North Northamptonshire Council v A Mother & Ors

This is an ex-tempore judgment. I am giving it as quickly as possible given the huge importance of the decision for this family. I have allowed extended family members and other members of their community, who have been at court each day, to come into court to hear the judgment.

This is a case about child [‘C’]. She was born in [2023]. Proceedings were issued by North Northamptonshire County Council on 10 July 2024 for a care order. C has been subject to an interim care order since 25 July 2024. She currently lives in the care of her paternal grandparents and has throughout the proceedings. C is the only child of her mother and father, who are the first and second respondents to this application. C has a guardian, [‘ML’].

C, it is probably relevant to mention, is a member of the Irish travelling community. She has a large family network about her. This brings a hugely positive and supportive aspect to her life. It also, and C’s parents have fully accepted this in their evidence to me, may bring from certain members of this community something of a distrust of the local authority and particularly perhaps social services which might sometimes hamper constructive working between family and professionals and obviously that would not be such a positive or supportive thing for C.

This cultural and heritage aspect is something that is important and is the context within which some of the events I have heard about should properly be considered but it is really important to say at the outset that C’s parents have worked fully with this local authority and I was impressed by what they said about how positive, if you can call it a positive situation, they themselves have experienced when working with the professionals.

C was not previously known to the local authority until 25 June 2024 when she was taken to [hospital] early in the morning by her mother and her paternal grandmother with a swelling on the back of her head. C’s mother and father both describe, and have consistently described, that they heard a cry that they have described as being an unusual cry at 4-4.30 in the morning of that day. They telephoned, as I understand it, the maternal grandmother to seek advice. I should say these are young, first-time parents with, as I have identified, a supportive family network around them and so quite properly nobody really made any criticism that the first phone call in these circumstances would be to a family member.

What the mother described clearly in her evidence to me was going to soothe C in the way that she normally would, which would involve stroking her head and that she, the mother, immediately felt a swelling, a lump, a soft part of C’s head that was unusual and worried her. She called, as I have said, the maternal grandmother, she called 111. One might have some sympathy for the mother finding 111 not sufficiently reactive given her concerns by this point and ultimately later on at 6.45am the mother took C to A & E.

Over the course of that day in hospital C was ultimately, following a CT scan that was conducted at 4.30 ish in the afternoon, diagnosed by 7pm as having a right parietal bone fracture and scalp haematoma. C had been in the care of her parents exclusively and together during the 24 hours prior to attendance at hospital. The parents were unable to provide any explanation for any event that could have caused this injury.

The medical opinion immediately was that the injuries sustained by C, (and when I say immediately I mean in the hospital) that the injuries sustained by C were likely to have been non-accidental in nature. Appropriate court-appointed experts have reported and I will set out their evidence in due course. I just say that the parents accept the contents of the medical evidence and no party has asked that the authors of the reports should give oral evidence to the court.

The local authority when presented with a child with a significant injury, a skull fracture, not unreasonably at all given the absence of any credible explanation as to how this came to pass in a 15 month old child, then issued proceedings, causing the enquiries to be made that have been made in this court arena and have acted appropriately on the basis of what they were presented with throughout the interim position.

I am really glad for C that she has had grandparents who have been able to step in and provide the excellent care that they have provided to her because what everybody always wants (and our courts always want) when parents, for whatever reason, cannot care for a child, what the courts hope for is the wider family to come in and step up and that absolutely is what has happened in this case and that is very much in furtherance of C’s wellbeing.

The local authority came into this hearing raising various matters of concern and their case in their final evidence has been that the paternal grandparents should carry on caring for C. Their case was that this should be under the mechanism of a special guardianship order. Whilst there are many positives identified in the assessments of the parents, (and there are many positives identified in the assessments of the parents), the local authority says that in the absence of a plausible explanation as to how this accident occurred, (assuming that it is was not a deliberately inflicted injury), then the local authority consider that there is just an unmanageable risk to C in returning to her parents’ care.

The parents had accepted that there may have been a lack of supervision that could have led to the injuries sustained by C, although have been clear throughout that they cannot give any details of a specific incident. They are prepared to work with the local authority in any way that is required of them.

The guardian in her carefully considered report proposes that if the court should find the injuries were caused either in an inflicted way or in an undisclosed accident, that there should be restorative work undertaken with the parents who otherwise demonstrate an excellent ability to care for C.

