Hampshire County Council v A Mother & Ors [2026] EWFC 72

[2026] EWFC 72Case No PO25C50093
IN THE FAMILY COURT
Date 30/03/2026
Portsmouth Combined Court
Winston Churchill Avenue, Portsmouth, PO1 2EB
Before
THE HONOURABLE MRS JUSTICE JUDD
Between
Hampshire County CouncilApplicant
Zosia Keniston and Grace Navas (instructed by Hampshire County Council Legal Services) for ApplicantKate Branigan KC and Baljinder Bath (instructed by Larcomes) for 1 st RespondentBen Birtchnell (instructed by Hepburn Delaney) for 2 nd RespondentSteven Howard and Syra Flaxman-Ali (instructed by Child Law Partnership) for 3 rd-4 th RespondentsHearing Hearing dates: 4 th-6 th, 9 th-13 th March 2026
Approved JudgmentThis judgment was handed down remotely at 10.30am on 30 th March 2026 by circulation to the parties or their representatives by e-mail and by release to the National Archives..............................THE HONOURABLE MRS JUSTICE JUDDThis 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, must ensure that this condition is strictly complied with. Failure to do so will be a contempt of court.

Introduction

[1]This is a fact finding hearing in care proceedings concerning two young children, X, aged almost three, and Y, just over a year. In March 2025, their mother was looking after both of them as well as the young child of her partner, a little boy called Z, aged two and a half, whilst her partner was out at work when Z suffered significant head injuries from which he subsequently died. This hearing has been listed to determine whether those injuries were inflicted or accidental. The background[2]The mother is in her early twenties. She started a relationship with the father when she was in her teens. She has said that he was very abusive to her, and the relationship broke down shortly after the youngest child was conceived. She remained living in a rented property with both the children. In late 2024, she met Z’s father and began a relationship with him. He began to spend time at her home. He had an amicable arrangement with Z’s mother whereby Z spent weekends with him and, after the start of the relationship with the mother in this case, Z started to spend Tuesday nights with them, with the mother taking him and her two children to playgroup the following day. The events of 5th March 2025[3]In this case, I have a good and early account of the events of 5th March from the mother herself. I have a recording and transcript of the 999 call she made that morning. This is followed by several hours of live recording from the body worn camera of the police officer who attended the home within an hour of the 999 call. As this mother was not the mother of the deceased child she remained at home during the course of the morning, together with her own children who were almost three and nearly one respectively. During the course of this recording, the mother spoke a good deal about what she said had happened that day. What is more, there is a lot of footage of her own daughter interacting with her and also with the police officer. This is all very valuable material from a forensic perspective.[4]The mother was interviewed by the police for the first time at lunchtime on 6th March, and gave a further account. She was interviewed on four further occasions, most recently in February 2026.[5]She has also filed a detailed witness statement in these proceedings and given evidence to me. The history she has given has been broadly the same throughout, as set out below.[6]Z’s father went out to work at about 7am that morning, leaving the mother with Z, X and Y. She was in the process of getting them ready to go out to playgroup, getting them dressed and washed, finding their shoes, and getting them something to eat. At around 8.30am, or thereabouts, the children were in the front room, which is adjacent to the galley kitchen. It was almost time to go. The mother said she decided to make herself a quick cup of coffee. The kettle had been boiled already for Y’s bottle, so she poured some water into the cup, onto a sachet of instant coffee. She said that X and Z were jumping on the sofa in the front room.[7]As she was making her coffee, she heard a bang. She saw that X and Z had fallen onto the floor. X was crying. She went to the children. X was trying to pull Z’s arm, but Z himself was lying still, with his eyes open as if he was stunned. She went to pick him up, and when she did so she said that he was completely floppy, like a rag doll. She put him over her shoulder, found her phone and called 999. She put him down on the sofa and spoke to the call operator. She gives more detail about this at various points, which I will refer to later.[8]On the 999 call, the mother describes Z as having short and sharp breaths. She also said that that he was very floppy, and sounded like he was snoring. She can be heard talking to Z, and said that his eyes were flickering at one point making her think that he was coming round. She also thought that his breathing was picking up, that he had a ‘little stretch’, and at one point that he was squeezing her hand.