Blackburn with Darwen Borough Council v M & Ors

These are Public Law care proceedings in respect of a young infant male (R), aged thirteen months. They were instigated in consequence of a referral by medical professionals, following R being presented to hospital in June 2024. The concern expressed by the hospital was that R had suffered deliberate salt poisoning and had also sustained a shaking injury. Both these pathologies are seen in the Family Court, albeit with differing frequency. It is unusual, however, for them to arise in relation to the same child. R’s mother (M) and father (F) share parental responsibility for R. The family is of British-Pakistani heritage. F resides in the UK on a spousal visa.

Following his birth, R lived at home with M and F. Also living in the household were extended family members and R’s aunt and uncle, who are children. Further extended families live in two adjoining houses and there is a wider extensive family network in the general area.

A referral was made to the Local Authority on 27^th June 2024. R had experienced a number of admissions to hospital following his birth in April 2024. These concerned reports of blood in his vomit, seizures, apnoeic episodes and choking. There were also reports of blood coming from R’s mouth and nose. Without exception, these reports were made by M. R was admitted to hospital on 1^st June 2024 and was, on the basis of the descriptions given, diagnosed with severe reflux and a cow’s milk allergy. So complex were R’s needs perceived to be, that it was felt he required a nasogastric (NG) tube. He was discharged with the NG tube in situ on 21^st June 2024.

A few days later, on 25^th June 2024, R was returned to the hospital with M, at least primarily, expressing anxieties about R’s diarrhoea and vomiting. R’s blood tests were taken and revealed high levels of sodium. Treatment commenced, but the sodium levels continued to increase to what was regarded as an alarming degree. On 26^th June 2024, R was given a milk feed, prepared by M. Very shortly after this his sodium levels again rose significantly. He became manifestly unwell, started choking and struggling to breathe. R remained in hospital where he was subject to further tests, including an MRI scan and skeletal survey. Those revealed that R had suffered bleeding to the brain. R remained in hospital during which time proceedings were issued and arrangements made for him to be placed in foster care on his discharge.

Dr. Malcolm Coulthard, consultant paediatric nephrologist, has prepared a report for these proceedings, dated 22^nd November 2024. For much of his career, Dr. Coulthard has been interested in the pathophysiology of kidney function in preterm and newborn babies. He developed a specialist interest in the diagnosis of causation and the safest treatment regimens for hypernatraemia (high sodium levels in the blood) in babies and children. Within this specialism has been a particular focus on distinguishing salt poisoning from other causes. He was one of the distinguished paediatric nephrology members of the Guideline Development Group for the Royal College of Paediatrics and Child Health, which produced the evidence-based guideline: ‘The Differential Diagnosis of Hypernatraemia in Children, with Particular Reference to Salt Poisoning: an evidence-based guideline (2009)’.

Dr. Coulthard reached a firm conclusion concerning the mechanism of R’s hypernatraemia. He considered that R had been given milk feeds, each of which had been contaminated with approximately five grams, equating roughly with one teaspoon full, of salt, once whilst he was at home at 4pm on 25^th June 2024, and once in hospital at 7pm on 26^th June 2024. There is no question or indeed any dispute that both these feeds were given by M. The first episode was not recognised as salt poisoning, however, the second was, and R was transferred to the Royal Manchester Children’s Hospital (RMCH) Paediatric Intensive Care Unit (PICU). There, in accordance with the Guidelines, R’s plasma sodium was brought down in a slow and controlled fashion, taking more than four days. Dr. Coulthard has told me both in his evidence and his report that the prognosis in most cases of severe acute salt poisoning is “excellent” but only when following controlled recovery. As I understand his evidence, this involves, somewhat counterintuitively, infusing sodium into the patient in order that the sodium levels are not expelled too quickly, which carries a real risk of damaging the brain.

As I have foreshadowed above, MRI scans revealed changes in the brain. Dr. Coulthard was concerned by these which he thought might be due to sustained osmotic demyelination syndrome. This is a very rare complication which occurs due to a particularly rapid rise in plasma sodium concentrate, in which the myelin covering the nerve fibres are damaged in part of the brain. Further, Dr. Coulthard noted that R’s blood pressure readings, including those prior to his salt poisoning, showed that he was hypertensive. 40% of the blood pressure readings were in the normal range, thus the majority were not. A significant number of the readings were severe (Stage 2). R’s blood pressure was very high, concurrently with extremely high plasma sodium levels. This was to be expected because medical treatment designed to slow down the rate of fall in the sodium concentration involves, as I have discussed above, giving substantial volumes of intravenous infusions with high sodium containing fluids, which inevitably increase the volume of blood in a baby’s circulations. Dr. Coulthard expressed concern that prior to admissions to RMCH, none of the medical staff at the earlier hospital had noted that R was hypertensive.

In respect of the neurological evidence, Dr. Coulthard, as he stated, was analysing the physiology from the premise of Occam’s razor, i.e. the simplest explanation with fewest assumptions. Whilst that is always an attractive and, perhaps sensible, starting point, it must be remembered that the Occam’s principle is heuristic, i.e. pragmatic problem solving, which must not be elevated to a process of logic. Axiomatically, the simple explanation might be wrong and lead to incorrect conclusions. Occam’s razor assists in prioritising hypotheses, but it does not determine which is true.

In relation to the changes in the brain, his approach led Dr. Coulthard originally to conclude:

“None of the opinions or facts that I have read in the Head Injury Pro Forma document has caused me to alter any of the views that I expressed in my report of 22nd November 2024, and my overall conclusion therefore, based on the principle of Occam’s razor, remains that [R]’s intracranial haemorrhages are more likely to be the consequence of his documented hypertension than on a hypothesised shaking incident.”

However, a further expert was instructed, Mr Ibrahim Jalloh, Consultant Paediatric Neurosurgeon. Mr Jalloh has extensive experience in all aspects of paediatric neurosurgery, including management of paediatric brain injury and abusive head trauma. He holds a PH.D. in traumatic brain injury and contributed to the National Institute for Health and Care Excellence (NICE), Head Injury Guidelines. Mr Jalloh noted that the intracranial haemorrhage was: multifocal; consisted of acute subdural haematoma between the hemispheres; traumatic subdural effusion alongside the left hemisphere; further bleeding in multiple compartments of the head which were indicative of additional subdural bleeding or subarachnoid haemorrhage. This pattern of intracranial haemorrhage he considered to be consistent with a shaking type injury, most likely to have been sustained within days of the CT scan on 27^th June 2024. Mr Jalloh was clear that R’s sodium levels and high blood pressure could not have been responsible for the intracranial bleeds. Mr Jalloh noted that trauma to the head, causing physical tissue deformations, will easily tear bridging veins, damage the arachnoid and result in subdural bleeding and subdural effusions of blood mixed with cerebrospinal fluid (CSF). Whilst there are causes other than trauma that can cause spontaneous subdural bleeding, Mr Jalloh was clear that these (e.g. vascular malformations and tumours) are rare and only really seen in older children and adults. He pointed out that non-traumatic subdural bleeds are also, but rarely, found in infants undergoing surgical repair or congenital heart defects; those with clotting deficiencies and some rare genetic causes.

Both Mr Jalloh and Dr. Hogarth, who reviewed the MR scans, were clear that hypertension only rarely causes intracranial haemorrhage and when it does occur, intracerebral parenchymal haemorrhage is much more likely than subdural or subarachnoid bleeding. In adults, Mr Jalloh told me hypertension is a common cause of bleeding within the brain substance. The blood vessels deep within the brain, i.e. basal ganglia and thalami, are prone to hypertensive bleeds, in part, due to the proximity of the small vessels in these locations to high pressure major feeding vessels. Premature infants are also considered to be prone to intracerebral haemorrhage. Other than in premature infants, hypertension is not independently associated with intracranial haemorrhage in children (Lo et al. (2008), Al-jarallah et al., (2000)).

Though Mr Jalloh has worked through the differential diagnostics with great care in his reports, it is not necessary for me to replicate that exercise here. With some diffidence, I summarise his conclusion. Even if, for the sake of a dialectic, hypertension might cause intracranial haemorrhage in infants (contraindicated both by published studies and Mr Jalloh’s own clinical experience), it would be very unlikely to produce extra-axial haemorrhage, i.e. bleeding outside the brain substance, in isolation, without intraparenchymal bleeding within the wider brain substance. Mr Jalloh did not consider that the absence of retinal haemorrhages or any associated markers of non-accidental injury, e.g. rib fractures detracted from shaking, as the most likely mechanism in this case.

It is necessary to say something in respect of the requisite force required to cause an injury of this kind. For obvious reasons, there can be no studies of any real relevance. However, it is important that the parents and the wider family concerned with this judgment should know the clear medical consensus that normal handling of a baby, accidental rough handling, and minor domestic accidents would not be expected to cause any brain injury at all. The degree of force required to cause these changes in the brain would be immediately perceived as unnatural, inappropriate and excessive by anybody who witnessed it.

Dr. Coulthard recognised the force of the above reasoning and the expertise of Mr Jalloh. He properly, in my judgement, yielded to the neurosurgical opinion. This opinion was supported and reinforced by the interpretation of the neuroradiological evidence provided by Dr. Kieran Hogarth. Dr. Hogarth’s conclusions are conveniently summarised in his report:

“(i)

Distribution: I note that the local reports described bilateral subarachnoid and subdural bleeding. I can only see left-sided bleeds. I cannot confidently identify and SDH/SAH on the right side.

(ii)

Timing: The subdural blood and the subpial/subarachnoid blood on the CT head scan are no more than around 10-11 days old on 27 June 2024. The subdural effusion cannot be aged accurately but there are no features to suggest that it is chronic. If caused by trauma, subdural effusions usually develop in the days following the injury and usually resolve after week or so.

(iii)

Inflicted versus accidental injury: Subdural haematoma is a widely recognised sequela of abusive head trauma; it is known from perpetrator confessions that this may result from a forceful shaking mechanism of injury with linear and/or rotational forces applied and with/without impact. Jayawant et al contend that inflicted injury is the commonest cause of subdural haematoma. The subdural haematoma is over one cerebral hemisphere only in this case. An impact against a soft semi-yielding surface could also produce this distribution of bleeding, including the subpial/ subarachnoid bleeding.

(iv)

I would agree with Dr Coulthard that hypernatremia is unlikely to have caused the intracranial bleeding.

(v)

In my view, the subpial/subarachnoid bleed and the SDH are unlikely to have been caused by hypertension, for the same reasons as outlined by Mr Jalloh. I have never encountered a case of intracranial bleeding in association with hypertension in an infant in clinical practice.

(vi)

Osmotic demyelination: The restricted diffusion in the diencephalon is a typical appearance of osmotic demyelination and can be seen in the context of salt poisoning.

(vii)

If the intracranial bleeds were not caused by trauma, then their cause is unknown.”

An experts’ meeting was convened on 3^rd March 2025, the minutes of which have been filed in these proceedings. Although the minute is described as a ‘Schedule of Concurrence and Divergence’, there is, ultimately, no significant area of disagreement in respect of salt poisoning or shaking injury. Ms Burnell KC, on behalf of M, has acknowledged the weight and consensus of the medical evidence. She has, however, on her client’s behalf, put it thoroughly to the assay in cross-examination.

The thrust of her contention has been to invite the Court to consider whether the cumulative impact of vomiting, reduced fluid intake, increased strengths of feeds and the use of Gaviscon either caused or, as I understand it, significantly contributed to the extremely high sodium levels. The postulated explanation was, with respect to Ms Burnell, an ambitious one. Dr. Coulthard rejected any explanation for such suddenly and dramatically elevated sodium levels other than what he describes as “exogenous salt administration”. He was very clear that the use of Gaviscon, excess vomiting, insufficient feed, dehydration, neither individually nor cumulatively could have resulted in sodium spikes of this level. The anticipated differences in likely concentrations of milk from a stomach of a normally fed baby, contrasted with one that has been salt poisoned, are very stark. This is because the sodium concentration of formula milk is very low (at around 10 mmol/l) and the impact of Gaviscon can be easily calculated. In cases of salt poisoning, the ranges of concentration seen vary from a minimum of 200 mmol/l up to over 1,000 mmol/l. For completeness, Dr. Coulthard also rejected the theory, advanced on behalf of M, that a nurse misapplying a sodium drip might have generated the sodium spike. The whole mechanism of the drip discounts that as a feasible possibility.

In cross-examination, Dr. Coulthard refined his conclusions to identify three separate administrations of salt. The first, he concluded, took place at home at 4pm on 25^th June 2024. The second at the 7pm feed on 25^th June 2024, and the third at the 7pm feed in hospital on 26^th June 2024.

I should record at this point that F is represented by Mr Feehan KC and Ms Korol. Mr Feehan has pursued a watchful and broadly neutral approach to the medical evidence. He has concentrated his forensic energy on the welfare issues, to which I will turn in due course. F told me, in the witness box, that he accepted the medical conclusions. He remains, however, entirely unable to accept that his wife has deliberately injured their son. Mr Feehan and Ms Korol make the following submission in their closing document:

“The court is aware of the position of the father which is that he permitted his counsel to explore within reasonable limits the expert evidence, even where that exploration tended to confirm the evidence of deliberate perpetration of injuries to [R]. He accepted that evidence and confirmed that acceptance to the court in his oral evidence.”

Before returning to Dr. Coulthard’s evidence, all Counsel have agreed that I should take the opportunity, in this judgment, to highlight the importance of ‘The Differential Diagnosis of Hypernatraemia in Children, with Particular Reference to Salt Poisoning: an evidence-based guideline (2009)’ by the Royal College of Paediatrics and Child Health. This document emphasises that salt in large enough quantities is toxic. Excessive intake of salt, whatever the reason, results in hypernatraemia. Hypernatraemia resulting from deliberate, non-accidental salt poisoning can be difficult to diagnose. The Guideline covers the clinical and biochemical diagnosis of hypernatraemia in children and is focused on diagnosis of poisoning by agents, including salt. It sets out how to approach the differential diagnostics and possible causes of poisoning. Crucially, it highlights what key tests will help distinguish excess sodium intake from water depletion.

Ms Burnell submits that it is “extremely unfortunate that the protocol management for high sodium was not followed by the Royal Blackburn Hospital”. Whilst properly prefacing her criticisms as primarily important in the context of the risks posed to R, she submits that it is also significant that the experts and the Court do not have the benefit of the recommended four-hourly sodium concentration tests; the gastric aspirate measurements; any alternative methods of assay; serial weights and any paired blood and urine samples. Each of these is prescribed by the Guidance. These omissions are “gaps in the medical evidence”, says Ms Burnell, which must be “considered when the conclusions of the experts are considered by the court”. That submission is carefully pitched. The failure to follow the Protocol is indeed lamentable. However, the factual matrix of the bottle feeding, acknowledged to be administered by M, followed by the striking elevation of sodium levels, in many ways, tells its own story. There is, in my judgement, in contrast to other cases of this kind, a naivety on M’s part and almost an inevitability of detection. It was with the same lack of guile that she told me that she had learnt that salt was dangerous to babies whilst undertaking a childcare course some years ago. Notwithstanding Ms Burnell’s endeavours, Dr. Coulthard remained clear in his conclusions.

R had been presented at the Emergency Department on 25^th June 2024 at 5.43pm, with a history which is recorded as “vomiting post feed”. It is expanded on in these terms, recorded by a nurse, “multiple episodes of vomiting this evening, mum tried another feed, oral feed was given at 10am, 10 ml, rest have all been LG”. The evidence establishes that there were no feeds administered in hospital before 7pm. The first sodium reading was taken at 7.50pm. This revealed significantly elevated sodium levels, at 162 mmol/l. In so far as a “rogue nurse” had been posited, this history, which is largely agreed by all, rebuts that suggestion. The salt levels at 7.50pm indicate that they must have been administered prior to admission, i.e. at home at 4pm on 25^th June 2024.

I think it is only fair to comment that the ‘rogue nurse’ theory was advanced with little conviction by M. My impression of her personality is that she is temperamentally disinclined to make criticisms of others. For reasons which I will expand upon below, her self-esteem has been corroded by what I consider to be an abusive relationship with her father (Q). Further, as Dr. Coulthard agreed in cross-examination by Mr Goodwin KC, on behalf of the child, the symptoms described by M, whilst at home and as set out above, are themselves consistent with salt poisoning having taken place. Discounting Ms Burnell’s alternative causes as unsustainable, there remain no explanations for R’s elevated sodium levels. Moreover, there is other evidence from which inferences can be reasonably be drawn, which reinforce a conclusion of salt poisoning. Mr Goodwin has succinctly summarised these thus:

During the assessments made in this case and reflected to varying degrees in the oral evidence, it has become clear that M has suffered from long-standing mental health issues, which have caused her to have periodic, extreme, emotional outbursts. Her medical records refer to her having “emotional dysregulation”. The wider reports reveal M to have been physically, verbally and emotionally abused by her father. This information emanates from a number of sources, including extended family members. Though he denied it, in the face of compelling contrary evidence, M’s father (Q) repeatedly failed to encourage or assist in enabling M to take up the mental health treatment that was offered to her. M’s mental health had declined notably from the age of sixteen. The records reveal repeated incidents of self-harm, not only cutting, but spraying aerosols directly onto her skin at very close range. She was referred to child and adolescent services (CAS). Within the family home, she was reported to hit objects, throw items about the home, and shout volubly. The triggers for such episodes are recorded as having been “trivial disputes in the family home”. The maternal grandmother told the police in June 2024 that M could “become angry” and that this has been an “issue since childhood”.

Q disavowed any ‘anger issues’ or any ‘heated arguments’. For the avoidance of doubt, that is contrary to the evidence of his own wife, daughter, and son-in-law. In the past, Q had told CAS that M did not want support. He told the GP that he disagreed with the view that his daughter was having “panic attacks” and considered she was “attention seeking”. Even the cursory history, as set out above, reveals that not to be the case. The Local Authority came to the view, articulated by Mr Jones KC and Mr Rothery, in their closing submissions, that Q did not want M to receive support for her mental health condition. I agree with that submission, it is the only reasonable inference that can be drawn from his behaviour. His daughter was plainly in great distress and his refusal to help her receive the appropriate care is, to my mind, deeply troubling.

I found Q’s presentation in the witness box revealed a personality which was selfish, rather childishly petulant, dishonest, evasive, and self-pitying. He displayed a striking incapacity to focus on anything or anybody other than himself. He is plainly the centre of his own universe. The Local Authority, drawing on the assessments and the oral evidence, describe the dynamics within the household, prior to R’s admission to hospital, as “a form of patriarchy headed by the grandfather”. Patriarchy derives from the Greek “patria” and “arkhē”. The former means lineage/fatherland; the latter authority/sovereignty. The emphasis is on a social structure in which men have control and women are regarded as subordinate. This is undoubtedly accurate to describe the structure within this household, but it does not go far enough. Patriarchy is a facet of Islamic religion. Though alien to modern Western values, it is predicated on principles of wisdom, kindness, fairness, and a benevolent and loving exercise of authority. These are not to be found in this household. Q exercises a dictatorial control. He has taken over all the arrangements relating to F’s visa, he has meticulously organised his “employment”, he controls every aspect of his life and finances. He has changed F and M’s accommodation at will and without notifying them, even to the point of arranging for their belongings to be transferred to new accommodation without them being aware of it. This shows no respect for their privacy, either individually or as a married couple.

The evidence has revealed that though F works long hours, he receives no income from his father-in-law. M also told me that she sometimes has, effectively, to raid the petty cash to buy essentials. Mr Jones has described this as “a form of slave labour”. That I believe is not an overstatement but entirely accurate. It was also very disconcerting to observe as it unfolded in the courtroom. Perhaps the most striking feature of it is the emotionless and uncomplaining way in which both parents describe it. M told me this is just normal for her. F told me that when there are arguments in the household, he tries to remove himself from them. That volatility, he said, had not been his experience of family life in Pakistan. Sometimes, he told me Q ordered him to go to his room. He always obeyed. He has little English and virtually no way of exercising or asserting his own authority. In his evidence, he tried to present his father-in-law’s behaviour as culturally normative. It is clear, however, not least from what I have recorded above, that he knows his father-in-law’s behaviour is unkind and brutish.

In addition to ‘handling’ F’s visa application, the spousal visa is due to expire shortly and requires to be renewed. That too remains in Q’s hands. He also assumes responsibility for F’s mobile phone bill. Indeed, it is difficult to find any agency in F’s life at all. The social workers conducting the assessment were plainly concerned at the lack of autonomy this couple appear to have. The report expresses it in this way:

“Concerns remain in respect of [M] and [F]’s autonomy in their relationship, away from maternal grandparents. They had moved out of the home where wider family were residing, but have subsequently moved again. This decision to move was made on their behalf by maternal grandfather, with [F] reporting that he was not consulted about the decision and [M] reporting that she had one conversation with her parents before being told ‘we have seen a house and you have to move here’. [M] shared that her father ‘does this often and has always done this’, reflecting that he makes spontaneous decisions on behalf of the family without discussion or notice.

These concerns were discussed with both parents in relation to their ability to make decisions independently, [M] said that she ‘tries her best’, but they are her parents, and feels that she can not go ‘against’ them. This remains a concern, as it suggests that [M] and [F] do not have autonomy over their lives, that [M]’s father continues to make decisions on their behalf. While this is challenged by parents, observations and discussions suggest that this is the case. It is considered that if [R] was to return to their care, parents would not always be able decide what is best for [R], or be able to work openly and honestly if this conflicted with wider family views.”

The language in which the social workers express their concerns is no doubt intended to be sensitive but, if they will forgive me for saying so, it is, in truth, pusillanimous. Mr Jones, as I have said earlier, describes what is going on in this household as “slave labour”. I have agreed with his use of that term. Shrouding these significant safeguarding issues in the ambiguous language of “concerns” and “suggestions” is not merely unhelpful, it obscures the gravity of the behaviour that has been revealed in evidence and either was or ought to have been obvious to those conducting the assessment. If it was, it required to be stated clearly. The fact that neither M nor F feels able openly to complain of their circumstances, serves both to indicate the extent of their repression and to mandate the clear articulation of it by the professionals observing it. Q’s denial of the reality of this couple’s situation is entirely disingenuous. I agree with Mr Jones that Q was “dishonest in relation to numerous aspects of his evidence”.

Into this unhappy family situation came further challenges with M’s difficult pregnancy. She suffered gestational diabetes, recurring urinary tract infections, and sickness. Her GP’s records refer to her worsening eczema. In December 2023, M attended her GP, reporting vomiting five or six times per day, ongoing for months. I note Q described her as “fine”. M was clearly distressed and vulnerable during her pregnancy. F did not have the wherewithal to help her. It was clear and quite touching, that despite F’s impotence to help his wife, the time in their lives when this couple was happiest was when they were both working in the shop together. They both told me this. F is a highly skilled dressmaker. His reputation has established itself very quickly. He also loves his work; he takes pride in it. He has made a number of traditional sarees and tunics for his wife, which she admires and appreciates.

When R was born, it became clear that M was not an instinctive mother. She struggled to understand how to handle her baby gently and appropriately. There are frequent descriptions of her handling him roughly. One nurse noted this whilst observing mother and baby in hospital. She initially put it down to the fact that M was tired, but several professionals have now seen this, including in the contact situation. F could not be more different. He is gentle and instinctive as a father and has grown in that role as time has passed. In what seems to me to be a kind and sensitive manner, he has endeavoured, unjudgmentally, to demonstrate, to his wife, what is required. She has not been the most rewarding of students. I do not say this critically of her. Her struggles may very well reflect her own experience of parenting.

It is significant that R has thrived in his foster placement. From the very beginning, he has revealed himself to be a healthy, curious, and strong infant. He has received what both parents fulsomely acknowledge as outstanding care from K and T, who are extended family members. The social worker told me with manifest pleasure that R is growing in confidence daily. He is now weaning better, crawling, showing every sign of emotional attachment and security. I was told how he will seek his carers out for assurance and “will nuzzle and cuddle them”. The social worker was so confident in her assessment of this couple that, on the Local Authority’s application, I was persuaded to authorise R’s move into the care of K and T, prior to this hearing. That confidence was well placed. R is loved unconditionally and claimed by his new parents. His interactions are described as “natural” and “true”. In differing ways, both parents give their support to this placement. They can see for themselves, in my assessment, how happy R is. R’s relationship with F has also blossomed. The two delight in each other’s company and I have been told, on a number of occasions, that R’s face lights up when he sees his dad. The Guardian considers there is a clear attachment.

F has told me that he would wish to care for his son and, if necessary, on his own. In view of the very serious findings made against M, she could not be part of the household. There are, however, two sizeable obstacles to F’s aspiration. Firstly, F is singularly lacking in the basic life skills required. F has virtually no grasp of the English language, which poses clear challenges in every facet of life. He has no cooking skills, no work permit, no income. Nor in the months that this case has been ongoing, has F made even the most basic of efforts to address some of these obvious issues. Decisions require to be made for R now. This is his right.

Despite the careful consideration given to F’s wishes to parent his son and the assessments of him, there is no evidence at all that he can generate the necessary change and, most importantly, not within R’s own timescales. Moreover, as Mr Goodwin correctly points out, F’s challenges go beyond practical difficulties. F presents his own risk to his son. He does not believe that his wife is responsible for that which I have found her to have done. R could have died by poisoning or by brain injury, both of which would have been in consequence of his mother’s actions. In failing to recognise the risk that M presents, F has disabled himself from protecting his son. In this case, that is not simply motivated by his loyalty to his wife, it is deeper and more insidious. F has an entrenched culturally interwoven dependence on the maternal family. He has been prepared to surrender his personal autonomy to an extraordinary extent. Though I have been critical of Q, F also bears responsibility for their distorted relationship.

The Guardian has referred to F’s passivity, which Mr Goodwin has described as “extreme”. It is characterised by his lack of curiosity and support for his wife’s significant mental health issues; his failure to acknowledge his wife’s pattern of disengagement from their son when having contact with him; his lethargic approach to his long-term immigration status; his failure to respond to the social worker’s repeated encouragement to strike out for some independence; his inability properly to acknowledge Q’s bullying and domineering behaviour; his total subjugation to Q’s authority. The Guardian sees no evidence at all of F making any, even rudimentary, attempts to provide a base upon which he can build to secure R the care he needs. It is not a work in progress, it is not even, at this stage, a choate plan. I do not doubt that F is sincere when he says that he is willing to separate from his wife to care for R, should the Court consider that to be necessary. The driver, in these circumstances, cannot be the Court, it must come from the father himself. In any event, the sincerity of F’s willingness to separate requires to be balanced against the likelihood of his being able to do so. For all the reasons above, I consider it unlikely that F will be able to disentangle himself from the maternal family. The challenges are labyrinthine for him, not least because they resonate widely, including with cultural pressures from the wider family in Pakistan.

It is impossible not to feel sympathy towards F. He is a quiet, well-mannered, instinctively kind, and self-deprecating man. He is also eloquent and extremely articulate. It is not difficult to see why R loves him so much and lights up on his arrival. Ultimately, however, this is not enough. R requires protection both from the physical harm of the type that he has already experienced and from the emotional harm to the risk of which contact with the maternal family will expose him. F has not demonstrated any capacity to protect his son from either. To do so would require him to assert his autonomy, which has been paralysed by his treatment within the maternal family. Mr Feehan does the best he can on F’s behalf and seeks a further adjournment for a further assessment. For that application to gain any forensic traction at all, it requires to identify some cogent basis upon which it can be said that F is able to separate from his wife and family. Mr Goodwin describes the evidence of this as “conspicuously absent”. I agree.

As I have stated above, the connected persons placement is with K and T. K is the younger sister of Q. K has very little to do with Q. She is unflinching in her criticism of him and very much blames him for M’s difficulties. She is under no delusion that he has physically and emotionally abused M. She is, by all accounts, a strong minded, independent woman. Her first marriage, which was arranged for her, failed. K initiated divorce proceedings which, in her quite traditional community, took great courage. She remarried to a man she met socially. They live a modern, busy life together and have three children of their own, the youngest of whom is six months. K is a registered nurse, employed as a school nurse. She is manifestly well placed to meet any medical needs that R might have in consequence of his brain injury. In particular, I note that she is trained to manage seizures. There is much optimism that R is developing without any medical sequelae. T has a degree in psychology, teaches, and has professional knowledge of child developmental theories.

K and T were both saddened that it had been necessary for R to move to a foster placement at the start of the proceedings. They claimed him instinctively and intuitively as their own family. They love him as they do their own children. They are also full of praise for the quality of care he received from the foster carer. I should add that M and F are similarly fulsome in their admiration of the foster carer too.

K and T have a comprehensive support network. They also receive a lot of support from their employers. T’s employer provides a wellbeing service for staff which he can access as required. The couple belong to local clubs and participate in sporting activities. They attend Mosque with their children and R also attends. The older boys are receiving lessons in the Quran from family friends. It is anticipated R will do the same when he gets older. They have a good network of friends and family who wish to provide help and support. The couple has been supportive of the Family Court process and of the criminal investigation. Though they have sympathy for M, they have a laser-like focus on R’s needs which they have demonstrated to be their priority.

At present, there is extensive contact with the parents which is not consistent with the long-term objectives of this placement. The plan is that R will remain with this family for the remainder of his minority. The Guardian has asked me to emphasise, so that all understand, this is not a holding placement with a view to rehabilitation. R needs a secure, stable, safe, and loving environment. He is fortunate enough to have found one within his own family. The protection of that placement is a high priority. The plan is to reduce contact to not fewer than six times per year for at least two hours on each occasion. Further, in this complex family dynamic, it is likely that R will, with his cousins, see maternal grandparents occasionally at family events. As will be obvious from the above, there is already a notable froideur between K and T and the maternal grandparents. Contact will not be more than three times per year, following the course of key religious celebrations. It is to be sensitively but carefully monitored.

The relationship between F and R is qualitatively different from and more beneficial than that between R and his mother. F is already a very significant figure in R’s life and recognised by him as his dad. Because of the risk M undoubtedly presents, contact requires to be supervised. This presents a real challenge and one in which it seems to me that K and T’s professional backgrounds equip them far better than most. That said, it is not, as everyone recognises, going to be easy and will necessitate active Local Authority support and supervision in the immediate term. There has been discussion, appropriately in my judgement, as to whether there should be greater contact between R and his father, perhaps unsupervised. Ultimately, the Local Authority and the Guardian concluded that as the parents remain together, it would become confusing for R to see them with differing frequencies. At some point, in appropriately developing language, R will learn the reasons for his separation from his parents. He will have to rationalise why it is that his father has chosen to remain with a parent who had caused him such serious harm. The nature and frequency of contact has to be honed to R’s present and developing needs. R is entitled to a relationship with both his parents, but his primary need is for a stable secure placement. Contact must be honed to meet both, recognising the importance of the latter. I consider the plan for six times a year balances those needs sensitively.

Following his very difficult start in life, R has been fortunate enough to have found himself in an excellent home. His transition there has been helped by a conspicuously good and sensitive foster carer. As will be clear from my reasoning above, I have absolutely no difficulty or hesitation in approving this placement. More than that, within the parameters of the possible, I regard it as a joyful outcome.

A question has arisen as to the appropriate legal framework to support the placement. The Local Authority is very clear that this is a case in which the protection of a Care Order continues to be required. The Guardian strongly supports that view. Guidance is to be found in Re JW (Child at Home under Care Order) [2023] EWCA Civ 944. It is not necessary here to review the circumstances in which the Court can make either a Care or Supervision Order, having regard to the ‘threshold criteria’, s.31(2) Children Act 1989, but it is relevant to consider the effect of a Care Order. Section 33 of the Children Act 1989 addresses the scope and ambit of a Care Order:

“33 Effect of care order.

(1)

Where a care order is made with respect to a child it shall be the duty of the local authority designated by the order to receive the child into their care and to keep him in their care while the order remains in force.

(2)

Where—

(a)

a care order has been made with respect to a child on the application of an authorised person; but

(b)

the local authority designated by the order was not informed that that person proposed to make the application,

the child may be kept in the care of that person until received into the care of the authority.

(3)

While a care order is in force with respect to a child, the local authority designated by the order shall—

(a)

have parental responsibility for the child; and

(b)

have the power (subject to the following provisions of this section) to determine the extent to which

(i)

a parent, guardian or special guardian of the child; or

(ii)

a person who by virtue of section 4A has parental responsibility for the child,

may meet his parental responsibility for him.

(4)

The authority may not exercise the power in subsection (3)(b) unless they are satisfied that it is necessary to do so in order to safeguard or promote the child’s welfare.”

A child placed in the care of a Local Authority under CA 1989, s.31(1) is ‘looked after’ by the authority for the duration of the Care Order [CA 1989, s.22(1)]. Part 3 of the CA 1989, in England, and the Social Services and Well-being (Wales) Act 2014 [SSWB(W)A 2014], in Wales, make extensive provision in respect of the duties placed upon Local Authorities with respect to ‘looked after’ children.

In England, CA 1989, s.22C establishes a default requirement for a looked after child to live with a parent or similar parental figure:

“22C Ways in which looked after children are to be accommodated and maintained

(1)

This section applies where a local authority are looking after a child (“C”).

(2)

The local authority must make arrangements for C to live with a person who falls within subsection (3) (but subject to subsection (4)).

(3)

A person (“P”) falls within this subsection if—

(a)

P is a parent of C;

(b)

P is not a parent of C but has parental responsibility for C; or

(c)

in a case where C is in the care of the local authority and there was a child arrangements order in force with respect to C immediately before the care order was made, P was a person named in the child arrangements order as a person with whom C was to live.

(4)

Subsection (2) does not require the local authority to make arrangements of the kind mentioned in that subsection if doing so—

(a)

would not be consistent with C's welfare; or

(b)

would not be reasonably practicable.

(5)

If the local authority are unable to make arrangements under subsection (2), they must place C in the placement which is, in their opinion, the most appropriate placement available.”

A Local Authority, in England, may only allow a child in care to live with a parent, person with parental responsibility, or the previous holder of a ‘live with’ Child Arrangements Order (made under CA 1989, s.8), in accordance with the Care Planning, Placement and Case Review (England) Regulations 2010 [‘CPPCR(E)R 2010’].

A Local Authority which has placed a child with a parent under CPPCR(E)R 2010, Part 4 must satisfy itself that the welfare of the child continues to be appropriately provided for by his placement [CPPCR(E)R 2010, reg 35 and Sched 7]. In particular, the local authority must provide such support services to the parent as appear to them to be necessary to safeguard and promote the child’s welfare [reg 20]. In addition, by reg 28, arrangements must be made for a person authorised by the local authority to visit the child from time to time as necessary, but in any event:

“(a)

within one week of the start of the placement;

(b)

at least every six weeks during the first year of the placement;

(c)

thereafter, where the placement is intended to last until the child is 18, at least every three months, and in any other case, at intervals of not more than six weeks.”

In the event that the Local Authority cannot place a child by the arrangements discussed at paragraph 45 above, there are obligations to find the most appropriate placement available and a kinship placement is to be given preference where it is assessed as meeting the child’s needs:

“s.

22C(5), CA1989:

If the local authority are unable to make arrangements under subsection (2), they must place C in the placement which is, in their opinion, the most appropriate placement available.

(6)

In subsection (5) “ placement ” means—

(a)

placement with an individual who is a relative, friend or other person connected with C and who is also a local authority foster parent;

(b)

placement with a local authority foster parent who does not fall within paragraph (a);

(c)

placement in a children's home in respect of which a person is registered under Part 2 of the Care Standards Act 2000 [F4 or Part 1 of the Regulation and Inspection of Social Care (Wales) Act 2016 (anaw 2)]; or

(d)

subject to section 22D, placement in accordance with other arrangements which comply with any regulations made for the purposes of this section.

(7)

In determining the most appropriate placement for C, the local authority must, subject to [F5 subsection (9B) and] the other provisions of this Part (in particular, to their duties under section 22)—

(a)

give preference to a placement falling within paragraph (a) of subsection (6) over placements falling within the other paragraphs of that subsection;

(b)

comply, so far as is reasonably practicable in all the circumstances of C's case, with the requirements of subsection (8); and

(c)

comply with subsection (9) unless that is not reasonably practicable.”

In Re JW (supra), Sir Andrew McFarlane (P) referred to the observations of the Public Law Working Group to the effect that there had been “an increased/significant variation in the number of children returning home under a full care order”. The President regarded that variation as being “of very real concern”. He perceived a lack of clarity as to why, in some areas, the practice is not uncommon and in others comparatively rare. There was a perceived risk that the making of Care Orders at home might provide false assurances to a Local Authority’s partner agencies because “the Local Authority is neither involved in, nor has a thorough oversight of, the child’s day-to-day care”. The President expressly endorsed the conclusion of the Public Law Working Group that:

“66.

...

a)

a care order should not be used solely as a vehicle to achieve the provision of support and services after the conclusion of proceedings;

b)

a care order on the basis that the child will be living at home should only be made when there are exceptional reasons for doing so. It should be rare in the extreme that the risks of significant harm to a child are judged to be sufficient to merit the making of a care order but, nevertheless, as risks that can be managed with the child remaining in the care of parents;

c)

unless, in an exceptional case, a care order is necessary for the protection of the child, some other means of providing support and services must be used.”

It requires to be emphasised that the President used the phrase “rare in the extreme” when contemplating a placement at home, with parents, under a Care Order. Here, however, I am considering a kinship placement, i.e. a placement in the wider family, as I have described. Both Mr Jones and Mr Goodwin submit that the strictures of Re JW do not apply because the plan is not for a child to be placed at home under a Care Order, but with extended family members. Broadly speaking, I agree, but I do consider that, by parity of analysis, the observations of the President in Re JW have some resonance, albeit less prescriptively.

In A and Others (Care Orders at Home) [2025] EWCA Civ 901, Baker LJ took the opportunity to review the respective roles of the Court and Local Authority when making orders. He described the case law as having given the matter “anxious consideration”, including Re S (Minors) (Care Order: Implementation of Care Plan); Re W (Minors) (Care Order: Adequacy of Care Plan) [2002] UKHL 10; Re W (Care Proceedings: Function of Court and Local Authority) [2013] EWCA Civ 1227; Re T (A Child) (Care Proceedings: Court’s Function) [2018] EWCA Civ 650; and Re T-S (Children) [2019] EWCA Civ 742. The case law identifies distinct and separate functions falling on each. The type of order which is to be made is, ultimately, the exclusive responsibility of the Court. In coming to that conclusion, the Court is required to consider the Local Authority’s care plan, as I have done here. That plan is prepared pursuant to s.31(3A), CA1989. No order may be made with respect to a child until the Court has considered the plan.

In a succinct submission, Mr Jones says: “This is an extremely unusual case. The facts involve a head injury, salt poisoning and a complex and harmful family environment in which the parents are effectively being exploited and manipulated by the maternal grandfather”. He points out, as I too have emphasised above, that this is intended to be a permanent placement in which reunification is not envisaged. We are not, therefore, Mr Jones argues, within the territory in which a Supervision Order might be a proportionate measure. I agree. Statutory Looked After Care (LAC) processes require the Local Authority to review R’s welfare and the scope for him to be cared for by his parents, but there is no plan for him to be moved. Mr Goodwin asked me to send a very clear message about that within this judgment. I do so.

The Guardian has carefully considered, as indeed has the Local Authority, whether a Special Guardianship Order (SGO) might be a more appropriate level of intervention. Her conclusion, which is expressed in firm terms, is that “now is not the time to make an SGO”. In particular, she considers that, in the immediate future, the placement will require to be assisted in “bedding down”, during which process “the authority” of the Local Authority will be necessary to send and reinforce the message that “interference by the maternal family” is unacceptable and will not be tolerated. She considers that there is limited prospect of any application to discharge the Care Order at any point soon. Mr Goodwin invites me to emphasise this too. I accept the point and endorse it.

Accordingly, what is planned for R is a permanent placement within the extended family in which there will be face-to-face contact six times a year with his mother and father. He will know them as his parents, living in his community, but they will not be undertaking the parenting role. The circumstances of his removal into care will be unfolded for him, incrementally and in changing language as he grows older. It will not be easy for him to understand, indeed a mother who poisons her baby with salt is not behaviour that many people can readily understand. It will be challenging for him and his carers. Added to all this, is an injury to the brain which may yet have consequences in the future, though as I have said, there is room for cautious optimism. Further, M’s volatile behaviour will probably recur at times of stress. In the background is the presence of the maternal grandfather, whose influence and control is malign and insidious.

I do not think that this placement should be categorised as “high risk”, largely because of the obvious empathy and skills of K and T, and the instinctive way in which they have claimed this child. They also have a familial impulse to protect him. That said, it would be facile to pretend that this is anything other than a placement which is going to require ongoing input and support from the Local Authority into the foreseeable future, and, perhaps at times, at an intense level. The level of risk generated by contact and by the maternal family generally, may cause peaks of increased risk as well as troughs of calm. This requires vigilance. I have wondered, on a number of occasions, whether a plan of this nature, against this factual backdrop and matrix of risk, would have been advanced even a decade ago.

As I have indicated already, I have no doubt that, with the support contemplated by this carefully thought through and progressive care plan, this is entirely the right placement for R. There could be no better. It balances all those features of risk which I have concentrated on above with the immeasurable advantage to R of remaining with his family, his culture, his traditions, all of which will reinforce his identity and hopefully, self-confidence. It also retains his father in his life, and, as previously noted, both F and R each take delight in the company of the other. There remains, however, much work still to do. The phrase “bedding in”, used by the Guardian, probably rather understates the challenge of the task ahead.

In my judgement, nothing less than a Care Order is required in this case. It is entirely integral to the effective operation of the care plan; it might even be argued that the plan would not be viable without it. It may be that the Local Authority might have to act swiftly to protect R and, in such circumstances, that will be made immeasurably more effective by the fact that they continue to share parental responsibility. As it happens, therefore, even if I were required to apply the full force of the strictures in Re JW to my analysis of the appropriate order in this extended family placement, I would have little difficulty in concluding that this was “an exceptional case”, requiring the full rigour of a Care Order.