I should say that C has throughout been having lots of very good quality contact with her parents, as I understand it currently four hours four times a week, supervised by the paternal grandparents and that contact is something that C really looks forward to and really enjoys.

The guardian goes on to say that if the court should fail to make any findings of culpability against the parents, she would propose a transition plan which would include a period of monitoring under a child in need plan, perhaps for a period of three months to provide support and guidance during what objectively may well be something of a difficult time for this family.

This hearing then was listed as a composite hearing given the nature of the issues and the obvious desire to avoid delay. This being the case, it was agreed that the appropriate, logical and fair way forward was for the parents to give their evidence first and that we should then pause to consider whether the court was in a position to give a judgment with respect to the fact-finding element of the case in order that the parties could then take stock and plan how best to move forwards. This has been possible and this is the judgment that I now provide on an extempore basis.

I start with reminding myself of the law. I apologise to the people assembled, there is quite a bit of law I have to deal with. We are in a court, I apply the law and I do need to read it into this judgment so if you wanted to take a couple of minutes to rest your eyes, this would be the time to do it. I am grateful to Mr Flatt who has provided, and indeed all of the advocates who have agreed with the note that he has provided which is an agreed note of the applicable law for me to have in my mind when I consider this part of the case.

He takes me first to the case of Re S (A Child) [2014] EWCA Civ 25. Can I just say to the advocates it may well be that we get a transcript of this judgment, so do not feel that every word has to be taken down. I think that might in this case be an appropriate course of action. So Re S (A Child) [2014] EWCA Civ 25 at paragraph 19:

“The term 'non-accidental injury' may be a term of art used by clinicians as a shorthand and I make no criticism of its use but it is a ‘catch-all’ for everything that is not an accident. It is also a tautology: the true distinction is between an accident which is unexpected and unintentional and an injury which involves an element of wrong. That element of wrong may involve a lack of care and/or an intent of a greater or lesser degree that may amount to negligence, recklessness or deliberate infliction. While an analysis of that kind may be helpful to distinguish deliberate infliction from, say, negligence, it is unnecessary in any consideration of whether the threshold criteria are satisfied because what the statute requires is something different namely, findings of fact that at least satisfy the significant harm, attributability and objective standard of care elements of section 31(2).”

Mr Flatt goes on to remind the court, it is well established that the burden of proof during the fact-finding exercise falls upon the party making an allegation and the standard of proof is the simple civil balance of probabilities and I am referred to Re B (Children) [2008] UKHL 35:

“My Lords, for that reason [says Baroness Hale in that case] I would go further and announce loud and clear that the standard of proof in finding the facts necessary to establish the threshold under section 31(2) or the welfare considerations in section 1 of the 1989 Act is the simple balance of probabilities, neither more nor less. Neither the seriousness of the allegation nor the seriousness of the consequences should make any difference to the standard of proof to be applied in determining the facts. The inherent probabilities are simply something to be taken into account, where relevant, in deciding where the truth lies.”

In Re A (A Child) [2020] EWCA Civ 1230 Lady Justice King considered credibility, demeanour and memory in the context of a fact-finding process and says this:

“Seventh, the evidence of the parents [and she is referring to guidance given by Mr Justice Baker in a different case] and 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.”

I am reminded also of the case of Re A (Children) (Care Proceedings: Burden of Proof) [2018] EWCA Civ 1718. Again, this is Lady Justice King. She says this:

“I accept that there may occasionally be cases where, at the conclusion of the evidence and submissions, the court will ultimately say that the local authority has not discharged the burden of proof to the requisite standard and thus decline to make the findings. That this is the case goes hand in hand with the well-established law that suspicion, or even strong suspicion, is not enough to discharge the burden of proof. The court must look at each possibility, both individually and together, factoring in all the evidence available including the medical evidence before deciding whether the ‘fact in issue more probably occurred than not.’”

And the advocates in that case have gone on to refer me to some other paragraphs from that judgment which I shall not read out but I am well aware of them.

I am reminded by the advocates of the importance of what we call a Lucas direction and how Lord Justice McFarlane, as he then was, in Re H-C [2016] EWCA Civ 136 emphasises:

“One highly important aspect of the Lucas decision, and indeed the approach to lies generally in the criminal jurisdiction, needs to be borne fully in mind by family judges. It is this: in the criminal jurisdiction the ‘lie’ is never taken, of itself, as direct proof of guilt.”