[9]The ambulance crew arrived at the end of the call, and so the mother then ended that call and spoke to the father. Z was taken out of the house into a waiting ambulance and treated there. Shortly before 10 am, 45 minutes after the 999 call, the police arrived and went into the home. They stayed there for a very considerable length of time. Z’s condition[10]When the ambulance crew arrived, initial investigations revealed that Z had unequal pupils, abnormal posturing and intermittent pauses in breathing despite his oxygen saturations remaining normal. There were no external signs of injury. The Air Ambulance was summoned with a critical care medical team. They found Z to have increased tone in all limbs, and he began to have a seizure. He was given immediate treatment and then transferred to hospital.[11]During the transfer, he became hypertensive with a low heart rate. He arrived at hospital at 11am. By that time, his right pupil was fixed and dilated, and his left pupil was small. There were no injuries seen on his body save those which were explicable by his age and mobility. He was intubated and ventilated.[12]A CT scan was performed which showed that Z had acute subdural haemorrhage, more extensive on the right-hand side. He had blood in the interhemispheric fissure. There was extensive bilateral cerebral loss of grey/white matter differentiation and associated brain swelling, demonstrating hypoxic-ischaemic injury. The deep grey nuclei remained visible but were lower in density than normal. There was generalised mass effect, and complete effacement of the cerebral sulci. The mid brain was distorted, the fourth ventricle was partially effaced, the third ventricle was slit, and the lateral ventricles were narrow. There was no fracture of the skull or scalp swelling. There were no abnormalities seen on the CT scan of the spine.[13]Z was taken to the operating theatre where a right depressive hemicraniectomy was performed but this could not relieve or halt the brain swelling. The family were told that he was unlikely to survive. A number of further investigations took place, including a CT of the abdomen and pelvis which showed hypoperfusion of the bowel, likely a phenomenon secondary to the brain injury. There were no other injuries. When he came out of surgery his pupils were fixed and dilated.[14]A later CT scan of the brain showed that the subdural collection had increased on the left convexity, extending over the frontal and parietal lobes. There was a suspicion of an acute venous sinus thrombosis. An ophthalmology assessment by the on-call registrar took place, showing that Z had extensive retinal haemorrhages in both eyes. An assessment conducted by the consultant the following day gave similar results, with the addition of bilateral and macular retinoschisis with haemorrhage.[15]The treating team at the hospital concluded that there was no prospect that Z would survive, and with the agreement of Z’s parents, it was decided that he would be extubated. He was certified dead at 9.30pm on 6th March 2025.[16]It was the view of the treating doctors that the history of a low-level fall was very unlikely to explain the constellation of injuries to the brain and eyes, and that these were more in keeping with inflicted injury. The proceedings[17]Emergency Protection Orders were sought and granted with respect to X and Y and they were placed with the maternal grandmother on 6th March. The following week they were placed in foster care where they have remained ever since.[18]Permission was given in the family proceedings for the instruction of experts, namely Dr. Leadbeatter, Consultant Forensic Pathologist, Mr. Jayamohan, Consultant Paediatric Neurosurgeon, Dr. McPartland, Consultant Ophthalmic Pathologist, and Dr. Kate Ward, Consultant Paediatrician. Later Dr. Keenan was consulted due to some concerns about the haematology results. I have had the benefit of reading all these reports as well as the reports provided within the criminal/coroner’s investigation, from Dr. Du Plessis (Consultant Neuropathologist), Dr. Malcomson (Consultant Ophthalmic Pathologist), and Dr. Annavarapu (Consultant Paediatric and Perinatal Pathologist).[19]The police have conducted a detailed enquiry and have disclosed their evidence into these proceedings. Medical records have been filed, as well as statements from the local authority and the mother. Findings sought[20]The final version of the threshold document was filed by the local authority at the end of the evidence.