Kent County Council v M & Ors

This hearing was listed as a combined Fact Find and welfare hearing for A. A is currently in local authority foster care subject to an Interim Care Order. For reasons which will become apparent, and which have contributed to this very lengthy judgment, the welfare aspect of the hearing has necessarily been adjourned to a later date. This hearing therefore proceeded as a fact-find only, with Week One in relation to B (the half-sister of A) and Week Two in relation to A herself. A further two days were necessitated given the way in which the evidence emerged from staff employed by the intervenor, Savannah Lodge, and I considered that it was important that each parent had a full day to give their evidence in light of their cognitive profiles. I apologise again for the length of this judgment, but in the circumstances of the case and so that the parents have a document to return to should they wish to, it has become unavoidable.

The application is brought by Kent County Council, represented by Ms Porter and Ms Clubb of Counsel. The Respondent Mother is M, represented by leading Counsel Mr Woodward-Carlton together with Ms Rainsford of Counsel. The Respondent Father is FA, represented by leading Counsel Ms Lewis, together with Mr Chippeck of Counsel. The child A is represented through her Guardian Ms Bradley and Ms Pryor of Counsel. At the PTR hearing, the court joined Savannah Lodge as intervenors and they are in attendance represented by Ms Kelly of Counsel. I commend the advocates at the outset for the sensitive and professional way in which they have conducted this case.

Given the nature of the case, which involves A’s half-sister, the non-subject child B, many witnesses appeared remotely via video link throughout the hearing. Other witnesses, parties and advocates were variously allowed to attend remotely at different points. The court was satisfied in endorsing these arrangements that the hearing was able to proceed effectively and that no party was disadvantaged by remote attendance. The court has done all it can by way of participation directions and ground rules for the conduct of the hearing to ensure the hearing is fair.

The background to the case is lengthy and complicated. The court is asked to make findings as set out in the revised schedule of allegations. In relation to B, this was a more straightforward exercise. Insofar as A is concerned, at the conclusion of the evidence from Savannah Lodge, it was confirmed by the Local Authority that they no longer sought to rely on any evidence at all from Savannah Lodge in relation to A, and only relied upon the CCTV footage which the court could view independently and which stood on its own merits. The allegations in relation to A therefore are considered against the expert medical evidence, the CCTV footage and the evidence of the parents themselves. There is a Concessions Document from Savannah Lodge as a consequence of concerning evidence in which they accept some failings on their part, and which I have incorporated into this judgment and address in due course.

Importantly, it is noted that the Local Authority commissioned a cognitive assessment of both parents by occupational psychologist Mike Crimes dated 17 January 2025. Mike Crimes concluded that Mother’s full scale IQ is 72, therefore in the borderline range. Mother was identified as having poor verbal comprehension skills, poor working memory and borderline processing speed. In relation to FA, his full scale IQ is 75, falling within the borderline range. He was identified as having low average verbal comprehension, low average perceptual reasoning, low average processing speed and extremely low working memory. The Mother had the benefit of an intermediary throughout proceedings, including for her meeting with her solicitors to review the CCTV footage. During the hearing when the parents gave their evidence, screens were pulled half-way across the court room not as special measures but as a means through which to reduce the pressure upon the parents resulting from the multiple pairs of eyes of the large number of people within the courtroom. Every effort was made to ensure that the parents could participate effectively and give their best evidence.

M was first introduced to FA when she was 4 years old at the time, as FA worked alongside MGF and FA was close friends with M’s parents (there is a 22 year age gap between FA and M). It is said that FA babysat M and her siblings when they were children and M shared memories of their summer activities, dinners and being collected by FA. Despite M’s family being aware of FA’s time in prison for harming his own child, FA continued to look after M as a child. FA recalled M’s parents visiting him when he was serving a custodial sentence in prison. Information received from Kent Police highlights FA has a concerning history of 13 convictions for 20 offences, including offences to both adults and children.

In 2002 there were care proceedings in relation to FA’s eldest child, D . Findings were made that D had sustained the following non-accidental injuries inflicted by FA (a) a spinal fracture to the right humerus; and (b) periosteal shearing injuries to the right radius, right tibia and fibula and left tibia.

Within those care proceedings FA was assessed by Dr Lachlan Campbell, Consultant Forensic Psychiatrist, who reported on 10 March 2003. The report noted that it seemed unlikely he was suffering from any major psychiatric disorder at that time. He reported having blank spells in which he has difficulty in remembering, which Dr Campbell said were rather suggestive of episodic emotional over arousal. There is also a psychological assessment of FA by Dr Lori Beth Bisbey.

On 16 April 2004 (when M was just short of her 6^th birthday), FA received a prison sentence of 2 years at Maidstone Crown Court for the injuries to D. The PNC does not reveal the plea, but the care proceedings papers say FA had pleaded Not Guilty. The father continues to dispute that he caused the injuries to D, even in these proceedings.

The parents in these proceedings started a relationship in 2022. The Mother relocated from Kent very early in the relationship, taking her two children with her, and moving into FA’s property.

On 21 March 2023 Mother’s daughters with a previous partner, B and C were registered on a Child Protection Plan due to concerns about physical and emotional harm, domestic abuse and parental mental health.

On 24 May 2023 a health visitor observed the following on B

B and C were placed in foster care. They were subsequently placed with their father, FBC, where they remain.

In July 2023, the Mother and FA were charged with offences in relation to the injuries seen on B. The police investigation concluded in January 2026 with no further action being taken against FA. The Mother had informed them that he had not had sole care of B, who had always been in her care. It is understood that the case against the Mother has been left ‘dormant’ for the time being by X police. Outside of the criminal investigation, there has been no investigation (which concluded either way) by Children’s Services in relation to B’s injuries to inform decisions about the children’s placement or the contact they should have with the Mother and FA (who was for a period of time their father-figure), and who remain in a relationship.

A was subject to a Child Protection Plan from 6 November 2024 as an unborn baby. There were concerns about A’s physical and emotional safety in the care of her parents. As set out above, there is a lengthy history of social services involvement concerning older children of both parents from previous relationships.

The then allocated social worker completed a pre-birth Parenting Assessment for the parents on 21 February 2025. She supported there being a parent and child placement to assess the ability of the parents to care for A and keep her safe in a highly monitored environment.

A Viability Assessment was completed on 13 March 2025 of the maternal grandfather and his wife, by a social worker from the kinship team. The assessor did not believe that the couple would offer a realistic option for A. During the PLO process, the Local Authority had made enquiries of other relatives and family friends as potential alternative carers (maternal great aunt, maternal grandmother and family friend), however no other person has put themselves forward for assessment.

The local authority were notified by Savannah Lodge on 31 July 2025 that A had been observed by staff at the residential placement with multiple bruises to her chest, back and pubic area, whilst supervising her being bathed by FA, on the evening of 30 July 2025. The parents were said to have given conflicting accounts as to how the injuries had been sustained.

Prior to this occasion, the parents had raised that they were concerned that there was a bite mark to A after she had been in the care of staff during their joint counselling session on 5 July 2025. It was reported that the mark on A faded and that there was no bruising or injury to A. Whilst the event of 5 July 2025 does not form part of threshold, it has played a significant role in these proceedings and I will detail the reasons further on.

A was taken to hospital by placement staff, accompanied by the parents, on 30 July 2025. The child protection medical report prepared indicated multiple bruises on the body of a non-mobile child which cannot be clearly explained by the history given from parents with a significant history around safeguarding children. The possibility of non-accidental injury was considered.

A strategy meeting was held on 31 July 2025 and the parents were arrested and their phones seized as part of the investigation. The parents were released on police bail with bail conditions not to have any unsupervised contact with A. Any supervised contact was to be agreed by Children's Services. Further, they were not to have any unsupervised contact with any child under the age of 16 save everyday inevitable contact unless agreed by Children's Services. In addition, Savannah Lodge gave notice in relation to the placement with immediate effect.

The investigation of Hertfordshire police is ongoing and it is understood that they have been in contact with X police regarding this incident and the information provided by the Mother in the parenting assessment; that she had previously left B and C in the sole care of FA despite informing X Police that he had never cared for them on his own.

A remained in hospital and was medically fit for discharge on 6 August 2025. On 6 August 2025 the Local authority placed A with a foster carer pending the hearing on 8 August 2025. The parents have supervised contact with A. In their evidence they told me how much that meant to them, seeing her growing and changing. The Local Authority’s plan was for A to remain in the care of a local authority foster carer following the initial hearing on 8 August 2025. The Court approved this care plan, with the parents not opposing it, and A currently remains placed with local authority foster carers.

The parents have said that as they have not caused the injuries to A it must have been one of the workers at the placement at Savannah Lodge. At the pre-trial review hearing, which was my first involvement with this case, I considered the question of whether Savannah Lodge should be joined as intervenors to the proceedings as a company, and so joined them. I also considered the question as to whether or not individual staff members should be intervenors or remain as witnesses, and at that hearing I took a proportionate approach, leaving them as witnesses only but allowing for them to have representation whilst giving evidence (should they so wish) and indicating that the question of each staff member being an intervenor would have to be reconsidered if required at the final hearing. The parents identified four staff members who were involved in A’s care. All of the workers denied having the sole care of A between the bath on 28 July 2025 and when the bruises were noted on 30 July 2025. Perhaps inevitably, the question of whether these witnesses needed to be joined as intervenors did indeed arise again, and I set out the difficulties below.

The Guardian at the start of this hearing had suggested that findings could be made against Savannah Lodge in relation to the way in which they supervised the placement and the safeguards put into place, which had clearly failed. I do agree with the Guardian’s view that it falls squarely within the remit of the Guardian to ensure that all the evidence is properly and fully explored on the basis that it is in the public interest and the interest of the child to establish the truth. Other parties were not seeking findings to be made against Savannah Lodge or staff members, and I indicated initially that I was not prepared to begin down that path as I was not conducting any sort of professional discipline hearing and the proportionate approach was to consider any shortcomings as “lessons learned”. As the hearing progressed, however, such issues became impossible to ignore and almost overshadowed the focus of the hearing (which was, of course, A) to the extent that much of the fact-find exercise in relation to A did indeed deal with the knowledge and training and actions of staff members which were woefully inadequate, if not so deficient as to be dangerous.

Savannah Lodge’s manager, EF, was present for the hearing and gave evidence on day 9, accepting that all of the shortcomings were ultimately the responsibility of herself and Savannah Lodge (“the buck stops with me”). Savannah Lodge were very ably represented throughout the hearing by Counsel, and being present each day were in the same position as everyone else hearing the evidence as it was delivered. At the close of the Local Authority’s case I heard submissions from the parties as to whether or not I can or should make findings against any individuals or Savannah Lodge as a company. I deal with this later, but certainly Ofsted need to undertake their own investigation regarding the events which transpired. I understand Savannah Lodge have self-referred, entirely appropriately, but given the issues of self-reporting which became apparent, this judgment is an essential document for Ofsted to consider.

For the avoidance of doubt, I say clearly that I am not intending to make findings or name any individual staff member at Savannah Lodge, including the managers. The evidence that ultimate responsibility rests with the co-manager/managers means I do not need to. Whatever the failings of individuals, it is Savannah Lodge as a company about whom my concerns are expressed.

I also make it plain that the issues I set out in due course about Savannah Lodge are so serious that, for the reasons articulated in this judgment, the court has strong concerns relating to the conduct and oversight of the staff at Savannah Lodge which may have wider implications for the safety of other children in the unit. On the face of it, these provide strong grounds for an urgent investigation by the regulator, which body should be sent a copy of the judgment, and which body has the statutory power to control and regulate the conduct of the service provided by Savannah Lodge.

It is not for the court to oversee any investigation by Ofsted or any regulatory body. However, such an investigation must take place, and the court will be informed by the outcome of that investigation in due course. I do set out my worries that A was harmed by being under the supervisory care of Savannah Lodge, and through the consequential delay caused to proceedings by the Local Authority being unable to rely on any evidence from Savannah Lodge. For some time now, A has been separated from her parents, and the circumstances of how that separation came about and the harm caused to A by that separation, is a matter for urgent regulatory investigation.

Mr. Justice Baker, as he then was, in Devon County Council v EB (2013) EWHC B44 (Fam) from paragraph 53 onwards,identified 10 important aspects he said the Court should keep in mind at fact-finding hearings. These are:

Further, in Re BR (Proof of Facts) [2015] EWFC 41, Peter Jackson LJ held as follows, at paragraphs 4-7:

In Re A (No. 2) (Children: Findings of Fact) [2019] EWCA Civ 1947, Peter Jackson LJ set out the questions for every fact-finder (paragraph 100):

In Re AA & 25 Others [2019] EWFC 64, Sir Mark Hedley, sitting as a High Court Judge, stated as follows:

In Re B (Care Proceedings: Standard of Proof) [2008] UKHL 35, [2008] 2 FLR 141, Baroness Hale considered the formula adopted by courts that followed from the judgment of Lord Nicholls in Re H and Others, namely 'the more serious the allegation, the more cogent the evidence needed to be to prove it'. Baroness Hale stated:

“[70] My Lords, for that reason I would go further and announce loud and clear that the standard of proof in finding the facts necessary to establish the threshold under s31(2) or the welfare considerations in s1 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.

[71] As to the seriousness of the consequences, they are serious either way. A child may find her relationship with her family seriously disrupted; or she may find herself still at risk of suffering serious harm. A parent may find his relationship with his child seriously disrupted; or he may find himself still at liberty to maltreat this or other children in the future.”

At paragraph 15 of the same judgment, Lord Hoffman observed that:

A judge considering non-accidental injuries always has to consider the whole picture before determining causation. The court must ask itself what was the context in which this alleged non-accidental injury came to be sustained and entertain the totality of the evidence before the court (Re B-T (Children) [2017] EWCA Civ 265). For example, an injury that might be accepted as accidental if it stood alone might take on a wholly different aspect if it is only one of a number of injuries (Re L-K (Children) [2015] EWCA Civ 830).

In assessing alternative possible explanations for a medical finding, the court will consider each possibility on its merits. There is no hierarchy of possibilities to be taken in sequence as part of a process of elimination. The court will not conclude that an injury has been inflicted merely because known or unknown medical conditions are improbable: that conclusion will only be reached if the entire evidence shows that inflicted injury is more likely than not to be the explanation for the medical findings (Re BR (Proof of Facts) [2015] EWFC 41).

The absence of any history of a memorable event where such a history might be expected in the individual case may be very significant. Medical and other professionals are entitled to rely upon such knowledge and experience in forming an opinion about the likely response of the individual child to the particular injury, and the court should not deter them from doing so. The weight that is then given to any such opinion is a matter for the judge (Re BR, above). A judge must demonstrate in his judgment the willingness to entertain that medical science might not have a definitive answer to each and every case, but there are some 'outlying' cases where the answer as to what has happened is simply unknown or, put more succinctly, not capable of proof on the balance of probabilities within care proceedings (Re B-T (Children) [2017] EWCA Civ 265).

Even where the medical evidence points to the injury having been sustained in a traumatic event, before reaching a conclusion as to causation, it is incumbent upon the court to consider the totality of the evidence, including the wider canvas evidence dealing with how likely it was that the parents would injure their child, how possible it would have been for either parent to have injured the child under the circumstances and the overall credibility of the parents and of their account of what had happened (ReA (A Child) (Fact-Finding: Head Injury) [2024] EWCA Civ 327, [2024] 2 FLR 709).

In Lancashire County Council v The Children and Others [2014] EWHC 3 (Fam) at

Any court conducting a finding of fact hearing should be alert to the danger of such a serious finding becoming 'a bolt on' to the central issue of perpetration or of falling into the trap of assuming too easily that, if a person was living in the same household as the perpetrator, such a finding is almost inevitable. As Aikens LJ observed in Re J (A Child) [2015] EWCA Civ 222, [2015] All ER (D) 229 (Mar), 'nearly all parents will be imperfect in some way or another'. Many households operate under considerable stress and men go to prison for serious crimes, including crimes of violence, and are allowed to return home by their long-suffering partners upon their release. That does not mean that, for that reason alone, that parent has failed to protect her children in allowing her errant partner home, unless, by reason of one of the facts connected with his offending, or some other relevant behaviour on his part, those children are put at risk of suffering significant harm. (Re L-W (children) [2019] 2 FLR 278).

The court should guard itself against making assessments of witnesses solely by virtue of their behaviour in the witness box. If the court attempts to determine whether a witness is telling the truth solely by their presentation in the witness box, the court risks making judgments that at best lack any rational basis and at worst reflect conscious or unconscious biases and prejudices. The only reliable approach is to focus on the content of the witnesses evidence and consider whether the oral evidence is consistent with other evidence that has been given, the evidence of others and with known or probable facts, (Re M (Children) [2013] EWCA Civ1170; see also Re J ( A Child) [2014] EWCA Civ 875).

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

As McFarlane LJ (as he then was) observed in Re H-C (Children) [2016] EWCA Civ 136 at §97:

Further, in assessing lies, the court must treat them with a sense of proportionality and must assess their significance in the overall context of the case: Re H (Children: Uncertain Perpetrator: Lies) [2024] EWCA Civ 1261, [2025] 1 FLR 893.

When assessing the forensic significance of a lie or lies told by a witness, a judge must do more than merely cite the case of R v Lucas; they must consider the probative weight to be attached to the lies in the context of the totality of the evidence, bearing in mind the Lucas principle (Re CK (A child: fact-finding) [2022] EWCA Civ 952 at [46]).

On Day 1, the hearing got off to a shaky start. It became apparent that the parents and their advocates had not yet viewed the CCTV footage from Savannah Lodge. This material had been provided by the Local Authority in September 2025, but in a format directly from the Lodge which could not be viewed on some devices without having to download specific apps such as Elmedia. I was dismayed to learn that, given the seriousness of the allegations made against the parents, in all the time since September 2025 the footage had not been viewed by them, nor had the matter at any stage been restored to court for judicial intervention. It was absolutely fundamental for these parents, who each have vulnerabilities due to their cognitive profiles, to view the CCTV material at a time and place convenient to them, in digestible bite-size chunks, so that they could absorb, reflect and then provide instructions to their legal teams. As a result, in the absence of having seen the footage, the court had to act as fairly as possible within the time constraints of the hearing. The witness timetable was reconfigured, to allow for a whole day for the parents and their advocates to watch the footage. It would have been impossible to fairly proceed with the fact-find in relation to A, in the absence of the parents having fair opportunity to consider the case against them. Every effort was therefore made to set aside Day 5 of the hearing for the parents to view the footage and provide instructions.

