Charlie (a Child)(Fact Finding and Welfare: Fracture), Re

The child had suffered and/or was at risk of suffering significant emotional and physical harm as a result of:

The Mother has two older children from previous relationships, and they do not reside in her care. The Mother was a party to other proceedings involving the half-sibling of Charlie and accepts that a PAMS Parenting Assessment of her was negative. The court made a final care order with the half-sibling of Charlie being removed from her care and placed in local authority care following concerns of exposure to domestic abuse, poor parental mental health and physical and emotional neglect.

The Mother accepts that her two older children both sustained unexplained injuries due to lack of adequate supervision whilst in her care and there were delays in the Mother seeking medical treatment for the children.

The child had suffered and/or was at risk of suffering significant harm in the form of neglect and emotional harm as a result of:

The Mother’s poor mental health affects her ability to provide safe and consistent care [to] Charlie.

The Mother accepts that Charlie is at risk of neglect arising from being unable to sustain her own tenancy following being evicted from her housing association property due to rent arrears. The Mother has failed to prioritise finding a stable and suitable home for Charlie and at the relevant date has no fixed abode.

Between 10pm on 14 October 2025 and 4.57pm on 15 October 2025 Charlie sustained an acute non- displaced spiral fracture of the lower end of his right humerus.

The expected mechanism of the injury identified in paragraph 3 is sharp twisting of the right arm by some force acting on the right forearm, or rotation of the arm around the back and the traumatic energy required is unlikely to arise out of reasonable normal handling of a child of Charlie’s age.

Charlie does not present with any underlying medical conditions to explain the injury, nor the propensity to sustain the type of injury referred to in paragraph 3.

The injury referred to in paragraph 3 would have caused Charlie severe pain immediately after the injury was sustained.

The Mother was the only person other than professionals having unsupervised contact with Charlie at the time he sustained the injuries referred to in paragraph 3. The Mother is not suggesting that anyone else was responsible for the injury to Charlie.

The Mother placed Charlie with the foster carer on her own for a period of time on 15 October 2025 for about an hour, the foster carer had Charlie on her own downstairs and the Mother was checking Charlie at regular intervals and could hear if he screamed.

The Mother’s account that when rolling Charlie would sometimes catch one arm under his body and twist to try and get himself moving has been discounted as the likely cause of the injury referred to in paragraph 3 and on the available literature evidence it is not possible to reasonably support the plausibility of the rolling over mechanism being the cause of the injury referred to in paragraph 3.

The Mother is under investigation by the police for assaulting Charlie, namely causing him grievous bodily harm with intent. The Mother exercised her right to silence when interviewed under caution and refused to disclose her mobile phone PIN code which has unreasonably delayed the investigation.

Dr Mohamed in his addendum report opines given that the exact mechanism was not sufficiently witnessed, which leads to a number of unknown parameters that could potentially relate to the injury it is not possible to completely exclude a combination of factors primarily led by the fall from a height being the cause for the fracture.

It would have been evident to any reasonable carer present at the time Charlie sustained the fracture that he was in pain and he had sustained a significant injury.

The Mother has provided inconsistent accounts to professionals about how Charlie suffered the fracture.

The Mother’s account that the Child rolled off the bed and fell on the floor on the morning of 15 October 2025 is unlikely to account for the fracture.

The injury is likely to have occurred when the Mother was upstairs with Charlie after the visit from the social worker on the afternoon of 15 October 2025.

It is not possible to identify the precise cause of injury on the balance of probability, only that it occurred in the Mother’s sole care on the afternoon of 15 October 2025 and that it was either an undisclosed accident which might have been the result of recklessness or negligence on the part of the Mother or an undisclosed infliction of injury.

Charlie suffered significant physical harm in the form of a fracture as a result of the failure of the Mother to act protectively by either inflicting the injury or failing to supervise him such as to prevent an accidental injury.

Because Charlie was, at all times relevant to the injury, in the care of the Mother she either knows the cause of Charlie’s injury but has failed to disclose the same or is unaware of the cause and has not disclosed why she cannot say what happened to cause the injury whilst he was in her care.

The Mother’s failure above puts Charlie at risk of significant physical and emotional harm.

The Mother has ongoing limitations in reflective functioning, emotional recognition and risk awareness, including difficulty identifying unsafe adults and a continued vulnerability to abusive or risky relationships, creating a real risk that she will be unable to consistently recognise and meet a child’s needs without sustained support.

The Mother has two older children from previous relationships, and they do not reside in her care. The Mother was a party to other proceedings involving the half-sibling of Charlie and accepts that a PAMS Parenting Assessment of her was negative. The court made a final care order with the half-sibling of Charlie being removed from her care and placed in local authority care following concerns of exposure to domestic abuse, poor parental mental health and physical and emotional neglect.

The Mother accepts that her two older children both sustained unexplained injuries due to lack of adequate supervision whilst in her care and there were delays in the Mother seeking medical treatment for the children.

The mother presented to services late in the pregnancy with Charlie (at 27 weeks and 6 days

pregnant). At the time, she was homeless, having been evicted from her previous accommodation and living with a friend.

…

Charlie and the mother moved to a mother and baby foster placement in [] on 14 March 2025, the mother agreeing to such placement pursuant to s.20 Children Act 1989.

Proceedings were issued promptly on 19 March 2025.

At the case management hearing on 11 April 2025 the court placed Charlie under the supervision of the local authority…

…

45...the parties agreed a consent order vacating the FCMH on 3 July 2025 agreeing the extension of the placement of mother and Charlie with the foster carer to enable the housing application to be submitted and inform planning for transition back to the community. The proceedings were timetabled to a FCMH on 6 August 2025 (B74 [160]).

At the hearing on 6 August 2025, founded on the tentative positive assessment of the mother and a plan to transition mother and child into the community, the court timetabled through to an Issues Resolution Hearing before District Judge Humphreys on 26 November 2025.

Very sadly and despite the positive trajectory that was seen as the precursor to the order of

DJ Humphreys on 6 August 2025, events in October 2025 (whilst Charlie and his mother continued to reside in the local authority foster care placement) significantly changed the focus of these proceedings.

