Birmingham City Council v AG & Ors

Initially the children shared bedrooms in a conventional fashion, one for the boys and one for the girls, with B, the baby, in with her mother. Downstairs there were two rooms and a kitchen. The mother, as I have already indicated, was unable to obtain a transfer of her tenancy until such time as the house was decorated. The children had drawn all over the walls, an indicator perhaps of the struggle mother was having in controlling the children before JA moved in.

JA offered to renovate the house. Unfortunately he did not go systematically round the house room by room and in addition to re-decorating he decided to lay new laminate flooring throughout.

By March 2008 on everyone’s account the house was chaos. The only usable rooms were one bedroom, a front downstairs room and the kitchen. All the children were now sleeping in the upstairs bedroom together. This was bad enough, but there was only one double mattress for all of them to share. The floors were bare wood and there were no sheets on the mattress. In addition to the mattress there were a few old cushions against which the children lay. The children’s toys had all been thrown out. The Mother blamed the children saying that they had said that they did not need toys and all that was left were a few jigsaws.

The children’s clothes can be seen pathetically laid out on the floor for the photographs to be taken by the police. They represent a stark contrast to the photographs taken on the same day of designer trainers, suit and clothing all bought by the mother for JA and of the laptop, printer and monitor to be seen in the mother and J’s room. These young children even had to wash their own clothing in the bath.

All six children were sharing the double mattress. Accounts differ as to how long this had been going on but I am satisfied that it was for a significant length of time and that although two mattresses can be seen abandoned in the garden on the photographs there is no sign or evidence that there had ever been a bed or even a mattress for each of the children. The Mother said that it was her intention to buy the children each a chair bed to sleep on. Again in contrast to the conditions in which the children slept, the mother and JA were sleeping on a newly purchased sofa bed with appropriate bed linen.

M and A continued to go to school each day. The other four children spent all day in the room, rarely leaving it or going out. The mother seemed oblivious to the effect this must have had on the children. In evidence she said the house was in disarray but denied that the conditions were disgraceful. “I was decorating. It could not be helped.” She admitted only that the task of educating the children was beyond her and that she had given up trying. By March she said the children were getting no education at all and she accepted that their lives were spent in the bedroom. She spoke again with the same oblivious attitude, “there was”, she said blandly, “nowhere else for them to go.”

The impression from the evidence is that the mother by this time was having very little to do with her children. They ate, slept and lived in one room with no external stimulation and only little contact with the mother and J. It is hardly surprising that the children would fall out, fight, make a lot of noise and in L’s case be defiant.

Dr C was probably stating the obvious when he said that the way the children lived must have had a psychological effect on them. He highlighted the lack of sunlight and the lack of interaction with other children. “Just the physical environment”, he said, “in which the children were living amounted to extreme neglect. This is terrible” he said in evident distress when looking at the photographs of the children’s room. No one who has seen the photographs could disagree.

Both the mother and JA were obsessed with food. The mother wished to lose weight. JA said in evidence that it had been his idea for them to change diets, although the mother said that she had introduced the new regime prior to JA living in the house. Before he moved into the house he said that all the family ate was junk food and he thought that they were all quite fat. On his own account the restriction of food was used as a punishment when he was a child and he readily accepted in evidence that in turn he did the same with the I children.

The photographs of the kitchen show a well stocked fridge with plenty of good quality healthy food; not just basic food but fruit juice and plenty of expensive fresh fruit. Neither the mother nor JA were malnourished and although they too were ostensibly on a ‘healthy eating’ diet this did not prevent them from sharing a take-out the night before K died. J put a lock on the kitchen door, high up and out of the reach of the children.

Both the mother and JA said that the lock was put there to deter burglars coming in through the kitchen windows. The children in the main say they were not allowed in the kitchen. I find that the lock was to prevent the children having access to food. These were not babies. The medical evidence is clear, that children of this age will forage to find food if they are hungry as they did at school. If they had been able to get into the kitchen during the day they would have done so. They were ravenously hungry. The medical evidence is that they were deprived of food for many months and this is accepted by J. Mother’s continual denial that they were not short of food and were only denied junk food beggars belief in the circumstances.

Once the children had been withdrawn from school they no longer had the benefit of school lunches. The children allege and I accept that they frequently only had two meals a day and even then it was severely limited both as to quantity and nutritional value. Z told the police that the children “only have breakfast and dinner but the mother and JA have lunch as well.”

Some time in February 2008 the mother went round to a next door neighbour’s where a Polish family called W lived at the time. When the door was answered the mother was at the door and it is accepted was angry and accusing a family member of the W’s of feeding K behind her back. She said a thin, underfed child, K, was brought to the door and that JA joined them. K pointed to the daughter of the house and said that she, the daughter, had been giving her bread. Mr W is clear that no-one had given K bread but said that there was no fence between the gardens and they used to put bread out for the birds. He could only guess that it was that bread that K was eating but was too afraid to admit it to her mother.

The W family have moved on and have been unable to be traced for the purposes of this hearing. Their evidence was not therefore tested in cross-examination. I note that Mr W gave the date of this incident as February which would tie in with the appropriate time of year for feeding birds and was many weeks prior to K’s death.

The children were fed in either one or two bowls which were taken upstairs and put on the floor in the room in which they lived. They ate like puppies around and from a communal bowl. The children had their own rules about eating; each could only eat the portion in front of where they knelt; tragically and inevitably however there was an element of survival of the fittest. It would seem that A, as the oldest, and biggest and B, as the baby and who was largely cared for by her bigger sisters, fared the best.

Z said they did not get enough to eat and they would not get any more food until the next meal.

JA accepts that the bowls in which the children’s food was given to them were only a quarter full. Mother said the other children stopped K getting her fair share and although she supervised a couple of times she soon stopped doing so in order to “get on with the decorating”. The mother and JA meanwhile ate downstairs off plates in the conventional Mer.

The mother said in evidence that the children were not starving and that there was ample food. They could get the food as they had “two arms and two legs and they had access to the kitchen.” Again and again in evidence she spoke of giving them fish and rice and “masses of vegetables”. She constantly asserted that the only time food was used as a punishment was by depriving the children of their pudding. Even setting aside the fact that these children were not getting anything like enough food in terms of nutritional and calorific input, the very system by which they were fed was appalling.

The Mother did not at any stage seem to have any regrets or insight into the degrading and neglectful way in which she was caring for the children or even, (to use a wholly inadequate word to describe what she was doing), the inappropriateness of putting a bowl of food on the bare floorboards from which these six young children had to sit around and eat - without plates and sharing one glass between them from which to drink.

The evidence is that on occasion the children did attempt to steal food. L described to the police how Z and K had stolen some peanut butter and were caught. They were made to eat peanut butter and chocolate spread until they were sick and for stealing food they said they would be beaten with a stick whilst JA sang a song.

It seems that near the end of K’s life the mother and JA were near the end of their tethers. The decorating was going on and on. The state of the house was indescribable. The children were difficult and despite the strict discipline and beatings meted out to them they were always complaining and wanting food. Mother’s perception was that they “just wanted to go back to the junk food”, whereas the reality was that they were desperately hungry and just needed food. It may have been the perception of the children that in the days before JA, they had lived on junk food but had then enough to eat and so yearned to return to it.

When the mother was shown the “before and after” photographs of the children referred to earlier in this judgment, she spoke of smacking L and Z “because they were so thin and would not eat”. She said they lost so much weight and they wanted it back the way it was before (meaning that they wanted to eat junk food). She said “I could not stand it any more” so on an occasion about three weeks before K died, she made a pile of sandwiches made of such things as ketchup, crisps, cheese, chocolate and peanut butter and force fed the children with them.