[21]It is alleged as follows:- i) Z, Y, and X, were in the mother’s sole care on the morning of 5th March 2025 at the mother’s home address when Z suffered significant injuries. ii) During his primary survey, Z had a seizure with dilated pupils and clonic or repetitive movements of all four limbs and arching of the back. Z had some bloody saliva through the trismus as a result of his injuries. iii) Z sustained the following eye injuries:- a) extensive haemorrhages in all four quadrants to the periphery in multiple layers of the retina; in the left eye the retinal haemorrhages extend from the posterior pole to the far periphery at the ora serrate and are “too numerous to count”; b) a peri-macular fold in the retina of each eye with overlying large retinoschisis cavities; c) severe expansive optic nerve sheath haemorrhage in both eyes, which is predominantly subdural, but subarachnoid and intradural components are also seen; d) a mild peri-papillary scleral haemorrhage around the circle of Zinn-Haller in the right eye; e) in both eyes there is epidural haemorrhage and soft tissue haemorrhage in both orbital fat and extraocular muscles, in addition to perineurial haemorrhage around cranial nerve trunks; f) a subtle focal left optic nerve sheath haemosiderin and cellular reaction fragments of neo membrane which suggest a previous bleeding in those sites. iv) Z sustained severe hypoxic ischaemic injury which resulted in extensive global loss of grey-white differential in the brain. v) Z sustained significant brain swelling causing raised intracranial pressure, which compressed the right lateral ventricle and the basal cisterns. vi) Z suffered extreme encephalopathy, associated with a period of abnormal cardiorespiratory function and consciousness. He had signs of rapidly progressive rising intracranial pressure, with subdural and likely subarachnoid blood seen in multiple locations, which was significantly associated with a widespread dark brain appearance on the initial CT scan. vii) Z sustained the following brain and spinal cord injuries: a) subdural haemorrhage (more extensive on the right); b) subarachnoid haemorrhage; c) pinpoint haemorrhages; d) hypoxic/ischaemic encephalopathy. viii) The culmination of injuries above was an extreme presentation of encephalopathy associated with a period of abnormal cardiorespiratory function and consciousness. ix) The injuries were not caused by any natural disease or organic condition. x) The injuries were caused by a single significant event on 5th March 2025. xi) The cause of each of the injuries was inflicted trauma. xii) The pattern of retinal bleeding, being bilateral, severe, multi-layered and extending to the periphery of the eyes, is very characteristic of abusive head trauma. xiii) The degree of force used to cause the injuries was significantly outside of the normal handling of a child. xiv) At the time the injuries were sustained, the injuries would have caused Z to collapse, lose consciousness and present as extremely unwell which would have been recognisable to any carer. xv) The injuries were inflicted by an impact and a shaking of Z by the mother of Y and X on 5th March 2025. xvi) Z died from his injuries at hospital at 21.32hrs on 6th March 2025. xvii) On a number of occasions, the mother went to the shop at the end of her road leaving either X or Y asleep in the house alone, without any adult supervision. This put X and Y at risk of physical and emotional harm. xviii) The mother regularly used cannabis; this put X and Y at risk of physical and emotional harm. xix) At the date of intervention, X and Y were at risk of suffering significant physical harm and emotional distress as a result of the physical harm caused to Z by their mother. The mother’s response[22]On behalf of the mother, it is accepted that she was alone with the children on the morning of 5th March 2025 and that Z sustained the injuries set out. She denies that they were inflicted by her and submits that they were the result of an accidental fall.[23]Specifically, she denies having shaken, pushed, or thrown Z, or having caused his injuries in any way. She agrees she smoked cannabis in the evenings when the children had gone to bed, and that she sometimes went to the shop leaving a child, or children, behind at home for a few minutes when they were asleep, but she says she never did so without asking a neighbour to keep an eye, and/or ear, open whilst this happened. The Guardian[24]At the end of the case, the Guardian invited me to find that the threshold was not met in this case, and to accept the mother’s account that Z had fallen from the sofa. The Guardian also invited me to find that the shaking type injuries likely arose from the way the mother handled Z in a panic following the accident. The Legal Framework[25]The summary of relevant principles set out by Baker J (as he then was) in Re JS[2012] EWHC 1370(Fam)still provides very helpful guidance for judges in fact finding hearings. The burden of proof lies with the body or individual who makes the allegation. The standard of proof that must be applied, both as to the making of a finding and as to the identification of a perpetrator, is the balance of probability. This is distinct from criminal proceedings. Findings of fact must be based on evidence, including inferences that can be properly drawn from the evidence, and not on suspicion or speculation. Evidence must not be evaluated in separate compartments, and a judge must have regard to the relevance of each piece of evidence in the context of all the other evidence, and to exercise an overview of all of it, before coming to conclusions.