Re AB (A Child: Diabetic Care) [2023] EWFC 149

‘Generally, AB now presents as a settled, stable, happy and sociable boy and the Local Authority has no concerns whatsoever for AB and the care that AB is receiving since he has been in his Father’s care.’

‘The mother said that she did not want insulin to be given intravenously if that could be avoided. There was no time when the mother was seeking more invasive treatment. When I was saying that the mother did not want IV treatment I was not saying she was being obstructive, simply she did not want it. She was co-operative, open to advice and plainly concerned for AB’s welfare. She was anxious to protect him against unnecessary medical intervention and was displaying anxiety about the effect of ‘all this’ on her son. She was also saying that she was anxious about how unstable his blood sugar levels were. A lot of parents are anxious when a child is diagnosed’. ii) Dr B said: ‘I remember how she talked about her son and her anxiety about what he was going through and the lack of explanation which she found upsetting and frustrating. I had no sense that the mother was enjoying the attention of being on the ward. At times she appeared exceptionally patient – prepared to stay for as long as it took. Paediatric care can be overwhelming for the parent. At times, I note, the medical records say she was overwhelmed’. iii) Headteacher of AB’s school said: ‘There was a collaborative relationship between the mother and the school. The Mother was wanting to work with the school to address the problems. The mother was keen that AB should be stabilised [C66]. He did not like injections but he was a stoical little boy. He was a good communicator and kept the school informed about what was going on. I am not suggesting that she was difficult or obstructive – anyone who read my statement as suggesting that would be wrong. She was very concerned that he did the best that he could at school. She was collaborative with the school, as was her mother. If someone suggested that I was suggesting that the mother was attention seeking, they would be wrong… The mother and AB have a very, very unique bond, a special bond. Ms W (works in the school) would say the same. They were very close. AB was really distressed when they were separated. His dream is to live with mum and visit dad. He misses his mum. AB liked adult company. He was very chatty and sociable and continues to be. AB is definitely very open about home life. He is an open boy’. iv) Nurse S said: ‘The mother engaged with me. I did not find her obstructive. She did contact us. We have a specialist line on which parents can contact us in hours and an out of hours number. When we have contact from our families, our aim is to stabilise blood sugars or answer parents’ enquiries. Our role is to give specialist standard advice, always tailored to that family. ...The mother contacted us as expected. We were unable to stabilise AB’s blood glucose levels and to avoid admissions. It was palpably clear that the mother wanted AB to be as healthy as possible and she wanted to do her best for him. She appeared to care deeply for him. Apart from the allegation of administering insulin there was no evidence of her mismanaging his regime. She was a younger mum and had a support network round her’. v) Nurse L said: a) ‘The mother was keen to work alongside me. I never felt that she wouldn’t call me if there was a concern. She made a habit of contacting me when she needed advice. I spent a lot of time calling her and I saw her frequently. I had no concerns about how she was with AB. It’s difficult to provide education when there is a young child to care for as well. I did not have any particular concerns – I would have noted them if I had. b) The Mother, like any parent, was knocked for six by the diagnosis and its implications grew. She took on everything that we taught her and carried it all out. She was absolutely very keen to get it right for AB. She was concerned that the school might not get it right and so we contacted the school quite frequently. c) She wanted to minimise for AB the implications of having injections and treatment. She rang me once when there were difficulties with injections and she wanted to know how to make it better. d) I did not form the view that she was trying to pump him full of as much insulin as possible. You often think: ‘what is going on?’, but then you do with diabetes. It’s a case of investigating why the blood sugar levels go up and down. In the early months of diabetes you do see levels going up and down – this was more than we usually see but this was a child who had periods of illness.’ vi) Dr A (psychologist) said: • ‘The mother never missed a session with me. She was engaging and engaged. I felt as though she was open to me. I would like to think that she formed a good therapeutic relationship with me. From the start she was using strategies that were really helpful with AB – a playful approach to explaining what diabetes is about. • My impression was that she was focused on making things better for AB. She discussed the effect of long hospitalisations on AB; that really worried her. She was very attuned in relation to the effect on AB of hospitalisation. • The mother was communicating to me her distress about the instability and uncertainty in his diabetes management. The view that I formed was that she wanted normality for him. • At no point did I feel that she was working against the nurses or being obstructive or disengaged. If I had picked up on any safeguarding concerns, I would have passed them on to other members of the team. I would be looking out for any signs that she was not working with the team. • I can’t tell you whether someone is being truthful but can say that her affect matched what she was saying. I can’t say whether insulin was given by the mother but I can say that when I had interactions with the family, I felt the engagement with me was appropriate and that there was a lot of love between the mother and AB.’ vii) When giving evidence about a discussion with the mother during the period of enhanced supervision (29th July to 24th August 2021) and in which the mother was informed of the suspicions of FII by proxy, Dr A said: ‘the mother responded very appropriately to this. It was a difficult meeting. She maintained her focus on AB. Nothing was ever said that made me think that the Mother wanted to hurt her son. Everything that I saw, made me think that she wanted to protect AB. I never formed the view that she did not care about the management of his diabetes. I did not think that I saw any attitude on her behalf – I thought that she was appropriately concerned about AB’s health. When times were tough for the Mother her responses for AB were entirely appropriate. She did not over-dramatize.’ viii) As Mr Goodwin QC and Ms Barrett submit in paragraph 9 of their closing submission: ‘In his oral evidence the father audibly laughed at the idea that the mother might want to hurt AB….when he was asked to confirm that it was terrible for the mother when AB was moved from her care, he spontaneously said ‘not just for the Mother, but for AB as well.’

‘in March and April 2021, he had water infections (UTIs), which I believe had an impact on the amount of insulin he required and how well I was able to manage his blood glucose levels. In April, he was also put on an insulin pump, which seemed to make him go really high, for reasons that I can’t explain, so he was taken off that on 13th May 2021. In June, he was put back on an insulin pump which again seemed to make him go sky high, for reasons that I can’t explain. It was also in June and July 2021, we had intense heatwaves (the hottest temperatures in the UK ever recorded) and during each heatwave, I noticed a very clear link between the heat and his multiple hypoglycaemic episodes. It was also during the June heatwave, that AB had his first ever symptomatic hypo. After he was put back on Novorapid and Lantus on 30th July, he has had regular but treatable highs and lows, aside from the difficult hypo on 3rd September 2021, which led to him being removed from my care. The admissions were not pleasant experiences; they were a combination of being exhausting, boring, stressful, distressing, lonely and isolating. For example, the nurses didn’t know how to do the correction doses on the insulin pump, so they would have to wake me up every two hours to do the doses whilst they watched. Being woken up every two hours for weeks on end is horrible, but aside from being tearful through sheer exhaustion, I never complained because I believed what I was doing was in the best interest of my son, who I love so much. I didn’t like being in hospital, in truth I hated it, but it had to be me with AB, as my mum worked, so could only help on the odd day here and there. The Father had work too so wasn’t able to help. I didn’t want to leave AB alone, so it would be me at the hospital, day and night helping with his care and making sure he was ok. I would sleep on a small pull-out bed next to him, on a noisy ward. It was noisy all of the time, even through the night. The nurses were loud, machines would be beeping, doors opening and shutting. It was awful.’

‘When AB was first diagnosed, I was invited to the hospital to have training – about 30 minutes. I was aware that AB needed to input the number that the machine calculated. I knew that the Mother was carb counting. The Mother could use a calculator. The Mother was more competent with injections than I was. As far as I was concerned, the Mother was not making mistakes. She could have been making mistakes but she tried her hardest. I did not tell the nurses that I was concerned about her ability with figures.’

‘In November AB was diagnosed with diabetes. I had an introductory session with the nurses. My mum came on the Friday or Monday for training. I think that it was one of those things where you get chucked into it and you get on with it. When AB was first diagnosed we did not do the carb counting – he was on a set dose of insulin. Carb counting came a few weeks in. We had to keep a food diary and my mum emailed the dietician. We did calculate carb but we did not put it into action to begin with. We had carbs and cals book for information to put into the meter. If AB was having a simple meal, sausage and waffle as he would have regularly…that was fine. However, it was more tricky when there were things like spaghetti and, for instance, you only had half a jar of Bolognese sauce and you then have to calculate it and I struggled with that. I would turn to my mum. I had my phone and calculator. I had to google how to do the carb counting manually on a calculator.’

‘numeracy is extremely important either for the calculation of short-acting doses or for interpreting the output from the calculations undertaken by the Smart Meter. Understanding the issues mother has with numbers would be important in this respect particularly her ability to adequately dial up/draw up insulin doses. Excess insulin administration could result from inaccurate carbohydrate counting where the meal carbohydrate content is overestimated, and consequently excess insulin is administered. This is harder to invoke as the cause of the July hypoglycaemic episodes which took place late evening and after the insulin infusion was switched off. There is the possibility that these episodes resulted from a bolus from an intravenous flush given at the end of the insulin sliding scale infusion (12). The Hospital has made the following comment. “It is the expectation that once an infusion stops, it is disconnected, and the cannula is flushed. Upon review of the documentation, we are unable to confirm with any certainty that this was done and therefore we cannot answer this question.” As argued earlier (page 12) this bolus alone would not explain the prolonged nature of the hypoglycaemia nor the plasma insulin concentrations of 9.7 and 160 mU/l that were detected. These values imply that additional exogenous insulin would need to have been administered.’

‘AB was started on Novorapid (ultra-short acting) insulin in doses of 2, 3 and 2.5 Units with breakfast, lunch, and dinner respectively with background insulin provided by the long-acting insulin Glargine, at 6 Units per day. The total daily dose was 13.5 Units or 0.8 Units/kg body weight/day. This is a high dose as the normal dose at diagnosis is 0.5 Units/kg/day, so it was not surprising that the dose needed to be reduced over subsequent days. The education and training provided was to a high standard. AB was over the age of 5 years so technically beyond the age of starting immediately on insulin pump therapy at diagnosis along with Continuous Glucose Monitoring.’

‘During AB’s initial admission following diagnosis of diabetes, he was commenced on insulin injections at mealtimes and at bedtime with the aim of maintaining blood glucose levels within or close to the normal range. His mother received training in the management of AB’s diabetes from the Diabetes Nursing Team and Dietician, together with support from the Clinical Psychologist. [The mother] demonstrated satisfactory understanding of diabetes and was assessed as competent in the day to day care of AB’s diabetes. Ongoing education and support has been provided by the diabetes multidisciplinary team and at no point has there been any concern that The mother lacked the knowledge or skills to safely manage AB’s diabetes.’

‘we have a checklist that we work through to assess competence and then we have a question and answer session, there are games that we play and scenarios that we discuss to check understanding [I3317]. The team would teach carbohydrate counting. The mother did not say to me that she was not able to calculate.’

