South Tyneside Council v CD & Ors [2024] EWFC 67

[2024] EWFC 67Case No NE23C50630
IN THE FAMILY COURT AT NEWCASTLE
Date 21 March 2024
SITTING AT THE NEWCASTLE CIVIL AND FAMILY COURTS AND TRIBUNALS CENTRE
Before
MR JUSTICE POOLE
Between
SOUTH TYNESIDE COUNCILApplicantCDRespondentsEFRespondentGH (THROUGH HIS CHILDREN’S GUARDIAN)Respondent
Re GH (Fabricated Illness: Kidney Stones)
Claire Middleton (instructed by STMBC Legal services) for ApplicantsAndrew Pike (instructed by Hannays Solicitors and Advocates ) for First RespondentAmi Dodd (instructed by PGS Law ) for Second RespondentGeorgina Hey (instructed by Ward Hadaway ) for Third RespondentHearing Hearing dates: 11-14, and 19-21 March 2024
APPROVED JUDGMENTThis judgment was handed down 21 March 2024 in court by circulation to the parties or their representatives and, following corrections, is released to the National Archives.This judgment was delivered in private. The judge has given leave for this version of the judgment to be published on condition that (irrespective of what is contained in the judgment) in any published version of the judgment the anonymity of the children and members of their family must be strictly preserved. All persons, including representatives of the media and legal bloggers, must ensure that this condition is strictly complied with. Failure to do so may be a contempt of court.

Introduction

[1]This judgment follows a finding of fact hearing concerning GH, a six year old boy, whose mother and father are the First Respondent, CD, and the Second Respondent, EF. GH’s parents have been separated since before his birth and he lived with his mother, spending limited time with his father until events in September 2023 which led to the Local Authority issuing public law proceedings and obtaining an interim care order under which GH was removed from the care of CD and placed in the care of EF where he remains.[2]The Local Authority’s allegations, set out in a long schedule of findings sought, concern CD exaggerating or fabricating illnesses suffered by GH. These include alleged misreporting and exaggeration of symptoms relating to his urination, constipation, and fever. In August and September 2023 CD sought medical attention for GH in relation to his passing kidney stones, including on 17 September 2023 when she brought GH to the Emergency Department of Sunderland Royal Hospital with a urine sample which contained two stones, the largest measuring 2.5 cm long which she reported had been passed by GH, from his penis, at some time that morning. It is now accepted that these particular stones cannot have been passed by GH and that none of the stones presented to clinicians by CD in August and September 2023 were passed by GH. GH’s maternal grandmother, JK, has given evidence that GH passed a number of stones when in her sole care on 16 September 2023 but the expert evidence that these were not kidney stones is unchallenged. I have to decide where those stones, the large ones handed over by CD on 17 September 2023, and the earlier stones she handed over to healthcare professionals, came from. The Local Authority alleges that CD has fabricated her accounts of GH passing kidney stones and has added non-renal stones to his urine samples. CD strongly denies having done so.[3]The schedule of findings sought comprises 44 numbered allegations but some of those are sub-divided, so that the total number of allegations comfortably exceeds 50. However, there are core findings that the Local Authority invites the court to make which can be summarised as follows: i) CD has misreported and/or exaggerated GH’s symptoms in relation to urination, constipation, and fever; ii) CD has sought further medical opinions and tests when none were indicated and has misreported or exaggerated information that she has given to professionals about what other professionals have advised; iii) Between 22 August 2023 and 17 September 2023 CD has presented GH to clinicians as having passed kidney stones in his urine at home but such reports were fabricated and she has added non-renal stones to GH’s urine samples. iv) As a consequence, CD has caused GH to undergo unnecessary investigations, tests, in-patients treatment, and monitoring, and has encouraged him to believe that he was a sick child.[4]The Guardian and EF support the Local Authority’s allegations.[5]CD has been assessed as having a full scale IQ of 64 (1st centile). She has been diagnosed with Autism Spectrum Disorder (“ASD”). Dr Swart, Consultant Clinical Psychologist, has advised that her ability to retain verbal information is “extremely poor” and her verbal comprehension index is low. In combination, these factors mean that her “ability to absorb and retain verbal information is extremely poor.” Following recommendations from Dr Swart and an intermediary assessment, CD has had the assistance of an intermediary at this finding of fact hearing. Ground rules were adopted which included regular breaks and the use of simple language when questioning. EF was assessed by Dr Clark-Dowd, Clinical Psychologist, who found his full scale IQ to be 71 (3rd centile) but that his verbal abilities were in the “extremely low range”. He does not meet the criteria for formal Learning Disability but an intermediary assessment was recommended and he was also assisted by an intermediary at the hearing with ground rules adopted.[6]CD’s learning disability is an extremely important factor in this case which I have actively considered in relation to all the findings set out below.