And that is further to be explained in this way: people lie for many different reasons. They lie because they are panicking, they lie because they are ashamed, they lie because they are lying about something else but in terms of whether it can be taken as direct proof of the issue in the case is only when effectively there is no other reason that can be seen or understood for that lying.

Mr Justice Keehan reminds the court in Re A [2011] 1 FLR 1817, findings of fact must be based on evidence, including inferences that can properly be drawn from the evidence and not on mere suspicion, surmise, speculation or assertion.

In considering expert evidence, I cannot, I am not entitled to, reject expert medical findings which are not contradicted, save in the rare case where an opinion is not capable of withstanding logical analysis. That is not this case but I have to remember, of course, and I am rightly reminded in this note of the law that the roles of the medical expert and the court are very different. I have to look at all of the evidence in the case, both medical and non-medical, and come to an overall conclusion on the question of significant harm and my task is summarised well by Lord Justice Thorpe in Re B (Non-accidental Injury) [2002] EWCA Civ 752:

“The expert of ultimate referral was there to guide the judge as to the relevant medical and scientific knowledge, inevitably expressing himself in medical language. The judge’s function was a very different one. He had to consider the question posed by section 31 of the Children Act 1989 as to whether [the child] was a child suffering or likely to suffer significant harm and whether that harm… was attributable to the care given to the child, or likely to be given to [them].”

I am also referred, I do not think it is necessary to read it into this judgment but I have it in mind, to the case of Re M (Fact-Finding Hearing: Injuries to Skull) [2012] EWCA Civ 1710. That is Lord Justice Munby. Perhaps it is important to remind ourselves, of this: the cause of an injury or an episode that cannot be explained scientifically can remain equivocal; recurrence in itself is not probative; particular caution is necessary in any case where the medical evidence disagree, must be careful about over-dogmatic experts and then something that is always important to come back and remember:

“The judge in care proceedings must never forget that today’s medical certainty may be discarded by the next generation of experts or that scientific research will throw light into corners that are at present dark.”

Then I am referred to what to do where there is an uncertainty about the perpetrator of an event, not relevant because very helpfully and very sensibly, it seems to me, the local authority has decided it no longer pursues, and it seems to me that is entirely right, a finding that the injury caused to C was a deliberately inflicted injury.

I have had the opportunity to, and have read, the medical evidence in the case and the other evidence, of course, in the bundle and I have heard evidence from the parents, and only from the parents, and I heard evidence from the parents the day before yesterday.

In terms of the medical evidence, I hope I can find the summary of the medical evidence in my bundle, (bear with me for one moment). The court received evidence from a Dr [‘V’], who conducted the initial child protection medical report and observed a right parietal bone fracture without depression with an associated large scalp haematoma and that there were no plausible explanations from family members to correlate with an injury of this severity and extent.

Dr [‘E’], clinical geneticist, was instructed and reported that there is no blood clotting abnormality or other medical abnormality identified in C, there was no underlying organic cause, no connective bone tissue conditions identified. The tests excluded coagulation and bleeding disorders and that C was unlikely to have osteogenesis imperfecta type 1.

Dr [‘W’], who is a paediatric neuroradiologist, reported that there is a right-sided cranial impact injury, an extensive acute scalp haematoma over the right side of the skull containing bright, acute haemorrhage, linear right parietal skull vault fracture, birth was not responsible given the appearance of the soft tissue swelling, no naturally occurring explanation or cause for the injuries. The possibilities therefore are an undeclared accident or that the injuries were inflicted. The combination of the force and usual reaction of a child to the fracture result in such events would be memorable.

Dr [‘R’], who is a paediatric consultant, reported to say he agreed that the injury of note was the right parietal skull fracture with an associated haematoma, there was no intracranial or retinal bleeding, blood counts and coagulation screens were normal, a blunt force trauma is the most likely explanation for the injuries and in the absence of a specific history there are two possibilities: undisclosed incident or inflicted injury.

It is probably helpful, in my judgment, to just read into this judgment a little bit more of the detail from the two main medical experts because it is right to say that the local authority and the guardian pin their advancement of their cases very much on the medical evidence. Dr W gives a little bit of expansion in this way:

“The vast majority of accidental head injuries are minor and result in no or very little injury. 15 month old children can be dropped by carers or carers can fall when carrying them. They can also climb stairs and furniture and may subsequently fall. There is no minimum height below which a fracture never occurs or above which one always does. Experience suggests that falls under one metre are unlikely to result in skull vault fractures unless they are complicated by falls directly onto point surfaces such as a radiator valve.”