A recalls that JA shoved the sandwiches into L’s mouth which made her sick and L then had to clean up her own vomit. So far as the latter episode is concerned the mother makes some limited admissions, she said that the children wanted food and having made it she was going to force them to eat it. A in his account creates a vivid image of the mother, angry and resentful making a plate of (as she sees it), junk food sandwiches. Instead of it being fun and a treat, the children were shouted at …. they wanted them so they were going to eat them.

When Dr C was shown L’s account of force feeding being used as a punishment he became distressed and struggled to compose himself. He said “I have never come across anything like this before. I am quite hardened and I am shocked reading it. Food was obviously an immensely powerful tool in the household.” I accept Dr C’s evidence.

The mother looked at the photographs and accepted that the children looked very thin. She refused, however, to accept any responsibility for it. “I knew how to look after my children. I knew what they needed.” Her constant refrain was that they had plenty to eat. Mother gave the lie to this in her own evidence about the sandwiches; that unpleasant incident had come about because the children were so thin and could not or would not eat. I have no doubt that the mother knew her children were too thin. The tragedy for her children was that she reacted not by changing the regime so as to feed them in an appropriate way, downstairs and supervised with sufficient quantities of food but, as she said in her own words about L, “she was really thin in the face so I smacked her and forced her to eat.”

The mother categorically denies that K died of malnutrition. She asserts that she did not look as she did when she died just two weeks previously. She insists that she died of food poisoning as a consequence of being given mouldy bread to eat by the neighbours. There is no evidence that the bread, if K even ate it, was mouldy let alone that it would have caused K any harm. Z put it simply to the police: they were very unhappy because they did not get enough to eat. Both Z and L spoke of missing meals if they were naughty and of Z and K stealing food from the bin and being hit with a stick if they were caught. Z was asked by the police what he thought was wrong with K. Z despite his very young age knew precisely what the matter was: he replied “she didn’t eat much. She didn’t eat enough food because she was missing out on meals.”

The children as I find were not only deliberately deprived of food, but they were also subjected to many and various punishments. The most common one was the use of a cane to beat the children. This was used on a frequent basis “to discipline the children.” A described the stick to the police. “It is very thin. It hurts very bad and it is green.” He said that they were hit on the legs and bottom. “He kept on whacking us with the stick.” He described L being “whacked so hard she bled and ran out of the house” and her mum had to follow her.

When the forensic pathologist, Dr K, carried out the post mortem on K late on the evening of 17^th May 2008 he found numerous marks on her body which had been made by the stick including some fresh ones, that is to say between 48 and 72 hours old. Dr K arranged to be taken to the house in the early hours of that morning in order to see if he could find an implement such as would have caused the injuries. He found the thin green stick propped outside the children’s bedroom door. When JA was asked in evidence where the stick had come from the answer was mundane. It was a stick he had bought from B&Q to prop up his Swiss cheese plant.

Whilst JA would “whack the children” as they called it, mother hit them with a flip-flop, a slipper or her hand. She denies using the stick and L alone refers to mother using the cane. In any event I am satisfied that the mother saw the children hit on more than the odd occasion. Mother originally said twice but then she accepted in evidence that it was more often than that that JA used the cane on the children. She said that she told JA that she did not approve of physical punishment. He accepts that she said something to that effect but he says that she did not try and stop him.

Time and again in relation to all the punishments to which her children were subjected the mother said that she could not have known what went on as she went out of the house to go shopping. Such an excuse does not bear even the most superficial examination. All the children had cane marks on them when they were admitted to hospital. Significantly K, L and Z who were the most malnourished also had the most evidence of physical abuse. Z, for example, had marks evidencing about 16 different strikes to his body. The mother went shopping she says three times each week for a couple of hours, whereas the children were confined to the house for five months and the nature of the punishments were such that she must have known what was happening. I find that having been at the end of her tether in trying to control the children prior to JA moving in she thereafter colluded in what she thought was an appropriate regime in order to discipline the children and to ensure that they showed her the ‘respect’ which she believed was her due.

JA said in evidence that he had never dealt with children before and so did not know how to handle them. He said he felt under “so much pressure in the house”, doing so many things that it all became too much for him. He admitted to beating the children with the stick and putting them in the back garden. He said that he had put Z and K in the garden shed as a punishment for about an hour. He denied, as was alleged by the children, that he had made them sleep in the shed but accepted that on occasion it had been dark when they had been put outside and that the children had been frightened by the shadows.

K and L described having to stand outside in their underwear in the cold and the dark and sometimes having cold water spilt on them. The mother and J, whilst accepting they both put the children outside as a punishment, denied that they were in their underwear. Even little B who was coming up to her 4^th birthday was put outside.

The children’s evidence is corroborated by a neighbour who saw “the thin child” in the garden in her underwear although, as I have already indicated, this neighbour has not given oral evidence. Neither the neighbour nor L knew what the other would say nor is it in my view unlikely that their accounts would tally had it not happened. I find that the children were put outside in their underclothes as a punishment.

One punishment that was used by both the mother and JA was to put the children “in detention”. This meant the children had to stand for anything up to an hour with their hands on their heads. Another and even more unpleasant punishment was that the child in question would be made to stand in front of a cold fan with their hands on their heads. L describes this happening to her and how they were made to wear their brothers’ boxers and stand for lengthy periods in front of the fan with their hands on their heads. JA she said watched her undress and put on the boxers, an anathema to a Muslim girl. Being made to do this L said, made her feel “undecent.” I accept L’s account.

The children also allege that K and L were made to have cold showers if they were rude and L gives an account of her mother being in the bathroom at the same time washing in warm water at the sink. Similarly they refer to A and K having to sit in cold bathwater as a punishment and of JA pouring cold water over L’s head and of them having cold water poured over them when they had been sent outside in the cold. Both mother and JA deny making the children have cold showers. The only concession they make is that they say on one occasion when she alleged that K had made L have a cold wash, JA had suggested that she should “have a taste of her own medicine.”

It is impossible for the court to make specific findings about the various incidents which involved cold water being poured over the children as a punishment. I find that the theme of cold water being used as a punishment is too consistent and recounted by too many of the children for a court to do other than conclude on the balance of probabilities that the children were regularly exposed to the use of cold water as a form of punishment. Whilst JA does not agree the detail, he does accept that making the children cold, whether means of a fan or otherwise, was a form of punishment used on the children in the household.

Only the mother and JA will ever know the full story of what happened to K, although through the evidence as it was played out during the hearing this court was able to catch glimpses into the utterly miserable time K was having at home. Dr C thought perhaps she was made scapegoat within the household and K, of all the children, certainly seems to have had a particularly grim time. It was striking that in all the days of evidence the court heard not one word of love or affection for K from her mother. Always it seemed to me, she was spoken of critically; that she would deliberately wet herself, that she had tantrums, that she was difficult. No allowance seemed to be made for her age or for her very significant learning difficulties. It is hard to imagine what it must have been like for K: JA said that she wet herself and that he would therefore hit her with a stick and put her outside. Her mattress was thrown out when she got urine on it. In the witness box her mother spoke of her resentfully on several occasions, for example, she that she did not believe that K had a Djinn. “She has always been difficult” she said.

Mother said in evidence that the week before K died was “very bad”. K was pulling out large chunks of her hair. Her hair was “so bad” that on Sunday 11^th May, just six days before she died, the mother shaved off K’s hair. She told me “K fought back and was very upset. She did not want it cut.” The mother denied that this was a punishment for pulling her hair out, but even if one accepted that to be so, it takes little imagination to see how punitive and distressing the mother’s actions must have felt to that little girl.