Chronology of Events

[7]GH was born in August 2017. His parents had already separated. He lived with his mother but spent time, including some overnight stays with his father. He is the first and only child of each parent. GH started nursery at the age of 4 and began at primary school in September 2022. CD keeps a clean and tidy home. GH attended nursery and school properly dressed and equipped and had a positive attitude. He continues to do very well at school. CD has always engaged well with teachers and staff. All accounts to me have been that she is pleasant and courteous in her interactions with others.[8]By her own admission, CD has been anxious about GH’s health. This resulted in 44 attendances seeking medical advice in GH’s first two years of life. Thereafter, CD has continued frequently to present GH to his GP, to Emergency Departments, and to hospital doctors, even after repeated reassurances about his condition.[9]It is right to note that GH has had genuine medical conditions that have required treatment. The Local Authority concedes that his genuine medical conditions have included: i) Chronic constipation, first diagnosed in 2021; ii) Episodes of tonsillitis (severe enough in 2021 to require hospital admission and intravenous antibiotics); iii) Two urinary tract infections; iv) Covid-19 infection; v) Mycoplasma pneumonia.[10]The Local Authority’s case is that CD has exaggerated and/or fabricated GH’s symptoms and illnesses in respect of three matters: i) Although it is accepted that GH has had problems with constipation, CD has refused to accept repeated assurances from healthcare professionals that he does not have any underlying condition. ii) CD has repeatedly reported that GH has had a fever but whenever he has been assessed by healthcare professionals his temperature has been normal and examination unremarkable. iii) Between 22 August and 19 September 2023 CD reported that GH was passing kidney stones. She provided healthcare professionals with samples of kidney stones she said he had passed. In fact GH did not have any condition affecting his kidneys and had not passed the stones. Chronic Constipation[11]The Local Authority accepts that GH has had a genuine health issue with constipation. Investigations have shown an impacted bowel and he has been prescribed Movicol and other medication. This will have intermittently caused GH some discomfort, perhaps even occasional pain. However, the Local Authority’s case is that CD’s reporting of symptoms has been exaggerated and her requests for medical investigation disproportionate.[12]In September 2021 GH was reviewed by Dr G, Consultant Paediatrician, who carried out a series of investigations which excluded any serious underlying condition. On 26 January 2022, only eight days after GH was discharged from Dr G’s clinic, CD requested a second opinion suggesting that GH needed a full body scan. On 31 March 2022 GH was seen by Dr B, another Consultant Paediatrician, reporting that GH was not gaining weight. Further investigations were all normal except that a bowel marker study showed a slightly slow gut. Following further reports by CD of GH suffering abdominal distension and pain, GH was admitted for a four night stay for detailed observations. He was largely well on the ward save for slight distension after meals and some episodes of pain. A tentative diagnosis of aerophagia (swallowing too much air) was made. On 1 September 2022 CD reported concern that GH was losing weight and might have ulcerative colitis. She requested an ultrasound scan and one was arranged for 15 September 2022 but on 14 September GH was taken to A&E by ambulance with what CD described as abdominal pain. At the hospital GH was noted to appear well and happy and no acute abnormality was found. The ultrasound scan on 15 September was reported as being entirely normal. Blood tests were normal. On 20 September at an out-patient clinic with Dr B, CD reported recurrent abdominal cramping pains and another battery of blood tests was ordered. All were normal. Despite repeated reassurance from Dr B, CD requested a third opinion and was referred to Dr M, Paediatric Gastroenterologist who, in November 2022, confirmed the diagnosis of constipation with no serious underlying problems.[13]Notwithstanding the repeated reports of difficulties with abdominal pain, virtually no such symptoms were ever noted when GH was at school. Neither did EF or his mother note any significant abdominal symptoms when GH stayed over at their home. Dr B recorded his considerable disquiet about the frequency and manner of presentation of GH by CD for medical attention, and CD’s inability to accept “hours and hours” of reassurance. Fever[14]CD has repeatedly presented GH for medical attention reporting high temperatures since early 2022. On 22 February 2022, CD took GH to A&E with complaints of high temperatures day and night not responsive to over the counter medication. GH appeared well on examination but a ten day course of penicillin was prescribed. A week later GH was taken by CD to the rapid access clinic reporting raised temperatures over the previous month but nothing remarkable was noted on examination. GH was referred to a Consultant in Infectious Diseases and a Paediatrician specialising in Immunology. All investigations were normal (save for an x-ray showing evidence of constipation). On 15 February 2022, CD provided GH’s school with equipment to measure his temperature and oxygen levels. On 2 March, GH was admitted to hospital for two days for investigations into his reported fevers and abdominal pain and CD reported that he was having fever “all day every day” at home. His temperature was normal throughout that short admission. CD was asked to bring her thermometer in to the hospital. She did so and it was found to be consistently recording a higher temperature than the hospital thermometer, although both recorded a normal temperature. CD was advised to stop measuring GH’s temperature.[15]On 16 October 2022 CD reported to a nurse practitioner that GH had been unwell with a high fever but on examination he was well and had a normal temperature. Nevertheless, CD continued to report fevers and night sweats. The infectious diseases team twice declined to accept a referral confirming that all investigations had been carried out (on 11 January and 18 February 2023). Kidney Stones[16]From early June 2023 CD sought medical attention for GH regarding urinary issues. An ultrasound scan of his kidneys on 4 August 2023 was said to be normal but CD was later recorded as considering that the scan had not been done properly. On 22 August 2023, the nurse practitioner at GH’s GP practice recorded, “CD states that child passed urine with ? stones in same this am.” This is the first record of a produced kidney stone but in her oral evidence CD was adamant that GH had been producing stones for some weeks prior to 22 August 2023.[17]On 27 August 2023 CD took GH to the Urgent Children’s Centre reporting that GH had been passing kidney stones into his urine all that week. CD now says this had happened for about six weeks. She handed over a urine sample containing some large stones and reported that he was passing about two stones a day. It was recorded that CD stated that GH was under investigation for a low immune system and had had recent blood tests. He had been complaining of lower abdominal pain and had cried when passing the stones. On examination he was alert and bright and all observations were normal. He looked “very well” and on examination of his penis no abnormalities were detected. Whilst at the centre he passed urine twice, cried when he did so but was described as being completely fine afterwards and was eager for the clinician to inspect his urine. He was admitted as an in-patient between 27 and 31 August 2023 and did not pass any stones. He did not demonstrate any signs of pain when passing urine. He made a noise when urinating and when asked why, he said he was in pain but was noted not to be distressed. CD reported to staff that GH had been urinating into a jug for about two months to monitor his fluid balance.[18]At the hearing, CD produced some sheets on which were recorded fluid input, urinary output, and notes about stones or other abnormalities. Each sheet had three columns suitable for recording fluids for one day. CD told me that a healthcare professional had given her one such sheet and she had then made photocopies of it for completion. The disclosed completed sheets show that on most days there were hourly entries, and some timed at half hour intervals. The earliest date on the disclosed sheets is 3 July 2023. The last date is 17 September 2023.[19]On 28 August 2023, during his in-patient stay, GH said to Dr K on a ward round that he had painful urination passing black stones that feel hard and “come out with urine.” On examination the following day GH stated that he had abdominal pain but had no response to deep palpation. He was noted to have stated he was in pain but observed to be playing and happy on the ward.[20]On 30 August 2023 a further ultrasound scan was performed and a possible kidney stone was detected (it is now accepted that no stone was shown on the scan). Prior to that result it was recorded that CD felt that the earlier scan had not been sufficiently thorough “feels she saw irregularities in the kidney on the scan. Mum concerned about wanting an overarching diagnosis/explanation for all GH’s historical issues.” GH went home on “home leave” that night, returning to the ward on 31 August whereupon CD reported that he had passed another stone on the night of the 30/31 August. She had not brought it in for the clinicians to see because she had had nothing to put it in. GH had not produced stones during his three previous nights on the ward. He was discharged on 31 August but on 1 September CD attended the ward with a sample bottle containing two small stones.[21]On 2 September 2023 CD again attended the ward reporting that GH was in the car outside in a lot of pain having passed stones in his urine. I rely here on the contemporaneous records for this attendance and the earlier attendance on 1 September 2023 but CD took issue with these records in her oral evidence.[22]On Monday 4 September 2023, CD attended hospital reporting that GH had been passing kidney stones for two weeks of various shapes and sizes and that the stones were now getting stuck in his penis. On examination GH was well but the tip of his penis appeared to be bruised. CD was advised to take GH to A&E which she did that morning, producing urine samples containing a mix of dark and white small stones. GH was admitted overnight for urine screening and further blood tests. During the attendance, CD expressed concern about GH having an undiagnosed blood disorder. Bloods taken during the admission were normal. CD was unhappy about the plan to discharge GH.[23]GH had been due to start year 2 of his school on 4 September but did not attend at all that week. I have received evidence that CD attended school and informed staff that she could not bring him in because he had been in hospital and she had to monitor his fluids and look out for stones. On Friday 8 September 2023, CD again took GH to A&E. She reported that he was in severe abdominal pain whenever he passed urine and stones were coming out almost every day, and “his penis had changed colour when the stones stuck in the penis in the last two days. Reported fever spiking every day.” GH was being pushed in a wheelchair but was noted to be active and happy and running around the assessment cubicle. Examination was normal and GH passed urine normally in the department. CD advised that GH was under investigation for a blood disorder and for a “metabolic and immune disorder”.[24]From Monday 11 September to Thursday 14 September 2023, GH attended school. He was not at school on Friday 15 September and spent time with his father. He did not, as was usually the case, stay with his father overnight. CD told me that GH refused to stay overnight because it was too cold in his father’s house and because his father and paternal grandmother did not believe he was unwell. CD took GH to his maternal grandmother’s house on the morning of Saturday 16 September 2023 and left him in her care whilst she went to the shops and had what she described as some “me time”. She collected GH at about 1700 hours and took him home. The following morning, at about 11.15 am on 17 September 2023 she arrived with GH at A&E with a urine sample that contained urine and objects including two large stones which she said he had passed. The largest was recorded as being 2.5 cms long and triangular in shape. Greenish plant-like matter was noted to be in the sample. CD reported that GH’s temperature had frequently been over 38C over the weekend and that GH had had intermittent abdominal pain, throat pain, and nausea. In the department GH was noted to urinate without any signs of pain or discomfort. GH was admitted to hospital. He did not pass any stones but on 19 September he went to the toilet. CD was seen to be standing behind him and she handed over the sample bottle with a stone in it to Nurse C.[25]A Paediatric Consultant, Dr V, was concerned about GH’s presentation and the fact that the large stones could not feasibly have been passed by him through his penile urethra. Children’s Services were notified and social worker G attended the hospital to speak to GH and CD. GH said to G and Dr V that it hurt when stones came out, that “mummy watched me and it came out and it hurt. Mummy helped pull it out”. He said that his tummy was sore when urinating. Following a strategy meeting held on 19 September 2023, these proceedings were then begun.