[26]There is no ‘pseudo burden’ on a parent, or any obligation to prove the truth of an alternative case by way of a defence and the failure by that party to establish the alternative case on the balance of probabilities does not, of itself, prove the local authority’s case; Re X (No 3)[2015] EWHC 3651 (Fam) and Re Y (No 3) [2016] EWHC 503 (Fam), Wolverhampton City Council v JA and Ors[2017] EWFC 62.[27]In Re A (No. 2)(Children: Findings of Fact) [2020] 1 FLR 755, Peter Jackson LJ said this at paragraph [100]: “The questions for every fact-finder are What, When, Where, Who, and Why? Their significance and difficulty varies from case to case. Some answers will be obvious while other questions can be extremely hard or even unanswerable. Sometimes a question may not need answering at all. At all events the questions come in no set order and each enquiry will suggest its own starting point. It will no doubt find apparently solid ground and progress from there, but conclusions can only ever be provisional until they have been checked against each other so as to arrive at a coherent outcome. At each stage, regard is had to the inherent probabilities and improbabilities surrounding what are inevitably abnormal circumstances”.[28]It must be borne in mind that discrepancies and inconsistencies in evidence can arise in ways that are not sinister or a result of bad faith, see Lancashire County Council v C, M, and F (Children: Fact Finding Hearing) [2014] EWFC 3: “in cases where repeated accounts are given of events surrounding injury and death, the court must think carefully about the significance or otherwise of any reported discrepancies. They may arise for a number of reasons. One possibility is of course that they are lies designed to hide culpability. Another is that they are lies told for other reasons. Further possibilities include faulty recollection or confusion at times of stress or when the importance of accuracy is not fully appreciated, or there may be inaccuracy or mistake in the record-keeping or recollection of the person hearing and relaying the account. The possible effects of delay and repeated questioning upon memory should also be considered, as should the effect on one person of hearing accounts given by others. As memory fades, a desire to iron out wrinkles may not be unnatural – a process that might inelegantly be described as ‘story-creep’ without any inference of bad faith. These words echo the words of Leggatt J in Gestmin SGPS v Credit Suisse (UK) Ltd [2013] EWHC 3560 as to the fallibility of human recollection, and the limitations of memory”.[29]It is the role of the expert to advise but the decision is that of the judge based on the totality of the evidence. The expert is part of the wider canvas of evidence which is to be weighed by the judge against the other evidence; A County Councilv K, D & L [2005] EWHC 144 (Fam).[30]In Re R (Children: Findings of Fact) [2024] EWCA Civ 153 the 8 month old child suffered a serious head injury at a family gathering with several adults present. The consistent account was that, while standing supported by her maternal aunt, C suddenly fell backwards landing with a rag doll under her back, striking her head on the carpeted floor. At paragraphs 33 and 34 of his judgment, Peter Jackson LJ stated as follows:
“33. The court was therefore called upon to evaluate a number of competing improbabilities. The first scenario involved C suffering injuries that were highly unlikely, individually and collectively, to have resulted from a banal domestic fall. The other two scenarios involved other kinds of improbability. In the second scenario, that of a child being shaken by an otherwise loving relative in the midst of a good-natured family gathering; in the last scenario, that of a sustained cover-up on the part of an entire family whose history contains none of the general risk factors that are associated with child mistreatment, while all of the protective factors are strongly present: cf. Re BR (Proof of Facts) [2015] EWFC 41 at para. 18. The court’s evaluation had to take account of the fact that unlikely events occur all the time, although the probability of them arising in any individual case is extremely low: ibid at para. 7. 34. I do not agree with the judge’s concept of speculation at paragraph 204. Of course he was right to say that the court’s task was to determine whether the local authority had proved its case on threshold on the balance of probability. However, that involved grappling with and drawing conclusions from all of the evidence, medical and lay. The medical appearances were clear and the explanation for them was highly likely; but it was not certain, as the judge acknowledged by his finding at paragraph 178i. Against that, the court had the accounts of six people who were with C at the time she was injured. It is wrong to describe the medical evidence as the canvas against which the other evidence was to be considered. Medical and non-medical evidence are both vital contributors in their own ways to these decisions and neither of them has precedence over the other.”