She goes on to set out some studies carried out by Lyons and Oates, Johnson et al, Burrows et al and I have them in mind, I will not read all of the details into this judgment but she goes on to say:

“Hence, low level falls are an uncommon cause of a fracture and most domestic impacts result in no injury. The fracture in this case is a linear parietal fracture. This is commonest [I think she says the commonest] skull vault fracture type from trauma of any cause. Some fracture patterns and complexity are uncommon in accidental trauma but even when such features are present, I make the point they are not pathognomonic of abuse much in the same way that just because a fracture is a linear one, it does not mean the cause was necessarily an accident. In other words fracture type does not infer or help with causation. There are no intracranial injuries but the presence or absence of such features correlates poorly with skull vault fractures and does not mitigate against the force needed to cause a fracture.”

She says:

“We return to the original comments I made. Skull vault fractures occur in memorable events. I accept a 15 month old child may not always be directly supervised but the force needed to cause the fracture and typical reaction of the child [just pausing to observe the word “typical”] would alert any nearby carer that there had been a significant head injury. If the court accepts the version that C was well and normal prior to going to bed on 24 June with no soft tissue swelling and became symptomatic with soft tissue injury in the early hours of 25 June 2024, then it would follow that there had been a traumatic event in that timeframe. Falling out of bed is being an occurrence which is not associated with injuries in the vast majority of cases. Hence, hitherto there is no adequate accidental explanation for these injuries.”

She goes on to set out under the heading of “non-accidental injury”:

“The possibilities are that there has been a trauma which has not been witnessed or declared thus far, or that the injuries were inflicted.”

She says:

“As stated previously, the diagnosis is blunt impact cranial trauma. There are no imaging hallmarks of shaking. Any accidental trauma must have involved a forceful impact injury to the right side of the head, likely C falling against a hard surface or object. She would have been in pain following any such trauma.

She goes on to talk about inflicted injury which is not relevant given the way this case is put. She then says:

“The absence of any intracranial bleeding or brain injury would tend to suggest any following symptoms were at most mild, though periods of floppiness and unresponsiveness cannot be fully excluded.”

And very fortunately for C she goes on to say:

“Soft tissue swelling and skull vault fractures of this type would be expected to heal without complication.”

In terms of Dr R’s report, the point to notice given the way that the evidence has developed in this case is what he says at E87 in paragraph 111 and 110 this:

“C would have suffered severe pain following the injuries. She would have cried or screamed out in pain and would have continued to cry for several minutes before settling on comforting.”

So that is the medical evidence or the relevant parts of it that have been focused on in particular in this hearing.

I heard from the parents. They are young. The father is 20 and the mother is 19. They are members of the Irish travelling community and they both took the trouble to explain to me that whilst in certain older members of their community that might lead to a reluctance to trust authority or the court system, the local authority, social services, that really was not their world view given their experiences. They themselves have co-operated fully with social services and did not object to having had to co-operate in that way. Their experience of the social workers has been, if you can use this term in such a terrible situation as they have faced, a positive one.

It may seem wrong, it might well be wrong, to take the parents’ evidence together but I am going to in this case. They were very similar. They told me exactly the same story and they told it in the same way. They had the same love and commitment to their daughter that shone out of their evidence. They both turned to me, they looked directly at me from the witness box and they swore to me that they could think of no set of circumstances that could describe what had happened to their daughter in a way that would fit the medical evidence.

They passionately wished that they could provide a version of events and they knew that this would all make this easier or more straightforward. Bluntly, they knew that this would enhance their chances of their daughter being in their care or coming home to their care, but they were unable to give a version and unwilling to invent a version and they stuck to that position throughout their evidence very clearly, very strongly. The mother said:

“I would give anything to know what had happened but I don’t know and I can’t say something I don’t know.”

And the father said something very similar.

The parents have been consistent and have remained consistent that they woke up at four o’clock-ish in the morning to hear a really unusual cry from C in her cot. The mother had described to me C as the kind of baby if you left her on her own she would scream and cry like there was something wrong but she would stop when you picked her up and I accept that evidence that C was, if we can call her this, a crier. The father said that the cry that they heard at four o’clock in the morning was not a normal cry. He said:

“I can’t explain it to you. It’s not the normal cry that she would do so we both went to look.”