Witness Evidence

[26]EF lives with his mother, PQ. GH currently lives with them under an interim care order. I heard evidence from both of them. Since being in EF’s care from 20 September 2023, GH has not passed any kidney stones. He has been generally well with a couple of short-lived illnesses and only one day off school as a result. He has not required any visits to healthcare professionals other than as directed for the purpose of gathering evidence for these proceedings. EF has a full scale IQ of 71. He appeared to me to be somewhat suggestible and to have previously accepted, without question, directions from CD in relation to GH’s health and care. For example, at her insistence, he had ensured that GH had urinated into a jug so that he could measure his urine output. He had photographed possible anomalies after GH had urinated when in EF’s care. Three photographs were provided to me. The first showed two tiny dots apparently attached to the side of a white toilet bowl which I was told was within a hospital. They look like nothing more than tiny stains on the bowl and no-one could reasonably conclude that they were kidney stones from the photographic evidence. The second showed a small dark object lying at the bottom of a white toilet bowl. EF told me that GH had drawn his attention to this as a possible stone. I was told that this photograph had been taken at home. It cannot be discerned whether the object is hard or soft. It could even be a small piece of faecal material. The third photograph is of a test tube shaped receptacle containing fluid which I was told was urine, within which is floating a small, white substance. The substance could be gelatinous, it could be mucous, or it could be tissue paper or cotton wool.[27]EF and PQ told me that GH was a lovely, happy little boy. EF said that for the first few days after he came to live with them, he noticed that GH made a humming noise when he went to the toilet to urinate. He was unsure whether or not this was due to GH suffering pain, but he soon stopped making the noise and he has had no difficulty with passing urine at any time in EF’s care. GH does continue to take some medication for constipation. GH has not exhibited any symptoms of abdominal pain when in his care.[28]I heard evidence from two members of the administrative staff at GH’s school. They gave evidence that CD would frequently call on them to talk about GH’s medical condition. On a date that they could only identify as being in early September, but when GH was not that week attending school, they said that CD told one of them, in the hearing of the other, that GH had been producing kidney stones and had been taken by ambulance to hospital the previous night. She said that she had found 20 stones in the toilet bowl. The school records show that GH did not attend in the week beginning Monday 4 September, and did attend hospital on 4 and 8 September. He attended school on the 11 to 14 September inclusive, but not on 15 September. It is likely therefore that this conversation took place on the morning of 5 September 2023.[29]I heard evidence from Dr L who saw CD and GH when he was brought to hospital on 17 September 2023. He recorded the history given to him by CD, “Today he has presented to ED and mam states he has woken up at 3am screaming in pain then has passed two very large stones. The largest being approximately 2.5cm in length and triangular in shape (urine samples from today’s attendance and stones have been imaged and sent to medical photography), there also appeared to be greenish? Plant matter inside the sample bottle. He then passed urine normally which was ‘dark and cloudy’. Mam is also concerned that he is not drinking enough fluids as he is scared to urinate. No frank haematuria”.[30]Dr L told me that when CD had gone to use the toilet, he took the opportunity to speak to GH alone. GH had recounted the events “in a similar manner to what his mother had said – woke at 3 am, tried to pass urine but was unsuccessful and went back to sleep. He then woke up again in pain and passed the two large stones one after the other. I specifically asked him if he had noticed a bulging in his penile opening as the stones had passed in the morning, but CD returned before GH could answer. In his oral evidence Dr L said that CD had said, “Yes it stretched.” Dr L noted that CD was reluctant to allow GH to answer questions alone.[31]Dr V was the Consultant Paediatrician who was called to attend on GH on 17 September 2023. He gave oral evidence and confirmed his detailed statement of what CD had said to him on admission on 17 September 2023 when she had also handed over a sample pot containing a number of stones, one of which measured 2.5 cms long. In his statement he wrote, CD told me that she had been asked by a doctor to measure GH’s GH`s urine output and GH was passing urine in a jug at present. CD told me that she saw GH having difficulty passing urine and saw him passing a kidney stone from his `todger` [penis] pointing to GH`s private parts. CD told me that this occurred on Saturday night at 03 00. She had brought the stones with her and they were taken by the medical staff and sent for analysis. She told me that the problem with the kidney stones was getting worse and that he was passing more stones. She told me that the stones were getting bigger. She also reports that GH was passing urine more often and that his penis had been `purple`. She told me she was concerned his body `is producing stones as a conveyor belt`. When I asked her specifically if she was present when GH was passing urine, she said `yes`. I asked CD to describe what she saw and she told me `I was with GH and he was having pain passing urine, and he cannot pass urine and I saw him pass the kidney stone in the toilet` CD also told me that one of the stones was `big` and `was stuck at the end of the todger` and she told me she had to `pull it out carefully`”[32]I heard evidence from Nurse C who said that on 19 September 2023, when GH had been an in-patient, she had heard GH ask CD if he needed to go to the toilet. She watched GH go to the toilet near to the nurses’ station, and CD stand behind him with the toilet door left ajar. He used a grey cardboard urine bottle. She heard no noises or expressions suggesting discomfort or pain. Then CD had said “Nurse. Nurse look it’s another stone.” CD came out of the toilet holding the cardboard urine bottle and shaking it. The nurse took the bottle and examined the contents. It contained only 1 ml of urine and a small round brown object.[33]CD gave evidence over the course of just over a day. She had regular breaks every 45 to 60 minutes in addition to an hour’s break for lunch on the first day. We paused at 3.30 pm on the first day of her evidence. Her intermediary was present alongside her throughout her evidence and Counsel framed questions in simple language. CD handled a plastic fidget item during her oral evidence. She was fluent in her answers and appeared to have fully understood the questions prior to giving the answers which I recorded. At times she demonstrated a very good facility for remembering dates and medical terms.