On 15 October 2025 at 17:57, Charlie was presented to the Emergency Department at Southampton General Hospital with a spiral arm fracture.

…

In light of the significant events that led to Charlie’s presentation to hospital on 15 October

2025, the local authority sought urgently to return the matter to court.

At the hearing on 17 October 2025, the local authority invited the court to make an interim

care order and to sanction Charlie’s immediate removal from the care of the Mother. The children’s guardian supported that position. HHJ Wright duly made the order sought and approved the interim care plan of separation of Charlie from the Mother.

Charlie is now placed with alternative foster carer.

[Paragraph 68]

Mother wishes to have three times a year direct post-adoption contact if the Court makes a Placement Order. I would not necessarily oppose this, but with the caveat that the priority for the Local Authority will be to identify the right adopters for Charlie in timescales compatible with his needs. If the pool of potential adopters reduces significantly because a high level of post adoption birth family contact is proposed, this could cause delay in achieving permanency for Charlie.

[Paragraph 92]

I support the Local Authority’s recommendations for twice a year direct and twice a year letterbox contact between Charlie and the Mother, and as already stated, would not stand in the way of her having [three] times a year direct contact, if adopters can be identified who will actively support this.

Dr Mohamed;

FC;

Ms White;

Ms Porter;

Mother; and

Ms Morgan.

A court may only make a care order or supervision order if it is satisfied –

that the child concerned is suffering, or is likely to suffer, significant harm; and

that the harm, or likelihood of harm, is attributable to –

the care given to the child, or likely to be given to him if the order were not made, not being what it would be reasonable to expect a parent to give to him; or

the child’s being beyond parental control.

Unhappily, the courts will inevitably have before them numerous cases where there has undoubtedly been a failure to protect and there will be, as a consequence, complex welfare issues to consider. There is, however, a danger that significant welfare issues, which need to be teased out and analysed by assessment, are inappropriately elevated to findings of failure to protect capable of satisfying the s 31 criteria.

…The principles are conveniently set out in the judgment of Baker J in Re L and M (Children) [2013] EWHC 1569 (Fam), to which I was taken. So far as material for present purposes what Baker J said (and I respectfully agree) was this:

“First, the burden of proof lies at all times with the local authority.

Secondly, the standard of proof is the balance of probabilities.

Third, findings of fact in these cases must be based on evidence, including inferences that can properly be drawn from the evidence and not on suspicion or speculation …

Fourthly, when considering cases of suspected child abuse the court must take into account all the evidence and furthermore consider each piece of evidence in the context of all the other evidence. The court invariably surveys a wide canvas. A judge in these difficult cases must have regard to the relevance of each piece of evidence to other evidence and to exercise an overview of the totality of the evidence in order to come to the conclusion whether the case put forward by the local authority has been made out to the appropriate standard of proof.

Fifthly, … Whilst appropriate attention must be paid to the opinion of … experts, those opinions need to be considered in the context of all the other evidence. It is important to remember that the roles of the court and the expert are distinct and it is the court that is in the position to weigh up the expert evidence against its findings on the other evidence. It is the judge who makes the final decision.

Sixth, … 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.

Seventh, the evidence of the parents and any other carers is of the utmost importance. It is essential that the court forms a clear assessment of their credibility and reliability.

Eighth, it is common for witnesses in these cases to tell lies in the course of the investigation and the hearing. The court must be careful to bear in mind that a witness may lie for many reasons, such as shame, misplaced loyalty, panic, fear and distress, and the fact that a witness has lied about some matters does not mean that he or she has lied about everything (see R v Lucas [1981] QB 720 ).” [I address this further below]

To this admirable summary I add three further points.

First, that the legal concept of proof on a balance of probabilities “must be applied with common sense”, as Lord Brandon of Oakbrook said in The Popi M, Rhesa Shipping Co SA v Edmunds , Rhesa Shipping Co SA v Fenton Insurance Co Ltd [1985] 1 WLR 948, 956.

Secondly, that the court can have regard to the inherent probabilities: see Lady Hale in In re B (Children) (Care Proceedings: Standard of Proof) (CAFCASS intervening) [2008] UKHL 35, [2009] 1 AC 11, para 31. But this does not affect the legal standard of proof, as Lord Hoffmann emphasised in the same case (para 15):

“There is only one rule of law, namely that the occurrence of the fact in issue must be proved to have been more probable than not. Common sense, not law, requires that in deciding this question, regard should be had, to whatever extent appropriate, to inherent probabilities. If a child alleges sexual abuse by a parent, it is common sense to start with the assumption that most parents do not abuse their children. But this assumption may be swiftly dispelled by other compelling evidence of the relationship between parent and child or parent and other children. It would be absurd to suggest that the tribunal must in all cases assume that serious conduct is unlikely to have occurred. In many cases, the other evidence will show that it was all too likely.”

Thirdly, that the fact, if fact it be, that the respondent … fails to prove on a balance of probabilities an affirmative case that she has chosen to set up by way of defence, does not of itself establish the local authority’s case. As His Honour Judge Clifford Bellamy recently said in Re FM (A Child: fractures: bone density) [2015] EWFC B26, para 122, and I respectfully agree:

“It is the local authority that seeks a finding that FM’s injuries are non-accidental. It is for the local authority to prove its case. It is not for the mother to disprove it. In particular it is not for the mother to disprove it by proving how the injuries were in fact sustained. Neither is it for the court to determine how the injuries were sustained. The court’s task is to determine whether the local authority has proved its case on the balance of probability. Where, as here, there is a degree of medical uncertainty and credible evidence of a possible alternative explanation to that contended for by the local authority, the question for the court is not ‘has that possible alternative explanation been proved’ but rather it should ask itself, ‘in the light of that possible alternative explanation can the court be satisfied that the local authority has proved its case on the simple balance of probability’.”

I agree with the judgment of Ward LJ. Family judges deal with increasingly difficult child cases and are much assisted in their decision-making process by professionals from other disciplines: medical, wider mental health and social work among others. The courts pay particular attention to the valuable contribution from paediatricians and child psychiatrists as well as others, but it is important to remember that the decision is that of the judge and not of the professional expert. Judges are well accustomed to assessing the conflicting evidence of experts. As Ward LJ said, judges are not expected to suspend judicial belief simply because the evidence is given by an expert. An expert is not in any special position and there is no presumption or belief in a doctor however distinguished he or she may be. It is, however, necessary for a judge to give reasons for disagreeing with experts' conclusions or recommendations. That, this judge did. A judge cannot substitute his views for the views of the experts without some evidence to support what it is he concludes.