JA’s account is not completely clear but it would seem that on the Thursday afternoon the mother went shopping, leaving him with the children. K, he said, was rude and attacking B. As a punishment she was “put in detention.” This, as has already described, involved standing in front of the cold fan and not moving. JA says that after about an hour K leant against the wall. He told her to take her hands off the wall because of the fresh paint and struck her with the stick. JA accepts that this explains the fresh tramline bruises found on her left thigh at post mortem it follows therefore that he hit her not once but twice. It was then he said that she fell to the floor.

No matter how much the mother may wish to distance herself from the death of K it is perfectly clear that the mother knew that something had happened to her when she came back from shopping on that Thursday. The mother described coming up the stairs and it being unusually quiet. She saw L standing with her shoulders hunched in such a way that she knew meant something was wrong. When she went into the front room K was on the floor with her head on JA’s lap. She said numerous times in evidence that she kept asking what had happened even though she had been told that K had fainted. “She thought”, she said in an unguarded moment in evidence, “he might have smacked her until she had passed out.” She was right in her surmise but did nothing about it. It is hard to understand how any mother coming upon that scene did not immediately call an ambulance.

A described what he found when at about 3.40 he got back from school. K, he told the police, had her head on his mother’s lap. His mother said that there must be a Djinn or evil spirit in K’s body. His mother was sprinkling water on K and saying “wake up, K.” K, he said, did not wake up that evening and when he came home from school the next day, Friday, she was sleeping on the mattress. That Friday night, he told the police, the mother slept in their room and in the morning “K’s belly was not moving” and the mother ran downstairs to call the ambulance.

The mother’s account is that shortly after she got home she went downstairs and then saw K walking across the landing to the bathroom. The mother said that on the Friday the 16^th K seemed better and was walking around. She was weak but up, although she had to be helped to wash and go to the bathroom. She tried to force her to eat something, saying that she could not sleep until she had eaten. Most of the Friday the mother said K was in bed and when she was up she was stumbling all over the place.

The mother said she noticed that K’s lips were bleeding as K ground her teeth but did not notice how severe it was. K was desperately ill by this time and it is inconceivable that any parent did not get help for her particularly as on her own account she believed K may have been knocked senseless by JA the day before. Anyone who has had the distressing experience of seeing the photographs of K’s torn and bleeding lips would be unable to contemplate a state of affairs whereby medical attention had not been sought for that if nothing else.

Neither JA nor A speak of K walking around but they do speak of JA reciting the Koran over her. JA said that in the last few days K’s face changed. She was pale “and did not look very good at all.” JA said that at the end he thought K was possessed by Djinn. He said that the mother did suggest getting help. He said “that is when I accept that K was possessed and that a doctor could not help her.” JA accepted that he told mother that K was tired and as a result she did not get help.

Even at this stage, the mother was not sitting with K nursing and comforting her or even watching over her. K by then had pneumonia and early meningitis. As she lay dying upstairs the mother was downstairs looking up Djinns on her laptop and eating a take-away with JA. Meanwhile the other children ate leftovers upstairs in the same room in which K was dying. The mother then fell asleep with JA on the new sofa bed downstairs. It is not clear when exactly the mother went up to the children’s room, but K died during the night, to be found cold the next morning when her mother woke up next to her.

JA explained that he thought that K was possessed from the time he had put her in the shed that she had come out from the shed cold, crying and frightened. She had seen shadows which she thought were the devil. She had said she had made friends with the Djinn.

By the end he said: “I thought something was terribly wrong. I didn’t know if she would die but I was reciting the Koran and thought I could do something myself. I was reciting mainly because I thought she was possessed. The purpose of reciting was to remove the Djinn. I was deluded.”

JA unreservedly accepts the blame for K’s death. How he treated her was how he was treated as a child. He said “I ended up treating her how my dad treated me.”

K was just seven when she died. L said “she didn’t wake up for three days.” I am satisfied that K was desperately ill from at least the Thursday when she had been beaten and made to stand for at least an hour in front of the fan. She died without medical treatment, without love, comfort or reassurance on a dirty mattress shared with her brothers and sisters in a room she had scarcely left for five months.

The mother said in her evidence that she had become scared of JA over the previous couple of weeks and that it was her intention to ask him to leave. Her plan she said was to take the children to her mother’s the next day and then K on to the doctor’s. She said that JA had been behaving strangely and that he had shouted to her on two occasions and had been disrespectful towards her. This was new evidence from the mother in the witness box. Having seen and heard her over two days I accept that JA was in the last weeks behaving strangely. JA himself believes that his mental health was deteriorating. I do not accept, however, that she was fearful of him and certainly not such that she would have been in any way inhibited from getting help for K had she chosen to do so.

The mother called an ambulance and it came Med, amongst others, by a paramedic called S H. Mr. H is an experienced paramedic yet he was reduced to tears in the witness box when he recollected the piteous sight of K’s emaciated body when he got to the house. K was taken by ambulance to the Birmingham Children’s Hospital. Attempts were made to resuscitate her. The mother was seen and spoken to by Dr D the consultant paediatrician, and the senior child protection officer for Birmingham. Dr D recorded that the mother was very distressed and blamed herself for not getting medical attention earlier for weight loss.

When asked specific questions the mother said that there had been no vomiting, diarrhoea or abdominal pain. The mother disputes this, but she said this and there is some contemporary recording that suggests that gastroenteritis may have been mentioned. In any event it matters little as the height of the mother’s case that K had food poisoning was that she saw some diarrhoea in the toilet bowl on the Wednesday before K died. Mother told the doctor that the other children had been bullying K over the last few weeks.

Later that evening a post mortem was carried out by Dr K. He gave as the cause of death: 1(a), bronchia-pneumonia with septicaemia due to 1(b), malnutrition.

Dr K found a total of 60 external injuries on K’s body. Not all of those were caused non-accidentally but of those 60 a large number of them were the tell tale tramline bruises indicating that a stick had been used upon her.

The other children were in due course taken to the City Hospital also in Birmingham so they could be physically examined. I heard evidence from Dr Michael P who has been a paediatrician for some 16 years and the consultant paediatrician at the City Hospital since May of 2003. Dr P examined Z and L as they seemed the two children in most need of medical treatment. At the same time and on the same ward a specialist registrar examined A, M and A.

Dr P’s first recollection of Z was of him sitting eating sandwiches having been taken from Accident and Emergency up to the Paediatric Assessment Ward. Dr P describes his concentration on his food, with his head down, deliberately conscious of his siblings around him and protecting his plate. Dr P describes this as an extremely abnormal feeding reaction for any child particularly for a child brought into to the foreign environment of a paediatric ward. Dr P said he had observed similar abnormal feeding patterns in respect of each of the surviving children.

When Dr P came to examine Z he was very quiet, uncommonly so and very accepting of examination. Dr P explained how after 16 years’ experience he was usually able to build a rapport rapidly with a child when he was examining him but not with Z.

When Z was undressed he was very emaciated. Dr P had not seen a child so emaciated in all his clinical practice. He had so little subcutaneous fat on his body that he had pressure marks down the whole of the length of his spine, something he said he simply does not see in paediatric practice.

Dr P assessed the body mass index of Z using recognised formulas and charts. For a boy of Z’s age the average BMI would be 16.3. For a child on the 0.4^th centile, that is to say the lowest centile on the standard charts, BMI would be 12.9. Z’s BMI was 12.4. Z’s presentation was so outwith Dr P’s experience that he discussed the case with all his colleagues, none of whom had seen a child in this condition.

In all the voluminous papers in this case there is little that creates a picture of this little boy’s personality. What is known is that he was the most seriously ill of all the five surviving children and that he had more scars on him (in excess of 16) indicative of being beaten with a stick more than any of the other children. That means in crude terms that he was least able to get food and seems likely to have been hit most often.