Somewhat is made by the local authority of the messages between the parents whilst the mother and C were at hospital that asked the father to tidy up the house. He put some washing on, he removed some large items and I think a dog that was at the family home, there was a metal bed frame and a sofa. Why do this, the question was asked, whilst your daughter is so unwell in hospital? Well, the answer was a culturally contextual answer and I absolutely accept that evidence. The answer was effectively:

“We are a house-proud community. We need our home to be clean when our family visit or it would be a source of shame and we knew that our family would convene with our daughter being in hospital.”

I accept that the tidying and the cleaning of the house does not take the case any further.

Somewhat was made by the local authority, certainly in the written documents, of the failure of the parents to volunteer the information to them of the maternal grandfather’s conviction for a sexual offence. This is perhaps a significant contrast to the other openness with professionals that the parents have demonstrated. It troubled the local authority. Well, it is true that this is a failure. The parents say that they thought the local authority would already know or have access to the information but, yes, perhaps they should have volunteered it but I have given myself a Lucas direction and I need to remember it and I need to apply it and it is not difficult to imagine the sorts of reasons that might lead parents not to volunteer information of that sort.

Somewhat is made of the parents’ deletion of text messages whilst at the hospital. Yes, this is potentially a concerning aspect in a case and, yes, I wish I could see what those messages say so I could be sure that there is not one that says, “Oh no, remember when she fell down those three stairs, we should have gone to hospital earlier and why didn’t we put the stair gate in?” but I cannot say that the parents are not telling me the truth when they say they have low storage on their phones and routinely have to delete messages. The context is the mother being at hospital for 13 hours, well, and longer but 13 hours prior to the diagnosis of the fractured skull with a child who seems very well. The undisputed evidence is she is running around at the hospital, eating, drinking, giggling, so bar the swelling on her head she is very well. There is a lot of waiting around and no doubt a lot of looking at phones.

I was troubled by the parents’ evidence about the purchasing and fitting of a stair gate during the date of 25 June whilst mother and C were at the hospital. It is almost the one part of the case that does not quite hold together and ring true in terms of what the parents have said to me and I myself asked questions of the parents about that. What though does that tell me? What am I able to infer from it? To what extent does it assist me to make a safe finding on the balance of probabilities?

If the purchase and the fitting had been done at a time post diagnosis of a skull fracture, (the diagnosis as I understand it was in the evening I think, seven o’clock on 25 June,) perhaps I might consider it more specifically probative of knowledge of a fall down the stairs, ie “our child has been diagnosed with a skull fracture, we know that she fell down the stairs, we know we didn’t have a stair gate, we must put one in quickly” but at the time of its purchase the evidence seems to be, and it has not significantly been challenged nor could it really, that the parents’ working assumption was that their daughter had either meningitis or some kind of infection that had caused the swelling. The fracture was not known about until later that day so I do need to be careful, it seems to me, as to what that information in and of itself can prove that during the day that his wife and daughter are in hospital the father went and purchased a stair gate and fitted it.

This is not, to perhaps put it mildly, an easy or a straightforward case and I can entirely understand why it is that the parties have adopted the positions that they have and that applies across actually all of the parties in terms of their approach to this case. No criticism at all of the local authority for bringing and pursuing the findings, that is their duty and obligation, no criticism of C’s guardian for trying to say to me, “Do your best to find the narrative so that C knows what happened”, no criticism of the parents for making or seeking to make the concessions that they made in terms of acknowledging a lack of supervision. I am certainly not going to utilise that concession in my balance of probability exercise in terms of determining the facts. So it is one of those cases where the court simply has to stand back and survey the whole wide canvas of evidence. It is absolutely a paradigm of that case.

Much of what I have heard is, in fact, limited to the evidence of the parents because they, of course, were the only people that were present during the relevant time. Some of their evidence, indeed, is accepted on the basis it appears to be accepted by everybody that bath time in the morning on the 24^th had a child who had her hair shampooed and clearly had no evident head injury which effectively puts the timeline for this incident, this injury, into that 24 hour period, or less than that in fact, when C went into hospital. We have rules of procedure, we have a process, we have rules of evidence and burden of proof and they are there as a very important safeguard and set of guard rails in a case like this, it seems to me.

So going back to the schedule of findings as drafted before this hearing started, I start with the inflicted injury. Nobody put to the parents in evidence that they had deliberately inflicted this injury. I can see absolutely why and just to be clear, because I am dealing with the pleadings, it would be grossly procedurally unfair even if I thought the evidence supported such a finding, which I do not, for me to make a finding of deliberate infliction.