Parties should understand that the court’s approach to witness evidence based on human memory will be in accordance with CPR PD 57AC, Appendix para 1.3.

This states that human memory:

is not a simple mental record of a witnessed event that is fixed at the time of the experience and fades over time, but

is a fluid and malleable state of perception concerning an individual’s past experiences, and therefore

is vulnerable to being altered by a range of influences, such that the individual may or may not be conscious of the alteration.

To these matters I would only add that in cases where repeated accounts are given of events surrounding injury and death the court must think carefully about the significance or otherwise of any reported discrepancies. They may arise for a number of reasons. One possibility is of course that they are lies designed to hide culpability. Another is that they are lies told for other reasons. Further possibilities include faulty recollection or confusion at times of stress or when the importance of accuracy is not fully appreciated, or there may be inaccuracy or mistake in the record keeping or recollection of the person hearing and relaying the account. The possible effects of delay and questioning upon memory should also be considered, as should the effect on one person of hearing accounts given by others. As memory fades, a desire to iron out wrinkles may not be unnatural – a process which might inelegantly be described as “story creep” – may occur without any inference of bad faith.

No judge would consider it proper to reach a conclusion about a witness’s credibility based solely on the way that he or she gives evidence, at least in any normal circumstances. The ordinary process of reasoning will draw the judge to consider a number of other matters, such as the consistency of the account with known facts, with previous accounts given by the witness, with other evidence, and with the overall probabilities. However, in a case where the facts are not likely to be primarily found in contemporaneous documents the assessment of credibility can quite properly include the impression made upon the court by the witness, with due allowance being made for the pressures that may arise from the process of giving evidence. Indeed in family cases, where the question is not only ‘what happened in the past?’ but also ‘what may happen in the future?’, a witness’s demeanour may offer important information to the court about what sort of a person the witness truly is, and consequently whether an account of past events or future intentions is likely to be reliable.

I therefore respectfully agree with what Macur LJ said in Re M (Children) at [12], with emphasis on the word ‘solely’:

“It is obviously a counsel of perfection but seems to me advisable that any judge appraising witnesses in the emotionally charged atmosphere of a contested family dispute should warn themselves to guard against an assessment solely by virtue of their behaviour in the witness box and to expressly indicate that they have done so.”

…

28…There will be cases where the manner in which evidence is given about such personal matters will properly assume prominence. As Munby LJ said in Re A (A Child) (No. 2) [2011] EWCA Civ. 12 said at [104] in a passage described by the Judge as of considerable assistance in the present case:

“Any judge who has had to conduct a fact-finding hearing such as this is likely to have had experience of a witness - as here a woman deposing to serious domestic violence and grave sexual abuse - whose evidence, although shot through with unreliability as to details, with gross exaggeration and even with lies, is nonetheless compelling and convincing as to the central core… Yet through all the lies, as experience teaches, one may nonetheless be left with a powerful conviction that on the essentials the witness is telling the truth, perhaps because of the way in which she gives her evidence, perhaps because of a number of small points which, although trivial in themselves, nonetheless suddenly illuminate the underlying realities.”

Still further, demeanour is likely to be of real importance when the court is assessing the recorded interviews or live evidence of children. Here, it is not only entitled but expected to consider the child’s demeanour as part of the process of assessing credibility, and the accumulated experience of listening to children’s accounts sensitises the decision-maker to the many indicators of sound and unsound allegations.

That a witness’s dishonesty may be irrelevant in determining an issue of fact is commonly acknowledged in judgments…in formulaic terms:

“that people lie for all sorts of reasons, including shame, humiliation, misplaced loyalty, panic, fear, distress, confusion and emotional pressure and the fact that somebody lies about one thing does not mean it actually did or did not happen and/or that they have lied about everything”.

But this formulation leaves open the question: how and when is a witness’s lack of credibility to be factored into the equation of determining an issue of fact? In my view, the answer is provided by the terms of the entire ‘Lucas’ direction as given, when necessary, in criminal trials.

Chapter 16-3, paragraphs 1 and 2 of the December 2020 Crown Court Compendium, provides a useful legal summary:

“1.

A defendant’s lie, whether made before the trial or in the course of evidence or both, may be probative of guilt. A lie is only capable of supporting other evidence against D if the jury are sure that:

(1)

it is shown, by other evidence in the case, to be a deliberate untruth; i.e. it did not arise from confusion or mistake;

(2)

it relates to a significant issue;

(3)

it was not told for a reason advanced by or on behalf of D, or for some other reason arising from the evidence, which does not point to D’s guilt.

2.

The direction should be tailored to the circumstances of the case, but the jury must be directed that only if they are sure that these criteria are satisfied can D’s lie be used as some support for the prosecution case, but that the lie itself cannot prove guilt. …”

Lies, however deplorable, are significant only to the extent that they affect the welfare of the child, and in particular to the extent that they undermine systems of protection designed to keep the child safe.”

Had the local authority proved that the injuries were inflicted as opposed to being accidental?

If the injuries were inflicted, who had the opportunity to cause them?

Of those people, could one person be identified on the balance of probabilities as having inflicted the injuries (a conventional 'known perpetrator' finding)?

If only two people…could have caused the injuries, but the one responsible could not be identified it necessarily followed that there was a real possibility that each of them may have caused the injuries (an 'uncertain perpetrator' finding).

Standing back from these three authorities, there is a distinction to be drawn between those cases where continuing direct sibling contact is considered to be necessary for the child’s future welfare, and cases where the achievement of an adoptive home is the overarching goal, with future sibling contact being desirable as opposed to a pre-requisite. In the former circumstances (as in Re P and Re R) the court has ‘a responsibility’ to make a s 26 contact order.