‘In terms of the advice given to the mother, if AB is found to be unconscious what advice would she be given? She would be advised to give an emergency intramuscular injection but we would always ask them to call an ambulance. It would be expected that they would contact the diabetic team at some stage to review BSL and to suggest insulin changes. I would expect a call the next day.’

‘ The Mother appears to have an appropriate understanding of AB’s diabetes, the treatment plan and the care required to manage his diabetes. The Mother was able to use the expert blood glucose metre to obtain insulin doses and was competent in inserting the Libre sensor. When reviewing blood glucose levels with the Mother and advising changes, I would provide education, information and rationale for the changes I was advising to develop her knowledge.’

‘my interactions with mum, both on the telephone and on the ward, were to offer support and advice. I haven’t had any concerns during those interactions that Mum didn’t understand the diabetes care required.’

‘I discussed AB’s progress with the PDSN and the mother. I was present on each of the ward rounds and I also updated her some evenings after decisions had been made. As to the mother’s understanding about AB’s diabetes and treatment, I know from the PDSN that the mother had had adequate training and was deemed to have taken that training onboard. My assessment was the mother was able to understand diabetes management and to use what she had been taught to control the diabetes. As to the mother’s ability to calculate the treatment, I am unable to answer that question. We did discuss activities and foods and her answers seemed appropriate.’

‘From all the information contained in this assessment it is clear to me that AB is a loved and cherished grandson who is deeply missed…They both spoke confidently about managing his diabetes.’

‘When I first heard the allegation that the doctors thought the Mother had been injecting AB on purpose, I was absolutely devastated and knew it wasn’t true. Our lives have been absolutely shattered by the allegation. We know our daughter and we know she wouldn’t have done that. We can’t believe it. We know our daughter. There is no way that she went around injecting him, behind our backs without us ever noticing anything. I am absolutely devastated for AB more than everything; what he has been through is just awful…Trying to support the Mother since AB’s removal in September 2021, has been really hard. She doesn’t want to be here, not without AB. She is absolutely broken and devastated being without her child…She puts on a brave face but she needs to be able to let it out and she is able to do that with me, her dad and her brother. It is mostly sobbing to be honest.’

‘Just to let you know that The Father, the Mother and I have some concerns about AB’s bloods in school recently. When he went to contact with the Mother last Wednesday, his bloods were over 30. Also, last Thursday after lunch Mrs W informed us they were 26. In contrast, over the weekend his bloods have been very good which leads us to believe something is slightly off. Over the recent weeks, we have noticed that before and after breakfast club, AB’s bloods seem to be okay, they can be slightly high but nothing that would seriously concern us. Before lunch, they also seem to be okay but there seems to be a pattern of high bloods after lunch, we are unsure what to put this down to when his bloods are good over the weekends and evenings. We are concerned about the long term impacts of this on his health having Diabetes. We would really appreciate your expertise and guidance knowing AB so well.’

‘When he is not at school he is stable. Something is not quite working when he is at school. I cannot explain why that is. Maybe we need to have someone else give the medication. I cannot explain this at the moment’. ii) Nurse S also said: ‘I would expect a child to have 3-5 hypos a week as he has been having with the father. Unconscious hypos would be exceptionally rare. It is very, very unusual to have a child who has an unconscious hypo. He has had none in the care of the father. He has not required hospitalisation in the care of the father’. iii) Nurse G said: ‘AB’s diabetes management was initially as per normal. He had significantly high and low blood glucose levels such as I have not seen before. It was challenging from that point of view. The swings from high to low were more than we would expect.’

‘Hypos therefore do happen in this age group as it is quite difficult to match up the insulin with the food. It would be unusual for this to get to the level of unconsciousness but may be in high 2’s… Exercise can be a factor that leads to fluctuation. Pen accuracy is a problem – this is a mechanical issue with the device. When you get down to e.g. 0.5 the error on what can be delivered can be anything up to about 5%. That may not matter for an adolescent or adult, but when you get down to a child of AB’s age, that can be an important amount. Insulin dosing probably accounts for the problems in March; there had been a readjustment of his dosing and that was associated with hypos. Understanding numbers and decimal points is quite important. There has to be accuracy of carb counting. The more glucose that is in food, the more insulin you are likely to require. He would have needed one unit of insulin to 15 gms of carbohydrate. You have to be a bit circumspect with pens since the lowest you can give is 0.5 units. A parent dealing with food intake would have to use their judgment because the increments in a pen system are not that specific’

‘What does the court do about unrecorded errors?’

‘[what] you may have to realise is that the admission of children for diabetes is fairly rare and you would need to assure yourselves that the general nursing staff on the ward and, perhaps the medical staffing on the ward, were able to deal with children with diabetes. The expertise may not be there. I would like to think that we have become good at managing this and so the experience that this might occur on a ward where there are mistakes is less than it was 20 years ago. Introducing the technology of the pump means that there is a different game to injections. You have to know your way around the pump and I would hazard a guess that it would not necessarily be the case for all of the staff – for instance the error about the Lantus on 21st August 2021.’

‘After the review strategy meeting on 24th August 2021, AB was discharged home. The strategy meeting was held at 11am [I3471]. I was at the hospital during this period, with him under supervision. One of the recommendations made at that meeting was for any remaining insulin at home to be brought back into hospital. My dad brought to hospital a carrier bag of insulin at around 2:20pm and an inventory of what he handed in was written by paediatric diabetes specialist Nurse G [I3976]. The timing of this is relevant as I had not had the opportunity to go home and “syphon off” some of the insulin we had at home into a hiding place. AB was discharged from hospital with only certain prescribed insulins [I3544],Novorapid and Lantus as described on the discharge summary sheet [I3969].’

‘I have avoided drawing sweeping inferences because in the absence of hard data it is unsafe to do so. There are episodes of hypoglycaemia. Apart from the specific dates that I have alluded to, it could be that the hypos are the sort of things that happen on a day to day treatment of diabetes.’ ii) He was asked at the outset of Mr Goodwin’s cross examination about his overall opinion and he said: ‘I have been very cautious about reaching adverse conclusions to the mother without hard data.’

‘Other than the episodes that I have quoted the others lack sound biochemical evidence to support unauthorised exogenous administration’

‘The only problems about the measurement on 2nd August is that he was receiving Novorapid and that would not be measurable in the [local area] assay.’

‘As to 16th March, as a starting point, the plasma insulin readings that we have for the 16th do not demonstrate the presence of covertly administered insulin. I can’t say anything more than that – the insulin used was Novorapid that cannot be identified in the [local area] assay. There was insulin action, but I cannot say that there was insulin. There is something around but I can’t say more than that. There is nothing in the plasma reading…there is only evidence of insulin action on that day. That’s as far as it goes. We don’t have a lot of information about this date. My bottom line here is that I don’t think that there is enough to advise the court that there is evidence of covert administration on that date. There is insulin around but that may be appropriate. It is really difficult to know what is there because the way that the assay was working. We are so close to the minimum detection rate of the assay – a reading of 1.7 could be 0 - that we cannot rely on it to say that there was insulin around at all…there are no markers at all. We just do not know whether there was Novorapid around that day’

‘he had had such severe sepsis that part of his kidneys were damaged leaving scarring. His kidneys do not function entirely normally as a result; it is my understanding that one functions at 25% and the other at around 75%. He remains under the care of Professor C …at TheChildren’s Hospital. He had eczema quite badly, too…He had multiple ear infections…he also suffered from issues with croup…We also had issues with weaning AB as he wasn’t interested in solids for a long time. He was diagnosed as being allergic to formula (cow’s milk) at about 12 weeks…’

‘On the 16th July 2015 AB presented unwell with urinary tract infection. Bilateral vesico-ureteric reflux was noted and subsequent assessment revealed 75% of function from the right kidney and 25% from the left. There was and has not been subsequently any evidence of chronic kidney disease that would alter insulin metabolism.’

‘AB spent most of today near me after yesterday's incidents. Whenever he wasn't being closely supervised children were complaining that he was hurting them or spoiling their games. Sometimes the children are winding AB up and encouraging him to chase them but there are other times when his behaviour has been unprovoked. During lunchtime he punched J, who punched him back. Later in the afternoon he scribbled all over one of the girl's pictures with no reason. At the end of the day I spoke to Mum, she said that she was disappointed that AB had been refused behavioural support. Mum said that AB needed boundaries but she feels that she is doing it all on her own. I explained that he has rules and boundaries at school at that we will support her.’

‘I first met AB and the Mother with AB’s grandmother on the afternoon of 6 November 2020 to continue with the structured education teaching plan that we use for newly diagnosed children and families. As part of the training session I used scenarios to check knowledge and understanding of the subjects covered. We discussed ‘what is diabetes’, the need for insulin and good blood glucose control. [We discussed] Insulin injections (storage and action of insulin), insulin sights and rotation of sights, blood glucose checks (demonstration of the equipment and discussed blood glucose target range), hypoglycaemia (signs and symptoms, treatment, use of glucogel). [We had a] brief discussion regarding hyperglycaemia - when to check for ketones. Mum appeared confident to do the blood glucose checks and I encouraged her to practise giving the insulin injection over the weekend.’

‘I am unconscious or fitting…Give nothing by mouth. Place me in a recovery position. * Dial 999 and contact parents.’

‘there was a simple reason for the reading of 61 – he had been ill.’

‘I am glad that AB and his family have coped well with his new diagnosis so far. He is taking injections and the blood test well on board. …AB is growing well…the next appointment for AB will be in six weeks.’

‘I reviewed him along with his mother in my clinic on the 19th November 2020. AB was settling with his new diagnosis and his mother was administering night time insulin (long acting) and meal time insulin (short acting) based on what he eats (carbohydrate counting), which is standard practice in diabetes care.’

‘…bearing in mind that he has been acting differently and having accidents and wetting the bed at night, I think, if you are concerned, you should definitely get it checked by the GP. This could be a urine infection and is better checked than not.’

‘[AB] was reluctant to eat initially, especially whilst febrile but was feeling much better and looked brighter prior to discharge. A long discussion was had with mum about managing his intake and insulin whilst unwell and she was given general advice about sick day rules as per The Children’s Hospital guideline. Diabetic team to be made aware of admission – they will contact diabetic specialist nurses to liaise with family for further support after discharge.’

‘Up until March 2021 there were two admissions with high temperatures, but I would not view these as abnormal.’

‘AB has been generally well in himself since the last clinic visit…AB’s blood glucose is high post prandially after breakfast and I have suggested to increase insulin for his breakfast from 1 unit for 35g to 1 unit for 30g. His morning waking blood glucose is normal. It is likely that AB may need more insulin for evening time, but I have left it to be reviewed in a few weeks by the Diabetes Nurse Specialist. …His next appointment will be in three months.’