On Day 2 of the hearing, the court was able to begin hearing evidence. The Local Authority had reviewed its schedule of allegations and reduced and refined the scope. I heard evidence from the Social Worker involved at the start of the proceedings regarding A. Both parents were said to have fully engaged with the Local Authority during the PLO process and Parenting Assessment. As part of the pre-birth assessment there was discussion around the Mother’s older two children, B and C. The main concerns and issues that the Social Worker outlined were that the Mother and Father gave inconsistent answers or were unable to give explanations about the bruising to B, and so it prevented further discussions as she was always presented with the same response. During the fifth parenting session, M stated that she understood the injuries to B “should not have happened but went on to comment ‘accidents happen’”. It was also recorded that M reported the gravity of the injuries did not sink in initially, and instead she thought she could “fix it over time with the children still in her care and prevent these injuries from occurring again in the future”. Following these observations by the Mother, the Social Worker wrote “we are concerned that M has voiced that these injuries should not have occurred however is still not clear how or who caused these injuries that happened not on one occasion but on multiple occasions.”

The Social Worker also set out that “when exploring B’s previous injuries at the beginning of my involvement (August 2024), M gave the following accounts: Bruising to left cheek B was allegedly walking hand-in-hand with C and hit her face on a dining chair. Bruising to the sides of her tummy C was allegedly "nipping" B with the pram buckle. For one bruise on her left arm below the elbow and approximately 3 bruises on her right arm, M reports she was supporting B to walk. However, M has since repeatedly described one occasion whereby M quickly “whipped up” (picked up) B under her arms when she reportedly fell over. In addition, M has also described B sustaining a finger and thumb mark/bruise as a result of M reportedly changing her nappy.”

The Social Worker also reported the discussions held around what the parents would do differently in the future in relation to A. “M was asked if a similar situation presented itself in the future and her baby girl was harmed or injured, would she do anything differently and how would she respond to this. M stated she would ask for support and advice from a health professional.” When asked the same question, “FA admitted he would feel panicked but would respond by taking their baby to hospital or GP to seek medical attention”. It leads the Social Worker to conclude “If any child is harmed or injured, a parent or caregiver’s priority should be to attend a local hospital or GP surgery in any event in order to urgently seek medical attention for their child, the fact that neither parent did this previously is a concern to the Local Authority that this would happen with A.” This is particularly pertinent when considering what then went on to occur in relation to A whilst at Savannah Lodge.

Insofar as FA is concerned, his views were challenged during the parenting assessment, particularly as he was charged and received a conviction for breaking D’s arm and served a custodial sentence. It was recognised as a complicating factor that FA did not recall any of the police investigation, including being interviewed or being in prison. The Social Worker set out that given FA’s lack of memory in relation to the injuries and the prison time he served it was difficult to get his understanding of why the Local Authority are worried about his conviction and the injuries that B sustained whilst in the care of M and FA. She said “we have been unable to explore these concerns in detail as FA is unable to recall any of the events. However, it does not alleviate the LA’s concerns as FA is not able to reflect of the findings of the Court.”

Other evidence from the Social Worker related to A, and so I will return to this in due course. However, it is plain from the assessment undertaken by the Social Worker that she very fairly set out the positive and negative factors when assessing a way forward for A in the light of the history of both parents having had children removed from their care with one confirmed instance of inflicted injury to FA’s child, and bruising thought to be inflicted to M’s child. Unlike other witnesses I heard from, the Social Worker did not shy away from the history and acknowledged that the current risk is assessed in the light of the background, rather than stating a simplified analysis where the parents were considered as at that date without being informed by past events. She concluded that the parents should be given an opportunity to evidence their new knowledge and skills in caring for A, and recommended placing the parents with A in a parent and child placement where there would be “trained and experienced carers available to oversee and guide the parents whilst safeguarding the child”.

I considered the evidence of the Social Worker to be fair and balanced, considering the positives as well as negatives. It would have been very easy, at the pre-birth assessment stage, to formulate negative views about the future for A, given the known history. To her credit, the Social Worker weighed up the risks and balanced them, and made thoughtful recommendations to the court to safeguard A. I return to her evidence later regarding A.

The court heard from DY, who had been an office administrator at the Y Children’s Centre, and who had observed bruising to the hip area of B two days earlier, when she saw the Mother placing B into her buggy. B’s top had ridden up, and the bruising seen. DY described the bruising in her brief statement to X Police as being about an inch in size and being round with “a bit off it like it had spread a bit”.

In her oral evidence to the court, DY confirmed that B had been in front of her and she had seen the bruise, but had not seen any other bruising. She was only able to report what she had then heard at work regarding a bruise on B’s eye, but she had not personally seen that bruise. I found DY to be a very straightforward witness, who readily confirmed that she relied on her statement, prepared two days after she saw the bruising, and that given it had been almost three years since the event she described her memory being as clear as it could be. There was no suggestion that DY was adding to her evidence in any way, to elaborate or embellish. I found her entirely believable. Her written evidence was short and to the point, in like manner to her oral evidence to the court. I consider that she had no agenda to pursue in giving her evidence and that she fairly set out what she knew, and also what she did not know. I have no reason to doubt her evidence.

I heard evidence from Dr T, the consultant paediatrician who examined B following the concerns raised by the Health Visitor when she had attended at home visit. In her report she sets out the medical findings:

Blood tests including investigations for underlying bleeding disorders were normal. This included normal platelet levels, coagulation screen, Factor VIII, factor IX and Von-Willebrand factor assays.

Dr T concludes: “B is a 14-month-old little girl who is at a stage of early mobility, where she is just beginning to take independent steps. She has many bruises for her age and stage which have features suggestive of abusive injuries.” She confirms that “Bruising is caused by blunt force trauma and the leakage of red blood cells into the subcutaneous tissues. It is not possible to accurately time a bruise from its colour or presentation.”

In her analysis, Dr T says:

“A Systematic review on bruising, RCPCH (updated 2020) identifies a number of key features that are indicative of abusive bruises:

Bruising in children who are not independently mobile

Bruising in babies

Bruises that are seen away from bony prominences

Bruises to the face, abdomen, arms, buttocks, ears, neck and hands

Multiple bruising in clusters

Multiple bruises of uniform shape

Bruises that carry the imprint of the implement used or a ligature

Bruises accompanied by petechiae, in the absence of underlying bleeding disorders

There are several features of the bruising which are suggestive of abusive injury, highlighted in the list above.

This includes the site of bruising on the abdomen, face, and the soft tissue of the thigh. Most accidental bruises occur on the front extensor surfaces of the body, particularly over the knees and shins. B had no injuries in this area. If there is accidental bruising to the face this is usually across the central “T-zone” including the forehead, nose, and chin. The bruising to B’s face includes the soft tissue area of the cheek.

Clusters of bruises of a similar, uniform size and shape were present on the abdomen.

The three bruises in a cluster on the back were described as caused by the dog jumping from the sofa and paws landing on B. Whilst this is a possible mechanism for this injury it raises concerns about the level of supervision of such a young child around a dog.

The bruises on both forearms are non-specific and could be either accidental or inflicted.

The 0.5 cm scars on the abdomen which are reported to be self-inflicted nail marks, could be compatible with this explanation.

The size of the most significant bruises (injuries 2 and 3) on the abdomen are not consistent with the size of a young child’s fingertips and therefore the explanation provided by mum. One of the abdominal bruises includes a 1 cm linear abrasion. This would also not be consistent with the size of a small child's fingernail, although might represent an injury from an adult fingernail.

There appear to have been two different explanations offered for the facial bruising. An inconsistent history for injuries is also alerting to possible inflicted injury.”

Dr T is very clear in her analysis, indicating features which are suggestive of abusive injuries. Concerning factors are B’s age and stage, the location and constellation of bruises, and the inconsistency of explanations provided. Dr T readily accepted that the bruising to the forearms could be accidental or inflicted, and the scars on the abdomen could be self-inflicted nail marks. She also accepted in her evidence that parents can often provide a variety of explanations for an injury in an attempt to consider how it could have been caused and so inconsistency of explanation has to be considered in that light. In relation to the bruising on the back, if it was caused by the dog, it raised concerns about levels of supervision of such a young child.

Dr T in her report considered the explanations for some of the bruising and felt that the suggested explanation that abdominal bruises were self-inflicted by B pinching herself was incompatible with the injuries observed, nor was it a behaviour observed whilst B was on the children's ward. It was considered that child of B’s size and developmental level would not be able to pinch with the force required to cause bruising. Further, facial bruising is associated with abusive injury. There also appears to be an inconsistent history provided for the facial bruising.

Dr T also prepared a Child Protection Medical Assessment Additional Report dated 20 June 2023. As a follow up to the joint paediatric forensic examination on 25 May 2023, there was a detailed ano-genital examination, at which B and C’s Social Worker was also present. The doctors considered that this was necessary, following review of the medical evidence on abdominal bruising and peer consultation, indicating a possible association between lower abdominal bruising and sexual abuse. Although happy to provide consent, M stated that B had “never been out of her sight”, and she was not concerned about the possibility of sexual abuse.

The examination of B on this occasion noted:

As with the previous examination, when approached by unfamiliar adults B became very distressed. Dr T reported “This is a behaviour termed “frozen watchfulness”. It is recognised as a behaviour which can occur in children who have experienced abuse”. The summary concludes “B had a normal ano-genital examination. After two weeks in foster care she had only two small bruises, compared with multiple bruises at the previous examination.” Dr T then concludes that “B presented with numerous bruises, likely to have been sustained in a non-accidental manner i.e. (the injuries were likely to be abusive). The position of some of the bruises (on the lower abdomen) can be associated with sexual abuse. Although B’s ano-genital examination was normal, the possibility of sexual abuse (in addition to physical abuse) cannot be excluded.”

Dr T was taken in evidence to the reviews to which she had referred in the preparation of her report and indicated they were an introduction into how to start to think about bruising. She agreed that in terms of comparative studies they are relatively limited, and of the ones referred to none were entirely on point with regard to the cohort. Dr T went on to confirm, however, that to take each individual study on its own will give limited information, but a systematic review (accepting limitations) gives a more thorough evidence base around bruising, and agreed that it gives a starting point for probabilities generally.

Dr T said the constellation of B’s injuries is “very very concerning” for abusive inflicted injury, in a way we don’t often see, confirming that B “sticks” in her memory and she was very concerned by her examination. She recalled how flushed B was in the examination, which can be seen from the photographs where she is very red in the face. Dr T confirmed that during the examination there were no concerns about M and B together. She agreed that it is not possible to age a bruise by appearance, and people might describe bruises in different ways eg “faint”, “fresh” and “dark” all depends on a person’s subjective viewpoint. It was confirmed that she “cannot be 100%” about any one individual bruise but the constellation of her bruises is “very very concerning in a way we don’t often see”. Particularly in relation to the bruising to the soft part of the cheek and whether or not there was an explanation such as walking into furniture, Dr T said she would not want to say “more likely than not” one way or the other whether it was accidental or intentional. In relation to the dog catching B on her back, again there was a possible plausible explanation, but Dr T indicated that she thought it was a concerning description regarding supervision if it was that, and was a very unusual cause for a bruise in 14 month old child.

It was confirmed that B was only just walking and toddling but the Mother and Social Worker had said she was falling down. In being challenged as to whether this could indicate an increased frequency of bruising, Dr T accepted that to some extent because she is still a small child at early stage of mobility. However, the types of bruises and impact that would be expected would be some bruising but on the shins and knees and that was not noted in examination, or indeed much of that once in foster care.

Leading Counsel for the Mother asked Dr T about different categories of bruising: those not uncommon and/or for which there is a broad explanation, then those which are unusual but potentially plausible eg the dog catching her on her back, and then a third category of bruises which are unusual with no obvious clear plausible explanation. Dr T agreed the abdominal bruising was in that third category. When she was asked about the risk of judging all bruises in the light of that category, Dr T considered that she and Dr V had been fair in their description of the bruises, acknowledging for example some bruises they think are likely accidental around the knee and elbow. Again, it was said that the constellation on abdomen in particular is highly concerning for being abusive and inflicted and with the sheer number (which could reflect lack of supervision and neglect as well) definitely made them feel extremely concerned a child has suffered abusive injury.

In the time between the first and second report prepared by Dr T, she had conversations with Dr V. She carried out the second report because of the abdominal bruising, considering whether the bruising could be a consequence of sexual abuse, to explore the issue in more detail. It had been considered that the bruising was really striking, causing the doctors to think carefully about it, and be sufficiently concerned about it such that it was proportionate to undertake the examination. The social worker for B and C was present at this second examination, but not the first.

The second examination showed nothing that was indicative of sexual abuse, which was said to be common regardless whether a child abused or not. It had been important to check, but there was no further evidence. The height of the concern was recognised to be lower abdominal bruising which raises the possibility.

At this second examination there were two bruises, compared to multiple bruises at the first examination two weeks earlier. The three small brown marks of pigmentation were considered to be pigmentation rather than bruises, and Dr T explained that in their original report, they had not been certain they were bruises, and the fact that they were still present a few weeks later helps us to know those three marks were not in fact bruises. The two bruises seen which were not in the first report but observed at this examination were confirmed to have been caused in the intervening period of two weeks, albeit recognising the caution required and the guidance about not aging bruises by appearance so that it was not possible to say when they had occurred in the intervening two-week period.

There was no description from the foster carer of anything leading to chest bruising. It had not raised concerns with the medical professionals that there were two more unexplained marks on chest, given some studies say indicative of abusive injury on torso, as a 1cm bruise over the bony area of the back would not be unusual to sustain, as the spine protrudes. Dr T considered it was a very small bruise, and likewise the bruise of 0.8cm on B’s lower chest, albeit on a less usual site, as one single injury of less than 1cm width in a child who was independently mobile and which is isolated on its own, was considered not to be alarming or suggestive of abusive injury.

In cross-examination, Dr T was challenged as to why her second report concludes with an indication that the numerous bruises B sustained were “likely” to have been sustained non-accidentally/abusively, whereas in her first report the use of language was very careful to outline that the bruises seen were “suggestive” of inflicted injury. Dr T confirmed that it had not been her intention to phrase the reports differently and her conclusions overall were the same. She relied on the number of features present which are indicative of abusive bruises, and I note that on that list four of the eight listed features are present for B. Dr T said she did not feel that her opinion had changed between reports, nor did she intend for it to come across like that, despite the expression in the first report of “suggestive”, compared to the use of the word “likely” in her second report. Dr T said her reports were “perhaps written differently, but opinion is that these are most likely to be inflicted injuries”, adding they have given much more of an individualised interpretation of each area of bruising in the first report which is more balanced for each, but her overall opinion is that there are enough bruises which are suggestive of inflicted injury that they would be concerned.

In conclusion, Dr T was asked about her experience as a consultant paediatrician, and she confirmed she carries out about 10-15 of these types of medical examinations yearly. Some of them are for physical abuse and some for sexual abuse. In terms of the examination of B, it stood out to her because of the age and stage of B, the number of injuries, her demeanour of “frozen watchfulness” and the location of the abdominal bruises being “exceptionally unusual”.

I found Dr T to be a straightforward witness, operating within the remit of her own knowledge and making appropriate concessions about matters rather than pursuing any agenda. Her written reports set out clearly her examinations, findings and her professional opinion. She answered questions in cross examination insightfully and reflected on what she was being asked to consider, rather than making any assumptions about what she thought she was being asked or attempting to circumvent questions. I have no reason to doubt her professionalism, her integrity or her evidence.

AY, Early Years Practitioner, gave evidence regarding a bruise she believed she had seen under B’s eye. The difficulty was that no one else had reported seeing this bruise, not even medical practitioners. When photographs were taken of B two days later, the bruise described by Ms AY was not present, about which Ms AY expressed surprise. She gave what she considered to be her “professional opinion” based on having worked at Y for 19 years and having witnessed bruises over that time, so she was fairly confident that it was a bruise and she mentioned it to a senior practitioner, who unfortunately did not come to view the mark. Ms AY confirmed that she did not take a photograph herself, simply a note and passed the information on.

Ms AY went on to confirm her view of B as clingy to her mother, and C as “evasive”, whispering and not using her voice and the Mother not engaging with C very often in the room. It was accepted by Ms AY that other professionals and adults had entirely different experiences of C. Regarding B it was confirmed that she only began walking at the beginning of April 2023, and had been observed to walk 2-3 metres unaided and seemed quite steady, and then would look for something to hold onto for balance or would go down to her knees.

At the time of Ms AY’s second statement in August, the girls had been in foster care for about two months. B’s reaction to having her nappy changed was to freeze and lie there. Ms AY felt that B’s behaviour was not typical behaviour for a child who had their nappy changed by a parent or by a worker who had been working with her for that amount of time. Albeit no concerns had been reported by Ms AY in her first statement, she said she was aware of some, but other members of staff had previously been involved in the nappy changes and so the behaviour had become more apparent as she changed her more often. As a practitioner, Ms AY said, you would try to make a child feel as comfortable as possible to feel safe, but B simply lay still and did not make a noise.

From these observations, Ms AY made a leap to a conclusion that there had been sexual abuse. She relied on her training, having worked for 19 years and undertaking child protection training, to be able to “spot” things and be accurate in their descriptions. The concerns relied upon to support Ms AY’s conclusion there had been sexual abuse was B being scared having her nappy changed and being very nervous when being taken to get her nappy changed. C whispering was another untypical sign relied upon to conclude the parents had sexually abused the girls, and Ms AY had not come across that before.

Ms AY was asked if she had observed B pinching herself. She said no, save that when the child was passed from the Mother or another carer she would cling on and pinch skin as clinging very hard, holding on very tight, such that the skin was pinched for grip. This indicates B was able to grip tightly, but does not address any suggestion that B had been seen by this witness pinching herself, nor is Ms AY able to give medical evidence as to B’s dexterity, as her evidence is anecdotal.

The significant difficulty with the conclusions drawn by Ms AY in her written evidence and confirmed in her oral evidence, is that whilst the witness had 19 years of experience working in childcare, she is not medically qualified or trained. No one else saw a mark or a bruise under B’s eye, which is surprising given the number of professionals involved with the family and the documentation that was undertaken. Ms AY did not attend the Child Protection medicals, like B and C’s Social Worker attended the second examination. She is not qualified to conclude that because of the fearful behaviour she observed during nappy changes, and because C whispered to communicate, that there was sexual abuse, or who had inflicted that abuse. Unfortunately on any analysis, Ms AY has drawn conclusions on the slightest of evidence of concern, not considered other explanations and jumped to a conclusion she was not qualified to make. It is very difficult to rely on the evidence of Ms AY, and I therefore place little weight upon it.

I heard evidence from the Health Visitor who raised concerns about bruising to B following her visit to the home of M and FA, when B had her clothes removed so she could be accurately weighed and was seen with bruises. She accepted that M and FA were living in an overcrowded space. It was a one-bedroom property, with one bathroom, a small living room in which the children slept alongside two bird cages, furniture and also a dog in the house. It was clearly too small for a family of four. It was a home that FA had lived in alone before M took her children to move in with him. It was not ideal for two growing girls, one of whom was learning to walk.

M is described as having had anxiety previously, and that she was not resistant but would chat with the social worker. B would not go to anyone at all, which was considered unusual. It was said that usually once a caregiver shows that they are speaking to someone, a child would smile or give some interaction back but B would hide away and M cuddled her and tried to comfort her.

It was confirmed that on a home visit on 20 March 2023, B was content and settled and again on 12 April 2023 both girls were playing in the living room together. B tried to walk to her mother but fell, and M reported B fell a lot. Apart from B’s clinginess to her mother, there were no standout features or concerning behaviours from the mother to B.