From a range of perspectives, it is possible to discern a clear shift over recent years in the direction of travel in understanding the approach to be taken to the issue of post-adoption contact. This shift has been driven by research (from a social work and psychological perspective) into arrangements that best meet the complex and life-long needs of children who are to be placed for adoption. The direction of travel is well delineated in the detailed analysis given by Baker LJ in Re R. It is underpinned by the extensive research of Professor Neil and others (both domestically and internationally). It was described in detail and taken up in the recommendations of the PLWG, and, importantly, it is endorsed by CoramBAAF, which has recently enhanced the focus on arrangements for a child to ‘stay in touch’ with family members post-adoption.

The question of how this shift in understanding should be reflected, if at all, by the court in making orders under ACA 2002, s 26 is at the centre of this appeal, and it is a difficult one. The difficulty, in part, arises from the binary nature of a court’s decision whether to make, or not to make, an order, where the underlying factors are in essence subtle and, to a large extent, involve looking into the future when a key element of that future, namely the attitude of specific potential adopters, is a known-unknown. It is easy to understand how courts may opt to play safe and decline to make a s 26 order, when faced with the ‘default opposition’ identified by the ALC, but, as was submitted, a court should consider whether the evidence in the case before it establishes grounds for holding that would-be adopters are likely to be deterred or whether, as the ALC submitted, research does not, in fact, support that conclusion.

…

74...The position of potential adopters should not, to use Baker LJ’s words, obviate the court’s responsibility to set the template for contact at the placement order stage. There will be cases where the importance of preserving a measure of direct sibling contact is such that the court should stipulate that that is so in an order, rather than leaving it to the adoption agency and adopters to negotiate. In other cases, the comparative importance of maintaining contact will be secondary to achieving an adoptive placement, and making a formal order may not be justified.

…

Finally, in terms of general observations on this issue, I wish to endorse Ms Conroy Harris’ valuable suggestion that a form of s 26 order which recognised the importance of continuing contact, but allowed for a significant degree of flexibility, might be the most appropriate means of meeting a child’s needs in some cases. An express order for finite contact arrangements, specifying the number and circumstances in which it is to take place, may not be apt in some cases. Given the number of uncertainties in play at the time that a placement order is being made, a more flexible statement of the road map for future contact that the court has determined for the child may well be more appropriate. In such cases, rather than having an order for contact in concrete terms, the court might record its views, and its endorsement of the future contact plans, in a recital to the placement order.

What type of harm has arisen and might arise?

How likely is it to arise?

What would be the consequences for the child if it did?

To what extent might the risks be reduced or managed?

What other welfare considerations have to be taken into account?

In consequence, which of the realistic plans best promotes the child’s welfare?

If the preferred plan involves interference with the Article 8 rights of the child or of others, is that necessary and proportionate?

The child had suffered and/or was at risk of suffering significant emotional and physical harm as a result of:

The Mother has two older children from previous relationships, and they do not reside in her care. The Mother was a party to other proceedings involving the half-sibling of Charlie and accepts that a PAMS Parenting Assessment of her was negative. The court made a final care order with the half-sibling of Charlie being removed from her care and placed in local authority care following concerns of exposure to domestic abuse, poor parental mental health and physical and emotional neglect.

The Mother accepts that her two older children both sustained unexplained injuries due to lack of adequate supervision whilst in her care and there were delays in the Mother seeking medical treatment for the children.

The child had suffered and/or was at risk of suffering significant harm in the form of neglect and emotional harm as a result of:

The Mother’s poor mental health affects her ability to provide safe and consistent care [to] Charlie.

The Mother accepts that Charlie is at risk of neglect arising from being unable to sustain her own tenancy following being evicted from her housing association property due to rent arrears. The Mother has failed to prioritise finding a stable and suitable home for Charlie and at the relevant date has no fixed abode.

Between 10pm on 14 October 2025 and 4.57pm on 15 October 2025 Charlie sustained an acute non-displaced spiral fracture of the lower end of his right humerus.

The expected mechanism of the injury identified in paragraph 3 is sharp twisting of the right arm by some force acting on the right forearm, or rotation of the arm around the back and the traumatic energy required is unlikely to arise out of reasonable normal handling of a child of Charlie’s age.

Charlie does not present with any underlying medical conditions to explain the injury, nor the propensity to sustain the type of injury referred to in paragraph 3.

The injury referred to in paragraph 3 would have caused Charlie severe pain immediately after the injury was sustained.

The Mother was the only person other than professionals having unsupervised contact with Charlie at the time he sustained the injuries referred to in paragraph 3. The Mother is not suggesting that anyone else was responsible for the injury to Charlie.

The Mother placed Charlie with the foster carer on her own for a period of time on 15 October 2025 for about an hour, the foster carer had Charlie on her own downstairs and the Mother was checking Charlie at regular intervals and could hear if he screamed.

The Mother’s account that when rolling Charlie would sometimes catch one arm under his body and twist to try and get himself moving has been discounted as the likely cause of the injury referred to in paragraph 3 and on the available literature evidence it is not possible to reasonably support the plausibility of the rolling over mechanism being the cause of the injury referred to in paragraph 3.

The Mother is under investigation by the police for assaulting Charlie, namely causing him grievous bodily harm with intent. The Mother exercised her right to silence when interviewed under caution and refused to disclose her mobile phone PIN code which has unreasonably delayed the investigation.

Dr Mohamed in his addendum report opines given that the exact mechanism was not sufficiently witnessed, which leads to a number of unknown parameters that could potentially relate to the injury it is not possible to completely exclude a combination of factors primarily led by the fall from a height being the cause for the fracture.

[E89]

Fracture of the humerus would have resulted in severe pain immediately after the injury was sustained, and it would have caused Charlie to scream/cry uncharacteristically for at least a minute or two. This would have been a memorable event and would have caused considerable alarm to any carers who were in the vicinity.

[MEDB254]

Mum reports she is unsure how this could have happened - has not had any falls, rolled off anything, or had any injuries today. Has not had any difficulties dressing him etc has not left him alone so does not know how this has happened

[H110]

Mother then volunteered her account to me, I did not ask any questions but she told me that she went to the bedroom with Charlie once I had left the address yesterday, Charlie fell asleep on her and woke a couple of times but settled himself. Then the third time Charlie woke, he was crying and wouldn’t settle.