[34]It was quite clear to me that CD has misunderstood or was unable to recall some important advice given to her by healthcare professionals. She had a good knowledge of prescribed medication, investigations, and diagnoses, but she has fixated on certain things said to her, elevating them to a level of importance that they were not intended to have, whilst disregarding or forgetting other advice that was important. For example, someone may have said to her that she could monitor GH’s temperature or even his oxygen saturation if she was concerned, but she has interpreted that as an instruction to do so over a prolonged period, even for it to be done when GH was at school. But when given important advice that there was no serious condition underlying GH’s constipation, she has effectively disregarded it and has maintained the view that doctors have simply not got to grips with GH’s condition and are missing something serious. She told me that she has felt “fobbed off” by doctors. She has not been satisfied by reassurance and she has latched on to any hints of a sinister underlying illness. I have no evidence that CD has adopted this approach out of malice or with intent to cause GH harm. It is true that she did occasionally express the view that professionals were out to do her down, but I do not believe that she has been driven by animosity to others. Rather, her anxieties and rigid thinking have led her to focus on passing comments that she has taken as suggesting that GH might have a serious condition, whilst ignoring clear and direct reassurances that he does not. I am sure that this tendency is due in large part to her learning disability and autism spectrum disorder.[35]In a similar vein, CD has somewhat obsessively recorded GH’s temperature and fluid balance. The reported fevers have simply not been substantiated when GH has been seen by medical professionals. There is a clear pattern of CD recording GH’s temperature, reporting high temperatures, but GH’s temperature being within normal range when measured by someone else.[36]The fluid balance charts appear to be meticulously completed but CD described to me that she would complete the times at the beginning of each day. Hence the times when GH is recorded to have drunk some fluid or to have passed urine, are usually only accurate to the nearest hour. Furthermore, in her oral evidence CD accepted that she had completed entries for at least three days, 11 to 13 September 2023, when GH had been at school between about 0900 and 1530 hours. So, it seems, had EF on 11 September 2023 when the handwriting appears to be his for most of the entries. CD explained that GH would come home from school and tell her what he had drunk so that she could complete entries on the record sheet. It is fair to note that there is perhaps only one entry for an amount of fluid passed as urine that clearly falls within school hours, and that may be an error in completing the form, but the entries for fluid input during school hours are clearly unreliable.[37]Whilst allowances must be made for error and confusion due to CD’s learning disability, there were other aspects of CD’s evidence that went to her honesty rather than to her level of cognitive functioning. CD’s evidence at court was that only once had she seen a stone within or emerging from GH’s penis. On that occasion it had been a large stone and she had “teased it out” with her fingers. At all other times she had either heard a stone fall into the jug he was using or seen stones in the jug or seen something in a toilet bowl. She maintained that on many occasions when GH had seemingly passed a stone, he had had no opportunity to access the garden or any plants in the house which might have gravel or stones within their pots. Parts of her evidence on these matters went to her honesty and credibility: i) I was struck by how freely CD introduced new evidence in her oral testimony in order to provide a rebuttal to a point put to her or to underline a point she wished to make. For example, when asked why, on her evidence to the court, she had never once stood by GH and watched him urinate to see whether he passed a stone given her heightened anxiety about the number of stones he was producing, she said that he had not allowed her to stand and watch him. This was not something she had put in any of her witness statements. Likewise she began to tell me of a clinician who had seen blood in a urine sample but had then simply thrown the sample away. This was new evidence apparently given off the cuff. ii) CD reported to healthcare professionals on several occasions in September 2023 that she had seen stones which had become stuck in GH’s penis. Now she states this happened only once. In her oral evidence she settled upon the night of the 17 September 2023 for this memorable event, but in her written witness evidence she gives an account of this happening on 4 September 2023. Even allowing for confusion as to the date, it is difficult to accept that CD is confused about whether this happened once, as she now says, or more than once, as she reported at the time to healthcare professionals. iii) CD’s reports of symptoms suffered by GH attributable to passing kidney stones are inconsistent with the physiological process. As Dr Coulthard has advised (see below) the process of passing a stone from the kidney to the bladder is well known to be excruciatingly painful. Most patients never pass the stone from bladder to urethra because the pain of the movement of a stone to the bladder is so great that they attend for emergency treatment, the stone is identified, and treatment is given such that the stone is never passed down the urethra. CD repeatedly reported that GH suffered abdominal pain on urinating when passing stones out of his penis. She did not report evidence of excruciating pain when not urinating or passing a stone from the penis. Also the pain on passing a stone through the penile urethra would not be abdominal but would be in the affected area. CD’s reports are consistent with her imagining incorrectly, what the symptoms would be on passing a stone, rather than reporting genuinely what symptoms GH was exhibiting. iv) On occasions too numerous to list, CD made a claim in her oral evidence that was flatly contradicted by contemporaneous evidence in the medical records or the witness evidence of others. When the conflict was pointed out to her, she said that the notes were wrong. These included the detailed evidence of Dr V, the evidence of the administrative staff at GH’s school, and medical records completed by Dr L. The inconsistencies between their evidence and notes, and the evidence of CD, were stark and cannot be glossed over as minor differences in recollection or confusion on the part of CD. For example, she told me that she had not taken GH to hospital on 16 September notwithstanding that on her evidence he had produced eight stones, because he was otherwise well, whereas the medical notes record her report on arrival at hospital on 17 September 2023 that GH had been ill all weekend. v) Often, CD’s evidence was internally inconsistent. For example, she denied that she had gone into GH’s school in September to speak to the administrative staff which, if so, would mean that they had both concocted their evidence of that event. Then, CD denied having told the staff that she had seen 20 stones in the toilet bowl on one day but was referring to 20 stones over a period of a few weeks. So, she denied any such conversation but then corrected their evidence about a part of that supposedly non-existent conversation.