The Health Visitor’s written evidence was in her statement to X Police dated 25 May 2023. It records that B is “very clingy to her mum. She is opposite to C. She is very aware of strangers and doesn’t like being left alone. I have given M some fine motor skill activities for B as she is a little bit behind. B scored quite high on the sociable and emotional chart. B has only been mobile for a month at the most. Yesterday 24th May 2023 on my visit was the first time I have seen her walk. I just [caught] a glimpse of it and it was only a couple of steps. There are no walker toys in the house.”

She goes on to say “Yesterday, Wednesday 24th May 2023 I conducted a home visit at 1.30pm to conduct B’s 13-15 month review. This was a planned appointment at home. I had a trainee with me for the day. When I arrived all of them were within. FA, M, B and C. The house was clean. Toys out. I observed a bruise on B’s left cheek. It was quite big. It might have been two. It was like a grey/brown bruise which I had to check wasn’t dirt. No swelling observed. I asked about it and M said she did it on Friday just before the social worker attended. She said that she had put out a chair for M and B had ran into the chair. I continued with the review and then I was going to get B’s weight. Just before her babygrow was M said that she had spoken to Y Children’s Centre about B pinching her sides. She said it makes her bruise and stated that B seems to bruise easily. I asked her if she noticed a pattern if B does this when she is tired. M said yes she does it when she is tired and also she suggested that B may be copying her sister C as she does it.”

The Health Visitor then confirms in her statement her observations of B as she was undressed to be weighed, and the explanations provided by the mother. “M took off B’s babygrow and I observed bruising to both sides of her tummy. I would describe them as small circular faded brown bruises. In clusters. Maybe 3 one side and a couple at the other side. I thought it was odd. I then noticed a very faint circular tiny bruise in the middle of her spine. I asked M about that and she said "oh the dog done that". M very quickly said about the children's biological paternal grandmother having a blood condition that causes her to bruise easily. She asked do you think B has that. I advised to contact the GP first thing in the morning to get an appointment to which she agreed. I also noted bruises on both of B’s arms, positioned on the inner bicep of each arm. They were similar to the ones on her tummy. Faded and circular. Possibly about 3 on one arm and 2 on the other. I didn’t ask M about those ones.” What I take from this report, shortly after the incident took place, is that the suggestion of whether B was pinching herself due to tiredness came from the Health Visitor first, and the mother agreed with what was suggested. I also note that there is consistency in the explanation of B having walked into a chair to sustain the bruising to her cheek, and that the bruising to the back was caused by the dog, but compare this against later inconsistencies as set out below. I do also consider that prior to the babygrow being taken off B, the mother was quick to prepare the health visitor for what she was about to see, noting B pinches herself, might be copying her sister, and that the paternal grandmother has a blood condition causing her to bruise easily (following from the comment before the babygrow was removed, that B seems to bruise easily). The reasons as to why the Mother prepared the Health Visitor for seeing the bruises could of course be considered to be entirely innocent. I am not convinced. There is no doubt that the Health Visitor was alarmed by what she saw on B, as was the medical practitioner Dr T.

In cross examination, the Health Visitor was asked about the bruising to B’s cheek, abdomen, back and her arms. It was readily accepted that for some of those bruises M gave an explanation, for example, the bruise to the cheek was said to be caused by walking into a chair. That explanation was also given to the Social Worker, and it was accepted that the Mother had raised the walking into a chair from the start. It was also talked about that a dog had jumped and caught B on her back. The Health Visitor describes the dog in her witness statement as being medium-sized. Her statement also sets out that the girls slept on the sofa and the girls jumped on the sofa and discussions about safety were held after that, and the parents obtained a bed for C following advice.

Although it was said by M that B pinched herself when tired, the Health Visitor observed no worrying behaviour from B to her mother or sister C, and nothing from C to B. What did alarm her were the bruises that she could obviously see when B was naked on the weighing scales. She said that at her age, when just starting to learn to walk they do fall but onto their knees, not onto their side. The Health Visitor had seen the children on four occasions since they were registered on 21 March 2023 until the date of her visit on 24 May, a day prior to giving her witness statement to the police.

I accept that the Health Visitor would have carefully observed the family and their home environment, being aware of the concerns leading to Child Protection meetings and the referrals received. If she had herself observed anything of concern in the behaviour or handling of M or FA to the children or the children to each other she would have raised it. Her witness statement is measured and fair and non-critical. She does not leap to conclusions but documents her observations and concerns. In her witness statement she indicated that on a visit to M and FA she spoke privately to FA to ask him if they would discover anything else when doing background checks, beyond the conviction that they were aware of already. FA had said no, but then it was revealed there were further allegations against FA of domestic abuse, concerns regarding harassment and possession of a weapon, which necessitated another visit to the family on 15 February 2023. It understandably raised concerns about the lack of openness and honesty, and also that M was defensive of FA in being quick to defend him and downplay the previous allegations made. Notably, there is nothing in her statement to confirm that, having met the children on four occasions, she was concerned at B being boisterous or flinging herself around dangerously and her Mother having to catch her or repeatedly save her from accidents. It is C about whom there were some behavioural concerns. B was very clingy to her mother, did not like being far away from her and about whom there were indications that she was a little bit behind in her fine motor skills. This contrasts heavily with the evidence of B and C’s social worker which I will come to shortly. There is no doubt that the Health Visitor was alarmed by B’s bruises, and no suggestion that her immediate thought was that these were the result of a boisterous child’s play or activity. It was the explanations given by M to the Health Visitor, alongside the locations of the bruises seen, that prompted the Health Visitor to seek immediate assistance from the GP that day rather than waiting even just one day to see the doctor in the morning.

Dr G, the expert paediatrician instructed in this case, was called to give evidence on the afternoons of Day 2 and 3. Unfortunately (and rather surprisingly) at the commencement of his evidence he had not appreciated he was going to be asked questions about B as well as A, but care was taken by counsel for the Local Authority to share with Dr G the photographs of B on screen. He had also, prior to giving evidence, been shown by counsel collectively aspects of the video footage from Savannah Lodge. In reviewing the part of the footage for A, he confirmed no changes to his report.

Insofar as general observations were concerned, Dr G’s evidence was that it is not possible to date bruises from their appearance, or to say how far in advance of a bruise appearing that the cause of that bruise occurred. With regards to the appearance of a bruise itself, where there is no imprint of implement, Dr G was challenged that it is not possible to deduce the intention of anyone who may have caused it. Dr G said he would dispute that, and the character and appearance and location of bruising does statistically tell you about the type of injury it is, whether it is accidental or not. To consider whether something is accidental or not is to consider intention, as if something is not accidental then it is intended. Dr G considered that if you cannot derive anything about bruises from their appearance, then the whole analytical process becomes meaningless, so you “can make inferences from appearance and location of bruises around the intention of person who caused the bruise”.

He was referred to the Royal College Systematic Review and asked if he accepted there were limited comparative studies. Questioning on this point became quite contentious, but ultimately Dr G maintained the stance that he did not see any deficiency in the numbers of comparative research studies there had been, albeit the number was quite small. He said in any field of research “we always want there to be more studies” and the conclusion of “more research is needed” is, as I understood his evidence, to be an unhelpful outcome of any study, because there is always more than can be done. Dr G was far less readily able to accept, as Dr T had done, that the comparative studies were limited, either in scope or number.

Dr G was challenged about being cautious in any conclusions if drawing from a wide age range of children. Dr G indicated that if we are looking at bruises which are suspicious, then saying because the child is younger that those locations aren’t associated with abuse, then he was not sure why that should be, or why the child would be more likely to have injuries in those areas. It was put to him that the obvious difference is around the types of accidents that children have. It was said that as they get older they engage in different sports, they can be more prone to different types of accident, but the younger they are, at this sort of age, they are less prone to sporting injuries, broken arms, or wrists or legs. There is a difference in the types of injury. Dr G indicated that when it comes to bruising to the torso, then certainly the evidence is quite consistent, which is that these are not commonly found accidentally. Dr G considered that was true of all ages. He said for the chest, back and abdomen, they rarely see that in accidental bruising of all ages. This was, Dr G said, fairly logical, and it is to do with when children try to protect themselves from more serious injuries, as some areas are more prominent (for example the lower part of the arm). The injuries are seen there because children and adults put their arms out to protect from a fall, to protect any delicate structures around the back and abdomen and their organs.

It was put to Dr G that “unusual things happen unusually”. It was conceded that this was possible, that you can see accidental bruising in areas that are more associated with abuse, and in the case of B it is multiple bruising. There were three locations, all associated with abusive behaviour. However, those three areas can also be found in accidental injury, although Dr G said “rarely”. He was referred to the three different case studies on which he had relied, that two of them do not identify the same concerning areas that the third study mentions.

Beginning with the injury/bruising to B’s face, it was accepted that the description of her walking into a chair could explain the cheek injury and bruising. There was a faint brown bruise, possibly two confluent bruises. Dr G quoted the study which showed it was more common in abused children but that in itself does not necessarily indicate abuse.

Dr G’s report relied on the Child Protection medical as a core piece of source material. He was challenged as in his own report he indicates that the report of Dr T and Dr V concluded these were inflicted injuries and the Mother’s explanations were inconsistent. Dr G had not re-read the child protection medical reports prior to giving his own evidence, and it was suggested he had mischaracterised the conclusions of those reports in an important respect: it was suggested to Dr G that Dr T and Dr V do not conclude that these were inflicted injuries. This resonates with the questioning put to Dr T who was asked about the differences in language used between the first report and the second, where there is movement from “suggestive” of inflicted injury to “likely”. Dr T’s oral evidence (which came between the evidence of Dr G heard in two parts over two afternoons), was clear that she had not intended to give a different impression between the two reports and confirmed her stance that these injuries were likely to be inflicted. Dr G’s reliance on the child protection medical reports, and his subsequent interpretation of the reports that these were inflicted injuries, did also not change when pressed in cross examination. However, he did concede that injuries to the forearms could be accidental, and scars could be nail marks, and could be compatible with that explanation. Where there is an explanation, even in an unusual area, that had to be considered in terms of plausibility. The bruise to the back could have been caused by the dog, which raised concerns again around supervision, and had there been a suggestion of repeated injury from a dog Dr G felt that would be “quite a thing” to suggest. Theoretically if that was happening then it could explain several bruises. I do note that only one bruise to the back is attributed to the dog. He maintained that a child of B’s size and development would not be able to cause the bruising seen to her abdomen. The conclusion was that the doctors were very concerned about the injuries and they were very concerned that at least some if not all are abusive or inflicted injuries.

Dr G was asked about many of the bruises to B being small, and his response was that you have to be careful with language and it is more helpful to mention the actual size of the bruise. If a bruise was of 1cm or less, it could be considered small, but that would not make it any less significant. To say that larger bruises are more likely to be inflicted, is an indicator but nothing more or less. He was not persuaded on arguments regarding the size of bruises, given their number and location. Dr G did concede that bruising could be caused by a 3 year old to another child, and so I direct myself to the evidence from others who directly observed the behaviour of C to B over a sustained period of time.

It was suggested that care needed to be taken when discussing the terms “abusive” and “intentional”, but Dr G was not persuaded something could be abusive through bad handling without there being any intention to harm. He considered that handling which accidentally causes injuries is not abusive, but careless, and if the Mother picked up the children too firmly causing bruising then he would characterise it as accidental and not abusive (if true). He also pointed out that Counsel may list many body parts which are not injured (no scalp injury, no head injury, no ear injury, no neck injury) but it does not detract from the severity of the injuries that were found on B. He said it would not be a sensible approach to list all the places which are not injured and say that as a result we should not be worried. When challenged as to whether or not he could make definitive statements about which areas of the body indicate abuse, and being reminded of the comparative studies he had relied upon which did not list all the same areas, Dr G confirmed he disputed that there is any suggestion otherwise that the abdomen, back and thighs are associated with abuse and rarely injured accidentally. (He also confirmed that in medical terms, the “leg” is below the knee and the “thigh” is above the knee.)

Dr G was also cross-examined in relation to responses to pain, with the way in which people respond to pain being variable, and this was accepted. However, Dr G pointed out that around age 3 or 4, a child has learned how to hide emotions if they choose to and not show emotions like pain. Prior to this age, if they feel pain, it is demonstrated. There is no objective evidence to distinguish different types of cry, or if a carer is not aware of the origin of a cry that there is any way to identify it’s cause by the sound.

Something which caused difficulty when listening to the oral evidence of Dr G was the combative stance adopted by him in response to questions. Even regarding a simple typographical error within the report there was a degree of hostility, until I intervened and explained he had written Dr V and Dr V, instead of Dr T and Dr V. This approach to questioning made it very difficult to make swift progress, and whilst the substance of the evidence which was given by Dr G I consider unproblematic, the style of delivery certainly was. This became particularly apparent when dealing with questions regarding the documents Dr G had viewed in the preparation of his report, what tests had been completed, and whether or not he had made reference to them in conducting his own independent assessment as required of as the expert paediatrician.

He confirmed that when assessing infant bruising to consider haematological or tissue disorders or skin conditions, they always think about those issues and in some cases have recommended additional testing including genetic testing to exclude the possibility when there is something in the history to indicate it may be present. Leading Counsel for the Father reminded Dr G that the Royal College Child Protection Companion makes it very clear when considering bruising, that one must consider differential diagnoses. Dr G explained that they do not in all cases undertake genetic testing or connective tissue testing, only when there is something in the history or something about child which alerts and draws attention. Routine screening is almost always done, basic haematological investigations certainly in a younger child. In general, there should be basic haematological investigations.

It was said that what is missing in Dr G’s report is any detail or analysis of blood test results, and so on the face of the report it reads as though he did not look at blood test results themselves for B. Dr G was mystified by this, and confirmed he could not see the reference, and said “ordinarily I would always refer to those”. He accepted as part of his duty in providing a paediatric overview that he should bring to bear his own independent analysis of blood test results. Dr G then referred to paragraph 9 of his report for B, which he said he was relieved to see he had included, which said “Routine blood tests were performed, including coagulation studies which were extended to include Factor VIII, factor IX and Von-Willebrand factor assays in addition to a routine coagulation screen and a full blood count”. The difficulty here is that the only reference in the report to the blood tests is that they were performed, and there is indeed no analysis of any results. It was a repetition of what was seen from the medical records for B. Dr G’s evidence was that “normally when looking at blood test results I would want to see the numbers rather than copy someone saying normal so I would like to think I had seen number, but I cannot remember exactly writing this”. He accepted that it was fundamental that those test results have been independently reviewed, but said that multiple safeguards mean that abnormal results would not be ignored and would be flagged as multiple people in the laboratory as well as the doctors would see them. He considered it unlikely that an abnormal result is missed.

In B’s second report, Dr G has not cross referred the bruises list provided by Dr T. He reviewed the photos but did not go through and identify every single bruise on the photo. It was put to Dr G that other paediatric experts set out each bruise and whether they can see what they are told is there or not, and whether they agree with what’s there. Dr G confirmed he had done this in cases where he did not agree with what was said, but this case he does agree, and so it was not itemised.

The lack of confidence in what processes had been followed in the preparation of Dr G’s report led to thorough questioning, as appropriate, in relation to other possible causes of the bruising. If the records showed that the mother has raised on more than one occasion a paternal history of easy bruising, Dr G felt that the question is how much investigation is required, as certainly it would be important know whether at least routine haematological investigations were completed, he would normally always include that in his report, so it was important to clarify whether that was done. He accepted there can be connective tissue disorders. It would have been important to get some clarity on exactly what is meant by easy bruising and how severe that was. Dr G could not recall any investigation into that, for B and her paternal family, but on looking through report, confirmed routine and extended blood tests were done. In Dr G’s experience, a parent having a history of easy bruising would not be enough to investigate for connective tissue disorders, and he was not convinced it was necessary based on history alone. Again, by setting this out in detail, this line of concern would have been more clearly eliminated, particularly for anyone reading the report with a non-medical background.

In terms of a genetic history, Dr G could not recall if he had seen some of the documents referred to, but he felt that put simply “we wouldn’t be interested in a second degree relative… we would not investigate a child because of easy bruising in a grandparent”. When challenged that some paediatricians and geneticists would investigate a child because a grandparent had easy bruising, Dr G said that the paternal history is different and presence in B’s father would be significant. He accepted that it would be useful to have more detail about any easy bruising B’s father might have and how that manifests and it was accepted that history would be informative if there indeed was a concerning history. There is nothing that I can see in any record to suggest that B’s father had a history of easy bruising that has been medically confirmed. Nor has it been mentioned in the social work involvement when B and C were placed with their father. I considered that this line of questioning, whilst admirably thorough, was not persuasive in this particular case.

In closing submissions, however, Father’s counsel reminded the court that FPR PD25B states that the expert’s report must:

“Describe the expert's own professional risk assessment process and process of differential diagnosis, highlighting factual assumptions, deductions from the factual assumptions, and any unusual, contradictory or inconsistent features of the case; (PD25B para 9.1(f)(ii)”

“Indicate whether any proposition in the report is a hypothesis (in particular a controversial hypothesis), or an opinion deduced in accordance with peer-reviewed and tested technique, research and experience accepted as a consensus in the scientific community; (PD25B para 9.1(f)(iii))”

I am reminded that when considered against the requirements set out above, Dr G had not provided:

The last point was particularly troubling to Father’s counsel during cross examination because despite agreeing that viral infections can cause transient blood clotting issues, Dr G appears to believe that because (in his view) one cannot explore every possible cause then none should be explored, which reveals a fundamental misunderstanding of his role and duties. He had not had the benefit of a full family history and/or considered the possibility of a connective tissue disorder such as EDS. Whilst I take on board the concerns raised by counsel about the way in which Dr G conducted his assessment and gave his evidence, I of course consider the wider canvas. There is evidence, other than medical evidence which, for example alerts me to the fact that once out of the parents’ care B ceased presenting with a multitude of concerning bruising, indeed any suspicious bruising at all. No concerning family history was reported by B’s biological father, and during the course of these proceedings no party has sought to make any applications for further specific testing. No one sought to recall Dr G following the extraordinary evidence from B and C’s social worker, despite the court asking whether any party sought to recall witnesses. The court therefore proceeds with the evidence it has, and bears in mind the wider canvas.

Again for A it was suggested there was no analysis of the blood test results that were recorded. Paragraph 7 of the report simply says “Full blood count and bone profile were normal”. Dr G did not consider this an omission from his report, as those were the results that he had which showed normal, so there was no further analysis required. He said a child with haematological disorder will not present with just one episode of being covered in bruises, going to be there all the time and so we have to view it in that context. In any event, Counsel for the Guardian was able to point to the coagulation testing results and the blood test results for A in the court bundle, and so the information is there even if not the subject of more than one sentence in the report. Viral infections were not considered by Dr G to require anything more than a pragmatic approach due to the very wide possibilities. In fact, Dr G indicated that there are an “unlimited number of possibilities for what might cause bruising” which underlined the need to be pragmatic.