[A68]

I've spoken to my solicitor and there's information that I've not given you and my solicitor has said I need to share with you and the police. Could you call me back or ask someone else to call me back please?

[H110]

…I attended a legal planning meeting with our solicitor X. During the meeting X had an email come through which she read out to me, she had received the email from Mother’s legal representative. The email explained that Mother has told her legal representative that Charlie

rolled off the bed on the morning of Wednesday 15th October 2025 but she did not tell anyone

because she knows he should not have been on the bed by himself and was worried about getting into trouble.

[H102]

During conversation at around 17:40 hours whilst under arrest, Mother said words to the affect of “I TRIED TO SAY THREE TIMES I WOULD COME IN” “IS THIS WHY THE SOCIAL WORKER WOULDN’T TALK TO ME” and “THERE IS SOMETHING THEY DON’T KNOW THAT I NEED TO TELL

THEM”. Mother signed this significant statement in my e-pnb at 18:42 hours when at the police station [see H99].

[C75]

32… Charlie fell asleep on me.

Charlie napped for about 45 mins/1 hour. When Charlie woke, he started crying as soon as he woke up. I tried to settle Charlie and after about 10 minutes, FC came up and knocked on the door, offering to help.

[C75]

Charlie had fallen asleep on me but my phone was on the other side of the room, so I put him down on the bed and walked across the room to get my phone. The duvet was not on the bed as I had put it on the floor ready to change the covers. As I turned around, I saw he had woken up and he was rolling off the bed. I accept I completely froze in shock, and watched as he fell off the bed onto the floor… He cried for about a minute or so, but I was able to comfort him.

…

I accept I did not mention Charlie falling off the bed to anyone until 16th October, when I told my solicitor and the Social Worker. I regret this but I was worried that I would be in trouble for letting him sleep on the bed on his own. I also didn’t think that the fall was the cause of his painful arm...

He was asleep on her chest;

He might have slept on his arm;

He had not suffered any falls or rolled off anything;

She did not know how the injury occurred;

He woke a couple of times and then on the third occasion was crying and would not settle;

He had not had a fall;

She did not know how the injury occurred;

There is information she has not disclosed;

He rolled off the bed;

No comment;

He cried when he woke up; and

He rolled off the bed.

I’ve retraced my steps and there was time between injury and writing my witness statement. Andy Collins [former social worker] came to speak to me and then says I went to get a phone charger to get bank statements and surely he told me that when he came, must have been there to get bank statements

I can’t say for certain, I think that could be a possibility

I always thought it was 10am but once I heard [foster carer’s] evidence heard him crying at 8am and later in the afternoon I retraced steps and came to conclusion likely it happened afterwards but I’m not saying for definite because I don’t know

Andy came to speak about bank statements and my first statement says I was going across room to get bank statements and Andy hadn’t had conversation about bank statements until that afternoon.

[E69]

It is generally agreed that a fracture of a long bone in an infant most likely is caused by forceful, unnatural shearing, twisting and/or bending across the level of the fracture, or by direct impact[1].

Being spiral-shaped Charlie’s fracture must have been caused by a twisting force. There must have been some force acting on the right arm which produced a torque in the upper-arm bone. Bowing, sharing or direct impact would not produce a helical fracture line.

The types of forces that are relevant:

A force acting via the forearm to twist the arm while the elbow is bent; and

A force that rotates the arm around the back while the elbow is straight.

[E70]

Hence, long-bone fractures are unlikely explained by any manoeuvre that conveys the energy that is produced by reasonable handling.

Self-infliction of fractures in infants must be very rare but not impossible. For example, mobile infants can push themselves to fall off furniture. The following may also be of relevance to upper-arm fractures.

Somers and coworkers[4] reported seven cases, all children from 4 months to 7 months old, where they considered it possible that an isolated fracture of the shaft of the upper arm bone could have been self-inflicted by the child rolling from a front-down to a back-down position trapping the arm behind them during the roll. But the authors of the study stress that "this case series alone should not be used in the court process as indicative of any form of proof that this mechanism is a credible explanation for a humeral fracture". The Somers study has been criticised, but only from theoretical vantage points. Specifically, it has been claimed that the magnitude of force arising from rolling would be insufficient to cause a fracture. However, there is no firm scientific proof either way.

It is not possible radiologically to prove exactly how any fracture was sustained. Accidental fractures are very rare in infants, which is why the likelihood of non-accidental causation is high in any case of infantile fractures. However, accidental fractures do occasionally occur and each case therefore needs to be assessed by its own evidence. It is therefore in my opinion important for the Court to be aware of the Somers study. The study may be controversial, but it does in my opinion show that fractures of the upper arm may possibly be self-inflicted by rolling albeit a rather unusual fracture mode.

…

The far most likely cause, a-priori, is the application of such force by external agency; however, one cannot entirely dismiss the possibility that a solitary spiral fracture of the upper-arm bone may have been self-inflicted through rolling and/or falling. I cannot provide any differential likelihood for any specific fracture by way of its radiological features. I believe that to be the province of the Court, and the opinion of the Court’s paediatrician will clearly be valuable.

[E71]

According to the mother (C75), Charlie had rolled off the bed on 15.10.2025, either onto the floor or onto some bedding that was on the floor.

Since the fracture was caused by twisting, whether he landed on the floor or on some bedding probably makes little difference. The important question is whether his right arm had twisted, be it when he rolled or when he landed. If it did, then this event needs to be considered a viable explanation for the fracture, in my opinion.

[E93/7.10.1]

There is no mention of any ongoing distress following this incident. Subsequently, I note from the statement of the foster carer that Charlie was able to use both his arms until he went back with his mother upstairs. Considering this information, the likelihood that the fracture was caused by the fall at 8 AM can be excluded.

[E93/7.10.2]

…the potential explanation of Charlie getting his arm caught under his body would not be compatible with the injury.

