeding. That is not to lay blame at any professionals door; C’s medical picture was unclear. However, equally, the blame should not be laid solely at the mother’s door.

On the basis of my finding above, it is clear to me that the mother’s actions in terms of her misreporting and over presentation of gastrological symptoms have contributed to the lack of progress for C. But there are other factors in this case which, when considered, indicate that other routes were available for C which were not progressed by medical professionals involved in his care.

If proven, this finding sees a step up from exaggeration, misreporting, over reporting and misrepresentation. This finding would mean an active participation by the mother in not only tampering with C’s medical equipment but, on the basis of the pain described by Dr Salvestrini, actually causing C pain and distress.

Dr Silvestrani, as indicated above, was adamant in her views in respect of how difficult it would be to accidentally remove a GJET, along with the pain, distress, and physical injury that such a dislodgement would likely cause.

Dr Silvestrani is a well-respected expert within her field and was clear in her opinion. I accept her evidence that it would be very unlikely that a properly inflated balloon positioned within a healthy tract, could be dislodged accidentally, let alone on 4 different occasions. There is no evidence before me to suggest that Dr Silvestrani is wrong in that opinion and no research has been provided to me to counter that view.

And so, I must consider that opinion against the wider canvass of evidence that I have before me. One of the most striking absences from that wider canvass of evidence is any concern, at all, being expressed by those clinicians who have then dealt with the immediate aftermath of the dislodgement. If Dr Silvestrani is right, then a dislodgement in circumstances where there is no infection of the tract and/or the balloon is fully inflated, should be causing alarm bells to sound. Further, the force that Dr Silvestrani suggests would be needed to dislodge a fully inflated balloon in the absence of infection, is likely not only to cause upset, pain and distress but also actual physical injury around the site. And yet, there is no mention of any concerns being raised about damage to the tract area within any of the medical records.

It seems to me, that the only concern being raised at all within the papers is by Dr O whose focus is not on the mechanism of dislodgement, but rather on how dislodgement can be prevented in the future.

I consider that evidence alongside:

When I look to the wider canvass of evidence before me, alongside the evidence of Dr Silvestrani, I am drawn to the conclusion that there was a combination of factors that made the accidental dislodgement of the GJET probable. I am unable to point to a specific cause, but I consider that material issues include:

On that basis, I do not find that the Local Authority has proved the allegation to the requisite standard.

I have set out above the confusing picture the evidence paints in respect of this allegation. I have been provided with pictures within the bundle of a syringe which contains matter. I am told by Dr W that the matter contained within the syringe is that which he describes as the feculent material. However, it is not clear which of the two syringes that NN left in the sluice, the picture is of. According to Dr Y, it matters little as he describes the two as being similar in appearance.

But if NN is right that she took two gastric samples, one from the used bag and one from the attached bag, then the similarity of the contents of the syringes becomes highly relevant. Further, when Dr W is making his comparison as between the contents of the syringe/s and the attached gastric bag, there is a significant passage of time; by my calculation some 3 hours.

This core of this allegation is based upon Dr W’s opinion that the contents of the syringe/s he examined were similar to the contents of a used nappy. It is based on his observation of the syringe and the nappy. There are no forensic tests which can be done to ascertain whether the contents of the syringe contained feculent material. Dr Mecrow suggests that a clinician could smell the contents to assist in identifying whether material is feculent. Dr W did not do so.

The evidence is so unsatisfactory that all I am able to say, on balance, is that there were two syringes produced for examination by NN, one from the used bag and one from the attached bag. The contents of those two syringes were similar and contained particulate material. The medical evidence is in agreement that if C had swallowed food, then it would end up accumulating in the gastric bag on free drainage. There is evidence that C had been at least chewing food whilst on ward.

The mother has suggested that if the material contained within the syringe was feculent, then it could have been contaminated accidentally by stools covering the port for the gastric bag tubing. It seems to me that the evidence is lacking in terms of that explanation. Although I do not accept that suggestion from the mother, I remind myself that a rejection of her proposition does not add to the strength of the case put by the local authority.

When I have looked to the broader canvass of evidence, I have considered whether this incident is an extension to the finding I have already made above in respect of the mother’s exaggeration of the 4 x vomiting into the mouth and swallowing. I have considered whether this incident is an example of the mother becoming desperate to show that C is as poorly as she reports him to be at home, and she has then acted to fabricate evidence to support her previous reporting.