Dr G confirmed that in this case, the pattern of bruising is not petechiae from viral infections. This is not viral type bruising. He had experience of viral rashes and bruising, and considered that these bruises do not have that characteristic and so they were not attributed to a viral cause, based on their visual appearance. This echoes Dr G’s earlier evidence that you can tell some things from their bruise by the appearance, albeit exercising caution.

Finally, Dr G confirmed, having looked at A’s blood test results during evidence, that he would not change his conclusions about the case in terms of stated abnormalities. He accepted that some might look at the test results and think there were abnormalities because creatine is slightly low but not of note in infants, slightly low but normal. The platelets were mildly elevated but in infants it is common and not of note. Other markers are just outside normal range so not of note. Dr G said “this blood count is normal”. Regarding further testing, Dr G did not consider any further testing necessary, having reflected on the blood tests results and the coagulation. He had watched the extra footage from the CCTV and felt that he saw nothing suspicious or troubling. The distressed cry of A could be attributable to colic or reflux. He accepted the limitations of CCTV footage of this type and that there is a lot that you cannot see or tell from video recordings as subtleties of expression can be lost, and the detail is not fine enough to be able to sense any pressure applied. Dr G said he would be hesitant to give any diagnosis based on videos, as it is not a thorough medical picture to give diagnosis, and there might be more than one cause of distress. He accepted that bruising must be interpreted alongside the medical and social history, developmental stage, full clinical exam, explanation given and relevant investigations.

I have set out Dr G’s evidence at length in relation to B and to a lesser extent in relation to A. I would not usually adopt such an approach, bearing in mind this was already going to be a lengthy judgment. The particular difficulty I have tried to address, by setting out the evidence in such detail, is of understanding the thought process followed by professionals, so anyone reading the report can see how the conclusions have been reached. This precise point was made by Leading Counsel to Dr G. As a consequence of the prickly nature of his responses to questioning unfortunately Dr G came across as extremely defensive, saying that he did not think he should “have to quote numerical figures” to prove he has seen the documents to which his report briefly refers and upon which he relies. I do not take issue with the underlying substance of Dr G’s evidence, but where there is any professional report it is not sufficient to simply set out a conclusion. The way in which that conclusion is reached is similarly important. How parents, professionals and courts can understand a conclusion of a report is by the way in which it is explained and the analysis which is given. It is no surprise that parents with cognitive difficulties, such as in this case, are suspicious of a report which makes conclusions without fully explaining why, and ensuring that there are no perceived gaps in the analysis. Dr G did at least consider the feedback given to him which he said he would consider, regarding setting out how he has reached his conclusions. Certainly the court would expect professional witnesses to prepare a thorough report, and have read that report prior to giving evidence in relation to it. Unfortunately Dr G very much gave the impression of someone who had come to give evidence ill-prepared. For the parents the perception of fairness is perhaps as important as fairness itself. I say again that whilst I take no issue with the substance of Dr G’s evidence, its presentation left much to be desired.

I heard from SY, who gave statements to X Police in answer to the questions they posed to her. She worked at Y Children’s Centre, supporting parents and children who could be at risk. She had worked with B, and C, and M. Her last date working with them was 18 August 2023 when she retired. It was confirmed that she had not worked with FA as he did not attend Y in August, albeit the Mother was still attending. SY confirmed that before the girls were placed in foster care, she had not seen any injuries to either one of the girls.

Early on, SY had become aware of historic concerns relating to FA’s conviction and sentence, and she said later she had been informed he had been in a relationship with a vulnerable young person. She was asked if the information had made her wary, but she confirmed that she kept a close eye on all families as she got to know them. Her evidence was that she worked with two files: a file on the family in the office which the mother could look at any time she wanted, and a social work Mosaic file if there were any major concerns. The police had access to the file, and SY said when she gave her statement she was answering questions as to what was on her file.

SY described B as very clingy and C as overly friendly, with no sense of danger because she would go to anybody. Regarding M, SY said she had to guide her a lot in parenting. She was worried about overcrowding at the family home.

One concern that SY had was in relation to M’s reaction to incidents such as C opening her legs touching her “privates”. In the two incidents which caused her concern, it was principally about the way M reacted, albeit it was accepted there is a wide range of reactions that different parents might give, all of which could fall within the normal range of reactions. Insofar as B was concerned, SY described her efforts to encourage separation between B and her mother, to give both confidence as she was not sure about the reasons behind B’s clinginess.

There were two incidents in July which caused SY to take particular note. She had not previously been present at B’s nappy changing, but following placement in foster care she had to supervise nappy changing at Y. SY described the incident with B lifting the doll’s dress and poking it, as something she had not seen anything like before. In relation to the marks she observed on B, she had been at lunch when it happened, and although the marks sustained by B were accidental the worry was that M had told SY a different cause for the marks to what the staff had observed. SY had no cause to disbelieve M, until the staff informed her of how the incident had taken place. It was hard for SY to reconcile why M had told her something different, when it was accepted as an accident. There had been no need for an alternate account. Similarly, SY observed that M had given conflicting stories as to the reasons for leaving the relationship with B and C biological father, FBC.

Insofar as FA was concerned, SY confirmed that she had tried to keep an open mind. She did not accept that the information she had read and been told about FA had affected the way she interacted with him. She related a conversation she had with FA in which she had said to him that a person at 20 years old is different to a person when aged 40, with that twenty-year age gap. SY said “I go on the person I see in front of me and not the person who was before”. She would not accept that her knowledge of the past affected how she observed the family. I was not persuaded by this evidence, albeit I have no doubt that SY was doing her best to assist the court and treat the parents fairly. The difficulty with not acknowledging the past when working with children and parents who are potentially at risk, is that risk can be misunderstood or even ignored. I would have been more persuaded if SY had recognised that inevitably the knowledge she had of the family did affect how she treated them, perhaps in being more cautious or careful, whilst at the same time recognising the need not to allow any bias into her observations or documentation.

SY found M to be chatty and followed advice to a certain degree. Like with many of the other professionals, SY found M was willing to listen and co-operated. SY observed however that M did not always initiate conversation or engagement with the children, even on the one occasion SY described where B was distraught whilst her nappy was being changed. They did not receive any information at Y or that was recorded on Mosaic as to M’s cognitive functioning. She was clear in her evidence as to how she would go over documents with some parents, as they did interact with adults with learning issues and had some with a diagnosis of autism. SY would offer to read documents for them, or print things on to yellow paper. I have no doubt that SY tried her best to be as helpful and non-judgmental as possible. She was certain M had not mentioned dyslexia to her, as she would have offered to read to M as well.

When it came to the week before the bruises to B were observed by the Health Visitor, when SY had gone on holiday, there had been a conversation with M in which M reported the family had a sick bug. When SY offered to go round to their home she was dissuaded so that she did not catch the illness. The consequence was, whether the illness was genuine or fabricated to keep professionals away from seeing B, SY did not see the children the week before she went on holiday, and they were accommodated whilst she was away. When the children were accommodated she said it was “not a surprise” to her, upon finding out. She had a feeling in her gut, she said, that something was not right which is why she had documented all her concerns.

I found SY to be a straightforward witness, albeit misguided in saying that a person’s background had no bearing on how she viewed them, when that was something that should have been carefully taken into account in her role. I had no doubt SY was trying to assist the court and be fair to the parents. I am not sure how far her descriptions of M’s reaction to C playing with her private body parts assists with the issues before the court for determination. Equally I am also not clear that the description of a lack of engagement with B at times adds anything to the factual matrix to be determined. There is a wealth of evidence of good interaction, as well as concerning interactions, and this is but one piece of the complex jigsaw puzzle.

I heard from the Social Worker for B and C who attended the second child protection medical and who had had involvement with the family. At the outset of her evidence the Social Worker was asked if she could recall February 2023 clearly. She said it is now 2026, and confirmed if she was asked questions without her statement she “would not have a clue”. In terms of her memory of working with the family, she confirmed she was relying on her statement for the information. Again, when she was asked about the visit on 12 May 2023 when the bruising was observed to the face, she said she could only remember from reading her statement which had jogged her memory, but she saw the bruising and the excuse they gave for it is within her statement. Similarly, it was mentioned by the Social Worker in her evidence that she saw B again on 19 May 2023 and the bruising looked different. She was asked if she recalled seeing not only this second occasion but the third occasion after hospital with further bruising which looked different. The Social Worker confirmed that she could not recall in particular and that she struggled to remember that period of time, but “if I said it looked different then it looked different”.

B was described by the Social Worker as being “horrendously fearful’ and that she used to shake as if she was convulsing. They met when B was living with her mother and FA and B was “absolutely petrified” to leave her mother at any time: “if you took her off M she would convulse. Never met a more fearful child in my entire life. We were really concerned about it.” The Social Worker described the convulsions being experienced by B “even when a few inches away” from her mother. The Social Worker said that M would say B has not been around anyone else, and B did not know how to exist without being attached to her mother. It was confirmed that there was a change when the girls went into foster care, and B was able to laugh and giggle, and she was not able to do that at the Mother’s home. The Social Worker was not able to say how quickly there was a change in presentation following the move to foster care and indicated she would need to check her notes, but they did notice change. In the 3 months prior to foster care there had been no positive change, but when the girls went into foster care they did see change.

The Social Worker commented that a nursery worker had said if they tried to take B away from her mother, she would pinch the skin of the person holding her. She “used to go tense and rigid, doing convulsions, her whole body was almost like being electrocuted, she would grip you and nails would go in, not like nipping as angry, it was how stiff and rigid she had gone.” This contrasts with the Mother’s explanation of B being bruised as a result of pinching or nipping herself, which the Social Worker said she had never seen. She was really clear that M had said C was pinching B and “none of us saw evidence of that”. C was described as an exceptionally protective sister who would try to take care of the babies at Y Children’s Centre. She was the most motherly little girl, and the Social Worker said there “wasn’t any element” where she would have hurt her sibling.

It was clarified that the Mother had said both – that B was pinching herself or C was pinching B. The Social Worker had never seen B pinching herself, and never seen C pinch herself. She also had never seen C pinch B or fight between themselves. So far, this accords with much of the evidence that has been given by other professionals who spent time with both girls; that B was clingy and quiet, and that C was more confident to the extent of having little stranger awareness. The Social Worker had maintained reliance on her witness statement, and confirmed her recollection in 2023 at the time of her statement was better than at today’s date such that she relied on her statement and what was within it.

However, the Social Worker then went on to give evidence on a point which is in her statement, but was not raised according to the documents at the second child protection medical (at which she was present). The Social Worker said that B threw herself around, numerous times, and if the Mother had not caught B then she would have had a skull fracture. The Social Worker said you “can’t stop” B from throwing herself around, and that she kept doing dangerous things. She needed catching frequently. This is not quite what the Social Worker sets out in her witness statement, which she had been at pains to say she was reliant upon. The statement the Social Worker gave to X Police states “B was throwing herself a lot. B threw herself full force at her mum”. This, in my view, is not the same as saying she was throwing herself about so dangerously that if her mother had not caught her she would sustain a skull fracture. Given the Social Worker was so keen to inform the court at the beginning of her evidence that she is reliant on her statement, I cannot place great weight on the additional emphasis provided so long after the events took place.

The Social Worker was asked, when B went to hospital did either parent say they had to catch B and this could be the reason for the bruises. The Social Worker said that she did speak to the professionals and said it was a possibility. She said she had never seen B doing anything to her face, but her body, and did mention she throws herself about. It was solely mentioned in relation to a possible cause of the bruising to the torso. I am surprised that if B truly had been throwing herself around to the extent a head injury would not have been unexpected, then this is something crucial that should have been documented at the time and specifically mentioned before a child underwent an ano-gential examination. Had there been an explanation for the injuries B would not perhaps have needed to undergo such an assessment.

Under cross-examination by the Mother’s counsel, the Social Worker again said certain things she cannot remember as the events were three years ago. She said she was not aware of the history when she started visiting, and M was defensive the first time they met but then went on to relax a bit and work with her. FA and M did take advice about improvements. The home was limited due to size, but they did take some advice, but not all of it. The Social Worker felt she had mentioned it, and said in a forthright manner that if there were improvements then she has mentioned it.

It was accepted the house was overcrowded. The birds took up a lot of room and there was a really boisterous dog. The house was designed for one person, not two people, the parents were in one bedroom and the children slept on the sofa. The Social Worker was really worried about some of the things in the main room, and said you would want a bedroom which was just a bedroom, not including tables or bird cages or televisions.

The Social Worker confirmed that she had been told B had walked into chair before her arrival, and that was why there was a mark on her cheek. In terms of whether that was a plausible reason for the bruise, the Social Worker said she would need to know B’s size to be reminded but there were foldable wooden chairs with hard edges in the room, and also the table would not have been cushioned. She did not recall C being rough with her sister, and her statement was put to her where it is said C can be rough with her sister and seeks out negative attention. The Social Worker confirmed she could not remember what she had meant by this in her statement.

The Social Worker confirmed that they had pointed out the house was not suitable and looked for an alternative. She felt that M choosing to move in with FA was not the best idea. It was a house given to FA as a single person. The dog was said to be very boisterous, jumping up constantly and jumped as high as the Social Worker. She said she was not against dogs, and FA had said the dog was fine with the girls but she was concerned that when hyperactive someone could be accidentally hurt. For example, if the dog was surprised by something it could be responsive to that.

The Social Worker’s evidence was that she did not know how the bruises were caused but a medical practitioner had indicated non-accidental injury. The Social Worker thought she was in the hospital, but there was a lot happening. She said her manager would have told her and she would have looked at the document at a later day. Even though the mother was upset at the prospect of removal of the girls from her care, she still co-operated and had regular contact. It was the health visitor who liaised with the girls’ foster carer.

The Social Worker was challenged regarding the girls’ biological father, FBC. M was said to telephone the foster carer every Sunday for an update which the foster carer found hard as she was not allowed to say to M that the girls were staying with their father. The Social Worker said she was starting to remember - that M was not the only one who made allegations from her relationship with FBC and that it was very much returned the other way. FBC was described as having a lot of information to support that he was abused by M. FBC had his contact at Y Children’s Centre too, and they had to be careful what they told the Mother about FBC being there as FBC had said he was petrified of M and FA and did not want to come into contact. The Social Worker impressed upon the court that they do not just accept domestic abuse claims from a mother, they treat the mother and father equally. They have to balance FBC’s rights as the girls’ father and keep him safe, to make sure the primary focus was on the children. In similar vein, trying to be fair to all, the Social Worker said that they are trained not to be judgemental in their practice, however she struggled to accept that knowing someone’s background would not affect how they are seen saying “I am not the judge”. She saw her job as keeping children safe, not prosecuting anyone for their past.

Following questions on behalf of the Guardian, the Social Worker stated that when she worked with B in May 2023 she was relatively recently walking and toddling. She could stand aided and was starting to walk unaided. In the witness statement, the Social Worker says she was falling a lot, which is why there was the idea of foam matting, as C was sure-footed so it was for B’s benefit. It was confirmed that B was really fearful of being out of her mother’s arms and was fearful of everybody, and so it was questioned how a child of B’s age and development could be throwing herself off a sofa. The Social Worker clarified she had not mixed up the two girls, as C was the high energy child charging around the room, but she insisted B would “chuck” herself, “no gracefulness about it”, “roll and go”. It was a miracle, she said, that B was not face-planting on the floor more often, and had remarked to the mother that she did not know how she managed to catch B every day for the whole day. Again it is concerning that this level of detail is not in the Social Worker’s witness statement upon which she had said she was so heavily reliant. In closing submissions, counsel for the Father reminded of the case of Lancashire County Council v R [2013] EWHC 3064 in which Mostyn J said “The human capacity for honestly believing something which bears no relation to what actually happened is unlimited.  Therefore contemporary documents are always of the utmost importance". I was referred to this in a different context but consider that it is apt when reviewing the Social Worker’s evidence.

It is for these reasons that I place very limited weight on the oral evidence of B and C’s Social Worker, and instead consider her witness statement as her better, more reliable evidence.

I turn to the evidence regarding A, which was heard in court during week two of the hearing, and then two further days in a third week having gone part-heard over the Easter break. I had already heard from the initial social worker in these proceedings, but I then heard from a number of witnesses who were staff members at Savannah Lodge. I will deal with their evidence in a different way to how the evidence regarding B has been set out, for a number of reasons.

Briefly, she confirmed in her evidence that she had used the parent assess techniques when working with the parents, bearing in mind their specific needs. There was no hesitation by her in confirming that the hospital had raised no concerns about the parenting of A, at the point of her delivery, and in recognising the endeavours of the parents in engaging with courses and utilising their initiative. However, she did also confirm, when asked if the parents were actively raising their concerns with her, that they did this only in response to questions asked of them. Her evidence in her statement and pre-birth assessment confirms “During this Parenting Assessment, neither FA or M have expressed regret or responsibility for their older children’s circumstances or injuries. Both parents are unable to fully account or provide an explanation as to how these injuries occurred in their care. This has not been able to be explored in depth due to them not being able to look at how these happened, both parents have a low level cognitive functioning and this has been taken into consideration. M has given possible reasons as to how the injuries occurred to her children and was clear that should A have an injury she would assume it is accidental and ask FA various questions around what had happened. FA also gave a similar account, but was clear he would respond to any possible future injuries by taking their baby to hospital or GP to seek medical attention.” She concluded “I have to seriously consider the risk of such incidents happening again, and potentially placing unborn baby at risk of significant emotional and physical harm. I am conscious that once born, baby girl will be very vulnerable and completely reliant on parents and the other significant adults involved.” This is why a parent and child placement with significant oversight was required, and why Savannah Lodge which offered 24/7 monitoring was chosen for A.

Questions were posed to the Social Worker about her interaction with Savannah Lodge. She said that she had worked with the placement service, sent off the referral, and when Savannah Lodge expressed interest in hosting the family then the Social Worker spoke with manager EF on 19 March 2025, before agreeing for the family to be placed at Savannah Lodge. When travelling to the Lodge, the Social Worker spoke with GH, EF’s co-manager, via text message to update the Lodge about their journey. On arrival she met with IJ during the placement meeting, and they discussed FA’s background with the police and their investigations so Savannah Lodge became aware of the concerns regarding FA’s eldest child’s injuries. The Social Worker confirmed that the Local Authority were told that at Savannah Lodge there was 24/7 camera footage and supervision, and the summary of their discussion was sent as part of the paperwork to get the Savannah Lodge placement underway. The Social Worker was specifically asked whether she was aware that there were blind spots in the view that the cameras had within chalet 4, and she confirmed “not at all”. I had already considered the Social Worker to be a measured and fair witness in relation to B and do not doubt her evidence in relation to A. I accept entirely her account of her interactions with Savannah Lodge, which sets the context for the concerning evidence which followed.