Why this little boy of nine who all the staff at school liked should have been picked out in this way may never be known. After admission to hospital Z wrote a pitiful letter to his mother: “Are you okay, mummy, and is K all right and okay? Is K breathing, living and loving and is she okay, mummy?”

One of the consequences of the rarity of a child being seen in this country in the condition in which Z was presented was that, as Dr P openly and honestly admitted to the court, he simply did not appreciate the precariousness of Z’s condition. As a result although Z should not have been able to eat too freely, the staff and (understandably) the nurses on the ward, felt totally unable emotionally to deal with the situation in which they found themselves and Z was allowed to eat too much too soon. As a consequence Z quickly manifested what is known as Re-feeding Syndrome.

Re-feeding Syndrome was first described in the Far Eastern prisoners of war cases after the Second World War. It is seen following starvation when the fat and protein stores in the body are broken down to produce energy. This leads to changes to the level of some of the salts in the body and particularly phosphate. When the individual starts to feed the body switches back to using carbohydrate to provide energy this causes an increase in insulin levels and a flow of phosphate into cells. This can lead to profoundly low blood phosphate levels which in turn can produce the clinical features of Re-feeding Syndrome. These include muscle breakdown, increased risk of infection, respiratory failure and heart failure. Professor M, when giving his evidence, said that often with prisoners of war after the Second World War, when the prisoners starting eating again they simply dropped down dead. There is no doubt that the Re-feeding Syndrome could have been fatal for Z.

Once the hospital understood what they were dealing with they were able to institute standard treatment to replace the chemicals and vitamins, in particular intravenous phosphate. Dr P said that had Z been an adult he would have been in imminent risk of death but as a young child his strong heart made him better able to withstand the effect of malnutrition on his body.

L also represented as quiet and slim with her skin drawn over her facial bones and significantly underweight. She unlike Z had no pressure marks. However, she did have oedema over her ankles which Dr P felt may well indicate low protein. He observed the same abnormal eating behaviour as regarding food as he had observed with Z. The appropriate average BMI for L would have been 17.5. Hers was measured at 13.7. She had four linear marks across her legs. L was not in such a precarious position as Z had been but she too suffered a much less serious form of Re-feeding Syndrome.

A was less withdrawn than the other two children. Dr P felt that as the eldest child he seemed to feel a degree of responsibility for his siblings. He was the best nourished of all the children although he too ate abnormally. He had only one area of what were believed to be stick marks. M and A were each on low centiles on the weight and height charts but that information in their case was insufficient in isolation to tell Dr P that they were underweight. M had only one linear mark. A seemed unscathed.

The children were each seen again by Dr P on 28^th July and again on 13^th October. Between the two examinations each of the children gained significant amounts of weight. Z had gained a staggering 9.5 kilos and his BMI had increased from below the 0.4 percentage to the 75^th centile. Dr P had never seen such a dramatic weight gain in all his professional experience. The other children made similar and appropriate improvements.

The evidence given by Dr P concerning the dramatic increase in the weight in the children between May and July was explored with him. He was asked about the change of diet from so called junk food to a vegetable, rice and fish diet. Dr P said that in his experience children of Afro-Caribbean origin tended to be more overweight than white European children although white European children are fast catching up. The treats of chocolate and crisps that were seen in the food diary kept after the children were taken into care would only have made a difference if sustained over a long period. At the conclusion of cross-examination Dr P said that his view was that Z and L had been deprived of food to a very significant degree over a long period of time. I accept his evidence.

Following the death of K the police commissioned reports from a number of medical experts. Subsequently in these proceedings the mother and JA were given permission to instruct their own raft of experts namely: Dr C, a consultant paediatrician, who conducted an overview in respect of each of the children, Dr S, a paediatric gastroenterology, Dr S, a consultant paediatric pathologist and Dr D, a consultant in Microbiology and Life Sciences.

On 22^nd January 2009 the experts instructed by the mother and JA had a experts meeting by telephone. There were no areas of disagreement between them. Their views were the same as the experts who had either treated the children or been instructed by the police and adopted by the local authority in these proceedings. Those experts were Dr K, the forensic pathologist who undertook the post mortem on K, Professor M, Emeritus Professor of Paediatric Gastroenterology and Nutrition, Dr G, a consultant medical microbiologist and Dr S, a consultant neuro-pathologist.

Despite the fact that there were no issues between the experts the court has heard live evidence from a total of 13 medical witnesses. This gave in particular the mother the opportunity fully to explore her hypothesis that K died of infection which in turn had led to weight loss rather than from malnutrition which led to the suppression of her immune system, leaving her open to the bronchia pneumonia which was the ultimate cause of death.

At the end of the oral evidence the consensus between the doctors remained unshaken and was usefully summarised in simple terms by Mr Keehan and Mr Weston on behalf of the Intervenor in their written submissions. So far as K was concerned they summarised it as follows.

So far as the other children were concerned it was summarised as follows.

Given the highly unusual nature of this case it is helpful to make reference to the evidence given by Professor M in order to have a better understanding of what happened to the children. Professor M is the Emeritus Professor of Paediatric Gastroenterology and Nutrition at the UCL Institute of Child Health in London. He has been a specialist in Paediatric Gastroenterology and Nutrition for some 30 years.

Professor M explained to the court the process of starvation. Protein, carbohydrate and fat are all necessary he told the court for normal growth. Sufficiences of all three are necessary for full bodily function and can be called X. In addition the body needs to grow as well as function. The body needs growth, being Y. A growing healthy child therefore needs both X and Y. When a child or a person becomes undernourished X goes relatively swiftly. If nutrition continues to be insufficient Y goes down as well and the child stops growing. That, he said, takes four to six months. The changes will not be seen in linear growth in under two months. This effect is seen in medical malabsorption cases where there is a time lag but once the body runs out of these nutrients it stops growing. Thereafter a child in the chronic phase of malnutrition will continue to lose weight but their height will also become stunted.

In his report prepared for the court Professor M elaborated. When protein and energy are particularly deficient it may be referred to as protein energy malnutrition. This he explained is further divided into marasmus where protein and energy are equally deficient and kwashiorkor where protein as a source of energy is in particular deficient. The means of assessing and grading protein malnutrition is via what is known as the Waterlow classification with grade 1 being the least severe stage of malnutrition and grade 3 the most severe. K, he said, suffered from marasmus and was grade 3 on the Waterlow classification.

Professor M’s evidence is that when a person loses 40% of their body weight they die. Z had already lost 32% of his body weight which Professor M told the court brought him too within grade 3 of the Waterlow classification. Dr P and Professor M were both clear that had there not been medical intervention, Z would have continued to deteriorate and would have died; understandably Professor M put it somewhat euphemistically: “Z would have got into the same state as K.” Using the same Waterlow classification L was on grade 2 of the scale.

One of the chilling features of the expert evidence in this case is that without exception all the papers and studies drawn upon to assist the court in reaching an understanding of what happened to these children are in relation to prisoners of war, famine children in Africa and the Northern Irish fasters in the early 1980’s. None relate to western children even in the last depression.

Professor M explained that the most recent information about what happens with excess fasting is in relation to the hunger strikers. He told the court there is a loss of body tissue and then oxidization of the body fat and then of protein. Thin people oxidise their energy sources quicker than fat people. Children have higher resting energy expenditure so they run out sooner than adults.

Bobby Sands and the other hunger strikers had no food at all whereas he felt it is likely that these children had some food. Effectively the body eats itself to survive which is why in extreme emaciation cases such as were seen in K there is a total loss of subcutaneous fat and muscle mass.

Dr M said that once the child or adult loses 40% of their body weight they die from infection because their immune system has become so compromised. He explained that the defence system becomes compromised, particularly the spleen and the thymus which are very important in instructing the body as to how to deal with infection. It was no surprise to him that bronchia pneumonia and meningitis were found in K. She had virtually no thymus and spleen left, which is as he would have expected to find her given how seriously malnourished she was.