However, I have returned to the primary evidence produced by the Local Authority and asked myself whether it is of sufficient quality that I can rely upon it. I have reached the conclusion that it is not. It is confusing and at times contradictory. The standard of proof remains the same for each allegation, regardless as to its seriousness. The evidence for this finding is far from cogent.

As such, I do not make the finding as sought.

As a result of the above actions:

Ms MacLynn makes the point that I must take care when I consider what treatments C has been provided with, given the unclear picture of his health needs and the lack of clarity in respect of how his gastrological issues ought to have been medically managed, There is some strength to that argument, as I have highlighted in respect of the medications that C may or may not have received if the mother had not presented C so frequently in respect of seizure activity.

However, I am satisfied that the mother’s actions have generally compromised the medical professionals ability to properly treat C, if for no other reason than I have found that the mother’s misrepresentation of gastric symptoms has contributed to the lack of progress in respect of C’s feeding development.

On the basis that I have made the findings I have, I determine that this finding naturally flows. As I have indicated above, clinicians make decisions on treatment, medication, and health plans on the basis of information that they are given by a child’s primary carer. If that information is consistently exaggerated, misreported, or misrepresented, then their ability to make good and informed medical decisions is compromised.

Again, Ms MacLynn suggests caution ought to be exercised in identifying treatments which have been undertaken, based on the mother’s reporting. There is evidence that some of the treatments and plans have taken place as a result of the mother’s misreporting or exaggeration. For example, the mother’s reporting influenced the treatment for C’s gastric issues by way of years of free drainage and repeated endoscopies.

I am satisfied on balance that some treatments that were performed were likely not to have been needed. However, I decline to make the specific findings as to the particular treatments sought by the local authority in respect of surgical closure and surgical insertion.

In any event, I am satisfied on the evidence as discussed above and upon the findings I have made, that investigations have been undertaken in respect of gastrological and seizure related issues that would not have been required, but for the exaggeration, misreporting and/or misrepresentation by the mother.

I accept the Local Authority’s submission that, on the basis findings that I make, and have now made, that the mother’s history of exaggeration, misrepresentation and misreporting make it probable, at the time that these proceedings were issued, that C would have continued to have been made subject to investigations and treatments which may be unnecessary, harmful, unpleasant and places him at risk of physical harm. It is not for me to undertake a welfare assessment at this stage as to the risk that such behaviour will continue into the future.

However, on the basis of the findings that I have made (and also refused to make) I take the view that since February 2022 the exaggeration, misrepresentation and misreporting by the mother had lessened. That is not to say that it disappeared altogether. But in my view that lessening in the mother’s reporting has resulted in a lessening in respect of the nature of investigations and treatments that may have been required, at the point that protective measures were put in place.

As such, the Local Authority has been unable to show that the mother’s reporting at that point was likely to mean that C would be subjected to procedures with a risk of death. That is a step too far on the evidence I have before me.

On the basis of the findings I have made, this finding naturally flows.

D is likely to suffer significant harm in the form of exaggerated, fabricated

On the basis of the above, I am satisfied that the following findings are proved to the requisite standard:

The mother has a general tendency to exaggerate, to both family members and professionals.

Between 2018 and 2022, C’s mother has exaggerated and/or misrepresented his symptoms when speaking to medical professionals as follows;

As a result of the above actions:

D is likely to suffer significant harm in the form of exaggerated illness due to a repeated pattern of the mother’s reporting of exaggerated medical needs:

Following the handing down of my written judgment, clarification has been sought in respect of paragraph 81 above. For clarity, that paragraph of my judgment reads as follows:

Those representing the mother have alerted me to an entry at C169 of the medical bundle. That entry refers to a note made by nursing staff on 05.08.2020. It reads:

I am grateful to the mother’s team for alerting me to the factual inaccuracy within my judgement. I have as a result considered that nurses note as part of the context of the finding that I made in respect of that incident and have considered whether it would have altered the finding that I made at paragraph 276 (2) (e) above. Having done so, I am satisfied that the nursing note from 05.08.2020 would not have altered the conclusions that I ultimately reached.

Although it does not impact upon the basis upon which I made the finding, I note in any event that the mother in her response document has accepted the finding that I made.

Between 2018 and 2022, C’s mother has exaggerated, misrepresented or fabricated his symptoms when speaking to medical professionals as follows;

Exaggerating and misreporting the frequency of epileptic seizures observed in C.

Exaggerating and misreporting the extent of C’s behavioural difficulties when in the care of others, which was not observed by the relevant professionals.

Informing professionals that C either has autism or is on the spectrum.