[E105/7.2.1]

the humerus is unlikely to come under any stress or strain when rolling over from supine to prone position as there would be no natural restriction of the shoulder movement in this manoeuvre. Therefore, while this selective case series does raise an important question regarding the possibility of a humerus fracture occurring from such a mechanism, the authors had themselves acknowledged that without definitive proof, this concept remains a contentious issue in that it is an unproven theory rather than accepted fact. Furthermore, as explained in my previous report, prompted by the Somers paper, a computer model assisted study that was undertaken to experimentally assess the possibility of fracture occurring in cadaveric humerus of infants of similar age found that the maximal strain generated by this manoeuvre was less than the equivalent force required to cause fracture. Therefore, based on the available literature evidence, it is not possible to reasonably support the plausibility of the rolling over mechanism being the cause for the fracture.

it is not possible to completely exclude a combination of factors primarily led by the fall from a height being the cause for the fracture.

If the account provided by FC, if that is accepted as true by the court then it would narrow the time window for fracture. FC says using both arms, equally says gave some cheese and bread, fed him and subsequently put both arms up and that would not be consistent with having sustained a fracture at that time, it was on the right upper arm and if sustained within the previous 12 hours he would not have been able to lift that arm.

[C76]

39...I also didn’t think that the fall was the cause of his painful arm, because he had been fine after the fall and only started to get upset later in the day after the Social Worker had visited and he had napped.

[E68]

The most important observation is that there was no sign of healing on 15.10.2025. The fracture was only partially included in the imaging on 17.10.2025, but there was no evidence of healing where the fracture could be observed.

Hence, the last date on which no sign of healing could be observed was 17.10.2025.

It follows both from clinical experience, and from the Prosser model that

The fracture was recent at the time of presentation, so it could have occurred as recently as 15.10.2025; while

The fracture was unlikely more than 2 weeks old on 17.10.2025.

My opinion is therefore that the fracture more likely than not had occurred on or after 03.10.2025.

[H180]

C crying upstairs offered help. Fed C yoghurt as seemed hungry. Not using (R) arm when sat in highchair. Screamed when I sat him up. Offered celery to chew. Called 111 @ 16.55

Taking it from (L) hand

M reports C has been asleep on her chest.

[MEDB254]

Today, sat with social worker until 3pm, seemed well. Mother went upstairs with Charlie, FC heard him crying, went up after 10 minutes. Charlie crying ++, brought him down and sat in high chair, screamed on touching right arm, not moving it

[H114]

Charlie was grabbing at everything with both hands and was happy and content. He was grabbing my sandwich and bringing both hands up to his mouth without raising any concerns. At some point during the conversation, [FC partner] popped downstairs and came into the kitchen, when he did he spoke to Charlie and Charlie raised both of his arms as response to seeing [FC partner] which is a normal thing for Charlie to do when he is around people he is familiar with and Charlie loved [FC partner].

[H109]

During the visit, Charlie showed no signs of discomfort, he was seen sitting on [FC?]s knee with his right side up against her and showed no sign of being in pain, Charlie was also seen using both arms freely.

[H114]

[Charlie’s social worker] left the house at about 1445hrs.

Mother took Charlie back upstairs after [the social worker] left. I had the baby monitor downstairs in the kitchen, whilst I was in the lounge. The monitor was on loud so I could hear it from the lounge. Just after 1600hrs, Charlie had been crying and it went on for about 10 minutes before I went upstairs and checked on Mother and Charlie. There was something different about his crying and I cannot explain what it was. It just made me get up and want to check on him.

I knocked on the bedroom door and Mother came to the door with Charlie on her left hip. I asked Mother if she needed any help and Mother replied that Charlie had been asleep on her. I looked at Charlie and he was bright red, crying and taking sharp intakes of breath, the kind people do when they can’t catch their breath. I have never seen Charlie get like this before and it worried me.

…

I then carried him downstairs and he settled a little bit with some rocking, but kept taking the sharp intakes of breath for a while afterwards…I thought Charlie might be hungry so I put him in the highchair. When I placed him into the highchair, I had my left arm around his tummy and right hand on his bottom to guide his body into the plastic high chair seat. At this point I had still not touched his arms.

…

It was while he was eating that Charlie slipped to one side. I straightened him by putting my open palms on each of his shoulders and gently moving him to sit upright. Charlie made a piercing scream and I instantly let go wondering what I had done. I initially tried to soothe him, the noise was awful, I have never heard him make this noise before, I will never forget it.

[H115]

I washed a piece of celery and he took it with his left hand and started chewing on it. I took it off his left hand and moved it towards his right hand and he did not make any attempt to use this arm. He will usually always grab things with both hands to go in his mouth but on this occasion he only used is left hand.

[E89]

Fracture of the humerus would have resulted in severe pain immediately after the injury was sustained, and it would have caused Charlie to scream/cry uncharacteristically for at least a minute or two. This would have been a memorable event and would have caused considerable alarm to any carers who were in the vicinity. Subsequently, he might have continued to have intermittent low-level crying/wincing for a variable period of time that would have lasted at least 20 to 30 minutes. There might have been loss of function of the affected limb…

[E91/7.5.1]

His carer would have also been able to notice a difference in the movements between his upper limbs with a reduction on the right side or the unusual way the right arm was being kept such as being extended (straightening of the elbow) and being floppy and less active whenever he was picked up. These symptoms would have been noticeable for about 24 hours..

[C72]

Charlie was not a baby who cried a lot, but I accept that on the odd occasion if I was unable to settle him for a while, I would start to feel a little bit stressed. I think it is normal for most new parents to feel a little stressed when a baby won’t settle, and I had the added pressure of being monitored in a foster placement. I would never get to the point where I was getting

angry with Charlie.

…

On 29th September, having looked at the foster care logs, I note it says that Charlie was unsettled and that I had a discussion with FC about this. I do remember having discussions with FC about feeling a bit stressed when Charlie was unsettled, but as I have said above, I don’t think my stress levels were anything out of the ordinary, given the situation.

[A58]

Can you ask your manager if I'm allowed any time away from placement for example I go and stay at my mums or sisters for a weekend? I've been in placement 7 months now and its starting to make me overwhelmed and stressed and I need a break from placement can you ask if it's a possibility please

[H112]

I would described Mother as occasionally being overly confident with Charlie and can be a bit rough when holding or handling him. By this I mean that her handling would be appropriate for a toddler but Charlie is still only 7 months old and therefore needs to be handled more gently [sic].