At the outset of the hearing, the Guardian had included in her final analysis her very serious concerns about Savannah Lodge, and indicated her view that Savannah Lodge failed in their duty to safeguard and monitor A’s welfare. The concerns related to the way in which Savannah Lodge had operated, the CCTV blind spots which had not been identified or made known to the Local Authority, and that A was harmed in this placement and any harm may have been exacerbated by their lack of action. As set out at the beginning of this judgment, I made it plain when I began to hear the case that I was not intending to embark on the process of making findings against Savannah Lodge. I was concerned with establishing threshold for A, by having a fact-find regarding A and her half-sister, before determining welfare considerations at a later stage. However, as the evidence from the Savannah Lodge witnesses progressed, it became clear that the difficulties with Savannah Lodge went far beyond CCTV blind spots, and were very serious concerns indeed. Those concerns became impossible to ignore and are directly relevant to A’s welfare.

EF’s evidence was that the “buck stopped with her” as co-manager. I was urged to consider the principles in Re W [2016] EWCA Civ 1140 (more of which later). Instead of findings, Savannah Lodge conceded I could make extremely robust “observations” within my judgment about the matters which were of concern, for further investigation if so required by Ofsted and any other regulatory agency. The witnesses from Savannah Lodge remained witnesses rather than being joined as intervenors, and to ensure that there is no identification of individuals, I refer to their evidence as a whole where possible or to individuals’ particular actions but without naming them. I make it plain that I consider the management of Savannah Lodge to be responsible for their staff members entirely, whether that be for any deficiencies in their training, failure to follow protocol, doctoring of documents and record keeping, failure to accurately record logs, failure to treat parents with known cognitive profiles fairly, and ultimately for failing to safeguard a child placed in their care. I also consider it the responsibility of Savannah Lodge, and not the individual witnesses, that there is now delay caused in these proceedings as a result of no one having faith in their documentation such that no reliance can be placed upon it in proceedings. It is the failures of Savannah Lodge which have necessitated a new parenting assessment (at what should have been the final stage in proceedings), and caused harm to A in delaying a final decision for her long-term placement and welfare.

The concerns with relation to Savannah Lodge focus on two periods: the events of 5 July 2025 and 28-30 July 2025. I will deal with each in turn.

On 5 July, it is common ground that the parents had a counselling session, during which time A was to be cared for by a member of staff. During this session A was very unsettled despite the best efforts of a member of staff to comfort her, and her cries were so loud the parents indicated they could hear her during their counselling session. The session came to an end and A was returned to the care of her parents. A body map should have been completed at the start and end of the session, documenting any marks or concerns about A, serving both the purpose of record keeping for Savannah Lodge and reassurance for the parents, given the reasons for their being placed at Savannah Lodge and these proceedings. It should have been very simple and straight forward, however, it was anything but. Rightly, in my view, the parents were entirely dissatisfied with the care and service offered by Savannah Lodge, which has been borne out by the evidence, and which is of equal concern to the Local Authority, the Guardian and now the court.

Counselling was due to take place between 11am and 12noon on 5 July 2023. Albeit there was some confusion introduced by the evidence of EF, it seems to be generally accepted that the session of counselling was 11-12, and one witness said the parents were running slightly late. Given this, the logs show that the initial body map for A was undertaken at 11.03am on 5 July. This should have been conducted in the presence of the parents, but there is conflicting evidence about this, and a strong suggestion that it was done without the parents either by one or possibly two staff members albeit at least under CCTV surveillance. There is evidence to suggest that one body map was signed by FA on behalf of the parents, but one of the witnesses from Savannah Lodge said that she had mistakenly dated it 6 July at 11.07am. Before handing A back to her parents at around noon on 5 July, protocol required there should have been a further body map undertaken. It is to be expected that the body map prepared and signed at the end of the session would be timed around midday, but the logs for the day do not show that a body map was completed then, and in fact the next time that a body map is mentioned as being completed is within the entry log commencing at 13.37, and there is a body map for 13.40. Again, the oral evidence was that this body map was erroneously dated 6 July, as the individual who completed it said she had got the date wrong.

Upon realising that the body maps were dated with the wrong date, evidence was given by the individual staff member that she had been asked by management to change the date to 5 July on the body map. It was co-manager GH who was on duty that weekend. Instead of crossing out “6 July” on each body map, to write “5 July” and initial the error, the evidence given was that the staff member completed a whole new body map document, despite only needing to change the date. This is problematic, because on any analysis, the body map document for 11.07am on both 5 and 6 July is exactly the same save for one key difference. There is not a new document, as suggested. On both body maps, the box containing the date and time, child’s name, date of birth, date/time of any injuries, who observed them, any information recorded and (crucially) the name and signature of the parent are exactly the same. Also, at the bottom of each page there is a comment under the figure of the child saying “no injuries where noted” (sic). The style of writing in all of this is exactly the same, with the same spacing between words, the same typos, the same signature. What is different, is that on the body map dated 6 July 2025, there is writing above the figure of the drawing which says “body map done while parents are having counselling and A is with staff”. That confirms that the parents were not present for the body map. But what is most interesting is that despite it being the exact same sheet for 5 July as 6 July (instead of simply changing the date, and the evidence being it was a new body map), on the body map for 5 July the writing has been removed above the child’s figure but carelessly so - as it is still evident that part of the letter “d” remains from the word “and” which had been in precisely the same spot as on the 6 July body map. There is no doubt whatsoever that the body map of 5 July is not a new body map as claimed by the witness, but a photocopy of the body map of 6 July, with the writing above the child figure removed, perhaps by tippex or some other means. The improbable evidence of the witness, that when rectifying the date mistake they wrote out an entirely new body map and the exact similarities are merely coincidence, is entirely unbelievable. I have no trouble in concluding that the body map at 11.07am on 5 July is a photocopy of an altered body map from 11.07am on 6 July.

I might understand that one single document had been altered and photocopied to save time, and forgive the evidence asserting the contrary. However, there are further body maps that have been copied or doctored. There is a body map from 6 July at 13.40, and precisely the same document again dated 5 July at 13.40. It is clear the 5 July version is a simple photocopy of the 6 July body map, and not a new one with the date change error rectified. There is a further body map dated 6 July timed at 13.16 which is a copy of the body map of either the 5 or 6 July body maps timed at 13.40, only on the 13.16 timed version, where at the bottom it had said “no marks observed” the “observed” has been removed and changed to “was observed on the leg”. It is plain to see that again for the document dated 6 July at 13.16 it is not an original document but an altered copy of a preceding document. There is also no reference in the logs for the day to a body map being prepared at 13.16 as well as 13.40 and one might query why it was necessary to prepare such a body map about the same incident so close together.

Then it gets worse. At some point, someone within Savannah Lodge has used the doctored body map of 11.07am on 5 July (with same writing, same typos, same signature of the father and same little mark from a “d” above the figure’s head, so that it could not be more obvious it is a photocopy) and created another body map, but with a time of 12.15. Again, not only was this body map not mentioned within the logs, but the evidence about its creation was extraordinary. The witness said in evidence that when preparing the body maps she had thought the date was 6 July. Upon realising that it should have been 5 July, management asked her to change the dates and so she says she produced new body maps. However, for the body map of 12.15 on 5 July to be an original document, it would have required that witness to believe at 11.07 on 5 July that it was 6 July by mistake, then just over an hour later at 12.15 that same day to remember it was 5 July, and then prepare another body at just over an hour later at 13.40 on 5 July but believing again it was 6 July. None of the evidence of this witness was logical or sensible. The logs do not support the creation of multiple body maps on 5 July, and they are not referenced.

The parents were criticised by Savannah Lodge for raising their concerns (and the Father was given a written warning for making a malicious allegation) because on 5 July when A was taken back into the parents’ care, they noticed at 12.31pm what they thought was a bite mark on A. Quite rightly, the parents raised a concern with Savannah Lodge by sending a photograph to the Lodge at 12.31, and at 12.36 the Mother addressed the CCTV cameras in their chalet demanding an explanation. At 13.20, FA called Savannah Lodge requesting to speak to staff, but it took a further 17 minutes for a worker at the Lodge to attend their chalet at 13.37 in response. The log entry in relation to this incident refers to the discussions with the parents by the member of staff, the parents’ concerns that the incident would be attributed to them, and then it records that a “second” body map was completed. If the multiple body maps completed on that day were genuine, then the second body map had already been completed at 12.15 indicating no injuries. There would have been no need to prepare a further body map as was apparently done at 13.40 to show the same, that there were no injuries. Even if it was said that the body map at 12.15 was completed on handover, it is inexplicable why the 12.15pm body map says “no injuries where noted” (sic), as the parents did not raise their concerns about injury until 12.31 at the earliest.

In evidence the staff member of Savannah Lodge said that the CCTV footage was reviewed for the hour that A was cared for by staff, and nothing untoward was noted, as all of the time spent with A had been under the surveillance of CCTV footage. Staff were concerned by reports that the parents had been sharing with other residents their worries about A having a mark on her leg, and that it was potentially destabilising for residents at the Lodge. The log from 7 July indicates that the Mother was spoken to, that they “reassured M that no member of staff had bitten A and showed her video footage from the time A was in staff care. It was reiterated that no discussions regarding personal matters should take place with other residents, and that any concerns should be directed to staff.” Evidence was given to the court that the Mother had been shown all of the CCTV footage of A being cared for in that hour’s time frame. The Lodge’s Investigation Report sets out “to provide transparency and reassurance, staff showed Mother the relevant CCTV footage from the period when A was in staff care. The footage did not show any incident of harm or inappropriate contact.” From reading this document one would understand that the Mother had seen all the footage so that she could be reassured.

However, the Lodge’s Investigation Report from 7 July also shows that the meeting with the Mother began at 15.15. FA’s meeting began at 15.30 on that same day, with the same staff members. There is no possibility that the Mother was indeed shown the whole hour of footage within a 15 minute meeting. Further, given the Mother’s cognitive difficulties about which Savannah Lodge were aware, it is extraordinary that such a meeting took place in 15 short minutes. Likewise for FA. The Investigation Reports therefore give a misleading impression as to what took place during those meetings. It also placed the parents at a disadvantage, and created a negative impression of them which they had not been able to properly address or challenge. It is particularly concerning that FA was given a written warning for making a malicious allegation in the above circumstances.

It is also disturbing that the brief report to LADO does not contain nearly the level of detail that would be expected from Savannah Lodge when making a referral. It presents the parents negatively. Anyone coming to this report would, at first glance, view the parents perhaps as being difficult and disruptive. The LADO referral indicates the parents raised their concerns “a few hours later” which is untrue, and that “upon examination, the mark had already faded and did not resemble a bite mark”. This is not what is recorded on the body maps. The photograph of the mark, which the parents took by 12.31 and which is in the bundle, looks like two partial semi-circular indentations. It is unusual enough that someone could not be blamed for raising it, and I do not accept that it was correct or fair for the LADO referral to record the event in the way that it does.

The incident on 5 July is relevant for a number of reasons. It paints a negative picture of the parents, in terms of their response to seeing what they thought was a bite mark, and also in terms of the relationship with Savannah Lodge. It would no doubt have engendered mistrust of the professionals at Savannah Lodge, if the parents felt they were not being taken seriously, and in fact criticised for raising concerns. Later, when it is said that the parents did not bring A’s bruising to the attention of the staff, one may have some sympathy as to why.

Various staff members were asked about their training, and from the list of training topics given it seems that there has been training undertaken. However, the impression that the witnesses gave was that there is a “frustration gap” between undertaking the training and it being properly put into practice. It is not enough to simply attend a course on learning disability awareness or recording/reporting, the learning must be effectively put into practice. The training is vital, but came across from the witnesses almost as a tick-box exercise. Certainly the parents in this case were not treated in accordance with their vulnerabilities, the recording and reporting was significantly flawed, and A’s safety was compromised by staff failure to follow protocol regarding moving away from blind spots or intervening after a prolonged period of distress.

The CCTV footage of the 28-30 July 2025 was referred to the witnesses for Savannah Lodge. One witness indicated that it was FA’s turn to care for A that week as the parents were being assessed as to how they managed independently of each other. The staff member observing the CCTV on 29 July did not see any forceful harm caused to A, or any forceful feeding, and said FA was simply trying a variety of techniques to settle A who, it was accepted, was a loud crier and suffered from colic. At the end of the time when FA was caring alone for A, the Mother came back into the main room from the bathroom to take over care, and A is observed to calm down. The witness was asked what factors might have resulted in Savannah Lodge staff stepping in at an earlier stage given the duration of A’s crying. It was confirmed again that FA was being assessed in how he managed to care for his child, so they had not intervened but if the Mother had been delayed coming back out of the bathroom to assist then Savannah Lodge would have stepped in. However, since the Mother came back in “at the right time”, she took A and settled her.

This led to an exploration in evidence as to the set-up of the CCTV monitors and how staff monitor sound, as the sound from the chalets does not come through the CCTV but through the use of baby monitors which are in each chalet. The suggestion that the quality of sound from the baby monitors is likely to be insufficient was refuted, and it was indicated that not only do the monitors pick up the sound of a child crying but also conversation and can be used to speak to parents in the chalets. If there is a noise on the monitor which catches the attention of the staff monitoring the chalets, they focus on the CCTV to watch on a screen what is happening. The difficulty with staff members having to watch any more than one CCTV screen at any time, with multiple small screens from each chalet on each large screen, is that inevitably a person cannot watch everything at once. To safeguard and observe 24/7, it would rely on a staff member observing any incident which occurs at just the right time. Even a split second’s inattention means something could be missed. Staff could not be faulted for being human, but where the problem remains is that staff are required to monitor more than one chalet and actively have their attention on one chalet for a moment at the expense of another. It is hard to understand how Savannah Lodge can offer their services as being 24/7 CCTV monitoring when staff are sharing their time between multiple units on two screens. A person wandering out of line of sight for mere seconds could easily be missed whilst human eyes are focussed on another part of the screen. An accident could happen in moments, or more serious incident, and it would not be picked up on. Once cries of a baby are heard on a monitor, that could be after the event, too late to intervene as a preventative measure. This is particularly worrying when families are placed in Savannah Lodge because of known risks, or risks that need monitoring and assessment.

Staff did not accept under challenge that they had failed to respond appropriately to A’s cries, albeit it was accepted that you cannot tell on CCTV if a child is being squeezed. They felt that they were monitoring the situation appropriately. However, from listening to all the witnesses from Savannah Lodge, it was not apparent that they all fully understood the reasons why M and FA were at Savannah Lodge with A, albeit some referred to risk assessments and a variety of reasons why they were there. Either this theoretical knowledge did not feed through into their understanding on the ground, or their training and understanding of the risk assessment was insufficient in the first place. I was concerned that one time estimate from a witness as to how long they would wait before intervening was between 10-15 minutes, which is wholly inappropriate where there are such identified risks of harm. It is understandable that the parents were being assessed to care for A as a family but also independently of each other, yet that does not account for such a long period of time before staff would intervene if A were significantly distressed.

The evidence of the staff member who noticed the bruising on A during her bath time on 30 July was very troubling. She prepared a police statement 3 weeks after the event, when it could be argued her memory was not as fresh. However, she also went to the hospital with A and her parents on 30 July itself, shortly after the bruising was observed. Here, only a few hours later, the facts of the evening which can be observed on CCTV were misreported to medical professionals. It was told to medical professionals that one of the explanations given by FA was that ink from his old tattoo may have come off on A, but this is not what can be heard on CCTV. This misreporting to professionals tracks through subsequent medical evidence and into social work documents. Further, the incident regarding the alleged bite mark from 5 July also feeds into medical reporting but negatively towards the parents as it is said, incorrectly, in the Safeguarding Child Progress Note dated 31 July 2025 that there were “some inappropriate behaviours by the parents towards staff, the home and other residents, reported by the home”, and that in relation to the bite mark there was “no clear explanation from the parents as to what happened”. Again this sets the parents in a negative light, and the comments travel through further professional reporting becoming almost an accepted fact. At this meeting were Hertfordshire Police, Kent Children’s Services and the IRO for A, who would have absorbed the information presented and the behaviour/explanations of the parents when it was untrue and highly prejudicial. The evidence from the staff member who observed the bruising and accompanied the parents to the hospital was at such odds with the CCTV from the afternoon and evening of 30 July that she was shown again the CCTV footage during her evidence and asked whether she wished to change her evidence. She confirmed that she did not. It was concerning that despite watching CCTV footage at direct odds with her own evidence, she was not able to exercise reflective practice and make any necessary alterations to her position.

Of all the staff members from Savannah Lodge who gave evidence, one did stand out as really caring about his role, having managed to build good rapport with M, FA and A. It was this staff member who was identified by management in the statement from EF who should have asked FA to come back in sight of the CCTV footage, albeit this was the moment he had turned his attention to the other family he was supposed to be monitoring with his full attention as well. The criticised staff member was the only one of all the witnesses who appeared to genuinely care about his work and have any capacity for self-reflection and improvement (whatever I might think about the quality of his evidence more generally). Surprisingly, no other staff members were criticised by EF in her written statement for their roles in the care given to the family or their supervision, or indeed in their failure to keep A safe. Having heard from a number of staff members over the course of several days, I considered that whilst their evidence left much to be desired across the board, the criticised staff member was the only one who gave any impression at all of trying to assist the court.

The registered manager, EF, confirmed that whilst she is the registered manager and GH is the centre manager, their roles overlap and they work together and are both responsible for decision making, staff supervision, risk assessments, and family placements, working in line with the regulations and national minimum standards. She was asked about the evidence of her staff and any lessons learned. EF described surprise at the evidence she had heard from her staff. She said:

“I have to acknowledge that the support workers don’t have the opportunity to come to court to give evidence. Something to take on board. I need to train up my staff especially regarding the area of giving evidence in court. What I saw was a staff team not able to articulate what was expected of them.”

I am extremely concerned that this appears to be the most significant “takeaway” for EF, and endorse that precise submission made on behalf of the Mother in closing. The urgent training the staff at Savannah Lodge need is not how to give evidence.

EF acknowledged that in hindsight she should have mentioned to the Local Authority that there were blind spots in Chalet 4 where M, FA and A were placed. She had felt confident in having previously worked with families with similar concerns and because there was a risk assessment in place. Since these proceedings, Savannah Lodge have taken action to adjust the CCTV including further cameras. It was said that CCTV has worked at other residential units, but Savannah Lodge recognised that they did not want a repeat incident of this case. EF did not accept that the set-up of Savannah Lodge only enables action to be taken after an incident has taken place, insisting that the combination of CCTV and baby monitoring for sound, alongside staff on the ground was sufficient. The difficulty with this, however, is that the evidence from the parents, and borne out by the records, was that staff were slow to respond to requests from the family, and slow to intervene when A was exhibiting severe and sustained distress.

EF accepted that the court was now faced with the task of trying to determine how bruising had been caused to a child in their placement, with evidence from the staff and documents from the placement which cannot be relied upon, which is hugely detrimental to A who has suffered and is now facing further detriment through delay. At the close of evidence, Savannah Lodge provided to the court a Concessions Document, drafted by Counsel, which I set out in full:

As promised at the conclusion of the first part of the fact-finding hearing, Savannah Lodge (“SL”) makes the following concessions arising from the oral evidence heard to date.