‘AB was again [i.e. after 19th November] reviewed in my clinic 3 months later on the 4th February 2021. Adjustments were made to his insulin doses based on his blood sugar level which is a standard practice of care. AB’s HbA1C (marker of average glucose levels for 2-3 months) had appropriately come down to 59 mmol/mol from 91 mmol/mol since the time of diagnosis. There were no concerns raised by any team members at this point. AB’s mother was interested in AB having a flash glucose monitoring system (Freestyle Libre - a sensor device that measures glucose levels constantly) which was subsequently arranged by the diabetes nursing team. AB’s blood tests at the time of diagnosis had shown the absence of diabetes antibodies (the presence of which is suggestive of type 1 diabetes whilst the absence does not exclude type I diabetes).’

‘when we did talk about school and AB’s learning and behaviour Mum said it was all down to him being poorly. Mum kept telling me that AB’s blood levels were high because he was stressed about the work. Mum showed me AB’s monitor, he has had several high peaks in his blood sugars Tuesday and Wednesday with levels above 20. She said that his levels were caused by his school work. I asked what support she has from the diabetic nurse and team; she said that, unless she contacts them they don’t call. She sends through his weekly readings. ….then she said that it doesn’t matter about carbs really as 2 units of insulin would do it. I asked her what she meant and she said that he could eat anything and we could give him two units of insulin and he would be OK. I told her we would not make that decision at school. She said that it was fine because Mrs W would phone and she’d say that the two units would be okay. I asked how managing AB’s diet was going. During our Zoom call AB was eating a large bag of crisps. Mum said it was fine, she thought they were doing well, I am concerned about the managing of AB’s diabetes. I haven’t seen his levels for a few months now but he wasn’t having spikes like that at school. I don’t know if we can or should contact the Diabetes nurse and ask how to manage AB.’

‘Following AB coming into school today and levels are still very up and down at 8:15 a.m. Mum has confirmed no insulin given as the levels will drop by themselves. At 10 a.m. levels 12.5.’

‘if you have any sort of infection your blood sugars can run high at the time that the body is fighting the infection.’

‘in early March the high levels were due to UTI. That would lead to AB being hyperglycaemic. But it also causes difficulties in managing insulin controls and leads to peaks and troughs as illness is not regular or constant’

‘thanks for sharing your concerns regarding the school’s current management of AB’s diabetes. It seems the main issue is training around the Libre 2. I have attached the Diabetes team’s advice sheet re Libre 2 for you to read. If there are any specific amendments that you would like the school to consider please let me know…I can tell the school…regarding his high BG levels, you were unsure if he has a virus, but you said that he doesn’t seem to be unwell. You and the school are concerned about high BG levels over the last 6 days. I look forward to receiving the ratios, once you check the meter. We can then make further changes to them if necessary.’

‘The diabetic nurse telephoned me back and I explained that we were concerned as AB levels were so high then low today. (Re: training November 2021 AB level @ 8.15 = 18.5, at 11.40 = 3.8, 1.00 pm. = 19.00) The nurse explained we should not worry about this - this is to be expected. The new device that has been fitted on AB’s arm would constantly monitor his levels. The nurse said the best way to describe it was it is like a person being in hospital and they are having two hourly checks, and the temp, blood pressure would ok however, if you wired the patient up to a monitor it would be a very different situation as in what we are seeing with AB different readings. We must remember if over 15 to make sure we check his Ketone levels.’

‘I guess that explains the high BG experiencing, at least you now have got to the bottom of it…his BG levels may naturally come down into the target range once the antibiotics start to work, so we may not need to alter ratios…I will try to make contact with the school today.’

‘AB was diagnosed with a UTI on 3rd March 2021. He had had raised blood glucose and ketones. I took him to hospital on 3rd March and again on 7th March as he still had the UTI and high blood glucose. It transpired he had been put on the wrong type of antibiotics on the 3rd March and he was given the correct type on 7th March. AB was discharged back home on the 8th March. During that admission, it was agreed by the doctors that AB’s “antibiotics may not be kicking in” so his “insulin requirements may be less” [I1587].’

‘I’m hanging I've been up for a week and a half straight.’

‘so fuck that, I’m giving him a correction dose’

‘two weeks of high blood sugars. Diagnosed with UTI two weeks ago…yesterday BMS were ‘unrecordably high’

‘On the 6th March 2021, AB was admitted with very high blood glucose levels (blood glucose levels>20 mmol/L). In the 2 weeks preceding the admission, AB reportedly had some symptoms suggestive of urinary tract infection and commenced on antibiotics by his GP. As AB’s blood glucose levels remained high, insulin doses were increased accordingly (Lantus increased from 3.5 to 6 units and meal time insulin (Novorapid) doses were also increased) during the course of his admission and he was discharged.’

‘18:26:00 …Mum gives 150ml milk before bed with no insulin mum advised to review this with use of the libre graphs. Mum anxious and responding lots to alarms on libre. Mum given some team libre arrows advice Mum advised to give less hypo treatment as was giving 3 wine gums - advised 2 based on ISPAD guidance 3g per 10kg body weight. Mum to call for review tomorrow morning with PDSNs please.’

‘Telephone with mum who reports that AB is ok today. Lantus 3.5 units given by mum last night (dose prior to hospital admission). Woke at 6.8 this am, hypo 2.9mmols 3 hrs post breakfast of 2.9mmols. 6.5mmols pre-lunch. mum will download libre and expert meter later and will call tomorrow. We discussed that we may need to reduce mealtime doses further. Mum happy with this information.’

‘So 3 weeks ago his sugar levels started to rise real bad he was high all day every day couldn't understand why I liaised with his team they changed his ratios to see if that worked then 2 weeks ago his alarm went off in the middle of the night to say it was high I tried to wake him but he wouldn't wake up I tried everything but he wouldn't move he was just lifeless so I called an ambulance and we've been here ever since that day hopefully get to go home today though :) be come off support after a week and he's been doing really well levels are starting to become stable…Turns out he had a urine infection nothing major you'd think but clearly it only takes a little infection to make him really ill.’

‘Why is she texting about calling an ambulance or being in hospital? Why is the mother being dishonest to M? These were private messages that the mother thought would never see the light of day. She sends these messages that are clearly lies and shows her ability to make things up. They are to do with medical issues.’

‘Other than in July I have not called an ambulance. I can’t remember who M is. I think that I had met him online. I can’t remember if AB’s alarm went off in the middle of the night at about this time…I can’t remember if I tried to wake AB up in the middle of the night at this time. I do not remember if he was lifeless or whether I called an ambulance in the middle of the night. I can’t remember this conversation. AB was not in hospital then.’

‘mum gave 1 gummy bear as per previous advice a few days ago because he was just about to eat 41g of cho. advised to go ahead and eat no insulin cover. BG 1 hour later was 9.8mmol Ketones 0.0. During this time Registrar was discussing a plan with Dr G. Plan was to give 2.5 units Lantus and 1:80g for tea. I advised I was unhappy with this and called Dr G directly. Discussed and advised I would give no more than 2 units Lantus maybe only 1.5 units. Advised tea eaten with no insulin cover but that I would call to review. Dr G advised he needed an admission Called mum to update and she was happy with this and will attend ED in the next hour. I have asked her to download the meter before she leaves. She can access it with her password. Plan from Dr G is to give 1.5 units Lantus tonight and 1:50g with breakfast tomorrow. PDSN to pick up in the morning. Congratulated mum on an amazing job overnight and today. Reassured her that this is unusual hence the review/admission to ED.’

‘AB’s admission from 10 March 2021 was due to a hypoglycaemic episode that occurred because of the mother’s failure to manage AB’s diabetic care and treatment, deliberately or without reasonable care.’

‘The admission in March 2021 followed dose adjustments for high blood glucose associated with a urine infection. Shortly after this AB presented with hypoglycaemia and this was recorded on both the Libre glucose sensor system and by blood glucose testing. Hypoglycaemia can be encountered at times during the first year following diagnosis. This usually results from ongoing insulin release from the remaining beta cells of the pancreas in response to high blood glucose. This endogenous release summates with any exogenous insulin administered leading to a greater glucose reducing effect than might be anticipated. There was certainly evidence of ongoing insulin action in terms of suppression of plasma fatty acids and 3-betahydroxybutyrate concentrations. Insulin had to be discontinued for periods of time which can occur during this phase of the disease process. The hypoglycaemia screens were unhelpful in terms of helping understand the cause. Plasma insulin concentrations were low on the screens of 16th and 18th March 2021 but we do not know what the insulin was likely to be as the [local area] assay would not be able to measure Novorapid or the long-acting insulin which is what AB was on. The Royal Surrey measurement on 18th March 2021 showed a concentration at the lower limit of detection for the assay which could be endogenous or exogenous. C-peptide was present in the 16th March screen suggesting some endogenous insulin production albeit not much although we would anticipate very little endogenous secretion below 4.4 mmol/l. Given the results available the diabetes team made appropriate adjustments to the insulin regimen.’

‘The following day there were two hypoglycaemic episodes at 02.20 and 09.00. C-Peptide was measured on samples drawn at 06.08 and was measurable at 265 pmol/l which is in the lower range of normality suggesting that any endogenous insulin being produced was regulated normally. A plasma cortisol concentration at 09.00 was 163 nmol/l which is low for that time of day.’

‘Overnight on the 14th March during an inpatient stay, AB required a continuous intravenous infusion of glucose over several hours to maintain a normal blood glucose level, although he had only received a very small dose of 1 unit of long acting insulin at bedtime.’

‘The next episode of hypoglycaemia took place on the morning of 16th March 2021 at 00.25 with two values recorded of 3.6 and 3.2 mmol/l. At this stage no insulin had been given for 24 hours to determine how AB would manage without insulin. At 03.03 with a near patient blood glucose of 2.8 mmol/l a hypoglycaemia screen was undertaken the results of which are shown in Table 1.’

‘I'm so fed up. Tired and drained. It’s like he goes from one extreme to the other. He come out if his hypo finally 2 But gone the other way and is now 31.2’

‘I was nervous about managing AB’s diabetes, given how unsettled it had been. His behaviour had been hard to manage because he was so bored and frustrated by [not] being at home and I had said how I felt I really needed a break….My Mum, thankfully, was able to cover for one night on 27th March 2021, so I got a night at home in my own bed.’

‘AB not managing to eat all his meals leading to hypo. I spoke to mother. Mother reports that AB’s meal yesterday had hardly any CHO (carbohydrate) and she sent it away for more CHO. Mum said that she has been giving him food from outside (purchased) or crisps to compensate…I re-iterated the importance of making sure that if he has not eaten his CHO, this is compensated. Mum understood this and said that she would compensate the missing CHO. I asked the mother to use her CHO counting skills to manage hits. I showed two menus (extra meal options) but mother said that the options were not something AB would eat. Plan: Ensure CHO intake in all meals. If not taken, give other CHO instead, such as yoghurt, toast etc.’