[31]In A (A Child) (Fact-Finding: Head Injury) [2024] EWCA Civ 327, the Court of Appeal allowed an appeal against findings that a baby had suffered an abusive head injury inflicted by one or other of her parents, and remitted the case for rehearing. The salient paragraphs of the judgment of Baker LJ are paragraphs 39 and 43:
“39. Furthermore, the consequence of the judge’s finding was that she was left with a highly unusual medical picture. The child suffered a ruptured cortical bridging vein for which the likeliest cause was said to be impact. Yet it is striking that an impact sufficient to tear this major vein left no other sign of injury. I am not satisfied that the judge gave sufficient consideration to this conundrum before reaching her conclusion that the injury “must” have resulted from a traumatic event. 43. In this case, the medical evidence pointed to the injury having been sustained in a traumatic event. But before reaching a conclusion on that point – and even more importantly, before finding that the injury was inflicted abusively – it was incumbent on the judge to consider the totality of the evidence, including, as Mr Tillyard submitted, the wider canvas evidence relating to these parents and how likely it was that they would injure their child, how possible it would have been for either parent to have injured the child under the circumstances without the other knowing, and the overall credibility of the parents and their account of what had happened. Instead, she found that, on the basis of the expert evidence, the injury occurred because of a traumatic event and that it was abusive.”
[32]The judge must also have in mind that it is not always possible to know the cause of an injury. This has been stated on several occasions in cases such as R v Cannings [2004] 2 Criminal Appeal Reports 63, Re U, Re B [2004] EWCA Civ 567, R v Henderson [2010] EWCA Crim. 1269, Re R (Care proceedings: Causation) [2011] EWHC 1715 (Fam). The words of Dame Elizabeth Butler-Sloss P in Re U, Re B, still have a resonance today:
“The judge in care proceedings must never forget that today's medical certainty may be discarded by the next generation of experts or that scientific research will throw light into corners that are at present dark.”
The medical evidence[33]There is a consensus amongst the medical experts that Z suffered from a catastrophic brain injury, with accompanying retinal haemorrhages. There were also findings in the spine and the posterior ribs. Dr. Annavarapu described the rib findings as fractures, but Dr. Leadbeatter did not. Following his evidence the local authority did not pursue a finding about this. Although the evidence from Dr. Keenan, Consultant Haemotologist, is not able to rule out Z having some sort of minor disorder, on the evidence before me this is extremely unlikely. Dr. Leadbeatter[34]In his report, Dr. Leadbeatter stated that there was evidence of subdural and subarachnoid haemorrhage in the brain and neck, and (largely) subarachnoid bleeding in over 20 sections of the spinal cord. From the post mortem images he noted a possible faded bruise, about 2cm in diameter, towards the top of the left side of the back of the head and somewhat more extensive and less faded bleeding in the soft tissues lower and more lateral in the right side of the back of the head. There was some other bleeding revealed in the dissection of the anterior neck and face which he could not say was not related to the surgery that Z had undergone.[35]Dr. Leadbeatter stated that the changes in the brain were the result of poor supply of oxygen or blood, namely hypoxic-ischaemic injury. Although there was some positive staining in the brain stem, he did not think it was well-defined, so that he was not convinced there was evidence of axonal injury to the neck. Axonal injury is a marker of stretch in the area, but there may be damage to that area that provides a basis for postulating a disturbance of breathing in the child. He saw axonal bulbs and evidence of bleeding into the higher cervical nerve roots but, albeit he said that some would say that they are markers of injury (something he would not disagree with), he would not be able to say what the precise mechanism would be to produce them.[36]Looking at the rib cage, the bone slides revealed changes confined to that part of the back of the rib closest to the backbone and to the lining of the chest cavity, those changes comprising a split at that aspect of the growth plate which contained hypereosinophilic debris, but without any breach of the covering of the bone (periosteum) or unequivocal repair tissue. He substantially agreed with the findings of Dr. Annavarapu, the Consultant Paediatric and Perinatal Pathologist instructed by the police, which are set out in the police bundle at PDF 1068 to 1071. The findings (identified on Micro-CT and by histological examination) were of a number of lesions to the posterior ribs, namely the right and left 7th, and left 11th.