As the Court has already been informed, SL does not seek to apportion blame to any one staff member.   SL takes responsibility for them as an organisation as a whole.

To stress at the outset, in response to the concessions made below, SL has made the decision not to accept any further assessments of families where there have been convictions or findings of physical injuries caused to a child by one or both parents being assessed. Even with the highest level of support and monitoring, A’s case has shown that the risk may still be too significant and unpredictable.

Between 28^th and 30^th July 2025, FA was not asked by staff to move out of blind spots at times when he was with A in them, or to turn around towards the camera, in contravention of the risk assessment, and as he should have been.

It is accepted that, whilst chalet 4 was the best positioned accommodation for A on the premises in terms of the family avoiding too much time with other families, a further camera should have been fitted in chalet 4, and both cameras should have been positioned so that she could be seen at all times, given the level of physical risk.

Chalet 4 now has an additional camera (installed on 9^th April) and the angles of both cameras ensure that there are no blind spots, even in cases where there is a lower level of risk to a child.

It is accepted that the level of physical risk posed to A has shown itself not to be adequately ameliorated by SL’s CCTV monitoring process because of the demands posed by the need for staff to monitor more than one family at once.

It is conceded that whilst staff were trying to give FA the opportunity to settle A successfully on his own as part of the assessment, those monitoring the CCTV footage should have sent a staff member on the ground to intervene when FA was struggling to settle A on 29^th July at 16:44 (onwards) and again at 20:21 (onwards).

SL accepts that when K cared for A whilst the parents were at counselling, there is no reliable written evidence that a body map was undertaken at the conclusion of her care.

In respect of the bruising seen on A by L, it is conceded that the account she gave to the police and the Court (including in her oral evidence) of what the parents did and said leading up to the bruising being observed and afterwards is significantly inaccurate when compared with CCTV.

In response, SL has already:

Standardised body map templates;

Implemented a new recording software (see below); and

Provided training from an external body map trainer to all staff via Smart Horizons.

It is accepted that the body maps that were provided in July 2025, when compared to those provided during this hearing, include photocopied duplicates with different times, dates and comments added.

SL has already initiated a disciplinary procedure, but in any event, it should not have happened.

Inaccurate LADO referrals for A were also drafted by management, which included copying and pasting from other documents into later ones.

Deficiencies in accurate record-keeping for A as set out at paragraphs 9,10 and 12 above demonstrate poor practice, which below the required professional standard.

In response, SL has already:

Purchased and begun to implement a new recording software called Clear Care. This is software for children’s homes specifically designed to increase transparency, enforce compliance and reduce risk. On the system, once documents are done and saved electronically, they cannot be changed. Any amendments are recorded as such, with the later date and time. This will replace all paper files.

Sent all staff on refresher training on reporting and recording.

This is the first such incident in 4 years, since SL was opened.

SL sincerely apologises to the Court for how A’s case was handled and accepts that their practice fell below the expected standard.

OFSTED were notified on 13.04.26 by SL of this, as it constitutes a serious incident.

SL seeks to assure the Court that lessons have been learnt, improvements have been made and systems are now in place to prevent this happening again.

SL remains fully committed to delivering safe, high-quality assessments and to supporting the court with accurate, reliable, and professional evidence at all times.

This document does not, in my view, go far enough in detailing the concerns with Savannah Lodge. The reflection that they will “not accept any further assessments of families where there have been convictions or findings of physical injuries caused to a child by one or both parents being assessed” reflects upon the fact that their CCTV/monitoring system is wholly inadequate in such cases, but ignores the deeper concerns about doctoring evidence, covering tracks, misreporting to professionals and LADO which could negatively affect any child in their care/assessment were such conduct to be repeated. Until all of these extraordinary failures have been fully investigated and addressed I consider that there may be a risk of harm to any child within their care/placement. It does not matter what the concerns are which bring a child or family to Savannah Lodge if, once there, Savannah Lodge are not able to demonstrate safe procedure or honest reporting.

Given the difficulties with the evidence of Savannah Lodge, it became apparent that the fact-find was going to have to go part heard and resume almost 5 weeks later to hear from the parents. In some ways, this allowed the parents to digest the large amount of evidence which they had sat and listened to for the first two weeks, particularly given their cognitive profiles. However, I am also conscious that by the time the parents were cross examined, some of the oral evidence would have faded in their memories.

The Mother began her evidence by sharing with me how her contact with A is progressing. She told me how amazing it is seeing A growing and walking around. I have no doubt that the Mother loves A greatly.

The Mother was able to accept that her husband’s history is a worry but also indicated her view that he is now a different person to twenty years ago, describing how he helped with C when B was attached to her hip. She said that she had never seen FA hurt any of her children. When asked about her knowledge of what happened to D, FA’s eldest child, the Mother said that she knew there was a broken arm but she had heard multiple stories and FA had told her he was at work when it happened and he could not be in two places at once. The Mother was reminded what the family court papers from 2003 show - that the Judge had made a finding that FA had caused the injury and there was more than one fracture – but the Mother repeated she had been told just one. Her conversation with FA had been quite some time ago, and whilst the Mother did not remember everything, she confirmed that he had told her what she had just said. The Mother was asked what she thought had happened, and whether she thought FA had hurt D. The Mother’s evidence was that it was very hard, looking at it now. Before, she said, there were other stories told and she was just getting to know FA. However, when she had first moved to X, she did not think he had hurt D. When pressed again about what she thinks now, the Mother said she still does not think that FA hurt D. FA had thought that he had been set up, and the Mother’s evidence was that two other people had also said this. She was unable to accept the judgment from previous proceedings and it seems to me her perspective is wedded to that of FA. She was unable to apply independent thought to all the information that she had heard or that she knew about, and I consider that she too readily accepted what FA had told her without questioning the impact upon her children.

The Mother was also challenged about what other matters were within her knowledge about FA, at the point of the visit from the Health Visitor on 6 February 2023. She accepted that there had been a “knife incident” and stealing from someone else in homeless accommodation. She also said that there was “something about indecent images on a laptop”, but she could not remember if she had mentioned all these things to the Health Visitor. When challenged if she was trying to hide anything, the Mother’s response was that she knew the situation was to do with FA so was “hoping he was going to be open and honest”. She accepted she was worried that he had not shared the information, but said that she knew there would be further involvement with the social work team and he would have an opportunity to speak. In terms of worry about FA being around her two girls, the Mother said that it was not a “massive worry” as she knew people could change and believed what had happened had taken place when FA was much younger and he was a changed person.

On any analysis of this evidence, it is apparent that the Mother took a great deal of what FA told her on trust. She was insufficiently curious. She had hoped he would be open and honest with professionals, even when that was not forthcoming, and she trusted him with her children on the basis of their short-lived relationship and the vague notion that people are capable of change. It is hard to know how much of this stems from the Mother’s cognitive profile and how much was her turning a blind eye to the circumstances. On the one hand her evidence was that she knew there was a risk, as FA’s contact with B and C needed to be supervised, but on the other hand she thought simply that people change and the risk was not a live factor for her children. On balance it seemed to me that the Mother was minimising what she knew about FA’s conviction history, the risks for her children and his honesty with professionals. That minimisation happened in 2023 and in my view was apparent as the Mother gave evidence at this hearing, some 3 years later. She viewed the supervision of FA’s time as having to take place because the Local Authority had said that it must be, not because the Mother herself truly appreciated the risk. She was complying but not fully understanding. Even the compliance was not complete and the Mother recognised that there were occasions, rarely, when FA was not supervised around B and C, mostly when she had to go to the toilet. Whilst appreciating that it is not easy to use the bathroom, shower or toilet alone when there are very young children (and particularly one as clingy as B), the requirements of supervision were there for a reason. FA’s own evidence in the proceedings relating to D was that the injuries to D occurred whilst he was alone with D and her mother was in the shower (even if he later disputed this). The Mother’s evidence was that she had only ever popped to the shops and left the girls in FA’s care prior to Social Services requiring his time to be supervised, and not after, which contradicts what she told IJ, albeit the Local Authority now do not rely on any documentary evidence from Savannah Lodge and it remains disputed by the Mother. FA’s friend, J, was said to never have been left alone with the children by either the Mother or FA.

The Mother said that she first saw the bruising to B when the Health Visitor had seen them, which I find impossible to accept given the number and sizes of bruises to B. She also said, when asked to think carefully about her evidence, that she was “50/50” as to whether or not she had seen the bruising earlier. The Mother’s case was that the children had not been left with her husband unsupervised save for short periods when she went to the toilet, and even then B would cling to her so she was not able to do that alone. For B to be constantly in her Mother’s care, or supervised by her when with FA, it is implausible that the Mother would not have seen the bruises on a child whose nappy she changed, whom she bathed on alternate days, and dressed and undressed each day. The bruises are numerous, some of them are 3.5cm and 4cm in length, and their colour is markedly different from B’s skin tone so that even on the photographs from the child protection medical the bruises stand out for all to see. I do not accept that the Mother had not seen any of these bruises prior to the Health Visitor’s visit and B being undressed to be weighed. I find that the Mother’s comment to the Health Visitor regarding pinching was a deliberate comment through which the Mother sought to anticipate what the Health Visitor was about to see and manage her reactions to it. The Mother’s evidence has changed between suggesting pinching caused the bruises and suggesting they were caused by her having to catch B. The Mother relied on it being a confusing timescale as to why there were different explanations. I am not persuaded that suggestion of confusion about timescales justifies the different explanations. The Mother also accepted that picking up B under her arm pits when she fell would not account for any bruising to her forearms, legs, sides or abdomen.

The Mother also said that she did not recall the bruises to the forearms, could not recall if she saw the bruises to the armpit beforehand or not, and the bruising which the Mother had thought to be caused by the dog she said was to the side of B’s tummy instead of the back which she had previously indicated.

The Mother’s oral evidence in relation to the bruise to B’s cheek was that she fell onto a chair, which is markedly different from the original explanation she gave that C and B were running together holding hands and she ran into the chair, and what she had said to the Health Visitor. The Mother accepted that the bruises on B’s sides, by her tummy button, her forearms and her legs would not be from catching her and scooping her up under her armpits. The statement from the Mother’s own father indicated that she had told him B was bruised from an incident between her or FA, but the Mother also did not remember telling him this. The Mother insisted that in their relationship there was nophysical violence, albeit she accepted she struggled a lot and got angry and shouted at FA. She did not recall any children being involved.

The Mother said of the bruising she was “quite concerned as to why it was happening” which does not accord with her evidence that she had not seen it before the Health Visitor’s observations, or her own suggestions as to why it was happening. She was challenged as to whether or not she was making up the reasons now, but the Mother said her memory had been jogged by the evidence of B and C’s Social Worker. However, the Social Worker had recorded B throwing herself within her witness statement, so this was not new information to the Mother, even if the way in which the Social Worker expressed it was new and exaggerated. Ultimately, when assessing credibility, I was not persuaded by the evidence of the Mother on this point. She said that when interviewed by the police she did not have legal representation and so was not directed on what to say, but I take the point from the Local Authority that had the Mother been telling the truth she would not have needed to be directed, even accounting for her cognitive issues and lack of representation. The Mother’s evidence in relation to the bruising is inconsistent and her explanations would not cause much of the bruising seen on B. When asked questions by Counsel for the Guardian, the Mother said that she knew of the worries about FA and accepted that it could have been that she did see the bruises, thought FA had caused them but had wanted to give him a chance and so had not said anything. She conceded ultimately it was a possibility that FA had bruised B.

I also heard evidence regarding footage recorded by a camera that the family had installed in the family home. I return to this again when considering FA’s evidence, but I was not persuaded by the Mother’s evidence regarding the deletion of the recordings from their device in their living area. The Mother was questioned about the recordings by X police and I do not accept that it was a coincidence or accidental that the material was deleted after the Mother had been questioned. She said that she did not remember how to delete the recordings and said she was “not sure” when she was asked if she was trying to hide something.

A key feature of the Mother’s evidence was her lack of memory regarding conversations and events. This is not completely surprising given her cognitive profile, but as the Mother’s evidence progressed it seemed to me that she was able to recall details that she wished to whilst being vague or having no recollection at all on more difficult topics. This was particularly evident when she answered questions about A, although I do of course accept that 2025 is more recent than 2023. She was far more readily able to recall her time at Savannah Lodge, particularly in relation to its impact upon her. She became tearful when she told me how she had been affected, and at the end of her evidence when I asked her if there was anything she wished to tell me that she had not already said, it was about herself that the Mother spoke and the impact of the events upon her. I also considered that a great deal of criticism has been levelled (quite rightly) at Savannah Lodge and the parents were certain that they had not injured A on 5 July 2023 so that was safe ground about which to give evidence. In matters relating to the children, for which she may have been responsible, the Mother’s approach was vague and unhelpful and unparticularised.

The Mother set out how difficult it had been for them as a family at Savannah Lodge. Although she got on with two male staff members, there had been an issue with the first key worker assigned to them. The Mother confirmed that she has now seen the CCTV footage. She had thought on 28 July that she had scratched A’s back with slightly long nails, and had concerns about A slipping in the bath. The Mother can be seen at 2.31mins into the video clip SL1 speaking about A sliding in the bath. A is not distressed at all at this time and carries on watching the washcloth and looking out of the window. At 3.39mins the Mother says that she might have scratched A but again A does not make any sound. The description of A being a baby who would cry easily would suggest that she was not hurt at this time. I consider that during the bath with the Mother on 28 July there is no sign at all that A was in distress or injury was sustained. The Mother conceded in her oral evidence that now, having seen the footage, she does not think she hurt A during that bath.

On 29 July it had primarily been FA caring for A, as the Mother was feeling unwell. The Mother said her recollection of this day was more “fresh on the brain” at the time of her statement.

It was suggested to the Mother that on 29 July FA was struggling with A, having taken on the majority of the care, and she was fractious. The Mother felt that FA had tried all the things she would have tried herself to settle A, but recognised that on 29 July there are two occasions seen on the CCTV footage when A becomes particularly upset.

The Local Authority point to A being extremely distressed in the clip SL2 at 49.14 mins after a period of being unsettled with in FA’s care while the Mother is in the toilet. At 49.14mins, FA has his thumb around A’s pubic bone and hands on her back when her cry changes and she loses her breath with her dummy falling out. At 49.33mins he bends down to put A on the floor with his thumbs on A’s back and fingers on her chest. Her cry again changes as he puts her down. The Local Authority’s case is that FA has excessively squeezed A, being frustrated that he could not settle her. His frustration is evident from his comments at 50.06mins when he says “(inaudible) I don’t fucking exist” when he sits on the chair outside of the camera’s view. At 50.13mins the Mother says “you wait when she is bigger it will be all you” and he replies “I doubt it”. It was conceded by FA in his evidence that he felt as though A did not like him when he struggled to settle her. There was also an occasion that he had to put A down in the cot and walk out of the chalet as a result of his frustration. The Local Authority say this level of frustration is evidenced in the video clips and has resulted in A coming to harm in his care.

In the clip SL3, FA starts to struggle with A from 46.32mins. At 51.10mins it is said that the pitch of A’s cry again changes to the point that she loses her breath, but it is not possible to see where FA’s hand is behind A, due to where they are sitting. At 52.08mins FA stands out of the sight of the camera at the door and A continues to cry and he moves back into the camera view at 52.16mins. The clip then continues into SL4 where at 1.44mins FA has his back to the camera with A obscured and her cry changes again. It is not until the Mother comes out of the bathroom and picks A up that she calms at 2.14mins. At this point A has been distressed for around 9 minutes without Savannah Lodge intervening despite the CCTV and the door being open.

In relation to the concerns that the parents did not raise the bruises with professionals themselves, both parents informed the hospital that they had not noticed the bruising. This clearly contradicts what can be seen in the CCTV footage. I consider that the parents misled professionals in this regard, because the footage shows not only the parents observing bruising to A but discussing it, albeit briefly. Before A’s bath on 30 July, FA can be seen showing the Mother a mark on A’s chest. He also shows the Mother a mark on A’s back, having called her over to him from the kitchen area, leaning A forwards and indicating the mark. When challenged in evidence, the Mother said she remembered that now, and she thought she was going to mention it to staff but forgot, and also that she wanted to give FA the opportunity to say something as she had previously been criticised for mothering him. However, neither parent took the opportunity to inform staff of the bruising a short while later and actively denied knowledge of the bruising at the child protection medical.

Interestingly, when the Mother was asked if she agreed that she had not protected C, B and A from FA, she said something to the effect of “no, as I did protect as best I could. Not like I neglected it and said I don’t care. I just thought I protected as much as possible”. This stands in stark contrast to her evidence that she did not think FA was a risk, and suggests she was aware of the concerns but had minimised them. However, moments later when she was asked if she was “covering up” for FA, the Mother’s response was “why does he need protecting”, reverting to a denial of any concerns. Ultimately I consider that the Mother’s evidence to the court was that she had been aware of significant safeguarding concerns regarding FA but had wilfully turned a blind eye, giving him chances and hoping he would be honest, in an attempt to create family life at the expense of the safety of her children. I did not consider the Mother to be a reliable reporter or a credible witness.

FA had the same courtesy afforded to him as he gave his evidence, with a screen drawn across the courtroom so that fewer pairs of eyes were upon him as he was cross examined. He confirmed his statements in these proceedings and to the police were true and agreed that he has poor working memory. He said sometimes he was “not great at remembering things but little things can trigger” his memory from the past, or if he was shown things. It was agreed that if a document or image was being referred to, then he would be able to look at it as well as having things read to him. I am satisfied all efforts were made to afford him the best opportunity to give his evidence.

He said that he had seen M with C, B and A and never seen anything in the way that she is with them that caused him any concern. He said he saw a loving mother with her children, and if he had any worries he “would ask her or have a word with parents or authorities”. This is not the approach taken in relation to A’s bruising at Savannah Lodge and was an immediate disconnect between what FA indicated he should or would do, and what happened in reality given that neither parent raised B’s bruising with professionals nor did they inform Savannah Lodge of the bruising they observed to A just before the bath time on 30 July 2025.

In relation to his previous conviction for GBH to D and the decision of the family court in 2003, FA considered that it was “a fracture to her arm and something to do with her leg I think”. He was asked now if he accepted the findings and that he caused the injuries, and his response was that “I still say it wasn’t me but I was found guilty”. He said D’s mother set him up, and her sister. He confirmed because of the thoughts that he had been set up, he feels that he definitely did not hurt D and everybody is wrong. He had told M that he had been set up.

Despite this, when M moved in with him, FA felt that the Local Authority should be involved, but then clarified that he did not think they needed help. He said they thought the social workers would know everything which is why he did not share details about his other convictions. This seems unlikely given the Social Workers at their visit outlined their knowledge and asked if they would find anything else, to which the response had been negative. M’s evidence was that she had been waiting for FA to share the information, which does not accord with FA’s evidence that they both thought the information was already known.