‘he had multiple hypoglycaemia screening blood tests however the results that have come back so far have not been concerning’

‘AB was again admitted on the 7th April 2021 with concerns about low blood sugar levels at home and difficulty in waking him to treat his low blood glucose levels. AB reportedly had his morning dose of long acting insulin (Levemir 0.5 units) on the morning of 6th April 2021. At 13.30 hrs his blood glucose levels was 23.2 mmol/L which then dropped to 3.6mmol/L at 15:15 hrs despite AB’s mother reportedly not giving him any meal time short acting insulin. AB was observed in the hospital for few days and during this period there were fluctuations with his blood sugars ranging from very low blood sugars to high blood sugar levels. During this admission he was also seen by multiple Endocrine and Diabetes consultant colleagues. The meal time NovoRapid Insulin was changed to Actrapid insulin (as this has slower onset of action than NovoRapid) on 9th of April 2021 and he was discharged on 13th April 2021.’

‘During April 2021 the hypoglycaemic episodes continued and were treated without any further evaluation. Pump therapy started at the end of April but was associated with high blood glucose values. These did not respond to the usual pump hyperglycaemia protocol and led to decompensation with polyuria and polydipsia. He responded to a high dose insulin sliding scale and then standard dosing with Actrapid and Insulatard short- and long-acting insulins.’

‘The further hypoglycaemic episodes in April were not evaluated any further but adjustments to the types of insulin used as well as a trial of insulin pump therapy were undertaken. These multiple insulin changes including technology changes might have been confusing particularly given mother’s problems with numeracy. How well she could cope with the low dose schedule using the pen system would need to be assessed particularly how easy would it be for her to confuse decimals and numbers. This is a particular issue with the pump where judgements on bolus amount need to be made using the decimal system.’

‘As there were concerns about low blood sugars, despite taking very small doses of insulin, a decision was made to put AB on an insulin pump which would enable insulin delivery at much smaller doses. The pump was commenced on 27th April 2021’

‘AB’s diabetes nurse, Nurse T, visited us at home on 27th April 2021 and a representative from Medtronic attended via a webcam to fit his insulin pump and teach me and my mum how to use it [I4358]. We were taught about basal rates, bolus rates, carb ratios and sick day rules. It was complicated but I felt I sort of understood what I needed to do. The type of insulin prescribed was changed to Novorapid. The data from the Medtronic insulin pump shows exactly what insulin AB received via the pump from 27th April to 6th May 2021, what carbs he had, what correction doses were given and what his blood glucose levels were [I2490 to I2509] [I2846]. In the days leading up to his next admission, I felt like I was managing the pump quite well as his levels were either in range or quite high. I spoke to Nurse T from the diabetes team who helped me work out new carb ratios in an attempt to bring his levels down [I4357]. There were also a few occasions when he wet himself but Nurse T advised to speak to the GP if that continued to occur and get a urine test carried out.’

‘The Medtronic pump was difficult and complicated. I had the training and even I found it complicated. I never changed the bit that went into his skin. I wouldn’t know how to do it so the Mother always did it. The needle would pull out a lot too and she would have to connect him back in. I had the training on how to use the pump, but I wouldn’t have been confident to use it by myself. I would have had to use my handwritten notes to work out how to use it; my notes had a step by step guide as otherwise I would have struggled. He wasn’t on the pump for long; he was on it then off it and back on it briefly. When he was on that pump, it just didn’t get on with him. Even the nurses in the hospital didn’t know how to use it, so would wake the Mother up to help. I was glad when he came off it. It was a huge amount of work…AB’s treatment plans changed frequently, sometimes on a weekly or even daily basis. They would adjust the ratios a lot verbally by telephone to the Mother. The Mother would quite often ask me about how to work the numbers out and I would explain it to her. It was a lot for her because it was changing all the time. It was hard for the Mother; she would ask “mum, how much is that add that?”. She never calculated figures in her head unless it was really simple.’

‘AB presented on 30th April 2021 with persistent high blood glucose levels. During the admission, AB required progressively higher doses which needed to be delivered via the pump due to his persistently elevated blood glucose levels. Even on a very high insulin dose (2.2 units/kg/day) and appropriate cannula changes, there was no real response noted with his high blood sugar levels. As AB's blood glucose levels remained very high with ongoing ketosis, he was then switched to intravenous Actrapid insulin on a sliding scale (continuous intravenous infusion of insulin which is adjusted depending on his blood glucose levels) to which AB's blood glucose levels responded and his ketones started to decrease.’

‘Between the 30th April and 19th May and again between the 4th and 10th July, AB received insulin by subcutaneous infusion using an insulin pump rather than by repeated subcutaneous injections. An insulin pump can be very useful in accurately delivering very small doses of insulin. On both occasions when AB was receiving insulin via an insulin pump, he experienced persistent raised blood glucose levels along with raised blood ketone levels which together indicated inadequate insulin delivery. No fault was found with AB’s insulin pump on either occasion when checked. Inadequate insulin delivery by his insulin pump continued whilst AB was a hospital inpatient. A sixfold increase in daily dose of insulin during insulin pump therapy failed to correct high blood glucose levels and as a result, AB was switched to an intravenous insulin infusion with rapid improvement in blood glucose and blood ketone levels. It is very difficult to explain the persistently raised blood glucose levels during insulin pump therapy despite much larger doses of insulin being administered. Careful observation did not identify any interference with insulin delivery from the insulin pump and these episodes therefore remain unexplained.’

‘I would like to say that I never felt judged by Nurse T and I feel that she explained things to me clearly and in a way I could follow. The doctors would come in and speak to me, but sometimes it was just like they were speaking gibberish and they would use words that I didn't understand. Nurse T didn't use medical terms and made sure I understood.’

‘The Actrapid was changed to Humulin S (rapid acting human insulin) from 19/5/21 as this comes in a pen and AB was discharged on 19th May 2021.’

‘I saw AB along with his mother in the diabetes clinic. AB was recently discharged from the hospital when he was admitted with episodes of hyperglycaemia and ketones not responding to high doses of Insulin delivered via subcutaneous insulin pump. Eventually his Insulin was then converted to human Insulin in the form of Humulin S and Insulatard. Ever since the Insulin formulation was changed there was a noticeable difference to his blood sugar pattern as noted in his Freestyle Libre 2. AB has hypoglycaemias 2 hours after his meals despite having Insulin free snacks a couple of hours after his main meals. I have reduced his Insulatard to 10 units and changed his ratios to 1 unit for 20 g for lunch and evening meal I am hoping that his hypoglycaemias might be better with this. AB is otherwise very well in himself. His HbA1c today is 84 mmol/mol. I will see AB again in three months.’

‘I think that it was the mother taking a deliberate decision to give him less because she did not think that he needed the full amount. I approve of what she did as long as we think that it is consistent with AB’s treatment. We respect the parent.’

‘After becoming AB’s named nurse, I became increasingly concerned that he may die as a result of his severe hypoglycaemic episodes. I was concerned for both his short and long term health, due to the continued unstable blood glucose levels and the unpredictability and unexplainable responses to clinical interventions for his diabetes management’

“my sons now a very brittle diabetic and we've just come out of hospital after spending 3 months straight in there”

‘This was not true. Further, at the time the message was written, AB had been out of hospital for over a week. The court is invited to find that the mother was exaggerating.’

‘I have spoken with Ms L and Mrs P about AB returning to school full time. We are concerned that AB's levels are still very erratic and that returning full time until he is stable could set his recovery back again. I know that you are concerned about the amount of time that he has missed but we need to have a proper conversation with you about AB's needs and maintenance before he returns full time. Please bring him for a half day Monday and we can arrange to have a proper meeting to discuss what happens next.’

‘AB fainted and collapsed by me on a bike ride.’

‘I don’t think that he was unconscious. I did not phone 999 because he ate the jelly babies. My brother said that his blood sugar was 1…something. The 1.3 came from my brother. I think that he scanned him.’

‘The only times I recall the Mother saying AB’s consciousness had been impacted during a hypo, was the time AB went out on his bike with her brother during a heatwave and once in her car. On the bike incident, the Mother told me that the brother said AB fell of his bike because he went unconscious. I can’t recall the specific word used to describe AB’s state but it was something that gave the impression that he had momentarily lost consciousness whilst on a bike ride. The Mother phoned me afterwards to tell me about the bad hypos and sent me a photo of him sat on the sofa looking clammy and pale. She said he had come up but that she had been really scared and worried. I reassured her by saying she had “done the right thing, you’ve got his levels back up, he is sat indoors and you’ve given him water”. I said to call the nurses if she was worried about him again.’

‘On Sunday 13th June AB was found [my emphasis] laying on the sofa and Mum could not rouse him for 60 seconds. His eyes were rolling. Mum shouted and shook him and he was rousable enough to eat jelly babies. His BSL was 1.3 at the time’

‘to get unconscious you are getting down to 2 – 2.6 mmols/l.’

‘I checked his bloods at 2:24pm (according to the Diasend finger prick log) and he was hypo with a reading of 2.3.’

‘Whilst we were in the reception area, he was a bit spaced out. Ms W, the receptionist, was also there (back then it was Ms W who was trained up to do his insulin). I had forgotten to pack jelly babies so my brother had to drive over and drop them off. We only lived 5 minutes away, so it didn’t take him long to get to us. At 9:03am, he was 6.4, which was within range. A mutual decision was made that AB should not be in school that day, so he came home with me.’

‘On 14th June 2021 the mother texted her brothers partner and reported: ‘his eyes were rolling to the back of his head. [The partner replied Fucking hell… mate do you think you should get him checked over. Did you end up speaking to the nurse today? ] …I tried ringing someone tried ringing back. I missed by a minute. Just had answer phone all fucking day.’

‘the mother did not speak to anyone in the diabetes team on the 14th, nor did she call an ambulance’

‘I had a telephone conversation with JM, diabetes nurse, on 15th June 2021 at 12:20pm [I4353]. I explained that AB was having moderate to severe hypos and how difficult the past few days had been. That discussion records that “Mum mentioned a few times that she didn’t want to be admitted to hospital and I have some concerns she is a managing AB at home during times when she might need to come to hospital due to fear of being admitted. I discussed this with Mum and asked that any time she can't wake AB, she must call 999 immediately” [I4353]…I agree that by then I had developed anxiety around returning to hospital as I knew at home, I had the support of my mum whereas in hospital, due to Covid, she was not permitted to stay and help. Saying this, it is clear from the number of hospital admissions and medical records, that I never prevented AB from going to hospital and always sought guidance from the diabetes team or at A & E when it seemed appropriate.’