Expert Evidence

[38]In addition to the expert psychological assessments to which I have already referred, I have received expert opinion evidence from Dr Mecrow, Paediatrician, and Dr Coulthard, Paediatric Nephrologist. I can deal with their very helpful evidence quite shortly. Dr Mecrow advised the court that the evidence suggested that GH was generally a well child. He reached the following conclusions in his written report which he maintained in his oral evidence:
“In the first two years of life, GH was taken for review by healthcare professionals on an extraordinary number of occasions. These reviews did not lead to any adverse effect on his health and although I believe that many of them were unnecessary, I do not believe that he was a victim of fabricated or induced illness at this point but rather would advise the Court that the pattern of consulting was almost certainly the result of excessive parental anxiety. GH has indeed suffered with a number of medical conditions which have required investigations and treatment some of which have proved difficult to treat. These conditions include chronic constipation, urinary tract infections, episodes of tonsilitis, mycoplasma pneumonia and infection with Covid 19. I cannot conceive of any way in which a child at GH’s age could have passed the stones that are said to have been removed from the tip of the penis or found in his urine. Fabrication of symptoms involving the insertion of extraneous substances into his urine is overwhelmingly likely in my view.”
[39]Dr Coulthard provided written evidence but was able to consider further evidence about the stones presented by CD as having been produced by GH before giving his very careful and well-informed oral evidence. He was very clear indeed that GH had not ever produced a single kidney stone. GH does not have a condition such as oxalosis which can give rise to production of stones in children. The stones were of different colours. Some were plainly too large to have been passed through a child’s penile urethra, or indeed from the kidney to the bladder. He described how excruciatingly painful is the passage of a stone from the kidney to the bladder along the ureter. Most children and adults present at an A&E department at that stage, their stone is identified and it is treated so that it never leaves the bladder to pass through the urethra and then exit the body naturally. He could not conceive of the possibility of GH passing a stone of more than 5mm diameter and that would be extremely painful to pass and would cause some physical trauma.[40]Dr Coulthard told the court that in his years of practice he had been involved with one 12 year old child who “faked” the passage of stones on one occasion by using gravel she had taken from a plant pot within the bathroom at her home. Members of her family had been having kidney stones. There was no repeat of the incident. He rightly raised this case to demonstrate that children can do surprising things and that faking the passage of kidney stone cannot be said to be impossible. He properly accepted that if the court were to accept that the stones presented by CD had not been emitted naturally by GH then it was for the court to determine how they had come to be presented at hospital as having been passed by him.

Legal Framework

[41]The following principles apply to this finding of fact hearing:a. The burden of proof lies on the party that makes an allegation of fact and identifies the findings they invite the court to make. There is no burden on a parent to produce an alternative explanation and the rejection of any alternative explanation does not establish the applicant’s case.b. The standard of proof is the balance of probabilities. The inherent probability or improbability of an event should be weighed when deciding whether on balance the event occurred, but the standard of proof remains the same however serious the allegation may be.c. Findings must be based on evidence not suspicion or speculation - Re A (A child) (Fact Finding Hearing: Speculation) [2011] EWCA Civ 12 per Munby LJ.d. The court must take into account all the evidence and consider each piece of evidence in the context of all the other evidence –Re T [2004] EWCA Civ 558, [2004] 2 FLR 838 per Dame Elizabeth Butler-Sloss, President.e. The opinions of medical experts must be considered in the context of all the other evidence. The judge must never forget that today’s medical certainty may be discarded by the next generation of experts – Re U, Re B [2004] EWCA Civ 567 per Dame Elizabeth Butler-Sloss, President.f. The evidence of the parents and any other carers is of the utmost importance and they must have the fullest opportunity to participate in the hearing. The court must form a clear assessment of their credibility and reliability.g. It is not uncommon for witnesses in these cases to tell lies in the course of the investigation and the hearing. The court must bear in mind that a witness may lie for various reasons, such as shame, misplaced loyalty, panic, fear, distress. The fact that a witness may have lied does not necessarily mean they are guilty of the matter alleged against them and the fact that the witness has lied about some matters does not mean that he or she has lied about everything: see R v Lucas [1981] QB 720. The court should invite counsel to identify the deliberate lies upon which they seek to rely, the issue to which they relate, and on what basis it can be determined that the explanation for the lies is guilt – see A, B, and C (Children) [2021] EWCA Civ 451, per Macur LJ at [57]. Similar caution should be applied to a respondent giving an unsatisfactory or incomplete explanation for an allegation made against them.

Guidance

[42]In February 2021, the RCPCH published new guidance, Perplexing Presentations (PP) / Fabricated or Induced Illness (FII) in Children, which includes a list of “alerting features” of possible Fabricated or Induced Illness (“FII”) which are not diagnostic, but which should, cumulatively, trigger a response from clinician:
“In the child • Reported physical, psychological or behavioural symptoms and signs not observed independently in their reported context • Unusual results of investigations (e.g. biochemical findings, unusual infective organisms) • Inexplicably poor response to prescribed treatment • Some characteristics of the child’s illness may be physiologically impossible e.g. persistent negative fluid balance, large blood loss without drop in haemoglobin • Unexplained impairment of child’s daily life, including school attendance, aids, social isolation. Parent behaviour • Parents’ insistence on continued investigations instead of focusing on symptom alleviation when reported symptoms and signs not explained by any known medical condition in the child • Parents’ insistence on continued investigations instead of focusing on symptom alleviation when results of examination and investigations have already not explained the reported symptoms or signs • Repeated reporting of new symptoms • Repeated presentations to and attendance at medical settings including Emergency Departments • Inappropriately seeking multiple medical opinions • Providing reports by doctors from abroad which are in conflict with UK medical practice • Child repeatedly not brought to some appointments, often due to cancellations • Not able to accept reassurance or recommended management, and insistence on more, clinically unwarranted, investigations, referrals, continuation of, or new treatments (sometimes based on internet searches) • Objection to communication between professionals • Frequent vexatious complaints about professionals.”
Parent behaviour The guidance also addresses parental motivation:
“There are two possible, and very different, motivations underpinning the parent’s need: the parent experiencing a gain and the parent’s erroneous beliefs. It is also recognised that a parent themselves may not be conscious of the motivation behind their behaviour.”

Analysis

[43]Whilst being wary of medical certainties, the expert opinion evidence in this case was authoritative, very persuasive, and completely clear: GH did not pass any kidney stones in the summer of 2023. i) It is rare for a child of GH’s age to pass kidney stones. ii) If kidney stones enter the ureter from the kidney to the bladder, this causes excruciating pain. There are no reports of that kind of pain afflicting GH. iii) GH did not and does not have oxalosis and he had no risk factors for creating stones. iv) If GH had a condition causing him to produce kidney stones, the stones would all be of the same colour whereas GH’s stones were of differing colours. v) Some of the stones – those above about 5mm diameter – were simply too large to pass from his bladder down the penile urethra and then to be emitted, even had there been evidence of trauma to the urethra or penis which there was not. vi) Even stones below 5mm diameter would cause some trauma on passage but there was no macroscopic or microscopic blood in GH’s urine and no evidence of trauma beyond one occasion when some possible bruising was noted to his penis. The expert opinion evidence has not been challenged by Mr Pike on behalf of CD.[44]In the summer of 2023 GH was urinating into a plastic jug so that CD could measure his urinary output in order to complete the fluid balance charts she had copied and which she thought important to complete. If he was not emitting stones into the jug for CD to put into pots and present to healthcare professionals, the question arises as to where the stones came from. Having considered the evidence carefully, I have no doubt at all that CD put the stones into the pots herself. The main reasons for reaching that conclusion are: i) It is highly unlikely that GH himself pretended to have passed the stones from his penis. CD herself did not suggest that GH put the stones in the jug. Mr Pike on behalf of CD put the best case he could that GH may have placed the stones in jugs and toilets himself, but that case is not at all credible. The burden of proof remains on the Local Authority – CD does not have to establish that GH was responsible. However, I am quite satisfied that GH was not the agent for putting stones in jugs or pots. Firstly, the evidence before me was that no-one had discussed the notion of kidney stones with him before he “produced” the first stone. CD told me that she had not discussed with him her own anxieties about producing kidney stones. As a 6 year old boy he would have had no notion of how the kidneys can produce stones which can then pass through the bladder into the penile urethra. Secondly, he would have had no motive to fake the passage of stones. Thirdly, for him to have been responsible he must have put stones in the plastic jug over a period of at least four weeks and then, as unaccountably as he had started, stopped as soon as he was placed in the care of his father. Fourthly, he would have carried out this campaign of deception wholly undetected by his mother or maternal grandmother even though they were sometimes in close proximity to him when stones were found in the jug. On one occasion he was naked in the bath when, according to both his mother and maternal grandmother, he passed a stone into the jug. How could he have achieved that deception? Finally, CD said that on a number of occasions when GH apparently passed a stone, he had not had access to any stones in the garden or otherwise. ii) Other than on 16 September 2023 and perhaps on one or two other occasions, the only other person present when a stone appeared in the plastic jug was CD. iii) CD has told the court that on one occasion she saw a stone wedged in the tip of GH’s penis such that she had to “tease it out”. She told healthcare professionals that she had seen this more than once. Even if it was on only one occasion, if the account from CD is true then, given that the stone was not emitted from the penile urethra, either the stone must have been pushed into the penis opening or the event never occurred and CD has fabricated it. I find it to be highly unlikely that GH pushed a stone into his own penis such that it became wedged inside. Accordingly, I am quite satisfied that CD’s account is untrue. I am fortified in this conclusion because(a) CD has variously said that the stone was large and that it was only a piece of grit;(b) that this happened once and that it happened more than once;(c) that the one time it happened was on 4th September, and that it was on 17th September. This would have been a memorable event had it happened, and CD’s significant inconsistencies point to fabrication. iv) I have already commented on aspects of CD’s evidence that go to her credibility. CD’s evidence has been riddled with internal inconsistencies and incompatibility with contemporaneous records. It is always possible that medical records may not be wholly accurate but in this case, there would have to have been multiple instances of widespread errors in the contemporaneous notes for CD’s account to the court to be truthful. I make full allowance for her learning disability but cannot avoid the conclusion that the core of CD’s evidence about the kidney stones is untrue. There would be a thread of consistency running through her evidence had she been telling the truth, but that thread is wholly absent. v) Despite her assertions of almost daily stone production, GH only appeared to produce one stone in hospital, and that was on 19 September 2023 when CD was standing behind him and when she then handed the cardboard urine sample bottle to Nurse C announcing that GH had produced another stone. Nurse C neither saw nor heard any evidence that GH had suffered distress or pain consistent with passing a stone. I discount the photographs EF took of possible stones in toilet bowls – they do not appear to me to be stones. vi) GH has not passed any stones, nor has he had any urinary problems, since he was placed in his father’s care in September 2023, some six months ago. It is possible he could have spontaneously stopped producing stones, but it is a striking fact that, once removed from CD’s care, the reports of kidney stones ended. vii) CD’s account is inherently improbable and incredible. All the evidence shows that she is anxious about the health of her child, yet when he starts to produce stones through his penis at an alarming rate, she maintains that she never stood by him to watch him when he urinated.[45]Mr Pike submitted that it is also inherently unlikely that CD would “plant” stones in the jug or pots. I acknowledge that submission, but find that CD’s fabrication in respect of GH passing kidney stones fits with an escalation in her attempts to attract medical attention for him. I bear in mind the RCPCH’s guidelines quoted above, and forms of parental behaviour that are alerting features of possible fabricated or induced illness. They include insistence on continued investigations instead of symptom alleviation when reported symptoms are not explained by any known medical condition or by the results of examinations or investigations, reporting new symptoms, repeated presentation at medical settings including emergency departments, seeking multiple medical opinions, and not being able to accept reassurance. All of those features apply to CD in the year or so before 20 September 2023. The chronology shows that CD pressed for further investigations of a possible bowel condition, including cancer and ulcerative colitis, and then for a possible underlying condition causing repeated fevers, but then when all possible investigations had been exhausted and she was effectively refused further investigations, new symptoms were reported, escalating to the reports of kidney stones.[46]Mr Pike submitted that the fact that in her oral evidence CD did not take the opportunity to blame GH for having planted the stones in the jug, pointed to her honesty. She could have blamed GH to deflect from her own responsibility but she did not do so. There are a number of reasons why CD may not have sought to blame GH even if she herself had fabricated the evidence of kidney stone production, not least that her fabrication was not designed to harm him but to bring medical attention to him which she felt was needed.[47]CD told me in her oral evidence that she felt she was being “fobbed off” by medical professionals. They were “hiding something”. I am sure that her reports of kidney stones were designed to initiate further investigations with a view to someone finding out what was wrong with GH. In fact there was nothing wrong with him save for some childhood illnesses and a problem with constipation. CD did not see it that way and wanted to prompt further medical attention and investigation, hence the false reports of kidney stones.[48]The fixation with a belief that something is seriously wrong with GH has been a prominent motivation for CD’s behaviour and is one of the motivations for FII recognised by the RCPCH 2021 guidelines. The other recognised motivation – some sort of reward or gain for the parent – is also present in this case: CD enjoyed having some power over others by reason of GH’s supposed illnesses and the need to address them. She would give clear instructions to EF to take temperatures, keep records of fluid balance and so on. She would make similar requests at the school and enjoy talking to staff about her son’s condition and needs.[49]GH stopped “producing” kidney stones as soon as he was removed from his mother’s care. In 2022 and 2023 he was never found to have a fever when in the care of others. The only evidence of fevers in that time is from reports by CD. GH is regarded as a well child at school and when in the care of his father.[50]I have had to consider the role of GH’s maternal grandmother. I regret to conclude that she has also been dishonest with the court. I am sure that she has done so in order to support her daughter. At meetings with professionals which she has attended she has been a staunch supporter of her daughter even in the face of compelling evidence that GH was not ill and was not passing stones. In her statement to the court she said that the first time she was aware of stones being passed was when she was present at her daughter’s house. CD had had to help GH remove a stone from his penis. Two stones were passed and CD handed them in to the nurse at the GP practice. The records show that that occurred on 22 August 2023. That was not a date when CD said she had teased a stone from GH’s penis. CD said that she had been alone with GH when that happened. The maternal grandmother then gives an account of GH passing a stone when in the bath with her and CD present. The clear medical evidence is that GH has never passed a stone. Although she does not claim to have seen it emerge from GH’s penis, her account is not consistent with GH having put it into the jug he was using or with CD having put a stone in the jug. Most clearly, the maternal grandmother has given unreliable evidence about events on 16 September 2023. She says in her statement that when GH was in her sole care and presence that day, he passed five stones. A record sheet was produced which records stones passed at 0600, 0700, 1000, 1100, 1600, 1700, and 1800 hours (two stones on the last occasion). CD’s evidence was that she recorded all but two of those stones. During the hearing text messages were produced after JK had given evidence, which showed that at 1730 hours that day CD texted her mother to say that GH had passed another two stones. Clearly GH was in her care at that time, not with his grandmother. And yet the maternal grandmother describes the colour and size of those stones in her statement. She cannot ever have seen those two stones.[51]After JK’s evidence had been given, a text from her was disclosed. It was dated 9 September 2023, written to CD, and referred to GH passing a stone. The maternal grandmother had not referred to this in any of her written or oral evidence. I accept that she may have thought on 9 September that GH had passed a stone but she cannot have been sure of what she had seen that day otherwise it would certainly have been included in her otherwise detailed statement.[52]The photographs taken by EF do not provide any corroboration of GH having produced stones himself, nor of his having faked passing stones. The photographs of dark objects are wholly inconclusive and could be images of stains or other material. The white substance photographed in the third image is clearly not a stone-like object within the urine sample and is not relevant to my consideration.[53]I turn to the findings sought. I see no requirement to make findings in relation to each and every one of the very many allegations set out in the Local Authority’s Schedule. I begin by addressing those allegations that relate to deliberate fabrication of illness, as opposed to misreporting or exaggeration due to misunderstanding or poor memory or which might be accountable by reference to CD’s learning disability and/or ASD. I stand back to consider all the evidence in this case. I bear in mind the burden and standard of proof and the legal principles set out above as they apply to findings of fact. This case has not been difficult to resolve – the evidence very clearly establishes the following findings (with the equivalent paragraph numbers as per the Local Authority’s Schedule). I have added some details to the allegations in the Schedule so that the findings can be precisely stated without reference to the multiple other allegations in the Schedule: i) Between 22.08.2023 and 17.09.2023 CD presented GH to medical clinicians reporting that he had passed kidney stones into his urine at home [6]. ii) CD fabricated her accounts of GH passing kidney stones and added non-renal stones to GH’s urine samples [19].