[H113]

Charlie is currently teething and so he is a bit more unsettled than normal…On Tuesday 14th October 2025 Mother had, what I would describe as an emotional wobble. I have seen Mother like this before, however I wouldn’t say this is a common occurrence.

…

Social services are looking at placing Mother and Charlie on a housing list for her to live independently with Charlie. Because of this I had found her a TV for sale and had collected it from a neighbour for her. I told Mother what time she needed to be ready to go and collect the TV. She wasn’t ready so I ended up going to collect it myself. When I got back to the house, Mother was getting ready to head out and Charlie was in the buggy.

I came back with the TV and handed it to Mother. She took the TV upstairs and I walked upstairs in front of her to open her door. When I opened the door, Mother said “I don’t want to be in this placement anymore, I can’t do this anymore”. Mother walked back downstairs with the TV and was clearly dysregulated.

[C74]

I do remember offering to carry the TV upstairs and when we went up, I remember getting upset and saying to FC that I wasn’t sure I could do it anymore. What I meant was that I wasn’t sure I could stay in placement anymore. It had been a very busy time as I had been trying to get paperwork up together for housing, as well as other admin tasks and caring for Charlie. It was difficult being in a placement and feeling monitored and this was with the Court proceedings in the background, and the worry that goes with that. I recognise now that I was just having an off day.

…

FC was gone for about half an hour and it was enough time for me to get myself together. When FC got back, I was feeling better.

I remember speaking to FC about my mental health on this day and questioning whether I should go to the GP. We discussed whether this was just stress because of the situation in relation to housing, or whether it was a deeper issue. Reflecting back, I think I was feeling overwhelmed and stressed at the time because of the extra things I was having to do, rather than it being anything more than that…

[H113]

The following day, Wednesday 15th October 2025, Mother came downstairs much later than normal, between 1000hrs and 1100hrs. Mother usually comes downstairs between 0900 and 1000 hours but this is dependent on other factors.

Earlier in the morning I heard Charlie crying around 0800hrs which is not unusual. At this time, I was upstairs in my bedroom, which is the room next door. The crying was heard via the monitor and through the bedroom wall. X came downstairs and into my bedroom and asked if I could hear Charlie crying and then the crying stopped.

Charlie cried for about 10 minutes in total which is about the amount of time it roughly takes for a bottle to be made and cooled. I would have expected Charlie to have settled once he had the bottle, which he did.

…

When Mother did come downstairs with Charlie, she was unable to tell me how many feeds Charlie had had during the night or what quantities he’d had. This was very unusual. Each morning we normally have a chat about the night feeds and how Charlie was and Mother can usually tell me the timings and the quantities. This can be seen in the daily notes I have given Police. Mother said she’d had a very disturbed night and that Charlie did not sleep very well but had eventually gone back to sleep. I thought this was a bit odd because when Charlie does cry during the night, I hear him. Our bedroom is next door to Mother’s and I am very in-tune with Charlie’s cries and noises. I did not hear him overnight.

Around lunch time, Charlie was a bit unsettled so I offered to take him downstairs. Mother stayed upstairs. Mother doesn’t cope too well with Charlie crying for prolonged periods of time. When this happens, Mother can become slightly irritated and use phrases such as ‘oooh Charlie’.

[C74]

I remember having had a bad night with Charlie, he didn’t sleep very much and was refusing his bottle.

[C75]

At 8am I was trying to get Charlie to have his milk but he was crying and refusing it, which is unusual for him. I thought he might have been teething…

[F166]

Mother did not ring the hospital or FC despite remembering [the rolling off the bed incident] and instead spoke to her solicitor the next morning. Mother said she wasn’t sure why she didn’t tell the hospital that evening despite remembering.

There do remain a number of concerns, including that Mother does experience some difficulties in being able to recognise her emotional state, and indeed concerns as highlighted in the case documents regarding her friendship with an individual who may pose a risk to children, with her also reporting that Charlie’s father was a casual encounter, describing that she considered there were ‘no red flags’, despite having met once and returning to his residence. In the context of her history, this does indicate that Mother may continue to experience difficulties in recognising and understanding risks that may be posed by others.

[F165]

Given Charlie’s level of vulnerability as a young infant, the failure to seek reassurance or assessment represents a missed opportunity to ensure his immediate safety and wellbeing and

suggests that Mother’s understanding of risk and thresholds for medical intervention may be compromised when weighed against her fear of professional involvement.

[F165]

it is clear that she already understood both the risk and the potential consequences of her actions. Despite this awareness, she made a conscious decision to proceed, indicating that the concern lies less with knowledge and more with judgement.

He would talk about problems and he was a man, slightly older than me I think and he was a man that probably is well off, I know he is, would talk about problems and he would send me money

He sent £4,000-£5,000 over 5 years

That was continuing up to October 2025

He would send me money and then the conversation would stop for a couple of months and when I spoke to him I would say I loved him.

[Paragraph 56]

Charlie will likely have enhanced emotional needs as he grows up, because of his early childhood experiences, and he may need therapeutic support in the future to support his emotional recovery. This is something his long-term primary carers will need to be alert to, as his needs evolve.

[E3]

Mother is functioning in the borderline range of adult intellectual ability and, whilst not meeting the criteria to be described as having a learning disability, may experience some difficulties relative to her peers in performing certain daily tasks and adapting to new or novel circumstances.

Mother has demonstrated evidence of significant improvement relative to her history regarding her ability to regulate herself emotionally, as well as to communicate in a more effective manner and to draw upon support provision. There do remain a number of concerns, including that Mother does experience some difficulties in being able to recognise her emotional state, and indeed concerns as highlighted in the case documents regarding her friendship with an individual who may pose a risk to children, with her also reporting that Charlie’s father was a casual encounter, describing that she considered there were ‘no red flags’, despite having met once and returning to his residence. In the context of her history, this does

indicate that Mother may continue to experience difficulties in recognising and understanding risks that may be posed by others. At this stage, there remains a real risk that at times she may experience difficulties in recognising her own needs, including a deterioration regarding her mental health, and therefore difficulties in her emotional availability for Charlie.

…

[E14/23]

…there are ongoing difficulties in addressing life stressors in a proactive and adaptive manner at times.