‘T call to mum, prompted by Mum calling out of hours advise overnight. AB having multiple hypos. Mum describes these as moderate to severe. On Sunday 13th June AB was found laying on the sofa and Mum could not rouse him for approx. 60 seconds. His eyes were rolling. Mum shouted/shook him and he was then rousable enough to eat jelly babies. His BG was 1.3mmol at this time and continued to be low for some hours after. On Monday 14th June AB woke at 10.8 but was hypo at 3.8 on arrival at school. Mum reports his eyes were rolling back and he was lethargic but did consume jelly babies which took him up to 9.2, Shortly afterwards he was 3.8mmol again and had further mild hypos that evening. Today he woke at 9.7 but was 2.7 on arrival to school. Mum describes AB as not being rousable for some time with eyes rolling and slumped on mums shoulder. He then 'woke up' and was able to have some jelly babies. Discussed with Mum the use of glucogel and told her to keep on her at all times. Also discussed calling 999 if she is not able to rouse AB. Mum mentioned a few times that she didn’t want to be admitted to hospital and I have some concerns she is a managing AB at home during times when she might need to come to hospital due to fear of being admitted. I discussed this with Mum and asked that any time she can't wake AB, she must call 999 immediately. T call to school to clarify events that mum describes. Spoke with Mrs W who works in school office and was with AB and Mum during the hypos today and yesterday morning. She reports slightly different events than Mum. According to Mrs W, Mum walked through the gates yesterday saying AB had a BG level of 1.0. She appeared panicked and told staff she had already given him a sweet. G said he looked pale but was not asleep/unrousable. Mum told school staff that he had had a really bad hypo on Sunday and she couldn't wake him so she threw water on him. This morning on walking into school Mum told school staff that his levels were ok. School staff asked Mum to recheck and stay until this had been done. G reports that his level was 2 and he was acting quite 'peculiar' which G thought was mainly behavioural. She did not see him asleep/lethargic or eyes rolling. G report's mum was saying to AB "stay with me, stay with me" which she felt was unnecessary given how AB was looking but did state that she is not a nurse and could have mis-read what was happening. School are really concerned about having AB back. They feel his diabetes is not currently managed well enough for him to safely attend. I discussed with them that it would be totally normal for someone with type 1 diabetes to have 3-5 hypos a week and for these to be easily treated and for the child to be able to stay in school during this. I did agree that currently AB’s diabetes is very difficult to manage and that I will discuss this with his PDSN and consultant to see how we can better support AB and school. G wanted to know if AB will be back to school tomorrow and reported to feeling nervous about this. I thought that perhaps given he has had three days of potentially severe hypos he would be feeling tired and run down and that it would be good for him to recuperate at home tomorrow. Will call Mum to discuss.’

‘sorry babe, ABs back in hospital…Keeps going unconscious…and not breathing [C asks: Fuck me, that’s not good mate. Is it cus the heat?’] Don’t know as he’s in hypos when it happens. The mother was asked in evidence by reference to this text whether AB did keep going unconscious; she said that he was having ‘hypos and it was hard to rouse him. I don’t remember that there as a time when he stopped breathing…I don’t remember. I don’t know why I did not ring 999 that day.’

‘are you OK? What’s happened to AB? We just seen your status? Is he OK?’

‘he keeps going unconscious when going hypo which isn’t normal for him.’

‘ABs losing consciousness during hypos so his consultant was worried with everything that’s happened with AB as he’s not a normal diabetic….horrible to watch him go fine one minute and then blue the next.’’

‘I have used the wrong term. I should have said ‘drowsy’

‘We invite the court to draw the following points from an analysis of these three days in June. First, there is no evidence of a propensity to exaggerate to professionals. Second, there is no evidence that her messages led to or influenced unnecessary hospital assessment or treatment of AB. Third, at the very most, they demonstrate that the mother used the lability of AB’s presentation as an entrée to a conversation at a point in her life where she had little else to talk about. The transformation of these messages into material probative of FII is not made out.’

‘Having had sight of the medical records, I can see that the concern that “FII” might be an issue was first mentioned on 16th June 2021 [I2673]. No one asked me if I was deliberately giving AB insulin inappropriately. None of the doctors asked me if I might be implementing the treatment plans incorrectly. I find it upsetting to learn of this, because I know that I was genuinely doing my best to do it all properly. All I ever did is try to do my best for AB’

‘during that admission the insulin pump therapy was recommenced.’

‘AB just had a really scary episode. Think it even shook Dad and my brother up…he wouldn’t respond…I was shining lights in his eyes, pupils didn’t even move.’

‘AB was again admitted on 19th June 2021 with recurrent episodes of low blood glucose levels, some of which were as low as 1.7 mmol/L despite being on very small doses of insulin (1 unit of Insulatard and 1 unit of Actrapid with meals). Following this, his subcutaneous Insulin was stopped and then a decision was made to try to deliver insulin via an insulin pump containing Humulin S. AB was commenced on an insulin pump again on 22nd June 2021. After the start of the pump AB's did not have major hypoglycaemic episodes and was discharged home on 24/06/2021 and the blood glucose levels to be by the diabetes nurse specialist team.’

“I’ve been in a hospital for 4 months”

‘The cause for a rapid drop in blood sugar is the administering of too much insulin. Although there are concerns, there is no evidence of any sinister administration of insulin or deliberate interfering with the child’s insulin to manufacture symptoms. There are unexplained hypos with no detectable insulin. The concerns are that blood sugars are dropping from 15 to 2.2 on a fairly constant basis. The hypos resolve but then he returns with the same story. During the last few days in hospital, his blood sugars have been on the higher side. There have been lots of changes to medication, but the requests or instructions to mum are fairly complex and there are no concerns regarding mum’s level of understanding. Mum is fully engaging with appointments and is always available for telephone calls and answers appropriately. There is no community paediatrician currently involved with the family as a previous referral from their GP was rejected. Community paediatrics would be able to liaise with school and mum. School have witnessed AB going low quickly, usually at the beginning of the day and are concerned. School have previously had appropriate training. There has been no period of enhanced observation tool being used as he is on pump currently .’

‘I would have communicated this to the nursing and medical teams. People would have been having their eyes and ears open about something sinister going on. At no point did anyone suggest that they had seen the mother acting in any suspicious way that might have led to enquiries. This was a busy ward. With a patient such as AB nurses would have been coming to the bed regularly to carry out checks – depends on how ‘regular is regular’

‘I asked that Mum ensures she has glucogen injection, ample supply of ketone strips, glucogel hypo treatments as well as pen filled short and long acting insulin…Reinforced message that if Mum concerned about semi-conscious hypoglycaemia to call 999. If high blood glucose levels and ketones 0.6 or more, to call PDSN’s / out of hours service for advice.’

‘On occasions during the week commencing 26th June 2021, whilst on holiday in St Ives, AB’s mother allowed him to remain disconnected from his insulin pump for periods longer than those recommended by his diabetes medical team “as he was having such a good time going in and out of the sea. AB had to be admitted to hospital immediately on return home (late on 3rd July) and, as a consequence of his mother’s failure to monitor and meet his need for insulin, was hyperglycaemic.’

‘We went on holiday to St Ives in June 2021. He was on the pump then. That was a really tough holiday for the Mother; she was supposed to be on holiday but ended up being on the phone to the nurses every day and at the laptop uploading data for the nurses. The Mother would get upset as she just wanted AB to have a really nice, normal time. She was constantly checking his levels. AB had a croupy cough whilst on holiday and ended up spending a day in the caravan as he was unwell. I presume that would have contributed to his levels. The Mother had bought AB a special diabetic cake for him as it was his birthday, but he didn’t like it. It didn’t taste very nice. He didn’t have a “treat treat” on holiday because his levels were so high. I could see the Mother trying to make sure he had a good time, trying to follow all of the advice from the nurses and just doing her best.’

‘you can’t go swimming whilst connected to a pump. These charts show figures that are consistently high, at times, well off the scale. There is an obvious problem with the amount of insulin that is being delivered. We would only advise that you can go for a whole hour off the pump as long as there are checks. One of the striking things here is that, overnight, you would expect the BGL to be in range but it was not. With readings in the mid 20’s, AB would have been irritable, seeking out drinks and experiencing hunger pain. There would be high levels of glucose in his blood but it would not be getting into cells. His ketone levels on 2nd July are worrying’

‘obviously I liaised with the diabetes team every single day….Once we were on holiday….Just because we were so far away -- not far away, but we were about, you know, three and a bit hours away. I downloaded for them every day when I could, when I had signal… You know, I always made sure it had got to them before, you know, they had finished…And I always rang them, they rang me. I was ringing out of hours if I need to. I would do everything they would ask---…and I would always be led by them. Any decisions wouldn’t be made or done without them okaying it.’

‘This was clearly a period of time during which the mother was struggling to manage AB and his diabetes. AB was asking for unhealthy snacks, he was wanting to go in and out of the sea and the mother understandably struggled to say no to him whilst on holiday. Whilst perhaps understandable, the impact cannot be understated. AB was placed in a very precarious position. By Friday 2 July, his ketones reached 2.3. There was not a single day during the holiday when he was not hyperglycaemic, often for a prolonged period of time. The mother agreed in cross-examination that if AB’s diabetes is not under control that that constitutes a real concern. That does not appear to have deterred her, however, during this holiday where the Libre records clearly show mismanagement.’

‘There is no evidence of reckless mismanagement during the week-long St Ives’ holiday on 26 June 2021. AB’s pump was disconnected in order for him to swim in the sea – Professor Hindmarsh advised that his patients would be told they could go a full hour without being connected. The ketone levels were fine, per Professor Hindmarsh. The mother was uploading the Medtronic pump data to the diabetes team and so they would have been able to identify if any disconnection had been ill-advised. None did.’

‘What I mean by this, was if the max daily dose was set to 3, but I inputted the amount of carbohydrates he was about to eat and the pump then calculated that he required 4 units of insulin then, in order to give him 4 units, I would have to override the max dose setting…Nurse G did not tell me that I was wrong to do that but endorsed my decision by advising me to increase the max daily dose setting on my pump.’

“Telephone call made to mum who reports that they are ok. Mum has found it stressful trying to limit unhealthy snacks for AB while on holiday. Mum reports that AB is ok, he has not required any medication for his Croup. Mum reports all ketones are negative.”

‘ABs levels are bloody shit lmao skimming hospital by skin of my teeth 🤣🤣🤣🤣. I do not think anything of forensic value comes from that text. I am grateful for being educated that ‘lmao’ means ‘laugh my arse off’

‘From the 10th to 21st July 2021 the Libre glucose sensor download shows numerous episodes of hypoglycaemia during the day and night. The timing of these episodes would be consistent not only with mismatch between short-acting insulin and carbohydrate content of food but also with the action of long-acting insulin.’