What then has been advanced by the end of the evidence as the case that the local authority, supported by the guardian, invite me to make? They invite me to find that this injury was caused by an accident that the parents then concealed. So that is the finding that I am being invited to make on the balance of probabilities.

What evidence is there that could support such a finding? I have the evidence from the experts that tells me, I have set out in this judgment already but that if it is not an inflicted injury, it is an accident that would probably have required a fall from at least a metre of height, not necessarily but probably, or contact with something called a point surface, the examples given being a radiator valve or a stone fireplace and I take that fully into account. I also take into account Dr Ws’ point that there is no minimum height below which a fracture never occurs or above one which always does. I take into account that whatever caused this fracture would have been, as the medics say, a memorable event and one which should have been obvious to attuned care givers but I am not dealing with any child, I am dealing with C.

C was a very mobile, 15 month old. By all accounts she was busy, she was a climber and she was a crier. She was a child who would become evidently distressed over various matters, as toddlers can, and then be pretty swiftly comforted. That is the context and I have parents who describe at four o’clock in the morning an unusual cry and they immediately noticed the swelling on her head and I accept then behaved entirely appropriately.

What do the medical professionals mean when they talk about a memorable event? What is the evidence that I can rely on as I am being asked to rely on? I come back to the evidence of Dr R, it is this and this is the top and the bottom of it:

“She would have cried or screamed out in pain and would have continued to cry for several minutes before settling on comforting.”

I am not being told that there was a child who would have been beside themselves for six hours, I am not being told there is a child who would have been evidently very, very, out of sorts for a long time thereafter, I am not being told that there would be a child who would have been noticeably very, very different for a very long period of time.

Several minutes is the period that the experts tell me she would have cried or screamed out in pain and essentially that is the definition of memorable on the evidence that I have got, a toddler screaming or crying for several minutes, then being comforted, then settling. We can use all of the medical terms that we like with the benefit of hindsight and I do not for a second take away from the fact this is a significant injury, it is, but the case is being advanced against the parents that they must be lying because they would have, should have, must have, observed a memorable event.

What is a ‘memorable event’? Crying or screaming out in pain for several minutes before settling. That is the definition of memorable on the medical evidence that I have. So the local authority and guardian say anybody would have noticed that and because they say they did not in a small, open plan property they are lying, you could not have missed it and therefore they did not miss it and that is effectively how the case is being put and what could they not miss? A child who would cry about dropping a chip crying but for several minutes and a bigger cry than the usual one.

I am afraid that I consider that piece of evidence, and I am sure I will be told if I have missed some of the medical evidence or if I am understating it but I consider that that piece of evidence is insufficient to scaffold a finding without more that, on the balance of probabilities, the parents did observe by sight or hearing this event and that, therefore, they have subsequently lied by omission or otherwise.

I have the evidence of the stair gate. As I have said, this is perhaps surprising. Had the parents said to me, “Our child is in hospital with a large bump to her head. We started to realise there may be questions asked about our home conditions and we panicked because we realised we should have had a stair gate in”, that would have made sense but that was not part of anybody’s case that was presented to me. So it is perhaps a surprising feature of the case but I am not here to be a detective, to postulate my own theories, or to go down tangents that are not part of anybody’s case.

My role is to determine the facts as they are presented to me within the context of the threshold exercise and to make findings on the balance of probabilities. I am unable to make a finding on the balance of probability on the basis of the evidence that I have read or heard as to how C came to sustain her injury. It is therefore an accident of unknown cause.

I then have to consider whether it was, as the local authority and guardian suggest, a witnessed accident in the face of evidence from the parents that it was not witnessed by them and I have set out what the medical evidence says in that respect and the limitations to that medical evidence. I am going to be clear. I believe the parents. They have consistently described waking to a child making a really unusual cry at 4.30 or four o’clock in the morning. They then did everything they should. That fact in itself actually fits really uneasily with the suggestion that there had been a previously witnessed or observed accident and that they then went on to, for whatever reason, initiate medical treatment at 4.30 in the morning.

That central piece of evidence actually I find inconsistent with a previous concealed act or accident. The father said to me in clear terms:

“If I had known she had had an accident, I would have wanted to tell the hospital so that my daughter could get the treatment she needed.”

I believe that evidence. I believe them when they say:

“There is nobody in the room who wants more than we do to know what happened.”

So, in conclusion, this is an accident of unknown cause and it is an unwitnessed accident. That is my determination on the facts.