[37]Dr. Annavarapu described these findings as fractures, but Dr. Leadbeatter was not happy with this description, in the absence of any disruption across the whole or part of the bone’s width. He preferred to use the term lesion. He was prepared to agree to the use of the term ‘injury’ to describe what he had seen but only on the basis that this term was not equated with the use of external violence. He stated that there is a debate about whether these lesions are a consequence of external violence or from ordinary internal changes in the bone, or in normal activity. Without there being an examination of a control group of children who are not known to have been the subject of trauma, it is not possible to be clear about the significance of such findings.[38]Dr. Leadbeatter agreed with the findings of Dr. McPartland, the Consultant Ocular Pathologist.[39]Overall, Dr. Leadbeatter was of the view that the evidence demonstrated one episode of trauma, shortly before the ambulance was called on 5th March 2025. He said that he had not come across the constellation of findings that there are in this case in the context of an accidental injury, and agreed that it would be highly unusual for the mechanism described in this case to cause the injuries that we see here. Nonetheless, Dr. Leadbeatter’s evidence about this was cautious, and he caveated it several times. He said that there are cases in the literature where injuries like this in a low-level fall have been described. Further, very few cases involve a child of this age and size. If there had been an impact on the back of the head (and the evidence of dusky bruising from the post mortem might be evidence of such) then this would fit with other cases where catastrophic injuries from low level falls have been described. Angular force as well as impact would be necessary, but he could not say that this could not have happened here. It is not possible to know what the precise mechanics are which have acted upon Z. In his oral evidence Dr. Leadbeatter would not go so far as to agree that the findings here would be more likely to be a result of non-accidental as opposed to accidental injury. Dr. McPartland[40]Dr. McPartland found multiple multi-layered recent retinal haemorrhages in both eyes. The haemorrhages extended from the posterior pole to the far frontal periphery ora serrata. Both eyes showed peri-macular folds with overlying large retinoschisis cavities. There was severe expansive optic nerve sheath haemorrhage, predominantly but not exclusively subdural, with subarachnoid and intradural components. In both eyes there was epidural and soft tissue haemorrhage in both orbital fat and extraocular muscles. There was perineurial haemorrhage around the cranial nerve trunks and foci of small fibrin thrombi within vessels in areas of haemorrhage. No papilloedema was seen.[41]Dr. McPartland notes that the subarachnoid space in the left retro-ocular optic nerve sheath was expanded and filled with fluid with relatively small patches of subarachnoid blood. She says she has not come across this finding before. A finding of blood in such a place is not uncommon, but fluid only is. Another unusual finding was surface large plump structures which stained positively for NFP and APP, which Dr. McPartland thought was likely due to neuronal damage at the surface of the perimacular fold and schisis cavity.[42]She found a cellular inflammatory reaction consistent with Z surviving for 36 hours after the incident. There was focal minor haemosiderin deposition in the left optic nerve sheath, of uncertain significance. She considers that the evidence is consistent with there being one traumatic incident shortly before the 999 call.[43]Dr. McPartland stated that it is very important to correlate ophthalmic pathology with neuropathology, other clinical and autopsy findings and other features from the wider investigation. Nonetheless, and in the absence of any underlying bleeding disorder, the pattern of retinal bleeding in this case is very characteristic of abusive head trauma. This applies particularly to peri-macular folds and retinoschisis. The former are more common in fatal cases, although they are not confined to trauma – such a finding having been made in a patient with leukaemia albeit this seems to be a single case. There is a hypothesis that the acceleration-deceleration forces of shaking causes tears, although peri-papillary scleral haemorrhage has been described in an adult with impact trauma to the back of the head.[44]In her report, Dr. McPartland stated that the mechanism of injury could be a shaking or combined shaking-impact mechanism of injury, with the acceleration-deceleration movement explaining the findings. She notes that Z was at an age which would make shaking more difficult but she has seen the eyes of children of this age and older with shaking injuries so this cannot be ruled out here. It is also possible that an injury mechanism involving angular acceleration of the head, terminating on impact, could mimic a shaking type of movement.