‘Libreview and Diasend reviewed. AB still experiencing overnight hypos, down to 2.4mmol last night. Telephone call made to mum, have suggested that she reduces Insulatard again tonight from 2.5units to 2 units. Pattern of hypos post hyperglycaemia so have suggested that mum changes ISF for all time block from 1u:20mmol to 1u:25mmol. Mum has made this change. Mum has been giving mealtime insulin 10 minutes before meals as that is what the nurses did in hospital. I explained to mum that I had not heard that the 30 mins before food had changed, so have advised mum returns to giving Humulin S mealtime insulin 30 mins before food. Also discussed with mum again about ensuring AB has a BG level of at least 6mmol before going to bed. Mum sure that she gives a bedtime snack as well as a bottle of milk but this does not maintain his BG levels overnight. I have suggested that mum trials different carb snacks for the evening meal to see if that helps to maintain BG levels overnight.’

‘ Obviously considering the conversation in that telephone obviously I must have been giving [the pre-meal time insulin] ten minutes like they were doing it in hospital I’m guessing, I assume I then would have then followed Nurse S’s advice and started to give it the 30 minutes before.’

‘Between 10th and 21st July 2021 AB suffered numerous episodes of hypoglycaemia at home, the timing of which was “consistent not only with mismatch between short-action insulin and carbohydrate content of food but also with the action of long-acting insulin.” This was as a result of the mother’s failure to manage AB’s treatment plans either intentionally or due to a lack of reasonable care.’

‘On the dates set out below, the mother failed to call an ambulance when she was reporting AB to be unconscious, not breathing, blue and/or unresponsive in direct contravention of the hypoglycaemia flow chart dated 1st November 2020 and the specific advice of AB’s paediatric diabetes specialist nurses: a) 13th June 2021, b) 19th June 2021, c) 15th July 2021.’

‘On the way back from the beach I remember his eyes rolling back from what I saw in the wing mirror. I do not think that we stayed on the beach too long. We stayed for about a couple of hours and we went back. I can’t remember anything that may have led to it. I can’t say why I did not contact the nursing team and I can’t say why I did not contact the emergency services.’

‘I can’t remember the exact date but around that time, I took AB on a trip to Brean beach. He was very active and running around having fun. On the return journey in my car, I noticed in my wing mirror that it looked like his eyes were rolling back in his head. I pulled the car over and checked his levels through a finger prick and he was a hypo. I reported this to the Children’s Hospital [I2798].’

‘The M took AB to Brean beach on the 15th July 2021 and reported that after 2 hours he “blacked out” [E2610, E2617, E2618]. No ambulance was called and no reporting to the diabetes team occurred. This, on balance, represented a serious and significant episode of mismanagement in that AB passed through the stages described by Professor Hindmarsh before being rendered unconscious without M seemingly taking any adequate steps to address his deterioration.’

‘Looking at those values, would you expect him to black out or pass out as a result of any of those values?’

‘from 16th July, he was hypo-ing really frequently and I was struggling to keep his blood sugar levels up. I believe that it might have been a combination of the intensely hot weather and the fact that his body was adjusting to the new subcutaneous injections that made this period particularly challenging. It is during this period that I started to give AB foods that were not good for him, but which brought his blood glucose up quickly. I was giving him Magnum ice-creams, crisps and chocolate bars in an attempt to being his levels up. It was such a difficult week and I recall feeing like I was running out of options as he wasn’t accepting his usual treatment (a digestive biscuit) and he kept getting low repeatedly. It was also a catch 22 situation, because when he got upset about the prospect of having to eat another digestive biscuit and I was refusing to give him something that he wanted to eat like an ice-cream or crisps, his blood sugar levels would drop because he was so upset. I admit that during that week, I gave in and wasn’t disciplined with his diet, but it was out of pure desperation. I barely slept that week because I was so stressed out by his levels….[para 149 at C190]…In terms of the ice-cream and chocolate bars that I gave AB during that period, I did not include them in the carb count as I counted them as snacks and snacks were allowed without insulin, so long as it didn’t exceed 10-15 grams of carbohydrates. During the hot period, he was less interested in eating lunch hence why he had to have so many snacks. He was always good at eating breakfast but, because he was having so many snacks in the lead up to lunch, by the time that it came to lunch, he wasn’t very hungry. I think that dinners were OK, it was mainly lunch which was the problem.’

‘There was a period in July when I was giving him more Magnums and crisps than I should have done. I tried to keep his levels up. I asked the nurses and they upped his carbs to 10 or 15 so that he could have a bigger snack to keep his levels up. It was not working. I did not want to keep him inside so that he could play. I was in a mess. He would have an ice-cream as a dessert – mini magnums – 12 gms of carb, I believe. H would have crisps, I know that it is not a great choice of snacks to give him…I was struggling and did not know what to do.’

‘what we have are periods of time, usually starting late evening where there is a start of a run of low glucose measurements. Some of them are fairly flattish. From 9 p.m. and early hours of morning there are low readings. At J1007 there are long periods of hypos from 16th to 18th July and 28 hypos are recorded over the course of three days. On 18th July most of the waking day (8 a.m. to 8 p.m.) is spent with AB being hypoglycaemic. The last hypo continued through the night until 4 a.m. the next day [J1006]. There were significantly low figures on 18th July - 2.4 and 2.9. There appears to have been no response to intervention. These readings are really quite concerning from the point of view of AB’s health. It looks as though there was intervention at about 10:00 on 18th when his blood glucose level goes up to 6.6. This is the time that the mother is referring to at C189 of para 146 when the mother says that she was giving him foods that were not good for him. ..That increases blood flow which promotes more rapid absorption of insulin from the injection sites. So, you can end up in a situation where you might not have an issue but then you go low because of the easy uptake of insulin in the hot weather. Magnum ice creams, crisp and chocolate bars have a high fat content which will slow down glucose absorption so you would not use them to raise the levels.’

‘Professor Hindmarsh analysed the data for 18 July 2021 with particular care. The heatwave might well have “promoted more rapid absorption of insulin from the injection sites”. In that situation “you can end up in a situation where you would not normally have any particular issue but on a hot day you might find you go low because of the easy uptake of insulin in hot weather”. One cause for the relatively flat line on 18 July 2021 could be “over-estimation of carbs” (XX by M). Magnums, crisps and chocolate bars might also have an effect - the relatively high fat to glucose ratio in ice-cream “smooths the absorption profile” of the glucose per Professor Hindmarsh. He emphasised that he had reached no adverse conclusions about the mother’s diabetes management that day and did not criticise the timing of her call to the nurses the following day: indeed he was sympathetic with her efforts – “it looked as if it was a very difficult situation they were in. She tried a number of options, not the best, but what she had available and obviously it was quite difficult to rectify the situation” (XX by M). That response, from the Chair of the Medical Safety Committee at UCH, hardly smacks of mismanagement.’

‘ABs sugars have been horrendous only reason we ain’t back in hospital is cause I've not told the nurses how bad if really is lmao.’

‘Diasend reviewed, see copy under charts. Time in range 44%, 1% above, 54% below and an average BG level of 4.3mmol. Telephone call made to mum, no answer. Message left to call office back. Data sent to Dr G as Diabetes consultant this week so that he is aware of the current situation.’

‘Telephone call received from mum who reports that the recent hot weather has really been affecting AB and he is suffering with continued hypos during the day and night. Mum reports that she has been keeping AB at home, indoors to prevent exposure to heat. Mum reports that last night, AB had a hypo of 2.1mmol and initially described him as difficult to rouse and that mum felt that she may have had to give the Glucogen injection, but then said he was screaming and alert. Mum managed to get AB to have some sweets and hypo was rectified. Mum reports that she spoke with a PDSN on Friday who advised to reduce Insulatard from 2 to 1.5units. I have advised that mum reduces Insulatard again down to 1unit from tonight. I have also asked mum to change the ICR for all time blocks from 1u:25g to 1u:35g. Mum confirms she has done this, and also confirms that she has been giving Humulin S 30 mins before all meals and giving AB snacks between all meals and before bed. Mum reports that she does not want to return to hospital as she feels that the team have not given any answers, nor do anything which she cannot do at home, however, of course would bring him back if necessary. Reassured mum that we will be in contact every few days to monitor how AB is doing and support mum.’

‘OA - Met by pt's mum, Pt laying in bedroom on the bed, a(V)pu, slightly pale in colour, normal WOB. HPC - 5/12 ago pt started having frequent hypoglycaemic episodes per day, mother stating approx. 15 hypo's per day and approx 6 hypo's per night. Pt has had 7 hospital admissions in last 5/12, longest admission was 2/12. Normally mother is able to self-manage, however this evening she was unable to wake pt for longer than normal, checked his BM which was 2.7. Mother attempted to put pt's medication in his milk and administer sweets but unable to do either as pt kept refusing. Pt normally comes around after approx 30 minutes, however tonight pt was still unable to be roused after 1 hour so mother called 999. Pt is under investigation for cause of hypo's, and mother talks to consultant on a daily basis.’

‘On 21 July 2021 the mother delayed calling an ambulance by over an hour. She indicated this to the paramedics on 21 July 2021 [SB E35]. She accepted the time delay in her oral evidence. She could not provide an explanation for the delay. The delay was unreasonable, against medical advice and placed AB at risk of serious harm.’

‘the night had been difficult because he would not take the treatment. I can’t remember what we were doing that day. I remember the night time. I was trying to wake him up.’

‘on this page we have quite a number of hypos. Where you have a succession of hypos, you lose some of your ability to register or show symptoms – therefore, the response may become attenuated and less observable…So, as to the level of 2.2 – a one off reading at that level you would see a number of changes such as possible unconsciousness and coma – with a number of episodes you might not have reached the level of unconsciousness. Here, he would have been asleep at 22:00. When the mother spoke to the ambulance crew she said that he had been having 15 hypos a day – you can see from this page that there were a lot of them. That is quite concerning because it does not look as though the interventions did make much difference.’

‘…patient laying in bedroom on the bed…HPC (history of presenting complaint) – 5/12 ago patient started having frequent hypoglycaemic episodes per day, mother stating approx. 15 hypo’s per day and approx. 6 hypo’s per night….normally mother is able to manage, however, this evening she was unable to wake patient for longer than normal, checked is BM which was 2.7…after 1 hour mother called 999…On examination…initially no interaction……patient reduced Glasgow Coma Score (GCS) on arrival… when crew attempting to rouse patient, patient gradually started to become more alert over 2-3 minutes… but still not opening eyes…Patient agreed to eat some sweets, becoming fully alert, GCS (15 in approx. 5 minutes…not cannulated…rang CH (The Children’s Hospital) advice line, spoke with SpR D who agreed patient could remain at home and advice for patient’s mother to speak to diabetic team mane.’