(f) ]

[54]In addition, I find that CD has misreported and/or exaggerated GH’s symptoms, and what other clinicians have advised her, when presenting GH to healthcare professionals, but that when doing so she has not acted dishonestly or maliciously. For example, in 2023 she repeatedly reported that GH had a blood disorder when investigations had ruled that out. There are very many instances of this kind of misreporting.[55]The conduct set out below arises from CD’s fixed beliefs that doctors had missed some serious underlying condition, and that she needed to be extremely vigilant to monitor GH’s condition, and from her inability to accept reassurance. I remind myself of Dr Mercow’s evidence that in the first two years of GH’s life the number of medical attendances could be attributed to excessive parental anxiety not FII. I am sure that anxiety also explains some of CD’s conduct from January 2022 to August 2023 before the reports of kidney stones. I am not sure that there is a clear line between categorising over-presentation and a drive for unnecessary medical investigation as due to excessive anxiety or due to unconscious FII. For the purposes of making findings of fact I do not regard it as necessary to draw that line. My specific findings are: i) From early 2022, CD misreported and/or exaggerated GH’s presentation, symptomatology, and health, in particular in relation to urination, constipation, and fever [6]. ii) From early 2022 to February 2023, CD misreported GH’s symptoms of high temperatures, fever, and night sweats [28 and 29]. iii) From early 2022 CD has sought further medical opinions and further tests for GH when none was indicated [8(1)]. iv) From early 2022 CD has misreported and/or exaggerated the information she gave to professionals about what other professionals had advised [8(2)].[56]I do not regard these found facts in the previous paragraph to be attributable to dishonesty or malice. However, I do find that they were due to fixated beliefs, excessive anxiety, refusal to accept reassurances, and rewards to CD that having a supposedly sick child brought her, as I have addressed above.[57]Since GH has been living with his father he has been well and has not produced kidney stones. He has had the odd short illness as can be expected of a young child, but he has not needed attention in hospital. When he was living with CD he was in and out of hospital a lot and was having tests and investigations he did not need.[58]I find that as a result both of CD’s dishonest conduct and her misguided conduct as set out above, GH has undergone multiple unnecessary medical tests and investigations including the taking of blood samples which CD has told me he found particularly distressing, ultrasound scans, bowel studies and physical examinations. He has had avoidable periods of in-patient treatment and avoidable medication. He has missed time from school as a result of unnecessary monitoring and treatment. He has been encouraged to believe that he was a sick child. Furthermore I note that he had a bruised penis tip when examined on 4 September 2023. I cannot know the precise circumstances in which this occurred because, as I find, CD has not told me the truth about teasing out a stone from GH’s penis on that or any other day. It is possible however that CD pretended to GH that he had a stone coming out of his penis and she caused bruising when doing so. Finally, I also note that GH has given accounts of passing stones and of it hurting when he did so. Either he has simply picked up on the reports CD was making, or he has been told to say this, or he has come to believe that stones he has been shown by CD had indeed come from his penis. I do not make any finding as between these possible explanations, but they all point to further harm to GH arising out of CD’s dishonest fabrication of illness.[59]I am satisfied that the findings I have made establish that GH has suffered significant harm and is likely to suffer significant harm attributable to the care given to him, or likely to be given to him if the order were not made, not being what it would be reasonable to expect a parent to give to him [Children Act 1989 s31].[60]These findings shall be recorded in a schedule to be appended to the order that will follow this judgment.[61]A short, plain language summary of this judgment is appended. I delivered that summary orally to CD and EF in court, in non-anonymised form, when handing down this full judgment in writing to the parties and their representatives.