In the days prior to her death Professor M would have expected K to have presented as sleepy, irritable, not wanting to eat, to have picked up infection, to have spasms and fits. It did not surprise him to be told there was twitching of the muscles and it was clear from the history that she was sleepy and that there was a loss of appetite. The difference he said between being asleep and being unconscious is that unconsciousness he would define as appearing to be asleep but being unable to be aroused.

Alopecia or hair loss such as K suffered could also be associated he said with malnutrition as it occurs with nutrient deficiency, particularly zinc. K was found to be low in zinc dependent enzymes.

Professor M looked at the photographs of K in the context of the mother’s case having been and remaining that K lost virtually all the weight in the last week of her life. Looking at the photographs taken the day she died he said “this would not occur in the last few weeks. It would take many months. She has suffered from extreme emaciation. There is complete loss of subcutaneous fat and muscle wasting not just on the buttocks which go first but in all four limbs. The bony prominences are made even more prominent by the complete lack of abdomen.”

The abdomen he noted to be concave which could suggest that she had not eaten for some days before the photograph was taken. The mother having looked at the photographs in the witness box denied that K’s stomach was flat on Friday and maintained that nearly all the weight was lost in that last week. I accept Professor M’s evidence.

Professor M noted blood in one nostril and the haemorrhagic lesions on the lips. The presentation of the lips was he said the same as one would see with severe malnutrition, lack of vitamin C, it could he said have been scurvy or severe vitamin K deficiency. One would not normally see such presentation in a well child for the simple reason that if a child chewed them to that extent they would simply stop because it hurt.

Professor M’s conclusion was that he did not think that K had suffered total starvation but that she had been seriously malnourished for a minimum of three months.

Miss Meyer Q.C. on behalf of the mother put to Professor M a number of questions designed to show that K had had sustenance in the days prior to her death. She put to Professor M that there was some sustenance in her gut at post mortem. Professor M said that it amounted to 14 grams or a little less than three teaspoonfuls which might indicate she had eaten something in the last 24 hours but that it had been very small. This would tie in with A’s evidence that his mother was trying to feed her and that she was “chewing whilst she was asleep” and also the mother’s evidence that she was trying to force feed her semolina.

The Professor’s view that K was suffering from marasmus at the time of her death was appropriately challenged by Miss Meyer. She suggested that K was suffering from kwashiorkor (the relevance of that being that if that had been the case it might have been possible to explain her state by inappropriate diet as opposed to deprivation of food). In response Professor M pointed out that at post mortem K’s liver showed marked acute atrophy. Professor M commented by reference to a paper by a Dr Portman that the pattern of liver alteration is in keeping with marasmus, a nutritional liver disease, which Dr Portman says, is seen in protein energy malnutrition. When asked about this by Miss Meyer, Professor M responded by saying that Dr Portman is “king of liver pathology and I would not dare challenge him.”

Miss Meyer explored with Professor M the possibility of the bread K may have eaten from the neighbour’s garden being mouldy and certain fungi having been ingested by K with severe adverse effects. Professor M regarded this as most unlikely. He commented that there was no evidence that K had ingested it, that it had had any mould on it or even if it did that the mould would have been in any way dangerous other than tasting unpleasant. He clearly regarded the proposition that this child died from eating mouldy bread as little short of preposterous and caustically commented that “we don’t know anything about her eating mouldy bread but we do know plenty of other things.”

Professor M was anxious that the court should be aware of the reality of what happened to K. Hunger, he said, is a painful experience in the early stages. “Make no mistake” he told the court. “Not having enough food is unpleasant and extreme hunger is very painful.”

Dr D conscientiously and using accessible language responded to Miss Meyer’s detailed and technical cross-examination about a number of the bacteria, some of which were extremely unusual and which were found in K’s body, including most unusually the presence of e-coli in the blood. Similar questions were asked of Dr G, the microbiologist, and a number of the other experts who felt able to contribute to the debate. It is not necessary for the purposes of this judgment to set out the microbiological issues which were explored as despite being put by Miss Meyer with skill and moderation she made no progress whatsoever in trying to establish a cause of death other than that stated by Dr K at the first post mortem.

I am satisfied in accordance with all the medical evidence that K died of pneumonia secondary to severe malnutrition and that all the other children suffered from malnutrition to a greater or lesser extent.

The concerns of the Deputy Head teacher, J B, had reached such a level by the time the three children had been withdrawn from school that on 19^th December 2007 she made a referral to social services. Miss B’s point of contact there was the referral officer R C. Her written referral centres on the food issues outlined earlier in the judgment in relation to each of the children.

Miss C as I understand it acts as a ‘gatekeeper’, receiving information from members of the public or professional people who have concerns about young people who may be at risk. Once she receives the information she then makes a decision in conjunction with her manager as to whether the referral meets the criteria for a social worker to visit the family.

Miss C’s evidence was that in having “scrutinised” the information provided by the school, the view was taken that as the school already had a working relationship with the family it would be better for them to continue with their work rather than their department intervene which might “antagonise the situation.” Miss C therefore contacted Miss B to say that the case did not warrant an assessment.

Miss B decided that in the absence of social services agreeing to become involved that she herself would visit the family home to ensure that the children were well. Accordingly she went to the house accompanied by Miss H on 29^th December. On arriving they could hear children’s voices. The mother eventually came to the door and the children became silent. The mother accepts that this was her pattern; when people came to the door that she did not wish to see she would ‘hush’ the children. The mother told Miss B that the children were well and that she was not happy with the school and that she had decided to keep K at home to “discipline her” and to sort her behaviour out. It was put to Miss B that the word “discipline” was not used. Miss B was quite clear in her evidence and I am satisfied that her recollection is accurate. The mother Miss B said agreed to come to the school the next day for a meeting and to make an appointment for the first day of term.

Miss B and Miss H were kept on the doorstep and did not see the children this surprised them as it was Eid, a time when visitors are ordinarily welcomed into a Muslim home.

Upon her return to school Miss B notified Miss C at social services of the outcome of the visit and her concern that she had not been able to see the children. Miss C said that her line manager would not make an assessment on the facts as they stood. She did, however, say that if there was a problem the school should contact the police to do a so called “safe and well check.” Miss C also told Miss B to ‘press hard’ to make sure that such a check took place.

Miss B in her oral evidence described being quite shocked when she was told to ask for a safe and well visit and the fact that Miss C had said that the police needed to be pressed hard to ensure it had happened. This, she said, had “left her with a feeling that if that was so why not go and carry out an initial assessment of the family?”

Miss B said that this was the first time she had ever asked the police to do a safe and well check. Miss B said that in any event such a check would not have allayed her concerns as given the history she felt that it was necessary to know what each child looked like on a day to day basis.

Later that day, the 29 December 2007, the safe and well check was carried out. P.C. P gave evidence. She recorded that the mother was frustrated that the police had come to the house. She begrudgingly called K to the door. K appeared healthy and was dressed in clean clothing. That fleeting glimpse of K satisfied P.C. P who recorded that she had no concerns for her welfare. She did not see or ask to see any of the other children.

On 21^st December 2007 the mother had spoken to SENAS, Special Educational Needs Assessment Services. She spoke to a Lynn W. The mother told Miss W that she was taking the children out of school and wanted to move them to a school called G P School. She said that her difficulties at G P were bullying by the children and by the teachers and that the children were not progressing or being challenged sufficiently.

On 3^rd January 2008 the mother wrote to Miss W saying “now due to the perfidious conduct of some of the staff members of G S I have withdrawn all three from the vicinity. All three children are on statements and they have on this for a time no advancements have rendered them benefit. The proof is in the letters I have received from yourselves stating that no change has been made to the statement for each child due to the incompetence of the tutors. This is why I have taken such measures.”