‘I did tell the paramedics that he was having frequent hypos every day and having 15 hypos per day and approximately 6 hypos at night.’

‘AB was again admitted to the children's Hospital on 22nd July 2021 with recurrent episodes of severe hypoglycaemia (blood glucose <3 mmol/L) despite reportedly being given a very small dose of Insulin. His blood glucose were as low as 1.9 mmol/L which required 3 boluses of 10% dextrose, continuous intravenous glucose infusion (10%), intramuscular glucagon (glucagon is a hormone that counter-regulates the effect of Insulin by increasing the blood glucose levels). AB required a concentrated form of glucose solutions (12.5%) to maintain his blood sugars at a safe level. Prior to the admission to the emergency department, AB was reported to have received only 0.5 units of his insulin in the evening. Due to the significant nature of hypoglycaemia AB's injections were once again stopped and it was replaced by sliding scale (continuous intravenous infusion of insulin which is adjusted depending on his blood glucose levels).’

‘On 23rd July AB was sleeping in his own cubicle. There would normally be the mother with him. There was bedding for the mother in that cubicle. The mother was present: ‘mum resident and updated with plan’

‘If the mother had behaved inappropriately that evening, I would have noted it in several documents. I would have documented it if I thought that she was trying to hide something from me. I would have noted if I thought that she was being evasive. I did not think that there was anything dodgy going on – if I had, I would have noted it.’

‘It is the expectation that once an infusion stops, it is disconnected and the cannula is flushed’; so, on that basis, the flushing would come after the insulin is stopped. Nurse CD said in evidence: ‘In practice you would flush it and take it down.’

‘If we assume that at switch off no further insulin enters the circulation and the half-life (time for 50% of the insulin to be removed from the circulation) of insulin is 4 minutes, then after 20 minutes with either infusion rate there would be undetectable insulin present in the circulation whereas the value 39 minutes after cessation of the insulin infusion was 9.7 mU/l. The assumptions that I have made is that there are no insulin antibodies present that would alter the removal of insulin or prolong its presence in the circulation. This would appear reasonable as there were no insulin antibodies present when measured. The degree of renal impairment is insufficient to alter insulin dynamics and there is no evidence of liver failure which would also prolong insulin metabolism.’

‘I don’t remember if the blood was taken through the cannula or separately. Good practice means that a sample should not be taken from the cannula but I do not have any evidence of how it was taken that night’

‘the document just gives you whole hours, it is not broken down into minutes’. ii) The nursing note of Nurse CD at I3384. The key part reads: ‘24.07.2021 0115 [there is a blot on the second 1 but Nurse CD said that it is ‘most likely’ 1:15] – sliding scale insulin currently stopped, BSL at 01:00 – 1.8. Doctors aware and will perform hypo screen’

‘I have reviewed the medical records from the evening of 23rd July 2021…From my review of AB’s drug chart I note that the sliding scale insulin was stopped at approximately 01:00 – 01:45 following AB’s low blood sugar of 1.8. It would have been myself who stopped the insulin.’

‘As to 25th, 26th and 27th July, the same applies to those dates as applies to other dates in July, save for 24th and 28th July. The hypos could be associated with flushing the line on those dates. I am concerned that you should not flush lines with insulin. I think that, in the absence of any biochemical support, I would be happy to ascribe the hypos on those days (25th to 27th July) to flushed insulin action. I don’t know if we confirmed that we substantiated that flushing was a regular event. It does sound as though it was standard procedure to do that but the evidence that it did happen was not as robust as we might have liked.’

‘Further hypoglycaemic episodes took place on the evenings of 25th, 26th and 27th July 2021 and occurred between 21.00 to 23.40 and appeared in time to be related to the switch off of at 20.00 of the intravenous insulin infusion which was done to prevent nocturnal hypoglycaemia. This may relate to the practice of flushing the infusion line after discontinuation of the sliding scale insulin infusion. The deadspace that would be flushed was 0.45 ml made up of a 22G cannula deadspace of 0.16 ml and the nonreturn extension set of 0.29 ml (information from the Hospital). This would represent an intravenous bolus of 0.45 Units of insulin. The correct way to clear the line would be to infuse 0.9% sodium chloride at the same rate as the insulin infusion was at the time of discontinuation to clear the line. If the deadspace is 0.45 ml that would mean running the pump for an additional hour which was not the case. An intravenous bolus of insulin produces hypoglycaemia (blood glucose 2.6 mmol/l) 20 minutes after administration (assuming a normal blood glucose at commencement of the test) which usually normalises 60-90 minutes after insulin administration. In this case the flush would have delivered a bolus of 0.45 Units of insulin which would be a fifth of the dose that would have been administered if AB was having the IIHT test of 2.’ ii) At E67: ‘Further hypoglycaemic episodes took place on the evenings of 25th, 26th and 27th July 2021 and occurred between 21.00 to 23.40 and appeared in time to be related to the switch off of at 20.00 of the intravenous insulin infusion which was done to prevent nocturnal hypoglycaemia. No detailed evaluation of these episodes with a hypoglycaemia screen was undertaken.’

‘there talking about transferring him to another hospital’

‘AB might be being transferred to gosh…Great Orman Street’

‘prior to this date, the necessary forensic approach was not taken on the ward?.’

‘I remember bits of that day. Bits and bobs. That night I was tired. I was tired every night. I was tired and exhausted. I wished I had more help…someone to take over. I don’t think anyone knew how tired I was. I was exhausted. I remember Dr J coming in that night. He was like any other doctor. I think that this was the first time we met him. He was nice to me and AB. AB was upset when his cannula was leaking and he had to have a new line. It was really hard to see him crying. He had problems on 26th and 27th with leaking cannula. I remember the day it leaked under the skin – 26th when we had to have a plastic surgeon. I remember thinking ‘that is my child’

‘And obviously, you know, I cannot -- I’m not going to sit here and say there wasn’t insulin in his blood because obviously there was, there was a blood test…I can’t sit here and say there wasn’t, but how that got into his bloodstream, I can’t give you an answer because it wasn’t from me.’

‘the fact that the pump was turned off one hour and 38 minutes late would also not affect the insulin readings at the time of the blood screen given the half- life of insulin.’

‘cannula failed whilst giving last dose of dex so not given’

‘On the evening of the 28th July 2021 the intravenous insulin infusion was stopped at 20.38. Prior to switch off at 20.10 the blood glucose was 15.6 mU/l. At 21.00 the blood glucose was 4.6 mmol/l consistent with ongoing insulin action from the infusion. By 22.00 the blood glucose had fallen to 1.4 mmol/l. Subsequent checks of the pump infusion system revealed no problems with the function of the device. A further hypoglycaemia screen was undertaken at 22.20 which revealed a high plasma insulin concentration of 160 mU/l. This was confirmed in the Royal Surrey County Hospital, Guilford result and the report by Professor T in Cologne where human insulin (no synthetic insulins of the Novorapid, Glargine or Levemir types were detected) was measured at 7.1 ng/ml (174 mU/l). The C-peptide was low at 92 pmol/l (132 pmol/l in Professor T laboratory) confirming that there was little in the way of residual beta cell function in the pancreas. This implies that the insulin measured is exogenous which, of course, it would be in anyone with Type 1 diabetes where insulin production is destroyed by the underlying disease process.’

‘The blood glucose was, prior to switch off of the insulin syringe pump at 20.10, 15.6 mU/l. At 21.00 the blood glucose was 4.6 mmol/l suggesting insulin action. By 22.00 the blood glucose had fallen to 1.4 mmol/l. Some of this initial insulin action may relate to the effects of residual insulin from the pump although a duration of 2 hours is a long time for the intravenous insulin bolus proposed. After 22.00 and through the night there was evidence of ongoing insulin action on the Libre download until around 02.00 on the 29th July 2022. This would be consistent with ultra-short or short acting insulin action although it is always difficult to exclude an effect of long-acting insulin in these situations. Looking at Figure 1 the data would fit with ultra-short or short acting insulin best. When using the subcutaneous route we have to use a different half-life the plasma terminal half-life to account for the fact that insulin is absorbed from the subcutaneous site. The plasma terminal half-life of insulin is 120 minutes. If we accept the 160 mU/l as the peak at 22.00 then we would expect at 02.00 there to be 40 mU/l of insulin in the circulation so overall slightly higher than depicted at time point in Figure 1 where we would place the 160 mU/l peak at 60 minutes on the time x-axis and the 40 mU/l value would be attained at 300 minutes on the x-axis slightly above the 20 mU/l obtained in the study. Note that in Figure 1b this implies that insulin action would be virtually over by 300 minutes and certainly by 360 minutes which tallies with the Libre data and clinical observations out to 04.00. To attain a peak of 90 mU/l on Figure 1 a dose of 0.2 Units/kg body weight of Novorapid was used so to attain a level of 160 mU/l (dose response is linear at these levels) would require 0.36 Units/kg or for AB approximately 8-9 Units of Novorapid insulin.’

‘On 28 July 2021 the Libre View shows that AB’s blood sugar was high all day. The insulin infusion stopped at 20.38 and the hypo screen was done at 22.20 Did you give AB insulin on the 28 July 2021 believing that he needed it?’

‘The court then pressed him on this point, resulting in subtle shifts in the language of possibility and probability. It was “probably unlikely” that the manipulation of the cannula in this way had resulted in a plasma insulin level of 160.9mmol/l approximately 1½ hours after the infusion stopped. It was “a possibility but unlikely”. It was “probably safe to discount that” because other cannula failures had not caused the same problem (all XX by HHJ). We note however that that logic does not stand up to scrutiny. We simply do not know if previous cannula failures caused high plasma insulin levels because of the paucity of available hyposcreens and the hospital’s failure to implement a rigorous blood testing regime. The only basis on which Professor Hindmarsh moved from accepting that cannula error was an equal possibility to “discounting” the theory was, therefore, unsupportable. When asked one final question by NGQC, the professor agreed that although this was not the likely explanation, it was “still possible”. He would “love to do those kind of studies to advance further” his understanding in this area. In conclusion, even on an analysis of the medical evidence alone, (without bringing into play the wider canvas material), it therefore remains open to the court to find that the high plasma insulin reading on 28 July 2021 was caused by cannula error rather than maternal interference. The wider possibility of inadvertent hospital error was not dismissed by Professor Hindmarsh – “that is why one has to be quite careful and take those kinds of things into consideration, yes” (XX by M). We invite the court to give this the most careful thought when considering whether the local authority has proved its case in relation to 28 July 2021.’