Exaggerating and misreporting the extent of C’s breathlessness and fatigue, leading to cardiological investigations. The mother also reported having obtained a wheelchair which was manifestly unnecessary for C by late 2022,

Exaggerating and misreporting C’s vomiting as being frequent during November 2022 which was not then witnessed during the hospital admission from 18 to 23 November 2022.

Exaggerating and misreporting C’s diarrhoea as persistent and severe between 18 and 23 November 2022.

Misrepresenting C’s gastrological symptoms to professionals and maintaining that he would become unwell if his gastric aspirates were not drained and his dressing needed to be changed, on a more frequent basis than suggested by independent observations.

Exaggeration and misreporting of C’s pain responses and requesting analgesia as a result, overnight on 22 November 2022.

Despite discussions with the mother and the importance of accurate reporting having been emphasised to her in November 2021, she has continued to over report and misrepresent symptoms.

The mother has hindered C’s feeding development as a result of her over presentation of symptoms, limiting his oral solid food intake.

The mother has tampered with C’s gastrojejunal tube causing it to become dislodged:

On 22 November 2022 the mother contaminated a bag containing gastric aspirate from C’s stomach, by adding feculent matter to the fluid and informing Dr W that she had drawn the contents from the stomach.

As a result of the above actions:

Medical professionals have been compromised in their ability to make

C has been subject to investigations and treatments. The treatments

C is likely to be subject to medical investigations and treatments which

C is suffering and is likely to suffer further emotional harm through the

D is likely to suffer significant harm in the form of exaggerated, fabricated and induced illness due to a repeated pattern of parental reporting of exaggerated medical needs.

In any fact-finding exercise the burden of proof of proving any allegation lies on the party seeking to prove the allegations. In the present case the burden remains on the local authority at all times.

The burden of proof must not be reversed. It is not for the parents to have to prove any matter. It has repeatedly been made clear that there is no pseudo-burden upon a parent to come up with alternative explanations, Lancashire v R [2013] EWHC 3064 (Fam).

The appropriate standard of proof is the civil standard of the simple balance of probability as confirmed by the House of Lords in Re B (Children) [2008] UKHR 35.

This means that if the local authority or another party proves an allegation to this standard, that fact must be treated as having been established and will bear on all future decisions concerning the children. Equally, it means that if allegations are not proved to that standard, then they must be disregarded completely. However it does not follow that a rejection of evidence mandates a judge to find that it is false; see Re M (Children) [2013] EWCA Civ 388.

The inherent probability of an event remains a matter to be taken into account when weighing the probabilities and deciding whether, on balance, the event occurred. Re B (Care Proceedings: Standard of Proof) [2008] UKHL 35, [2008] 2 FLR 131 In Lord Hoffman said at paragraph [15] –

Findings of fact must be based on evidence not speculation; see Re A (Fact Finding: Disputed findings) [2011] 1 FLR 1817  Munby LJ (as he then was)

The judge must decide if the facts in issue have happened or not applying the binary system made plain by Lord Hoffman in Re B (Children) [2008] UKHR 35 at paragraph [2]. This applies to the conclusion as to the fact in issue, not the value of individual pieces of evidence (which fall to be assessed in combination with each other).

The court must take into account all of the evidence and consider each piece of evidence in the context of all the other evidence and look at the overall canvas. Evidence should not be assessed in separate compartments. The judge must assess and evaluate the evidence in its totality; see Re T [2004] 2 FLR 838  Butler-Sloss P

The evidence of the parents and of any other carers is of the utmost importance. It is essential that the court forms a clear assessment of their credibility and reliability. They must have the fullest opportunity to take part in the hearing and the court is likely to place considerable weight on the evidence and the impression it forms of them; see Re W and another (Non-accidental injury) [2003] FCR 346. 

However, in assessing and weighing the impression which the court forms of the parents, the court must also keep in mind the observations of Macur LJ in Re M (Children) [2013] EWCA Civ 1147 at [12], that –

When considering the 'wide canvas' of evidence the following section of the speech of Lord Nicholls in Re H and R (Child Sexual Abuse: Standard of Proof) [1996] 1 FLR 80 remains relevant –

The evidence of witnesses and the explanations given by them are of the utmost importance and a clear assessment of their credibility and reliability must be made by the court. In the context of the consideration of a wide canvas of material in reaching the factual decisions in the case, investigations of fact should have regard to the wider context of social, emotional, ethical and moral factors. The assessment of credibility generally involves wider difficulties than mere 'demeanour', which is mostly concerned with whether the witness appears to be telling the truth as he or she now believes it to be. With every day that passes the memory becomes fainter and the imagination becomes more active. The human capacity for honestly believing something which bears no relation to what actually happened is unlimited. Therefore, contemporary documents are always of the utmost importance.