FA accepted that sometimes he would be on his own with C and B. He, like the Mother, said that this did not happen after they were told his time must be supervised, save for one time FA recalled having to break up a fight between the girls when the Mother was in the shower. He thought the fighting came before they were unwell in the week before the bruises were discovered. About having his time supervised, he said it was “hard but had to be done”. They did look after the children together in the same room, and he would often help with C and also changed B’s nappy. At home he would not try to prise B away from M. He accepted that she was clingy, and had that bond with her mother. He said whilst he became upset in himself, it was understandable and C would cuddle him.

In relation to the injuries to B FA’s memory of when the injuries were found was said to be “not that clear”. He was in the house when the Health Visitor saw the bruises, but he confirmed that he had not seen them before the Health Visitor saw them. He was challenged that he had changed nappies, been around at bathtime, and his evidence had been the accommodation was small, but he still did not remember any bruises. FAalso backtracked in his evidence to suggest that he had not really changed B’s nappies that often. I consider this to be unlikely. In such confined accommodation, where the children did not have their own bedroom but slept in the living area, where the parents cared for the girls together and where he changed B’s nappy, it is highly unlikely he had not seen the bruising or changed her nappy infrequently. I consider that he had seen the bruising. The photographs indicate bruising that is immediately obvious even to a lay person or the untrained eye. FA’s evidence that he had not previously seen the bruising before the Health Visitor is entirely implausible.

FA could not remember which bruise the dog had caused, and said B got the bruises as she was “clumsy”. She would sometimes fall over, but could not remember how she would fall over. He was not able to assist the court with how B came to have bruises to each side of her face by her eye, and denied seeing B hit her face on anything. He confirmed the Mother had told him that B had hit her face on a chair before the social worker arrived, and thought he was in the toilet when it happened but he was not sure. The dog would get under their feet sometimes, such that they would nearly trip over him and said it was a possibility that B might have tripped over the dog but he had not seen this himself. C was described as being a bit rough to her sister but grabbing B and trying to run with her, and because C would squeeze her own tummy whilst watching television that B had maybe copied her. FA then could not remember any of the circumstances of this behaviour, whether over or under clothing, whether any pain caused her to cry out. He did not remember the suggestion made of B hitting her face at Y Children’s Centre and could not assist with the challenge put to him that none of the workers there had seen it. He did not remember it, or M telling him.

With regard to B “throwing” herself off furniture, it had not been mentioned by FA to police, and he said he remembered she had rolled off the sofa a couple of times which he saw and was B copying her sister, but he was not sure how she fell and if it was from standing or sitting although he said her “belly would go over cushions onto the floor”. His memories of someone having to catch her were at night time, but he could not remember where the hands would be placed in order to catch her.

FA was reminded that the medical evidence shows the bruises needed a lot of force to be caused but he could not think of anything other than B hitting her face on the chair that made him worry she had been hurt.

I listened carefully to the evidence of each parent regarding the recording device they used to monitor the girls at night in the living area. The Mother had said she could not remember how the videos were managed, and the recording was not on all the time as it was used on an ad hoc basis. The device could record but it needed a button pushed. Once made the recording would be stored on a tablet until deleted or it could be transferred to a mobile phone. FA was asked about the recordings which were deleted. He said that once a recording had been transferred to a phone then was no point keeping it on the memory card if it was on the phone. The Mother had told the police that FA had tried to “do something” and all the recordings had been deleted. It happened just after the police had spoken to the Mother. FA accepted that this was a possibility but then said “me and technology are not that great really”, denying that he was hiding anything or had deleted the recordings on purpose to prevent the police from reviewing them. This seemed a surprising assertion for him to make after he had just described how the device was used by them and the recordings could be transferred. It was suggested to FA that three things had been said by the parents to cause the recordings to be lost; rebooting the camera, changing internet provider and having to format the SD card. In evidence FA said it was a possibility that all those things caused the recordings to be lost. He said he could be a “cheapskate” and got cheap SD cards, which he said “go” after a while and need to be formatted to work again. He thought they had needed to reboot numerous times, but was not too sure. He did not know about the “crash” on the tablet that M had mentioned, and had not had a conversation with her about it. FA explained that to reboot the router he would turn it off for a few seconds and then back on again, which would reset everything if it was not working properly. To format the SD card he had to take it out the camera, put it into the laptop as you could not do it straight from the camera. He said it was like putting a memory stick into the laptop, and it causes a window to open which tells you to reformat. Despite FA’s assertions about his ability with technology, it appeared to the court that he was sufficiently capable of handing the devices he owned and knew how to manage them. It seems to the court not mere coincidence that so soon after the police asked about the recordings from the camera that they were deleted, and in my view suggests either that they knew there would be something to hide or they at the very least thought there was a risk of something adverse being shown on the camera device.

FA was asked about the witness statement that M’s father had given in which it was detailed that M had reported B being hurt as a result of an incident between “M or FA”. I was concerned when he said that he only saw that witness statement the day before he gave his evidence. Along with the CCTV footage, one would have expected FA to have viewed all the evidence from the Local Authority or been taken to it by those representing him. I take account that FA’s cognitive profile and that he might not remember seeing it before the hearing, but if indeed it was the case he had never seen it until the middle of the hearing that would be very concerning. In any event FA denied there being an injury to B caused by an incident between him and the Mother.

FA was then asked questions about A. FA described seeing A during contact sessions and said it was good. He was enjoying her being on her feet and spending time with her. I have no doubt FA loves A. He said he had “never had a chance before with oldest daughter”, so his experiences with A were new to him again. He had been nervous about going into Savannah Lodge. At the start he said he had found it “ok”, until they had wanted to go to different places and had to be chaperoned, and it was confusing with some rules. He said “things went downhill from there, it affected me badly and didn’t want to be there but wanted to be there for A”. Given the concerns apparent before the court regarding Savannah Lodge I am not at all surprised it was a difficult experience for both parents. FA accepted he had sent some inappropriate messages, and said his mental health was not very good. He felt that everyone else was able to do what they wanted but they were not allowed, being kept away from everyone else. FA felt this was intentional to stop them interacting with anyone else. He described being “stuck in room 24/7, same old walls, not allowed out really. If in garden had to be chaperoned, half an hour then back again, whilst everyone else stayed out”. He felt down, he did not eat sometimes and said he was “just not myself”. It was accepted by FA that he would get angry but said it was directed at himself as he felt he was doing something wrong although he then said “obviously I wasn’t” and when he felt frustrated he would walk away and take a moment. I make no criticism of FA for doing that.

FA denied squeezing A, even without realising. He said he had not used excessive force due to frustration and so did not cause the bruising. He said he had not seen the bruising to A until the Savannah Lodge worker saw them, but then was challenged that this was incorrect. He was reminded about the CCTV footage which shows A being undressed and FA seeing something on her front and calling the Mother over to show her. There is also another occasion, a few minutes later, when A is on FA’s knee facing away from him and he notices a bruise on her back, again calling the Mother over so that she can take a look. It is abundantly clear from both the CCTV footage and the Mother’s own evidence that both the Mother and FA knew about the bruises to A’s chest and back before the Savannah Lodge worker saw them, and also the emerging bruise to A’s groin.

Overall, I did not consider FA’s evidence to be helpful but I have to bear in mind that for both these parents there are cognitive limitations, difficulties with memory over time (particularly for FA) and I take on board the submission made on behalf of FA that there was a tendency to follow the direction of the last question posed to them. However, there were moments where matters put to the parents elicited clear information, such as FA’s ability with technology. Despite them each denying they were hiding information, and bearing in mind their difficulties, I did form the impression that there were some questions they were more able to answer than others because they were “safer” questions. Anything relating to harming the children itself was met with wide memory loss. Matters relating to their own personal feelings and mental health was, on the other hand, something they were able to articulate. I did not find FA to be a believable, reliable witness. I very much formed the view that each parent was not being honest with the court or, indeed, with themselves.

Given the extraordinary way in which this case unfolded, advocates prepared written submissions for which I am extremely grateful. It is well known that not every piece of evidence needs to be referenced, nor all points of submission. This judgment has been rather more detailed than would perhaps ordinarily have been the case, and it is hoped the reasons for that are apparent. There has been a finding of fact exercise in relation to two children who are connected but about whom the evidence is (save for Dr G) entirely separate. The egregious way in which the parents were treated by Savannah Lodge has also loomed large in the court’s mind and the question of whether to make findings or thoroughly robust “observations”.

To avoid repetition, I make it clear that any findings are on the balance of probabilities and that I have carefully considered the law, the evidence (both written and oral), and the bundle as a whole. In my analysis I do not refer to the allegations that the Local Authority no longer seek to rely upon. In the same way, I do not analyse the accepted allegations, but they are within the final schedule and ultimately set out in my final conclusions.

In closing submissions the Local Authority maintain that the injuries suffered by B, as reported by the hospital on 25 May 2023, were inflicted by either the Mother or FA. In respect of A, having reflected on the evidence, the Local Authority now seek to prove that the bruising to her was inflicted by FA and not the Mother. There are additional findings sought by the Local Authority and I refer to their updated schedule below. The Local Authority’s submissions were available one day prior to the submissions from all Respondents to ensure fairness and fair opportunity for response.

The parents and B and C’s Social Worker mention bruising to B’s face after a fall and B hitting her face on a chair. The mother mentions this in her second Police interviews. This is also mentioned by the Social Worker in her police statement. However, this injury was to the right side of B’s face. In addition, the Social Worker was clear that she saw the bruising fading on 19 May 2023 during her visit to the home and the bruising that she saw to B’s face on 25 May 2023 in hospital was different. The Health Visitor in her statement to X Police is clear that she saw bruising to the left side of her face on 25 May 2023.

Unfortunately, the bruising on B’s face in the photographs from X Police is difficult to see due to the redness of her face. However, the photograph at N390 in the bundle and the close-up at N391 are the left side of her face. The photo at N392 is the right side of her face with a faint mark on her eyebrow.

The Mother was clear in her oral evidence that the injury from B falling onto the chair was her right side, as was B and C’s Social Worker. When the Mother was asked to explain the injury to the left side of the face, she was unable to. FA was also unable to say how it happened, saying in oral evidence that he was out of the home a lot. Strikingly, the Social Worker said in her statement to the Police that had she seen the injury on the 19 May that she saw on 25 May she would have said that B should have gone to hospital. I consider that the written statement of B and C’s Social Worker is far more reliable than the evidence she gave to the court under cross-examination, and have no reason to doubt the statement she gave closer in time to the events occurring.

Dr G opines that “the maxilla is also not the most prominent aspect of the face; the zygomatic, nose and mandible protrude beyond it, and largely protect it from injury. Taking all this together, my opinion is that B’s facial bruising is more likely to be inflicted, most probably by the hand of an adult carer.” It is submitted on behalf of the local authority that a memorable event must have occurred in order to cause the injury to the left side of B’s face. The Mother recalled the incident with the dining chair on 12 May 2023, emphasising this point. The Mother told the Health Visitor that the injury had been caused “on Friday just before the social worker attended” (which date we know to be 19 May) which did not happen. The Social Worker was clear the bruising that she saw was on the 12 May and had been resolving when she saw her on 19 May 2023.

The parents point to there being accidental explanations accepted by clinicians as plausible, that there are accidental explanations which have not been considered properly by any paediatrician and there is a complete absence of expert scrutiny as to the extent and result of investigations done during her admission to hospital. I disagree with this submission, albeit have expressed grave reservations about Dr G who very much gave the impression of having not done his homework thoroughly. I am able, however, to rely upon and accept the evidence of Dr T who was an impressive witness and for whom B remained in her memory, such was the shocking extent of her injuries. Even where Dr G’s manner of giving evidence left much to be desired, and he was not as thorough as he should have been, I consider the evidence of Dr T to be sound. I consider the wider canvas, particularly the absence of injury and repeat bruising to B following her removal from the parents’ care.

I agree that the Mother was not honest with the Health Visitor on 24 May 2023 and has not been honest to the Police in her interviews or in her statements to this court. I agree that the Mother must have known how this injury was caused and find that she has not been honest either because she caused the injury to B’s face herself or knew that FA had caused it and wanted to protect him. The evidence from the parents in court did not assist me with understanding either the history or issues of causation, and whilst it is not for them to disprove the Local Authority’s case, I find that this injury to B was inflicted and not accidental. I cannot say which one of the parents was the perpetrator, having regard to the law and the facts in this case, and should not be tempted to strain to do so. Both were present in the home together which was by all accounts cramped and chaotic. The parents both maintain that FA was not left alone with B save for the shortest of time periods for necessary toileting, and even then B was clingy and with her Mother. I disregard what was reportedly said to IJ as the Local Authority do not rely on any evidence from workers at Savannah Lodge. Therefore the parents have maintained they were together at all times with B and it is not possible to distinguish which of them caused the injury to her face. I accept the medical evidence that this was an inflicted injury therefore and that, given I cannot identify a single perpetrator and choose between them, both the Mother and FA are in the pool of perpetrators. There is not only a real possibility, on the balance of probabilities, that they are the perpetrators but it is likely.

There is significant bruising to B’s abdomen as seen in the photographs from X Police from N379. When the Health Visitor attended the home on 24 May 2023 and the bruises were seen, she says “just before her babygrow was removed the Mother said that she had spoken to Y Children’s Centre about B pinching her sides. She said it makes her bruise and stated B bruises easily.” This conversation took place before the Health Visitor took off B’s Babygro. The Mother denied in oral evidence that she had said this to get ready for the Health Visitor to see the bruising. The Mother said that she did not remember seeing the bruising before this.

In the Mother’s response to the schedule, she said that she may have caused the bruising putting B in the bath when she was unwell. This was not said to the Police or professionals after the injuries were found. Other than this explanation, the Mother said that she did not know how the injuries had occurred and did not remember seeing them. FA also said that he had not seen them and did not know how they could have been caused other than B pinching herself. In his police interviews, FA also suggests that C could be rough with B and repeated this in his oral evidence.

None of the witnesses from Y Children’s Centre said that they had ever seen B pinching herself. The foster carer also said that she had never seen that. In addition to this, the foster carer and nursery workers also commented on how caring C was towards B. It was Dr G’s view that B would have been upset and have cried or shown obvious distress when the bruising was caused and FA did not recall in his oral evidence B being distressed when she was said to pinch her sides. I do not find it believable that the Mother or FA would have failed to see such extensive bruising to B. It is so extensive that even a brief glimpse of B’s tummy by DY was enough for her to see a bruise around B’s hip when her top rode up. I find the parents knew B was bruised and that the Mother was fully aware that the Health Visitor was about to see this bruising when she attempted to excuse it and prepare her before the removal of B’s babygrow.

In her oral evidence, the Social Worker for B and C questioned whether the bruising could have been caused from B “throwing herself around, off furniture and needing to be caught”. This was not observed by any other witnesses or mentioned by the parents. I have already made comment as to the graphic descriptions given by the Social Worker going well beyond her witness statement at the time, and my view that her oral evidence is significantly less reliable that her written evidence. It is submitted on behalf of the local authority that this would not be an explanation for the bruising to B’s sides or lower abdomen. When the Mother gave evidence, and in her statement she mentioned picking B up under her armpits if she fell. She did not describe gripping her sides.

Dr G’s written evidence stated that accidental bruising of the abdomen is uncommon, and that bruising to the abdomen is suggestive of physical abuse. He also observed that the presence of bruising of the lower abdominal wall in a child can be a sign of sexual abuse. He was of the opinion that the injuries to B’s abdomen are more likely to be inflicted injuries, and that they, or some of them, might represent child sexual abuse. Dr T had arranged for an ano-genital examination after the first child protection medical because she was concerned about sexual abuse, but the results of that examination do not assist the court. I cannot go so far as to make findings of sexual abuse towards B but certainly the bruising itself was so concerning that it remained in the memory of Dr T for a long period of time.

I find that the type and location of bruising indicates that these are inflicted bruises. No memorable event is identified by either parent despite Dr G saying that B would have been in significant pain at the time that the injuries were caused. Again, neither parent says that they saw the bruising before the Health Visitor saw it which would not be possible if she was dressed and undressed by them.

The foster carer in her statement to X Police confirmed that there was an occasion in the first week in June 2023 when C said “no slap me’ and repeated it 3-4 times. She later said “no slap B’ about B. Whilst this piece of evidence is not determinative in and of itself, I bear it in mind when considering the wider canvas and the medical evidence about causation. Given the force required to cause the bruising to B I am not persuaded that it can be explained by the suggestion of B throwing herself around and needing to be caught or “scooped up” under her arms. Considering all the medical evidence, particularly from Dr T, I find that the bruising to B’s abdomen was inflicted. Again, as with the facial bruising, I find that the parents have not been honest in relation to the injuries. I find that either the Mother or FA caused the injuries and the other parent knew that the injuries had been inflicted and did nothing about it.

Given that it was one of the two parents who inflicted the abdominal bruising, but I cannot say which precisely, then once again the Mother and FA are both in the pool of perpetrators.

The parents have said that the bruising to B’s back was likely to be caused by their dog. However, the mother said in her oral evidence that she thought that the marks caused by the dog were smaller and on a different side. I bear in mind the passing of time and memory fading, alongside her cognitive issues. FA was similarly confused in his oral evidence on this point and I bear in mind the submission that he tended to follow the thought process of whichever advocate had last asked him a question. Dr G’s view was that “it is uncommon to see accidental bruising to the back in children. It is possible for a dog’s paw, or paws, to cause bruising. However, when taken together, and in the overall social context, these bruises are suspicious of an inflicted injury.” I agree that the wider canvas is important, and the context of all the other worrying bruising to B. I bear in mind the conflicting evidence about the dog and its size, with one witness stating it was medium but another saying the dog could jump as high as she stood. I am not satisfied, taking into account the views of Dr T, Dr G, the lay evidence and the wider context, that this injury is explained by a dog. I find that this injury is an inflicted injury either by the Mother or FA and the person who did not cause the injuries knew they had been caused and did nothing to protect B. Again, both parents are in the pool of perpetrators because I cannot identify which of them caused the injury but it is one of them.

Taking the injuries to both arms together, the Local Authority rightly accepts that Dr G has said that bruising near the elbow and forearm may be accidental. However, the Local Authority maintain that these bruises should be considered in the context of the significant bruising on other areas of B’s body. They rely on neither parent being able to say how the bruises were caused and that they had not seen the bruising before it was pointed out to them, however I remind myself that it is not for the parents to disprove the allegation. The Local Authority again take the view that the parents have not been honest and one or other or both of them inflicted the injuries and the person who did not cause them knew that B had been injured. On this particular allegation, the Local Authority remind me of FA’s past history regarding his daughter D as part of their submission that these arm injuries are inflicted. I do not consider that it is appropriate, where there is an acceptance of a plausible explanation by the medical expert and where the area of the injuries is more likely to be accidental, that I should look back 20 years to a previous incident of proven harm. I have tried very hard in these proceedings to not fall into the trap which the witnesses from Y fell into. I can neither disregard the past nor allow it to affect my considerations to the extent that I cannot see beyond it. Therefore whilst I do not ignore the history for FA, and have borne it in mind, I consider that it is not a determinative factor which can bolster a weaker allegation. I do not consider that the injuries to the arms are inflicted injuries and therefore allegations of injuries relating to the arms are not proven.