‘The introduction of the strict surveillance regimen was associated with a marked reduction in hypoglycaemic episodes on the Libre glucose sensor download from 30th July 2021 onwards. Occasional hypoglycaemic episodes were noted usually late mornings and nearly always associated with a high post breakfast glucose spike. This is not an uncommon problem in paediatric diabetes.’

‘The initial 24 hours of the strict surveillance regimen was associated with high blood glucose values and thereafter the insulin dosing was gradually increased so that by late August 2021 the total daily dose was more appropriate for someone of his size at 0.5 Units/kg/day. This was achieved without a return to the persistent hypoglycaemic episodes that had occurred previously. The lowest glucose noted on the Libre and checked by finger prick blood glucose testing on only one occasion was 2.9 mmol/l (Tuesday 24 August 2021) with the majority in the 3.5-3.9 mmol/l range which is very mild.’

‘D and I have been to speak with mum and the enhanced one to one observation has now commenced. The ward staff are clear of the documentation log which they need to complete during this time…D has written a clear plan in AB’s notes regarding use of the sliding scale.’

‘Mum informed strategy meeting tomorrow at 11:00 AM. Reason for meeting is our escalating concern about AB’s blood glucose levels, especially the prolonged period of hypoglycaemia overnight on 28th July which was refractory to Rx (i.e. medical prescription). Picture consistent with strong insulin action, confirmed by measurement of high insulin levels in AB’s blood. Unclear where/ when AB given the insulin as infusion pump stopped at 2038 hours . Mum advised to go home to meet with social work team ahead of strategy meeting. Mum naturally upset and concerned that AB may be taken from her care will stop clearly denies giving AB any insulin.’

‘Mum told me a little bit today about recent events such as the move to 1:1 observation and how initially she had felt very angry and defensive but feels more accepting of this now. I reinforced that we are here to support, not to judge, and all want to get a better understanding of what is going on. This is a good opportunity also for mum to step back and focus on own wellbeing. Mum said she has been able to do this and has been going home for a few hours every day to have a break. I encouraged her to continue with this and for mum’s mum also to continue to take over when possible.’

‘Mum expressed sadness about the discussion yesterday and is stressed. She reiterated that she wants to work with the diabetes team.’

‘I let Mum know that FII would be a possibility.’

‘At discharge on August 24th, AB was receiving 14 units of insulin daily compared with 1 unit or less when admitted only 4 weeks earlier. AB’s dose of insulin at discharge is typical of that required in a boy of his age and size and duration of diabetes. Such a rapid change in insulin requirement is impossible to explain and provides a further indication that AB must have been receiving additional insulin injections prior to this admission’

‘A Strategy Meeting was held on the 24th August 2021 (I3541) which concluded that the mother had administered insulin on numerous occasions. As Dr B, Consultant Paediatric Diabetologist, pointed out hyperinsulinaemic hypoglycaemia is a dangerous condition. The brain is reliant on a constant supply of glucose for energy and normal function. The brain only has sufficient stores of glycogen to convert to glucose to last for 20 minutes. Thereafter the brain will switch to ketone bodies such as 3-betahydroxybutyrate as an alternative energy source. In non-ketotic hyperinsulinaemic hypoglycaemia glucose is no longer available in adequate amounts to maintain normal brain function and the production of ketones is suppressed by the high circulating insulin concentration. This can lead to seizures, brain cell death, coma and on occasions death. As a result of the Strategy Meeting AB would be allowed to the maternal home however with grandparents in charge of treatment.’

‘that conclusion was the shared conclusion of professionals present at the strategy meeting. It was the opinion of the group. I was then asked to feed it back to the mother and family the outcome of the meeting. The medical information that I gave was essential to that meeting. There was one outstanding investigation which I explained to the mother over the next 24 hours – the results of a blood sample measuring insulin anti-bodies – these can cause the delay of action of insulin after it is administered – That is a very rare condition (only one or two case reports). Subsequently no antibodies were found in his blood and so that alternative explanation was ruled out finally.’

‘AB was readmitted to hospital on 3 September 2021 following episodes of hypoglycaemia whilst in the mother’s care.’

‘we did absolutely everything that was asked of us and complied with everything that had been out in place. All of the insulin was locked away and the Mother wasn't helping with AB’s insulin nor did she know how to access the insulin. The Mother was being really good about the rules too and would leave the room when I did the insulin, as she wanted to do everything properly. I am absolutely certain that AB was not left unsupervised at any point.’

‘…After AB was discharged home in August 2021, a Safety Plan was put in place so that my contact was supervised at all times by my family members and his medication kept in a locked box and not administered at all by me. All of AB’s medication and medical equipment was kept in locked boxes provided by the social worker and the key was kept hidden from me. I did not have access to or possession of any insulin or syringes. The social worker undertook four unannounced visits during this period and has confirmed that we were adhering to the safety plan. The first time she visited she checked that the medication was in the box – and, of course, it was. As part of the requirements requested of us by the hospital and social services, my family were asked to keep a log of what food AB ate and how much. This food diary was kept from 24th August to 3rd September 2021 and was taken by the police on 4th September 2021 during their search of our property. We had also been asked to keep an insulin diary, recording what time he was given his insulin, the amount he was given, and by whom. The family member giving him his insulin would need to sign the diary to confirm it was them who had administered it. For some reason, the police did not take this insulin diary when they searched our home on 4th September 2021 and I only discovered it some weeks later. I still have it in my possession and exhibit it here to my statement (EXH/BR/5) – [it is at C235 – I have looked at it]. During the period at home from 24th August 2021 to the date that he was next admitted to hospital (3rd September 2021), AB’s levels were monitored by the diabetes team remotely, as we continued to upload the Libre and Diasend data every few days. My mum spoke regularly to the diabetes nurse Nurse S and it was noted that AB was above his target range for most of that period but with some hypos mid-morning. Nurse S provided guidance to my mum via telephone and their conversations are recorded at [I4328] to [I4337]. My mum was asked to bring AB into hospital the night of 3rd September 2021 following a hypo at 9:27pm which was had been unusually difficult to correct. Friday 3rd September 2021 itself was a normal regular day in my view, aside from the fact that AB had been climbing that morning. This was the first time he had ever been.’

‘AB was admitted on 3rd September 2021 when he was brought by his grandmother with concerns about low blood sugar levels on the evening of the 3rd September when the blood sugar levels were ranging between 3.5 to 3.7mmol/L. The low blood glucose levels were felt to be secondary to change in AB’s increased activity level. He was monitored for a few days in the hospital and was discharged back to remain under his dad’s care after a strategy meeting.’

‘The hypoglycaemic episodes were generally mild although the interventions with Jelly Babies may have prevented them becoming more serious. The reasons for developing hypoglycaemia in type 1 diabetes have been presented in my report (Figure 3). It is possible that the hypoglycaemia resulted from undertaking a new exercise earlier in the day and possible mismatch between insulin doses and food intake. The time course is consistent with the administration of ultrashort acting insulin at 16.30.’

‘In my statement, at para 221, I say that I remember staying in the bedroom with my mother and holding his hand while he fell asleep…That is the truth. It is not what I said in her police interview at H63. I had been in a cell for 12 hours.’

‘there is a lot of detail there…this is the day afterwards. Were you telling the truth to the police when you said you went to bed a bit earlier than AB?’

‘I did go to bed earlier…I can see what I said in the interview…I don’t know why I told the police that I wasn’t there when AB fell asleep. I was scared at the time of the interview. I have never been interviewed before. It was scary. I was very scared and it is hard to remember what was going through my mind. I was not alone with AB at any point that night. The interview account is wrong. The statement account is correct.’

‘Since in The Father’s’s care, AB has presented as a typical child with diabetes; having high blood sugar levels due to various common factors , blood ketones when unwell which have resolved with standard sickness advice and has responded to hypoglycaemia with simple sugar treatments. AB's diabetes has responded in a way which is normal when compared with that of his peers with diabetes. AB has been attending school, no longer uses a pushchair nor has a bottle. AB is now on the standard insulin regime try a pen injection which all of our diabetes patients commence at diagnosis. There have been no hospital admissions since in The Father’s care.’

‘it is back to where it was in Jan – Feb’

‘I find it hard to know why AB has not been in hospital since living with The Father. I can’t speak to that or explain why the Mother was asked to bring AB in and the Father isn’t. I think the Mother was anxious and calling often, whereas I don’t know if the Father does that to the extent that the Mother did. I have seen the data from the Accucheck Aviva meter (finger prick machine) and can see there have been regular highs (up in the 20s) and in the same day lows (down to 3.4) whilst AB has been in The Father’s care. I haven’t seen the other data from the Libre Review so don’t have the full picture, though. We aren’t invited to any hospital or health appointments for AB so we don’t exactly how he is doing. The Father’s partner, recently told me about a particularly difficult night on the 25th June 2022 (the morning of the 26th), where AB was hypo for a long time during the night. He had his blood sugar levels tested by the finger prick (Accucheck Aviva meter) at 00:52 (4.2), 03:35 (3.6), 3.55 (3.6), 4:00 (3.4), 4:14 (3.9). I exhibit a photograph of the Accucheck Aviva meter readings from that night [EXH.KR-1]. I took this photo during a contact with AB as the meter is always handed over along with his other diabetes equipment. I always ask his Partner and yhe Father how he is doing at the beginning of contact and check the finger prick meter so I know roughly whether he is going through a good or bad patch. The Partner will often say “it’s been a nightmare, he’s been going high” or she’ll tell me that “he’s been having bad hypo’s”. The Partner did say to me about a month ago in the park that a nurse said “don’t take this personally but do you think AB had been sneaking food behind your back?”. I know the nurses have advised that it’s normal for a child with type 1 diabetes to have three hypos a week but for AB, he can have them three times a day. I’m not in a position to say why he is still suffering from multiple hypos as I am not there to witness it.’

‘AB has not had any significant episodes of ongoing hypoglycaemia since being discharged from the hospital and being under the care of his father and extended family members.’

‘The school started carb counting on 13th September 2021 [it looks as though it should be 16th – C74]. Initially. the school and home were using different apps [C81]. In November we switched to the ‘carbs and cals’ app.’ ii) The CPOMS records of the school for 19th October 2021 state at C80 that Nurse G came to the School the week before to check that everything was OK with AB’s diabetic care at the school [C80]. The headteacher said in evidence that there was uncertainty around whether the teachers were using the right, safety, needles and giving him the right insulin. The nurse was asking the school to make sure that everything was entered onto the machine every time because ‘it looked as though we have not given insulin. I confirmed that we have given AB insulin every day’

‘AB has suffered emotional harm by thinking of himself as an ill child.’

‘AB has suffered significant harm emotionally and to his social development through unnecessary and prolonged stays in hospital and due to the mother’s handling of his diabetes.’