Therefore, in my view, there is a real risk that during periods of a deterioration regarding Mother’s mental health, a child in her care is exposed to inconsistency in Mother’s ability to respond to their needs or indeed to recognise their needs at times. There is, however, a reduced risk that a child in her care would be exposed to significant emotional dysregulation and in particular Mother is better positioned to be able to express her needs and draw upon support relative to her previous difficulties. However, I would also raise concerns that Mother may expose a child in her care to other individuals that may pose a risk, although to some degree

this is untested, given that she reports that she has not been in an abusive relationship for around two years..

[F41]

Mother’s history of parenting her older children is complex and deeply concerning. Those children experienced significant neglect, exposure to frightening experiences, and a lack of consistent, emotionally attuned care, which contributed to their emotional and behavioural difficulties. This context cannot be overlooked when assessing her current parenting.

It is also important to recognise that Mother is a vulnerable adult with a history of trauma, including a difficult childhood and abusive relationships. These experiences have impacted her ability to understand and meet the needs of her children in the past. However, in the context of her parenting of Charlie, this assessment has considered whether it is now safe and proportionate to recommend that Mother and Charlie be given the opportunity to live together in the community with ongoing support. The evidence suggests that, with the right level of structured, sustained intervention and monitoring, this may be a viable option.

…

10.6…Throughout the Parent Assess scoring, Mother is evidencing good knowledge across the areas, but needs to implement this into daily life.

[F42]

10.7…she has applied learning from the carer and professionals involved, and at present, Charlie’s needs are being met in this structured and supportive environment.

…

While there is evidence of meaningful progress and a foundation upon which to build, any recommendation for Mother and Charlie to live together in the community must be approached with caution and underpinned by a robust, multi-agency support and safeguarding plan, with clear contingencies in place.

Whilst Mother appears to be in a more stable and reflective place, it is important to acknowledge that her childhood trauma, ongoing anxiety, and difficulties with emotional regulation are likely to be tested further once she transitions into independent living.

…

10.12…I recommend that Charlie continues to live with and be cared for by Mother, and that they transition into independent living with the ongoing involvement of the safeguarding team.

[F160]

A finding that the injury occurred whilst Charlie was in the care of the mother, that the mother’s description of an accident [i.e. rolling off the bed in the morning on 15 October 2025] does not adequately account for causation of the injury and that it is not possible for the court to determine whether it was either in the circumstances of an undisclosed accident or by some other, undisclosed non-accidental mechanism.

[F161]

…there are no concerns with Mother’s family time with Charlie and that it is a positive experience where she is able to meet his needs.

[F162]

… if the Court decides Charlie can return to her care, she will need housing support again, similar to the support offered at the end of her mother and baby placement.

[F163]

While it is recognised that caring for a baby who is crying is inherently stressful and that most parents will experience periods of heightened pressure, this was an identified area of concern within my first assessment regarding how Mother manages stress. At that time, I expressed worry about Mother’s ability to cope during periods of sustained pressure, particularly when caring for a young baby. Despite Mother being placed in a mother and baby placement, which provides a significantly higher level of support than would be available to her in the community, Mother reported feeling stressed and overwhelmed and stated that she felt she was not getting a break. This was despite Mother having told me that FC, the foster carer, would provide her with breaks and practical support when needed…This is particularly significant as the level of support available within the placement exceeds what Mother would realistically have access to in the community, raising ongoing concerns about how Mother would manage stressors independently and the potential impact of this on her ability to safely care for a child during periods of increased pressure.

[F164]

3.15…I asked Mother how much of the response to Charlie’s first injury [a bruising injury identified in May 2025], and social care knowing that he fell off the bed, prevented her from telling anyone what happened through fear of being persecuted. Mother told me “quite high. But if I had any suspicions he was hurt, I would have told someone. I regret it.”

When considering this in the way in which Mother recalls events, I am concerned that Charlie did not receive any medical advice, professional reassurance, second opinion, or even a precautionary check following the fall [in the morning on 15 October 2025] as Mother describes, particularly given his age and subsequent unsettled presentation.

[F165]

3.16…Mother has acknowledged that her previous experience of statutory intervention following Charlie’s earlier injury had a ‘quite high’ impact on her decision-making, indicating that fear of further scrutiny or perceived punitive responses from professionals influenced her judgement. This raises concern that Mother’s anxiety around social care involvement may act as a barrier to her seeking timely medical advice for Charlie, even when there is a clear incident or indicators that would warrant this to be in his best interests. Given Charlie’s level of vulnerability as a young infant, the failure to seek reassurance or assessment represents a missed opportunity to ensure his immediate safety and wellbeing and suggests that Mother’s understanding of risk and thresholds for medical intervention may be compromised when weighed against her fear of professional involvement.

[F167]

4.2…observed throughout the assessment is an ongoing difficulty with decision-making under pressure. While Mother demonstrates some insight in hindsight, particularly in acknowledging responsibility and expressing regret, her ability to apply this knowledge consistently in real-time situations remains a concern. This aligns with earlier findings that identified judgement, rather than knowledge deficits, as a central issue.

[F171]

The absence of a clear and reliable explanation for the injury, combined with delayed disclosure and Mother’s acknowledged difficulty prioritising safeguarding responses and parenting decisions when under stress, limits professionals’ ability to fully assess risk. The uncertainty surrounding causation, alongside concerns about judgement and seeking support and advice as required, has implications for Charlie’s safety. In this case, I would not recommend that Charlie is returned to Mother’s sole care.

Significant Children’s Social Care involvement with older half-siblings [C8];

Concerns about the Mother’s attachment style and its impact on parenting capacity [C8];

Risk of neglect arising from the Mother struggling to cope with the challenges of full-time parenting [C9];

Risk arising from lack of settled housing [C9]; and

Risk arising from unsafe adults [C9].

[C229]

A Placement Order would enable the Local Authority to progress with an adoptive placement, offering Charlie the opportunity to grow up within a safe, secure, and nurturing family environment that is committed to meeting his needs throughout childhood and beyond. Adoption provides the highest level of legal and emotional permanence, reducing the risk of future placement disruption and offering a clear and stable plan for Charlie’s future.