As an aside; this letter to Miss W shows a fundamentalmisunderstanding on the part of the mother. The references in that letter to “no change” related to the provision of services to the children under their Statement of Educational Needs and were not and not intended to be, any form of assessment of the children’s progress. Had the mother read the children’s school reports or attended at their parents’ or special educational needs meetings no doubt this would have been explained to her and she would not have made such a fundamental error in her understanding of their progress. Their progress was in fact steady and recorded in detail on the unread school reports.

On receipt of the letter the Special Educational Needs Assessment Service wrote on 10^th January 2008 to a man called I H who is the Educating Otherwise advisor. His background is that he is a former Head teacher. His duty is to contact parents who remove their children permanently from school and discuss with them their proposals for home schooling. Only when satisfactory arrangements are approved and in place can the children’s names be removed from the school roll.

Mr H was reminded that Z and L had Statements of Educational Needs and therefore it was the duty of the authority to ensure their particular special needs were being met and that the provision was suitable. To that end Mr H was asked to respond to SENAS within four weeks.

Letters were also sent to the mother and to JA asking for details of the proposed timetable and curriculum they intended to use in educating the children at home. No such information was ever provided to SENAS.

On 28^th January 2008 a liaison meeting was held at G R P School. Miss R M, an educational social worker attended the meeting. The school expressed their concerns for the children, describing them as being “at risk”. They told Miss M of their unsuccessful referral to social services before Christmas. Following the meeting at school Miss M’s concerns were sufficient that she too decided she would make an unannounced visit to the house. She was not aware at that stage that the mother had quite appropriately been speaking to SENAS.

Accordingly on the afternoon of 28^th January 2008 Miss M attended the house on her own. She knocked several times and waited for some time and when she had no reply looked through the letterbox and the window. She did not hear anyone inside. She left a message for the mother saying who she was and how she could be contacted. The mother, JA and the children were in fact all in the house at the time and knew that Miss M was at the door. At the beginning of the hearing the mother’s case that she only knew this because a neighbour had told her. Subsequently in oral evidence she accepted that they had seen Miss M peering through the letterbox and had chosen not to answer the door. This was one of a number of examples where I am satisfied the mother told blatant untruths in evidence.

On 30^th January, in response to a message from the mother, Miss M spoke to her on the telephone. The mother I am satisfied was aggressive and the conversation heated. The mother demanded to know “who Miss M thought she was”, peering through her letterbox. She threatened to take her to court for invading her privacy and she told her she was in breach of EU law. Miss M explained to the mother that as an educational welfare officer she needed to conduct a home visit. The mother, she said, simply shouted over her and was not listening. Miss M said in evidence that she was obliged to bring the conversation to an end. I accept the evidence of Miss M about the nature of this call which I find followed the pattern of a number of mother’s exchanges with professionals where she raised her voice, was aggressive and refused to listen to what was being said to her.

By this time Miss M as well as the school was also concerned about the situation. She spoke to her team manager who advised her to contact social services. before doing so Miss M spoke to Mr H and told him what had happened. So concerned was she by the aggressive nature of her conversation with the mother that Miss M suggested to Mr H that in the event that he was to carry out a home visit he should take a second person with him. Miss M asked Mr H whether or not the children should stay on the school register and Mr H confirmed that they should until such time as home schooling had been authorised. Having spoken to Mr H, Miss M then spoke to Miss C at social service.

Following her conversation with Miss M, Miss C recommended the carrying out of what is known as a CAF, that is to say a Common Assessment Framework assessment. This is low scale intervention where local agencies (other than the local authority work), with families in order “collaboratively to resolve any issues they face”. Miss M said in evidence that she told Miss C in terms that she did not think that such an assessment would work as the mother would not co-operate and the whole basis of a CAF assessment is co-operation. Miss C agreed to discuss the matter with her manager.

On 8^th February 2008 following receipt of the letter from SENAS, Mr I H went to visit the mother and children together with a Mr R L, a senior educational social worker. Prior to making the visit Mr H had written to the mother making an appointment. The letter made it clear that the purpose of the visit was to ensure that the children were receiving “an efficient full time education at home.”

Mr I and Mr R were seen in the rear sitting room. Mr R referred to a “rudimentary” classroom having been set up with a display board with writing on it on the wall although, he said, there were no chairs or other items that were what he referred to as “resources” for teaching. Mr I described there being some basic readers and one or two books around. Mr H’s assessment was that the mother seemed keen for the children to learn.

At the end of the session which lasted about an hour the mother was provided with a form called an Educating Otherwise Advisory report. This sets out recommendations in tick box form as to what should be taught to the children. In addition it recorded that teaching plans were to be sent by the mother to Mr H by the end of February.

Although Mr H and Mr L were in the house for about an hour and their discussions centred entirely around the education of these four children they were not at any time seen, nor did Mr H nor Mr L ask to see them. Mr H’s recollection is that JA said that the children had had a late night and were asleep upstairs.

The plans were not forthcoming at the end of February but it was not until following the Easter break around about 7^th April 2008 that Mr H wrote again to the family saying that a further visit would take place on Wednesday 16^th April. Mr H and Mr L attended the property on 16^th April but there was no reply. Mr H did not follow up this abortive visit prior to K’s death a month later.

During the course of his evidence Mr H was understandably tense and somewhat defensive. He explained that he is the only advisor to Birmingham City Council with regard to Educating Otherwise. He alone, together with the educational social worker, deal with some 350 families. He has no administrative assistance and so all letters are typed by him, he also keeps his own diary.

Mr H expressed with considerable strength of feeling his perception of the limitations placed upon people in his position as a consequence of the terms of the home schooling provisions. He is not, he told me, entitled to require children to be seen neither is he allowed to ask parents about their ability to teach their children. In the present case therefore he was unable to discover that the mother herself had had learning difficulties as a young woman and could do nothing about the fact that the children were no where to be seen.

Mr H defending himself about what had happened referred the court with some vehemence to the Government website and a document called “Elective Educational Guidelines for Local Authority.”

Whatever enquiries are hereafter made about what went wrong between December and May, it is no part of this court’s duty to analyse the detail or adequacy of the law surrounding home education. Mr H was acutely conscious that parents have a right to educate their children at home and drew my specific attention to the guidance which I note says:

“where a parent elects not to allow access to their home or their child this does not of itself constitute a ground for concern about the education provisions being made. Where local authorities are not able to visit homes they should in the vast majority of cases be able to discuss and evaluate the parents’ educational provisions by alternative means.”

Mr H was vague in his evidence as to what, if anything occurred between February and April. He said in oral evidence that he had not got the plan from mother and had written back to her. That then that would seem to indicate that he was not in a position to tell social services, or indeed anyone else, that he was satisfied as to the educational provision to be provided for these statemented children.

The documentary evidence covering this period of time is incomplete and mainly in the form of emails. Such email evidence as is available seems to suggest that Mr H did in fact give approval indicating that he was satisfied with the proposed educational provision despite the fact that mother had failed to provide any educational plan. The names of the children were accordingly moved from the school roll. This meant that the children were longer be categorised as unauthorised absentees and so another possible route of monitoring the children was lost. |It was for that very reason that the school had up until then resolutely refused to take the children off their roll.

In the emails it shows that on 28^th February Mr H spoke to a Laura Cartwright who was the reviewing officer at SENAS. Mr H confirmed that he had conducted the home visit and it is recorded that he had reported that the parents were able to supply adequate information about their plans for educating the children and that he was satisfied that they were sufficiently set up for home teaching.

Miss C recorded that this was to be put into writing and sent to SENAS. Once the paperwork had been received SENAS would amend the children’s statement to enable home teaching. The contents of this conversation were forwarded to Miss S on 29^th February and undoubtedly played some part in the decision to abandon the initial assessment.

Mr R L, the educational social worker who had attended the meeting at the house with Mr H on 8^th February 2008 said in evidence that he was satisfied that he and Mr H had complied with the home education guidance and that by May 2008 the children’s needs were or were going to be met. Mr L said that he would not have expected the email confirming that the parents were able to provide adequate information as to the educational provision for the children to have been sent prior to the plan (which was due to be received at the end of February) having arrived. Mr L was extremely anxious to avoid any personal responsibility for what had happened and said firmly that Mr H had followed his own procedure and that it was not his job to see if the parents had the capacity to teach.

Meanwhile on Thursday 31^st January, Miss C and her manager reconsidered the referral that had been made to social services and Miss C contacted Miss M. She said that they would carry out what is known as an Initial Assessment on the I family. Miss M rang G P School to tell them that social services had accepted a referral but that in the meantime the children should be kept on the school roll.

Understandably both the school and Miss M were considerable relieved that as of 31^st January social services had accepted a referral and intended to carry out an Initial Assessment whereby they would go and see the family and carry out checks with other agencies. This the court was told is the next step up from a CAF assessment as unlike the CAF assessment ,the local authority are the main lead in investigating the concerns which have led to the referral.

On the same day, 31^st January 2008, the case was allocated to a social worker called A.G. On 1^st February Miss G endeavoured to contact Miss M with a view to arranging a joint visit to the house to discuss with the mother the completing of an Initial Assessment in respect of the six children. Miss G subsequently told me in evidence that whilst an Initial Assessment does mark the acceptance by social services of a referral it still requires the consent of the parents before any enquiries can be made about the children from third party agencies such as the school and the health services.

It now seems to be common ground that this was a misunderstanding on her part and no such consent is required although parents are asked to consent/co-operate with the assessment as a whole. The social worker therefore intended to go to the home at 36, L R and ask the mother to complete the relevant consent forms enabling enquiries to be made. When Miss G contacted Miss M’s office she discovered that she had in fact left the department and that a new educational social worker, S S, was now dealing with the case. Unfortunately very shortly after referral was accepted and the case allocated to Miss G she went on annual leave and did not return until 18^th February.

On 18^th February Miss G wrote to the mother telling her that a referral had been received from educational welfare. She said that the concern related to her having withdrawn the children from school and that so far as they were aware the children had not been seen by any professionals since December 2007. The mother was told in the letter that on 21^st February at 3 o’clock a joint visit would be undertaken by her together with S S the new educational social worker.

The visit was as unproductive as that of Miss B and the police. The mother eventually answered the door but would not allow them into the house.

Miss G, standing on the doorstep, tried to tell the mother about the initial assessment and that it would centre around educational issues. Miss G told the court in her written material that as the referral was, as she put it “of an educational concern as opposed to a child protection concern”, that was how she had phrased it to the mother when she saw her on 21 February 2008.

Miss G wrongly told the mother that her consent was necessary in order for the initial assessment to be carried out. When it became quite clear to her that the mother was not going to give that consent she told the mother that they would leave so long as the children were seen.

Initially the mother refused to bring the children to the door but eventually brought, I am satisfied, L, K and Z to the door.

There is some disagreement in the detail of this meeting as between Miss S, Miss G, the mother and JA, who was present for part of it. The detail matters not as what is incontrovertible is that the visit was made, the mother and JA refused to allow them entry to the house and refused to co-operate with any assessment. Although three of the children were brought to the door they did not on any level engage with Miss G or Miss S and hovered at the back behind their mother and were seen only for a matter of minutes. When requested to say who he was, JA refused.

It goes without saying that during the course of this visit Miss G did not get to the stage of the mother signing the form which she says would have permitted investigations to have been made of third parties. At the conclusion of the visit Miss G told the mother that as an assessment had been opened, she needed to see the other three children. The mother said A was asleep and the other two were at school. Finally the mother agreed for Miss G to return to the house at 4 o’clock the following day in order to see the three other children. By the time the social worker got back to the office the mother had already rung to say that Miss G was not to go the following day to see the children.

Miss G spoke to her manager about the mother’s refusal to allow her to go and see the other three children. Miss G said in evidence that as they knew that Education Otherwise was involved, they agreed between them that another visit to see the other children would not be necessary and that as the referral had specifically concerned the three children they had in fact seen at the house that day, they would abandon any further attempt to see them. Had the referral of G P and Miss M been treated as it should have, that is to say as having raised child protection issues as opposed to merely issues of school attendance, it is hard to imagine that such a view would have been taken.

When asked in evidence about the visit to the house Miss G said that the mother’s hostile and unco-operative attitude was not in any way unusual and I have no doubt that is the case. Even after she received the message from the mother complaining about the visit and saying that she was not to go back and see the other children, “alarm bells”, she said, “did not ring”.

Miss G took the view that she had seen the children and even though it was only brief “nothing had stood out.”

This visit was in itself was insufficient for the purposes of even an initial assessment. The Department of Health’s Framework for Assessment known and referred to as The ‘Lilac’Book, provides the framework which informs such assessments. Paragraph 3.1 of the ‘Lilac’ Book sets out a list of enquiries which “may be undertaken.” The only mandatory enquiry is seeing the children. The paragraph says in terms that “as part of an initial assessment the child should be seen. This includes observation and talking with the child in an age appropriate Mer.”

Miss G said that she was not sufficiently concerned by what had happened when she visited the house and the subsequent telephone call from the mother to move on from the initial assessment to any sort of child protection investigation. Miss G told me that despite the history, a child protection investigation would only have been triggered if she had seen the children on their own and they had made a ‘disclosure’ or she had not been allowed to see the three children subject to the referral.

With respect to Miss G, that rather begs the question; had she seen the children or any of them as is expected and anticipated in an Initial Assessment she may have had more information, if only from the children’s physical appearance, that would have led her to conclude that a child protection investigation was necessary.

As it was, even though an Initial Assessment is deliberately designed to be a brief assessment which is not too onerous a piece of work for social services to undertake, it was not completed but simply shelved without even speaking to the children’s schools from where the anxieties had stemmed and the referral had been made.

The Initial Assessment was abandoned on the basis that Education Otherwise in the form of Mr. H was now to be involved. Miss G accepts that she at no stage spoke to Mr. H and that she herself agreed with the decision to abandon the assessment. She accepted that she knew the detail of the school’s concerns before the visit to the house and said in evidence that she thought in hindsight that “perhaps the welfare issues should have been considered in more detail.” In so far as I can see it, the welfare issues were not considered at all and should have been at the forefront of any social work enquiries about this family.

Miss G concluded her evidence by saying that as no further work was to be done on the case on the basis that Education Otherwise would be involved; her recommendation had been for the case to be closed. It was awaiting formal closure when, as she unfortunately phrased it, “this incident occurred.” The incident to which Miss G refers is the death of K.

The Guardian has submitted to the court that K’s death was preventable. It was. Initial and core assessments are carried out by social services department according to the Framework for Assessment of Children in Need and their Families, referred earlier in this judgment as the Lilac Book. The guidance says “In practice this means in planning, preparation and coordination with professionals in other agencies in accordance with the principles in 1.23.”

Paragraph 1.23 sets out the principles which should guide inter-agency, inter-disciplinary work with children in need.

The guidance goes on in paragraph 1.51 to say: “Understanding what happened to a vulnerable child within the context of his or her family or a local community cannot be achieved as a single event. It must necessarily be a process of gathering information from a variety of sources, making sense of it with the family and very often with several professionals concerned with the child’s welfare.”

At paragraph 5.43 the guidance says: “When a child has special educational needs or is disabled the schools and educational psychologists will have important information about the child’s development, the level of understanding and the most effective means of communicating with the child. This information should be sought before the beginning and the end of the assessment.”

The Guardian submits that it should have been clear to social services what their role and that of the educational welfare services were when they received the initial referral from G S. The Guardian says that faced with the mother who was reported to be unco-operative and aggressive towards the professionals and a man who when seen by the professionals consistently refused to provide details of his name (and this court would add also the refusals to allow professionals into the house or to speak to the children) the Guardian submits that the appropriate course for the local authority should have been to consider a section 47 Children Act enquiry, that is to say

“(1)

Where a local authority

(a)

---

(b)

have reasonable cause to suspect that a child who lives or is found in their area to be suffering or is likely to suffer significant harm,

the authority shall make or cause to be made such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare.”

Even, says the Guardian, if this was later downgraded once all the professionals involved with the family had shared their information in an appropriate forum, such an enquiry would have provided a coordinated response from all the relevant professionals, namely health, school and educational social workers and the health visitors.

I agree with the Guardian’s analysis. Social services, despite the concerns of the school and the unco-operative attitude of the mother when they visited the house, decided to rely on Mr H and the educational social worker and abandon their own investigations.

As a result of each professional carrying out his or her own duties in isolation, information was not passed on and relevant connections were not made. The most glaring example being that if only anyone had asked, they would have discovered that both M’s school and the other children’s schools had largely identical concerns.

It seems extraordinary to me that no alarm bells rang with social services when the mother cancelled the appointment for A, B and M to be seen by Miss G. A referral had been accepted which, contrary to Miss G’s initial evidence, related not only to education but to serious welfare issues and Miss G on her own account was aware of the issues which had been raised by the school. Put at its baldest, at the very least a proper initial assessment should have been completed. The children had been withdrawn from school and the mother thereafter had been reluctant (at best) to allow the children to be seen. Added to this there was an unknown male in the house with the six young children in circumstances where he was refusing to identify himself.

The court is acutely conscious of the enormity of the task faced by these or any other social workers. It is also conscious that none of the professionals involved between January 2008 and May 2008 have had the benefit of legal representation or the opportunities of making submissions to this court. A serious case review is currently being conducted and no doubt the social services and educational welfare involvement will be analysed in a way that is not open to this court. It is no part of the function of this court to second guess their findings.

The fact remains however that M’s school was seriously concerned and the school of L, Z and K were voicing their concerns about these children, in particular their concerns relating to their belief that the children were not being fed properly. The schools did all they could to bring their concerns to the attention of the relevant authorities. These concerns were not taken sufficiently seriously and were not adequately investigated.

The school drew social services’ attention to the family the day after the mother withdrew them from school. Between then, December 2007, and K’s death in May 2008 the police had one glimpse of K and Miss G and Miss S a brief glimpse of K, L and Z. No professional person, whether teacher or social worker saw the children after February 2008 and no-one tried to see them.

It is beyond belief that in 2008 in a bustling, energetic and modern city like Birmingham, a child of seven was withdrawn from school and thereafter kept in squalid conditions for a period of five months before finally dying of starvation.

K’s death was caused by and is the responsibility of her mother and the Intervenor, but on the evidence before the court I can only conclude that in all probability had there been an adequate initial assessment and proper adherence by the educational welfare services to its guidance, K would not have died. Merely looking at the photographs of the house and the conditions in which the children were living confirms in my mind that had social services even seen the bedroom in which the children lived or the Mer in which they were fed, they would undoubtedly have intervened.

No-one who saw the Intervenor either earlier in the trial when he broke down or later in his evidence from the witness box, could fail to have been affected by what was I am confident his genuine anguish. His pain was coruscating as he spoke of the brutality of his father to him as a child and of his own dawning realisation that despite his earnest desire to be a completely different father he himself had become a carbon copy, inflicting identical punishments on the young children in his care as had been meted out upon him as a child. Like his father before him, he was responsible or largely responsible for the death of a young girl.

I accept that initially he had good intentions. I suspect that in the early days he made time for the children, time that the mother did not have as she got through the daily grind of caring for six children alone on a modest budget. The children were certainly fond of him at the beginning.

No matter what pity an onlooker may feel for the Intervenor in this horrifying example of history repeating itself, it is important not to understate the magnitude of what he did. The local authority rightly point out that even if JA now appreciates and bitterly regrets the brutality of his actions that does not detract from what was done to the children and the lasting impact upon each of those who survived.

It may well be the role of a psychiatrist or a psychologist to determine whether the mother is blocking out the horror of what she allowed to happen to her children. As matters stand at the conclusion of the evidence she is maintaining an indefensible stance. All the medical experts, including the four instructed on her behalf, are united in saying that K died from complications brought about by malnutrition. The mother continues to put forward the far fetched proposition that K died of food poisoning caused by mouldy bread which she may or may not have eaten probably some three months previously. She makes no attempt to explain why if that is the case, the other five children were all malnourished, save to denying that that was the case in the teeth of the medical and photographic evidence.

The mother in the early years did quite well. The evidence from the children’s schools and indeed from the grandmother and her sister show a pleasant, caring woman whose life centred around her children following the breakdown of her marriage. Only after JA moved in did she seem to become difficult and aggressive to outsiders, particularly the school, she even as I find excluded her own mother who hitherto had been of considerable support. I have no hesitation in finding, as I have already indicated, that the mother welcomed J’s new strict regime at the beginning as she was finding it increasingly difficult to control her children.

The mother now accepts that removing the children from school was wholly contrary to their best interests. It was the worst sort of blind, unthinking behaviour. Had she bothered to read the children’s school reports and attend meetings she would have known that she had hopelessly unrealistic expectations of them and that social issues were being dealt with at school. Had she fed them they would have not had to steal food. Managing four of the children at home every day and making some attempt to teach them was always going to be a mammoth task.

Extraordinary as it may seem, on balance it seems to me that it was probably the decorating that pushed both the mother and JA over the edge. What had been a strict household with some use of corporal punishment spiralled out of control into a cruel and punitive regime as room after room became unusable for week after week.

The mother and JA were working all hours but, as can be seen on the photographs, in an ineffective way so that nowhere was finished before the next room was started. Without looking at the photographs it is hard to imagine the general chaos of the house and the contrast between the mother and J’s room and the squalor of the children’s room. Mother and JA became exhausted and fraught and less and less patient with the children. The children in turn must have been bored. They were having no exercise and no stimulation. It is clear from the evidence and from the mother’s own account, that they were getting increasingly demanding as they scrapped with each other and were undoubtedly miserable because they were hungry.

I accept that the mother was sick of the whole situation and was desperate for the decorating to be over. She may have intended that once it was finished she would ask JA to leave. The fact remains that she did nothing to prevent or to stop his brutal treatment of her children and I find that she was fully well aware of what went on and to a lesser degree treated the children in a very similar way. She hit them with flip-flops, put them “in detention” and put them outside if they were naughty, in addition she routinely deprived them of food and on occasional force fed them.

I accept that in the last couple of weeks JA’s behaviour seemed to become increasingly strange as in layman’s terms, his mental health deteriorated and that during that time he became increasingly brutal to the children. The death of K was no single episode of momentary loss of self-control such as the courts are all too familiar in the so called baby shaking cases. This was sustained and punitive brutality to very young children over many months of a type which thankfully is virtually unheard of in this country.

At the risk of being guilty of creating sound bites in relation to what was a very complex picture, it is worth enumerating a number of pieces of evidence which serve to demonstrate to the court the full enormity of what was going on at 35, L R between about September of 2007 when JA moved in and 15^th May 2008 when K died.