Dr G is of the view that the injury to B’s thighs are likely to be inflicted rather than accidental. I can see from the photographs a pronounced bruise across the thigh above the knee, which I consider would have been seen by both parents before observed by the Health Visitor. I remind myself of Dr G’s evidence in relation to these injuries but also the evidence of Dr T. Should there be any doubt about Dr G’s evidence (and I have already said the substance of his evidence was acceptable to the court, if not the manner of delivery) I rely on Dr T and all the other available evidence to me through the wider canvas. I find that the injuries to B’s thighs are inflicted injuries caused by either the Mother or FA or both of them. Again, it is a pool finding as it is impossible to distinguish between the parents.

The submission of the Local Authority is clear in relation to this finding. Dr G has said that B would have been in ‘significant pain’ from the injuries. A parent would have been expected to have known that she had been hurt and both parents have said that they did not know that she had been injured. I have already indicated I find that they would have known she was injured from having seen the bruises. I do not accept the evidence from the parents that they did not know about the bruising or see it before the Health Visitor undressed B to weigh her. Given the bruising to B is significant, which is evident from even the briefest of glances at the photographs, I am extremely concerned that both parents knew of the bruising and failed to take action. When the photographs were referenced in cross-examination of the parents, the Mother made some steps forward to recognise the level of injury sustained, but this was minimal at best. I do not accept the parents simply had not noticed the extent of bruising to B, given their cramped living arrangements and the fact they were nearly always together. It is not believable that they had failed to notice the bruising. Dr T’s evidence that the bruising remained in her mind because of the severity was compelling. The Social Worker confirmed that had she seen the bruising she would have said that B needed to go to hospital. I find that both parents knew the bruising was there, and they knew who had caused it and how, and they each chose to do nothing about it. B suffered and the Mother and FA failed to seek help for her and protect.

The court heard the evidence of both the Mother and FA in relation to FA’s previous conviction and fact-finding decision in relation to the injuries to D. FA maintained that he was ‘set up’ and that he did not cause the injuries. Concerningly, the Mother only thought that D had one fracture when she had a number of fractures as a baby. The Mother confirmed that, before social services visited her, she would leave B and C in the care of FA. Once social services became involved, she said that she no longer left them unsupervised because that is what she was told to do. I understood from her evidence that she had complied with the requirement and considered it was necessary because Social Services “said so”, but that she did not believe in herself that it was necessary.

I was concerned that the Mother did not know FA very well before she and the children moved in with him, other than the Mother knowing him when she was a young child and FA being a family friend and having babysat her. The Mother’s evidence was that she moved to live with FA because it was either that or being homeless, which on the face of it was not much of a choice at all. She was aware of the conviction and the other issues for FA, including the concerns around domestic abuse with his previous partner, but nonetheless trusted him to care for the children. I have concerns about the Mother’s decision making abilities and an inability to prioritise the children. Certainly in my view she did not prioritise the children by choosing to live with FA, and then she failed to protect them as the injuries to B became apparent. I find that the Mother failed to protect B and C from FA.

The Local Authority sets out the injuries that were caused to A at finding 10 of the schedule. It is submitted on behalf of the Local Authority that these injuries were more likely than not to have been inflicted by FA and not the Mother. This is an amendment to the attached schedule following a review of the evidence in the hearing. One of the matters that concerned me during the hearing was that despite the medical evidence being available to the Local Authority prior to the final hearing, in relation to bruises and the impossibility of dating them from their appearance, that the Local Authority had not sought to review the CCTV footage before the bath time on 28 July 2025. It appears that the view was taken that because there were no visible bruises at bath time on 28 July 2025, but there were two days later, that the bruises must have been caused in the intervening period. Unfortunately the medical evidence tells us very clearly that it is not possible to age a bruise. It is entirely possible the bruises were caused before the bath time on 28 July but simply had not yet begun to show.

In addition to the stress experienced by the parents at Savannah Lodge, the parents were having relationship difficulties as confirmed in their oral evidence, with FA also experiencing difficulties with his mental health. The Local Authority consider that this impacted on the Mother’s ability to protect A and FA’s ability to manage his frustration when caring for her. It is submitted on behalf of the Local Authority that the existence of the CCTV has been helpful. The Local Authority says that, on a balance of probabilities, the 3 video clips from 29 July 2025 (SL2 at 49.14mins and 49.33mins, SL3 at 52.38mins and SL4 from 0.00mins) are occasions during which A sustained the bruising while in the care of FA. This is during the day when the Mother says that FA had the majority of the care of A as she was feeling unwell.

I was taken to the CCTV footage of the bath on 28 July when no injuries were seen to A. This is also the bath when the Mother said that she may have caused the injuries. The Mother is seen when she bathes A and at no point does A become distressed. The Mother can be seen at 2.31mins into the video clip SL1 speaking about A sliding in the bath. A is not distressed at all at this time and carries on watching the washcloth and looking out of the window. At 3.39mins the Mother says that she might have scratched A but again she does not make any sound. The description of A being a baby who would cry easily would suggest that she was not hurt at this time.

I have considered the CCTV footage at Savannah Lodge at length and watched it repeatedly. The evidence from Dr G was that he did not observe anything that was more than reasonable handling during the incidents pointed to by the Local Authority. He did accept that the bruising could have been caused by A being squeezed and that he could not tell how hard A was being squeezed from the CCTV alone. The Local Authority maintains that during the occasions on the footage they rely upon, FA used “force beyond normal handling; a force obviously greater than that which a carer would tend to use with a child”.

I accept that A is extremely distressed in the clip SL2 at 49.14 mins after a period of being unsettled in FA’s care while the Mother is in the toilet. At 49.14mins, FA has his thumb around A’s pubic bone and hands on her back when her cry changes, and she loses her breath with her dummy falling out. At 49.33mins FA bends down to put A on the floor with his thumbs on A’s back and fingers on her chest. Her cry again changes as he puts her down. It is submitted by the Local Authority that FA has excessively squeezed A being frustrated that he could not settle her. His frustration is evident from his comments at 50.06mins when he says ‘(inaudible) I don’t fucking exist’ when he sits on the chair outside of the camera’s view. At 50.13mins the Mother says ‘you wait when she is bigger it will be all you’ and he replies ‘I doubt it’. In evidence, FA said that he felt as though A didn’t like him when he couldn’t settle her. There was also an occasion that he had to put A down in the cot and walk out of the chalet as a result of his frustration. I am asked to find that that this level of frustration is evidenced in the video clips and has resulted in A coming to harm in FA’s care.

In the clip SL3, FA starts to struggle with A from 46.32 mins. At 51.10 mins the pitch of A’s cry again changes to the point that she loses her breath, but it is not possible to see where FA’s hand is behind A due to where they are sitting. At 52.08 mins FA stands out of the sight of the camera at the door and A continues to cry and he moves back into the camera view at 52.16 mins. The clip then continues into SL4 where at 1.44mins FA has his back to the camera with A obscured and her cry changes again. It is not until the Mother comes out of the bathroom and picks her up that she calms at 2.14mins. At this point A has been distressed for around 9 minutes without Savannah Lodge intervening despite the CCTV and the door being open. The Local Authority have maintained that, on the balance of probabilities, FA squeezed A during this incident causing some of the bruising.

When considering the causation of the injuries, the local authority relies on the opinion of Dr G that squeezing could have caused the bruising together with A’s presentation during the occasions outlined about, albeit he did not see anything of concern in the footage he was shown nor anything that indicated a moment where FA squeezed A. The Local Authority relies on A’s changes in cry being indicative that she has been hurt at those moments, because Dr G stated his expectation that the bruises sustained by A would have been painful to receive. I am invited to consider the parents’ explanations for A’s bruises, by her laying on toys or rolling onto her dummy, or slipping in the bath or being held too tight in the bath. I am invited to consider and then discount those explanations.

Dr G accepted that the response of different children to pain varied. He saw nothing in the presentation of A in the CCTV from 29 July 2025, which enabled him to conclude that it resulted from abusive injury or even inappropriate handing, there being a range of possible and non-suspicious explanations, for example wind or colic.

As I have indicated, I have watched and listened to the CCTV footage repeatedly, particularly at the times pointed to by the Local Authority and others in submissions. I accept the medical evidence that rolling on a toy or dummy is unlikely to have caused the bruises. I am not persuaded that A slipping in the bath caused the injuries. I discount the parents’ explanations, but again they do not have to disprove the case brought against them, or prove an alternate explanation. However, as much as I am not persuaded by the parents’ explanations, I am also not persuaded by the Local Authority that the bruises to A were inflicted injuries. I do not see any evidence of FA squeezing A. I do not accept that her change in cry can be attributed, even on the balance of probabilities, to that being the moment the bruising was caused. There are many other reasons why A’s cry could have changed, and she was described by most witnesses as being a loud crier, and she suffered with colic. I do not accept that the moments identified by the Local Authority were the moments when A received the bruising.

That means I do not know when A did receive the bruising, because the footage shown to me indicates a good level of child-focussed care of A, in circumstances which would have been difficult for any parent. I have no doubt that it would have been very hard being cooped up in a small space, during a hot summer, where time outside had to be chaperoned and was limited, and where Savannah Lodge had treated the parents unfairly and the relationship of trust had broken down (save with the two male staff members). It is therefore not possible to say when the bruising was sustained from the footage I have seen, or how it was caused, or by whom. I am not satisfied that the Local Authority have proven their case in relation to the bruising to A being inflicted by the Father between the bath time on 28 July and the bath time on 30 July 2025.

The lack of finding of inflicted injury to A does not mean that I am without concerns about the parents whilst at Savannah Lodge and in light of the reasons why they were there. Both parents denied that they knew of the bruises to A before the bath on 30 July save for the mark on her chest that FA says they brought to the attention of a staff member who, in fact, gave evidence that he had not been told of a mark on A’s chest.

The clip of the bath [SL5] demonstrates that at 3.27mins FA has undressed A and sees something on her front showing the Mother. She says at 3.37mins that she ‘lays on her front and her dummy is there’. Then at 9.49 mins FA sees the mark on A’s back and calls the Mother over. She says at 10.06mins ‘I know it is the toys’ at 10.09mins FA looks at the camera and then mouths something to the mother. The Mother says ‘I don’t know’ then walks to the kitchen. Given the reasons why the parents were at Savannah Lodge, the history of FA and the bruising to B, the Mother’s lack of concern at what FA was showing her is extraordinary. Even if I accept the Local Authority have not proven their case of inflicted injury to A, I am dismayed by the attitude of the Mother to bruising, given the wider canvas. She appears wholly unconcerned by what she sees. No doubt there is an argument that it is because she believes she knows why the bruising is there (toys, dummy, slipping in the bath), but nonetheless I find her casual attitude problematic.

Both parents lied at the child protection medical saying they were not aware of the bruises. The way in which the parents reacted to believing A had been bitten by someone on 5 July, when they were absolutely confident they could not be blamed, contrasts sharply with the way the parents behave when they observe bruises to A whilst she is in their care. I can hear on the CCTV footage that they do not bring the bruises to the attention of the staff member supervising bath time, and she has to raise it with them. The parents are not open or honest about the appearance of the bruises and, like with B, do not seek help or advice for her. I find that the parents were fully aware of the bruises to A prior to the bath time on 30 July 2025 and failed to mention them to staff.

Given the Local Authority have not proven their case in relation to A’s bruises being inflicted injuries, I do not consider that the Mother has failed to protect A from FA in this particular regard. However, I have already made observations about failures to be honest with professionals, failures to take the appropriate action upon seeing the marks, and a concerningly casual attitude bearing in mind the history. A finding of failure to protect is not simply a bolt-on, and I do not make this finding.

I therefore make findings as follows, having regard to the colour-coded revised schedule, which should travel with this judgment:

In summary, for ease of reference, all allegations relating to B are proven save the injuries to her arms. It is not proven that A suffered inflicted injuries, but I do find that the parents knew about the bruises and did not bring them to the attention of the staff at Savannah Lodge.

Insofar as Savannah Lodge is concerned, I say this. I agree with the submission on behalf of the parents that the written and oral evidence from Savannah Lodge has revealed a complete disregard for transparency, fairness, proper procedure and accuracy. More than that, it has shown a willingness to covertly copy and alter important documentation and present it to the court as authentic.

At the start of the fact-finding hearing, the Guardian had wished to seek findings against the placement for what she considered were failings of such a magnitude that that was the appropriate response on A’s behalf. That decision was reviewed by me in light of the need to take a proportionate approach and focus on the issues that would affect care planning for A, but that change of position in no way reflected a concession on the Guardian’s part that the quality of care (using the word in the widest sense) which the placement provided the family and A was acceptable. In fact the evidence has shown that Savannah Lodge fell very far short of what would be acceptable care. The Guardian was right to raise her misgivings, respectful in accepting the court’s initial view that it was not proportionate to pursue findings at the outset of the fact-find, and then wholly appropriate in re-emphasising her earlier position of grave concern. Had I had any notion at the start of this multi-day hearing of the direction of travel of those concerns, which became greater with every passing day of evidence, I might have taken a very different stance at the outset regarding findings.

I heard submissions from all parties during the hearing, at the conclusion of the Local Authority’s case, in relation to whether or not I can or should make findings against Savannah Lodge or individual staff members, or whether I should make “extremely robust observations” instead. I was referred by Counsel for Savannah Lodge to the case of Re W (A Child), Re [2016] EWCA Civ 1140. In that case the Judge made some significant findings against named individuals in his judgment without it having been apparent during the course of the hearing that he was considering doing so. It came as a complete surprise to those individuals and was no doubt a horrible shock. It remains my intention in this case not to make findings against individual staff members. They continued throughout this hearing as witnesses only and were not joined as intervenors. Savannah Lodge manager EF gave evidence that the “buck stops” with her. Any failings of the staff are failings of Savannah Lodge. Submissions were made that making findings against Savannah Lodge would potentially leave the case open to further litigation as in Re W, risking delaying the welfare decision for A which has already been significantly derailed by the Local Authority effectively having to start “from scratch” with their parenting assessment. I do not wish to cause any further delay for A, who has suffered enough harm already. I also consider that the welfare decision for A is capable of travelling entirely separately from the issues of findings against Savannah Lodge, and the timing of publication of this judgment and any anonymisation.

This case, however, is markedly different from Re W. It was apparent from the outset of this final hearing that the Guardian sought findings but had acceded to my view about proportionality and the ability of the court to conduct what might then stray into the realms of professional discipline. As far back as the pre-trial review when I joined Savannah Lodge, they were aware of the Guardian’s position. Individual staff members were permitted to have legal representation whilst giving evidence. Savannah Lodge were at the very least on notice of the question of findings, and they remained aware of it continuing as an issue as the evidence from staff at Savannah Lodge became ever more unacceptable and extraordinary. At the point at which the evidence indicated documents had been altered and doctored, LADO referrals had been made on a false premise, there had been misreporting to police and clinicians, and other egregious failures, Savannah Lodge were unable to ignore that the question of findings was very much still a live issue. There is no suggestion in this case that, should the court make findings or “extremely robust observations”, it would come as a surprise to Savannah Lodge. Indeed, I consider their Concessions Document, whilst helpful to a certain extent, is an attempt by Savannah Lodge, at the conclusion of the Local Authority’s case, to control the narrative in recognition of the seriousness of the court’s concerns. Witnesses were fully cross-examined on all the issues relevant to their involvement, and Savannah Lodge were represented throughout the hearing. EF was present daily until the evidence of the parents, when KL took her place. I do note that no party in their closing submissions invites formal findings against Savannah Lodge, but given that it is ultimately a matter for the court I do not consider that I am prevented from making findings should I so wish.

Re E (A Child) [2025] EWCA Civ 1563 was a recent appeal decision in which the decision of Ms Justice Henke was upheld. The grounds of challenge in that case were that the Judgment contained findings which were unfairly made and wrong and that their publication, naming her, would violate the appellant Aimee Dover’s Convention rights. The concluding paragraph of the appeal judgment says “In conclusion, we direct that this judgment may be cited. We consider it important to emphasise the exceptional nature of Re W and to underline the following. A witness of fact will generally have no legitimate ground of appeal in respect of adverse findings contained in a judgment, provided the criticisms have been fairly put to the witness in cross-examination for comment or response before the findings are made. A witness who is at risk of adverse findings does not, for that reason, have any right to intervene or to have legal representation.” In the present case, Savannah Lodge were named as intervenors and legally represented, beyond being witnesses. I accept that I did not hear from the co-manager, GH, but EF’s acceptance that the “buck stops” with her means that I did not need to, and no one invited me to. Re E confirms therefore that I can make findings against Savannah Lodge.

I also consider that should this judgment be published, Dr G should be named. Whilst he conceded at the conclusion of his evidence that there were ways to improve, I am deeply concerned that an expert would come to court to give evidence (even if remotely), not aware that they were to be asked questions about two different children and clearly having not prepared themselves in readiness for cross-examination. If I am to name Dr G, he should be invited by the Local Authority to attend the formal handing-down of this judgment, with representation if he so wishes, in order that he might address the court on the issue of publication and anonymisation.

I have also considered the case of Re XY (Twins Inflicted Injury), [2024] EWFC 413 (B), in which the court named the nanny found to have inflicted injury. No one in this present case has been able to show that the staff at Savannah Lodge caused any direct physical harm to A, and the parents did not pursue their case in cross examination that because they had not bruised A themselves, someone at Savannah Lodge must have. However, the lack of inflicted injury to A may be considered to be more a result of luck than judgment, given the concerns in 2003 for FA and the findings that I have made about both parents from 2023 (far closer in time to A’s placement in Savannah Lodge). I recognise the concerns of everyone in this case that A has been harmed by the separation from her parents following the placement at Savannah Lodge breaking down, and the harm caused to her by the Local Authority having to restart their assessment of the parents. The significant delay for A along with separation from her parents is a cause of harm, not easily remedied. I invite advocates at the formal hand down of this judgment to address me in relation to not just publication of this judgment but also removing any anonymisation for Savannah Lodge within it. I also invite further consideration as to whether or not it remains disputed that case law allows me to make findings against Savannah Lodge as a company.

The Guardian seeks permission for the Concessions Document and any relevant part of the Court’s judgment at the conclusion of this process to be disclosed to Ofsted and within Cafcass. Consideration also needs to be given, in the Guardian’s submission, to whether the document itself, or a summary of its contents, should be made available more widely amongst practitioners who may have had clients at the placement recently so that they can consider whether any of the failings which the placement accepts in its document had, or may have had, any bearing on their own cases. It is proposed that this issue be considered further and addressed at the hearing once judgment has been handed down. I am conscious I have yet to hear submissions from other parties in relation to this but my view is that the Concessions Document, and the parts of my judgment relating to Savannah Lodge and A’s care, should at the very least and as a priority be shared with Ofsted, CAFCASS, Local Authorities and the Judiciary, if the point of wider publication naming Savannah Lodge is not settled in the affirmative.