A (A Child) [2020] EWCA Civ 1230 in the Court of Appeal concluded that the Court must be mindful of the fallibility of memory and the pressures of giving evidence. Lady Justice King observed that – 

In considering the evidence of an expert witness, the court must not confuse the functions of the expert and the judge whose roles are distinct. It is for the court to make the factual decisions based on all the available evidential material in the case, not just the scientific or medical evidence; and all that evidence must be considered in the wider social and emotional context; see A County Council v X, Y and Z (by their Guardian) [2005] 2 FLR 129.

If the court disagrees with an expert's conclusions or recommendations an explanation is required; see Re B (Care: Expert Witnesses) [1996] 1 FLR 667 and Re D (A Child) [2010] EWCA 1000.

In Re B (Care: Expert Witnesses) [1996] 1 FLR 667 Ward LJ gave the following guidance as regards the evidence of expert witnesses –

Butler-Sloss LJ continued –

In assessing the expert evidence the court must bear in mind that in cases involving a multi-disciplinary analysis of the medical information conducted by a group of specialists, each bring their own expertise to bear on the problem, and the court must be careful to ensure that each expert keeps within the bounds of their own expertise and defers, where appropriate, to the expertise of others (see the observations of Eleanor King J (as she then was) in Re S[2009] EWHC 2115 (Fam)).

The court is not precluded from making a finding that the cause of harm, in this case the infections, is unknown. In Re R (Care Proceedings: Causation) [2011] EWHC 1715 (Fam) Hedley J said at paragraph [10] –

In Re U (Serious Injury: Standard of Proof); Re B [2004] EWCA Civ 567, Butler- Sloss P explained at paragraph [23] that –

The court should be cautious when evaluating the evidence of a dishonest witness; see R v Lucas [1981] QB 720 –

In Re (1) A (2) B (3) C (CHILDREN) [2021] EWCA Civ 451 the Court of Appeal confirmed that while a Lucas direction was not required in every family case in which a party challenged factual allegations, it would be good practice, when such a direction was required, to seek Counsel's submissions to identify the following: 

Macur LJ stated:

In Re D (A Child) Care Order: Evidence) [2010] EWCA Civ 1000, Hughes LJ (as he then was) highlighted the objective nature of the threshold test, noting that –

In Re B (A Child) Threshold Criteria) [2013] UKSC 33 Lord Wilson said at paragraphs [30] and [31] that, when establishing threshold, there is –

In Re S (Split Hearing) [2014] EWCA Civ 25, Ryder LJ held at [19]-[21] –

In the present case, this may mean that even if the court is satisfied that the mother did not deliberately mislead professionals, it is clear that she did in fact do so, and that has placed the child at risk of harm.

In relation to specific matters of Perplexing Presentation, the Court may be further assisted by the following decisions of the High Court, as to the approach to be taken.

In BR & Ors, unreported, it was said that;

Many allegations of conduct labelled as FII will rely on inference. The first task for the court is to ascertain the objective facts. The second task is to determine whether the facts permit inferences to be drawn so that the allegations are established on the balance of probabilities. The court and witnesses must guard against allowing retrospect to distort an objective view of the facts. A belief that FII has occurred, and that a parent has been deceitful, may cause witnesses to re-interpret past events in a way that hinders the court in its first task.

In Re H, Mr Justice Hayden emphasised the importance of the paediatric overview;

In the Re 5 Children decision, Mr Justice T reviews the legal framework at paragraphs 16 onwards and in particular;

Drawing on this Lady Justice King in A (Children) [2018] EWCA Civ 1718 stated that:

In R v P (Children: Similar Fact Evidence) [2020] EWCA Civ 1088 the Court of Appeal at paras 24-26 considers when and how the court should rely upon propensity/similar fact evidence:

Finally, the court is referred to the judgment of Mr Justice Gillen in Re G and A (Care Order: Freeing Order: Parents with a Learning Disability) [2006] NIFam 8, para 5, specifically endorsed by Munby P in Re D (A Child) (No 3) [2016] EWFC 1. In particular, the court’s attention is drawn to the appendix in Re D, which sets out a number of factors which must be taken into account by courts when considering parenting with learning disability/difficulties. The court’s attention is drawn in particular to paragraph 4 of that list, which makes it clear that the court must consider the relevance of learning difficulties when considering the threshold test as well as at the welfare stage of proceedings: