“B has a diagnosis of autism, sensory processing disorder and speech and language delay. B has no concept of danger and can be a clumsy child. I’ve noticed within the last few weeks he seems to be getting bruises on his legs and other areas very easily after a small bump and some bruises without injury which is causing me concern.”
“I was not aware that G had 2 subdural haematomas until the CP medical was sent to my legal representative. She has never presented with any symptoms. I do not recall any event, accident or time that G would have hurt her head. The only time that I can think of was when B threw his iPad and it accidently hit G on the side of her forehead. G was in her bouncy chair and my uncle and cousin were present. B does not have spatial awareness and threw out of nowhere the iPad which hit the right side of her face above the eyebrow before the hairline. G cried initially but nothing extensive, I knew that she was ok because she did not seem fazed by it. She was not sleepy nor distressed. There was no mark left either so I did not feel medical attention was needed. This occurred around July/August 2024.”
“They have been seen in Clinic with the Foster Carer and it is clear that both children still have bruises which are being body mapped regularly by the Foster Carer and Nursery. This is despite being in different circumstances to before. There is sufficient evidence that B and G bruise disproportionately when they have had witnessed injuries. There is a genetically identified abnormality in one of the clotting factors present in both B and G. They are likely to bruise at a lower level than other children.”
“I am not aware that the court considered it necessary to address material omissions in light of the applications for permission to appeal that it refused. I am similarly unclear on the basis on which the court is now seeking to make additions to the judgment (although there are of course circumstances in which clarificatory addenda may be appropriate). In the circumstances, please could the court ensure that any additions to the transcript of judgment are clearly marked e.g. by the addition of an addendum paragraph rather than changes to the body of the judgment which the court gave.”
“B has a diagnosis of autistic spectrum disorder. There are references to his increased activity and a tendency to injure himself from parents and professionals. Hyperactive/very active children often injure themselves more than others.”
“Resolution of significant bruising seen on 13.09.24 when re-examined on 29.09.24 in grandmother’s care is significant. Where inflicted injury is suspected substitution with sensitive care is usually followed by a resolution of bruising. This remains a strong indicator for previously inflicted injury.”
“A sentinel (minor) injury is one that is associated with severe physical abuse in infants.”
“There was no history of encephalopathy with no retinal haemorrhages. In the absence of a medical cause, findings indicate a likely shaking acceleration/deceleration injury. Following head trauma the point of deterioration is most likely to be close to the point of injury. No such history is provided. The force exerted would have been in excess of normal or rough handling. The perpetrator would have been aware of this. For some infants, symptoms of encephalopathy may be mild and resolve rapidly.”
“Genetic testing confirms a single heterozygous variant in the Factor V gene that is likely to explain reduced levels of Factor V. Severe Factor V deficiency would be expected if a variant was found in both copies of the gene. In addition, genetic testing has demonstrated a heterozygous pathogenic variant in the HPS1 gene. If both copies of the gene were affected this would be expected to lead to Hermansky Pudlak disorder, which can be associated with abnormal platelet function. Impedance platelet function testing in [the child] was normal. It is likely that [he/she] is a carrier of HPS1 but she does not appear to be affected. In light of [his/her] ongoing bruising with minor trauma, the borderline Factor V level and the additional genetic findings, it is possible that [he/she] has a tendency to bruising with minor or no trauma.”
“The Factor V level could have been significantly lower at the time she presented with her intracranial bleed when she was much younger.”
“Variants of uncertain significance are genetic changes that are present in genes of interest but have not previously been described as causing clinical problems Factor V is one of the proteins involved in the coagulation cascade, important for normal blood clotting. This change explains B and G’s low FV levels. We can tell from our functional tests that the Factor V levels are not low enough to explain spontaneous bleeding in isolation but it is possible that this along with the HPS1 carrier status has a combined effect that has made B and G more likely to bruise or bleed with minor injuries. Over the time we have known B and G, we have noted their tendency to bruise very easily and this has persisted in each of the settings where they are looked after (foster carer, nursery, supervised visits with mum and dad). On this basis, I have updated my report for the safeguarding investigation to say that we cannot be sure G’s intracranial bleeding and B and G’s bruising could not be explained by these results.”
“The blood clotting investigations to date have identified a mild reduction in factor V but not a definitive blood clotting disorder that could cause bruising or likely to increase the risk of bruising. Not all blood clotting disorders have been tested for and therefore these disorders have not been diagnosed or excluded.”
“The gene studies have identified 2 findings in both children. 1. Both B and G have a variant of uncertain significance in the factor V gene. This means that the gene is not the standard common gene for factor V that is seen in the majority of the human population. We all have many variances in our genes. It is what makes us individuals and unique. Some variances (differences) in genes can cause disease and are pathological. Some differences do not cause disease and are not pathological. The difference or variance found in B and G is of uncertain significance. This means that the pathological significance of this gene is not known as there is insufficient data in the literature. It is possible that this is a variant that causes slightly lower factor V levels but no bleeding problems. It is possible that this variant causes a mild factor V deficiency and an increased risk of bruising and bleeding. 2. In addition, both B and G have been found to have another gene abnormality in that they have one abnormal copy of a gene called HPS1. B and G both have one abnormal gene and one normal gene. This is considered to be a carrier state and not a disease. If both genes were abnormal this causes a disease called Hermansky Pudlak Syndrome. In Hermansky Pudlak syndrome with both genes abnormal there is a mild to moderate bleeding disorder. This is very rare. Hermansky Pudlak is a form of platelet storage pool disease. In the disease state it would be expected that platelet aggregation testing would be abnormal and the definitive testing of platelet nucleotide release would be abnormal. The platelet aggregation testing and platelet nucleotide release in B and G are both normal. I consider taking all information together of results of the HPS1 gene test showing a single gene abnormality and the normal platelet aggregation testing and nucleotide release assay that this is most likely not to be of relevance. This is not certain. It is possible that the carrier state gives a mild weakness of platelet cell function. I would state that with the information as is current that ‘on the balance of probabilities’ the single copy of abnormal HPS1 gene, with normal platelet aggregation and normal platelet nucleotide release in B and G is not of significance and is not causative or contributory in the bruising or bleeding diagnosed.”
“The levels of factor V slightly below the reference range and the finding of a single F5 variant of uncertain significance (VUS) gives some uncertainty in this case. As stated, it is possible that this gene is a variant that causes slightly lower factor V levels but no bleeding problems. It is possible that this variant causes a mild factor V deficiency and an increased risk of bruising and bleeding. As the levels of factor V are very mildly reduced I consider that with the information as current and ‘on the balance of probabilities’ this is a safe level of factor V and probably not causative or contributory to the bleeding diagnosed. Given the uncertainty, I consider it reasonable both for clinical management and this court case that further investigation is performed. The children do not need further testing. It would be very useful to understand the significance of these genes by testing initially both parents and then potentially further family members. For example, if the parents or other family members are identified to have either of these genes then their own personal bleeding history and in particular any lack of bleeding history such as having surgical procedures with no issues would be very relevant.”
“It is therefore unlikely that there will be a described co-inheritance case of factor V deficiency and Hermansky Pudlak syndrome and extremely unlikely to have sufficient cases to draw conclusions in terms of co-inheritance of disease. Co inheriting the carrier status of factor V deficiency and HPS1 will be more common but will still be very rare. I have not seen cases described of co-inheritance of the carrier status in the literature.”
“My view is that it is possible that the combination of the 2 traits (heterozygous factor V variant of uncertain significance and HPS1 carrier state) that on their own are not likely to cause and bleeding or bruising problems may cause bleeding or bruising problems in combination. The issue for the court is how likely this is. As previously stated this case is complex from the haematological perspective and there is uncertainty. With ongoing bruising in both children in different environments of nursery and foster parents it does seem that these children are experiencing bruising more than usual. We cannot be certain with the current information of the subdural bleeding in G. Subdural bleeding usually takes a significant injury or a severe abnormality of blood clotting to be present to have a spontaneous bleed. No evidence of further subdural bleeding in either child is evidence that there was a significant traumatic event that caused the diagnosed subdural bleed. It is my view that while the combination of mildly low factor V levels and a carrier state for HPS1 with normal laboratory platelet function could possibly cause a spontaneous subdural bleed on the balance of probability I consider they have not. On the balance of probability I consider it probable i.e more than 50% than trauma was the cause rather than a spontaneous bleed with no trauma caused by only the haematological findings.”
“There are intermediate density subdural collections seen over both frontal lobes. These contain some areas of higher density in keeping with fresh (re-)bleeding seen within them, although these may represent thrombosed veins. Looking posteriorly in the midline are smaller collections that are almost isodense to the brain, likely representing subdural collections also.”
“… there is no appreciable difference in size in the subdural collections. MRI scanning does show that these are mostly proteinaceous fluid within the subdural collections, but there are membranes that can be seen, indicating that they are chronic subdural haematomas. The posteriorly placed bilateral subdural collections seen up at the vertex can still be seen and are not changed in size. There are a few smaller findings that are either veins or membranes in these areas. I cannot convincingly see clear evidence of connection between the posterior vertex and the frontal collections, but regardless, there may a level of communication since they are in the same space. The posterior fossa and upper spine appear normal with no evidence of bleeding or injury that I can see within them.”
“The earliest mechanism by dating is birth. The studies that have that have looked at what is actually only a small number of the total number of births that take place, would suggest that elective caesarean section carries with it the lowest risk of asymptomatic subdural bleeding [he referred to three research papers commonly cited, called respectively the Whitby, Looney and Rooks papers, which he appended to the report]. In those babies that have had such, they would be expected in to reabsorb by one month old, and all to reabsorb by approximately three months old. However, one we note the small sample size, it is not safe to discount the possibility of birth related subdural occurring and remaining. It must be a very rare event overall given the lack of experience of this – I have had 2 clinical cases where I am convinced there was a high likelihood of such in 22 years as a consultant. The locations of these bleeds in G are seemingly separate – so this would in my view seem even more unlikely to be an explanation (as opposed to if there was just one area with a subdural collection).”
“I would defer [to] the other two experts in these regards but there seems to be none at the moment. The lack of any clinical ‘encephalopathy’ or radiological brain injury would, however, be in keeping with such an explanation, were one to be found.”
“The last option is a non-accidental injury. Impact trauma would be a rather unlikely cause of these collections, given the symmetrical nature of the bleeds seen and the interhemispheric locations posteriorly – I cannot exclude it but would not favour it. However, these would be in keeping with a shaking injury. This would be the sort of mechanism that may be associated with a period of brain dysfunction also …. Shaking injuries can be associated with mild brain dysfunction or sometimes none at all, and they can occur on multiple occasions … The forming of membranes (which only needs the original subdural bleed to occur previously) would then rebleeding to occur without any further traumatic events and can be associated with normal handling. Therefore, the findings, if caused by a shaking event, may have only been caused by one event. The finding of multiple ages of blood completely confounds any ability to date from the radiology. There are no brain injuries that allow me to date any further either radiologically or from the clinical history.”
“While I understand that this may not be associated with spontaneous bleeding, it does raise the question of whether events that are within normal handling or perhaps not memorable to carers, may have provided sufficient energy to cause a traumatic bleed, although not a significant trauma. I also raise the question about the episode or episodes involving the iPad and whether this level of trauma in a child with a predisposition to bleeding or similar may have been sufficient to explain some of the subdural bleeding, or indeed the initial onset of such.”
“Assessing the risks of instrumented elective caesarean section is difficult from the literature to assess regarding subdural bleeding. There is evidence to suggest that elective caesarean section overall is related to the lowest risk of asymptomatic subdural bleeding. However, alongside this, is a clear suggestion, sometimes within the same papers, that instrumentation increases the risks regardless of mode of delivery. Therefore, the combination of these makes it difficult for me to give a clear sense of direction other than it is likely that even if an elective caesarean section has the lowest risk, the addition of forceps would increase this risk by some level. And therefore, perhaps it would be reasonable for me to "sit on the fence" and say there is to my understanding certainly a risk of subdural bleeding after forceps through a caesarean section. And of course this needs to be put alongside a potential increased bleeding tendency. I will also note that there is no available history of an encephalopathy within the notes in keeping with a previous postnatal trauma. I am now less clear whether the combination of genetic changes in G may have put in place a risk of bleeding from events that are either minor enough to not have been noticed, especially if several occurred of differing types, or of the sort reported by parents.”
“In the event, experts, whilst noting the blood disorder, particularly Dr Robinson, who had the role of drawing the various strands together in a paediatric overview, felt it was more likely than not that B’s and G’s injuries, each of them, that it was more likely than not that they were non-accidental injuries, even taking into account any blood disorder, and that the injuries were non-accidental injury.”
“The parents say, and I stress they do not have to prove anything, but their evidence is important both on paper and in the witness box and should be considered, but they say this – and I summarise this – each one says ‘I wouldn’t do that. I would ask for help if there was a problem. If I had done something, I would tell. Moreover, knowing the other parent as I do, I cannot imagine he or she would do anything like that’.”
“neither medical nor non-medical evidence has precedence. Credibility assessments and proper exposition of the evidential canvas are central, and I have to be realistic but at the same time careful not to be selective.”
“I take the view that the burden of proof as it should be, lies with the local authority; and what I have heard on the evidence I take the view and I find that it is insufficient to make a finding on that particular injury.”
“In respect of the other injuries which I will come to in turn, the local authority case is not based simply on frequency of bruising but rather the ‘disproportionality’ of the bruising, compared to other periods – disproportionality based primarily on location of the relevant bruise/injury and lack of explanation for it/them.”
“I appreciate that the parents do not have to prove anything, but as an explanation I am finding that difficulty lies within it. If it happened before and it did not result in a bruise in the past, then I am finding it difficult to understand why the parents are saying that rolling on to the dummy would have been a cause of the bruise on this occasion. So, why do they think it was the cause of the bruise on this occasion?”
“114. He said that a bleed from birth was extremely rare and he went further: the location of the bleeds frontal as opposed to birth bleeds or posterior. He then referred to the nuances and specifics for G and said that there was a slightly higher chance that it related to birth. 115. He is later saying that if there were no concerns about the ability to clot then he would be fairly hawkish, saying that it was not birth related, but he could not exclude it. And he said if there was no clinically relevant bleeding disorder, then the birth related bleed would be exceptionally rare. If she had a disorder, then the chances would be elevated above exceptionally rare, but if a minimal increase in bleeding risk, it probably remains exceptionally rare. If there was a substantial risk, then it becomes more realistic, fifty per cent chance or more, but then indicated that that was not his understanding from the summary of the evidence.”
“there are two blood disorders, and the question is the effect not simply of each one separately, but in combination. And as I understand it both are relatively rare …. And it is common ground that the combination of the two blood disorders is completely uncharted territory.”
“The carrier status might give a mild weakness of platelet cell function so should look at the clinical picture on the ground. But if there is no history of easy bruising then very unlikely that HPS1 was relevant.”
“130. Under cross-examination on behalf of the mother, Dr Keenan was asked about the uncharted territory, the “unknown unknown”, and he said that even if the combination did create a bleeding clotting disorder, it would make a minor difference to the risk of bruising and would not cause spontaneous bleeding. He accepted he had only seen one significant Factor V case, but on that case it did produce unusual bruising; but nevertheless pointed out that he only has experience of one Factor V case. 131. Each and every expert and each and every professional from their different perspectives accepted that the rare disorder taken singly, was something of an unknown quantity, and in combination there was no research at all. All accepted, and that included Dr Dickens, that you look at the clinical position on the ground to see if there was a disproportionate pattern of bruising because blood disorders, as they said, do not come and go.”
“He said neither child had a pattern of disproportionate bruising. It was normal knocks and scrapes and the bruising was explained. He had not considered that the bruising had required medical attention, but also said that he logged only the large bruises; and the point has been taken up on behalf of the parents, to say that that is not a proper log and if you are looking for a pattern or checking for a pattern you look at it all, and you should undertake a proper analysis of all the bruises and you do not effectively just pick and choose, either based on size or possibly on location. I note that point. And they say that it is a point well made, and in fact better made, because Dr Dickens’ evidence is that on her appointment on 28 August she had a clear view that the foster carers were saying that the bruising had continued in their care and, as I understand it, she saw bruising and she considered from that that both children bruised more easily.”
“but I am unclear on the basis for this. She saw bruising on that day I understand, but there is no body map, no history, nothing to say whether they were explained or unexplained; nor the location; nor the size of what she saw; it seems the frequency was based on, what she says were the foster carer’s comments.. She has not analysed the full period”
“I am grateful for the chronology which has been provided on behalf of the parents which sets out the bruising and the timings of the bruising and the dates …. But of course the analysis of the full period was done by Dr Robinson. He considered the logs of the foster carers and saw no pattern of disproportionate bruising. He accepted that there was one bruise which was unexplained on B to the left posterior thigh, but considered that one bruise did not make a pattern. On the other side, the parents say that because of the flawed logging by … the foster carer, that means, virtually by definition that it will be a flawed analysis by Dr Robinson. So, that is B.”
“I asked the father about the bruising when the children were in foster care. He said that ‘he did not think there was an increase in bruising but still large amount of bruising. About the same number as before the increased bruising’ (i.e. before September 24). ‘It was the same number as for the vast majority of his life. The appearance no different. As to etc it was not unusual in foster care.’”
“These were well loved children and, it has to be said, very visible children. These were not children who were hidden away from health visitors or nursery or any of the like.”
“on the flip side that notwithstanding the existence of those risk factors, that on the whole they had been able to weather those particular problems. But there were underlying problems, notably within the relationships. There were violent episodes and that is accepted by the parents ….”
“I know that the local authority points to the interviews and say that the parties lied. I am not sure I would put it that way. It is rather that either they did not recognise it as a problem or at least the depth of the problem or rather more that having heard them in the witness box they just did not want to go there, and bottled it up. It is not so much that they were lying in the sense that that they knew the truth and consciously tried to conceal it; it’s a bit more subtle than that – it is rather more that they were dishonest with themselves, that they minimised their own problems.”
“Neither would or could contemplate that inflicted [sic] or could have been inflicted. They just did not want to go there. For most of the relationship they worked well both separately and as a team. With B they noticed a problem in his behaviour developing and they moved fast and early and did something. In respect of the bruising the mother moved fast and early and did something. She made an appointment with the GP. The exception is the bruise to G, the rib which nobody seems to have noticed or thought was particularly significant.”
“it is one thing to have a stressful job when all is well at home; but stress at work and then stress at home, there is no respite, and that is an entirely different matter …. From what was said in the witness box it was unclear how much the father was at home and the amount of to-ing and fro-ing under the domestic roof. But it seems to me that when I heard their evidence it seems that when they were under the same roof they were not really speaking, and that you could on occasions cut the atmosphere with a knife.”
“164. Taking all the matters together – the atmosphere in the home; the unusual pattern of bruising not seen, I find, before or since the pattern noticed by the mother at roughly the beginning the of September; the subdural haematoma, with no explanation and unlikely to be caused at birth because of the time since birth and because of the location and indeed the time since the birth; the bruise to G’s rib, which is one off, so a bleedings disorder resulting in a general pattern of odd bruising being unlikely; the expert opinion and analysis placing unlikely event or explanation on top of unlikely explanation; and I do not think that the haematology assists the parents when I consider the pattern of bruising over time including when events occur but with no bruising (e.g. G being hit with a tablet). Blood disorders do not come and go. Thus I have considered that possibility of unknown cause and I cannot see that I can make that finding. 165. To summarise – I find that the bruises to B, three of them (but Dr Robinson was equivocal about one, and I give the benefit of the doubt to the parents on that) but three of them I find were non-accidental injuries, but also the subdural haemorrhage also not only non-accidental injury but likely to be a shaking injury; the bruise to the rib was unlikely to be caused by the dummy clip and so inflicted. It was all caused during a period of high tension within the family home and you might say it was something of a perfect storm, and I make those findings of non-accidental injury. 166. In all probability on a balance of probabilities it is more likely that the injuries were caused by one parent. It is right that the father has flashes of anger and can be violent – not as I say a daily diet, but there are those flashes; and I also note his conduct in the hospital which caused a bystander to express their concerns. 167. It is right that the mother took B to the GP as soon as she felt concerned, and it is said why would she do that if she inflicted the injuries? But equally there is no suggestion or evidence that the father stood in the way of that. Similarly, the hospital, both were surprised at the existence of the subdural, as they said to me. But to balance, primary care fell to the mother; so the circumstances were more open to her than for the father and as I understand it in the main when the father was present so was she. She had a high level of resentment for the lack of support and her frustration it has to be said was palpable – perhaps not unreasonably so, but nevertheless I observe that it was there. 168. It is not clear to me the timeline about the father and when he was moving in and out, but I do not think that the mother moved out. She appears to have been on hand when the father was there and even with the benefit of hindsight there is no suggestion or evidence that the bruising occurred when she was not there or even coincidentally when the father was. And both were adamant that the other would not do it. I cannot say that one is more likely to have inflicted the injuries than the other.”
“I do not find that there was a failure to protect. There was of course violence in the relationship, but that does not mean that either party should consider that if there was bruising or injury to the child that it would necessarily flow from that on a balance of probabilities that the father had caused it. That does not mean that the violence within the relationship is not insignificant, and I agree with the guardian that it does need work, but that is not the same thing as linking it to a failure to protect.”
“It is right that in September these children were halfway home and the local authority were considering the risks and considering that they could manage the risks, and of course it has now crystallised into findings and they are serious findings of serious injuries; but nevertheless it is also right that it does not take much to recognise the tensions in the home at that particular time; it is also clear that in general the parenting appears to have been good and if at all possible I would want the local authority to see if there is a route for these children to go back home, and I would want that to be considered and see whether it can be managed.”
“The last two processes – evaluation and explanation – are the critical elements of any judgment. As the culmination of a process of reasoning, they tend to come at the end, but they are the engine that drives the decision, and as such they need the most attention. A judgment that is weighed down with superfluous citation of authority or lengthy recitation of inessential evidence at the expense of this essential reasoning may well be flawed. At the same time, a judgment that does not fairly set out a party's case and give adequate reasons for rejecting it is bound to be vulnerable.”
“I stress they do not have to prove anything, but their evidence is important both on paper and in the witness box”
“In a case where the medical evidence is to the effect that the likely cause is non-accidental and thus human agency, a court can reach a finding on the totality of the evidence either (a) that on the balance of probability an injury has a natural cause, or is not a non-accidental injury, or (b) that a local authority has not established the existence of the threshold to the civil standard of proof … The other side of the coin is that in a case where the medical evidence is that there is nothing diagnostic of a non-accidental injury or human agency and the clinical observations of the child, although consistent with non-accidental injury or human agency, are the type asserted is more usually associated with accidental injury or infection, a court can reach a finding on the totality of the evidence that, on the balance of probability there has been a non-accidental injury or human agency as asserted and the threshold is established.”
“Over the time we have known B and G, we have noted their tendency to bruise very easily and this has persisted in each of the settings where they are looked after (foster carer, nursery, supervised visits with mum and dad).”