[45]She sets out a number of differential diagnoses, which include Terson’s syndrome, which involves a rapid rise in intracranial pressure. There are rare cases of bilateral extensive multi-layered retinal haemorrhages in infants with this syndrome. There are three case reports of infants with ruptured aneurysms of the middle cerebral artery and one with a vascular malformation.[46]She states that retinal haemorrhages are rare in the context of household domestic falls. There are isolated cases, for example of a child who fell down stairs, and a few more that she draws attention to, when children have fallen on the back of the head. None of the accidental falls described, however, included findings of peri-macular folds, even when the outcome was fatal. Given the fact that the putative fall was not witnessed and it is not known to what extent it involved being pushed by the other child, or a rotational element, Dr. McPartland stated she could not rule out Z’s case as being somewhat similar to the very rare cases described in the literature. However, the constellation of injuries here would make it a unique case in the literature, particularly because of the peri-macular folds and retinoschisis. She, therefore, remains very concerned about the possibility of an undisclosed non-accidental injury mechanism in this case. Mr. Jayamohan[47]Mr. Jayamohan is a Consultant Paediatric Neurosurgeon based at Oxford Children’s Hospital. Like the other experts I have heard from he is highly experienced as a practitioner and an expert witness. He prepared a main report and two addendum reports dealing with questions raised on behalf of the parties. He also attended the experts’ meeting. It is his view, expressed in all his reports and his oral evidence, that Z suffered an impact injury, with or without an episode of shaking. From a neurosurgical perspective, he considers that the injuries to the brain could be caused by impact alone, as a result of a fall from the sofa as described by the mother, if Z had fallen onto the back of his head. The initial CT scan shows right sided subdural bleeding into the interhemispheric fissure (which spread to the other side after neurosurgery) as well as extensive loss of grey-white differential in keeping with severe hypoxic ischaemic injury. If the dusky appearance on the left side of the brain as noted by Dr. Du Plessis is a bruise, that would fit with a contrecoup type of injury following an impact.[48]Mr. Jayamohan described a phenomenon, known to him and other neurosurgeons as ‘big black brain’ after a traumatic injury to toddlers, consisting of a reaction to trauma which consists of extensive widespread swelling of the brain tissue with apparent hypoxic ischaemic injury to the whole or part of the brain associated with subdural haemorrhage, associated with extensive brain dysfunction and a mortality rate of up to 70%. This could be what happened to Z, as, in Mr. Jayamohan’s view, the impact energy would be sufficient from a fall from the sofa.[49]Alternatively, shaking can lead to widespread hypoxic ischaemic injury, albeit this too is rare in a child of this age. He would suggest the level of force required by shaking would be significantly outside of normal handling because of the musculoskeletal strength around the neck which would need to be overcome.[50]Mr. Jayamohan deferred to the other experts so far as the eyes and ribs were concerned, and also the findings from the nerve roots. What he did say, however, as a clinician, was that the description of Z after the event was not typical of the response of a child to a severe shaking injury sufficient to cause death. Usually, this would lead to a very swift cessation of breathing, and the need for immediate resuscitation. This is not what happened here, for (if the mother’s evidence is to be accepted) Z reached out for her at one point, and his eyes were flickering or moving. Further, the ambulance crew noticed that one pupil had ‘blown’ and this later was followed by the other, and that Z was in a deteriorating state. Mr. Jayamohan thought that this clinical picture did not fit easily with an episode of shaking. Dr. Ward[51]Dr. Ward is a consultant paediatrician with long experience of providing expert evidence to the Family Court. She prepared a detailed report, but as her report was filed after the experts’ meeting she was not in attendance. In her report she considered and excluded any illness, disease or medical condition as playing a role in Z’s condition, albeit she noted that it was not possible definitively to exclude some sort of blood or bleeding disorder, for the reasons set out by Dr. Keenan. Nonetheless, and like Mr. Jayamohan, she considered it to be extremely unlikely.[52]The conclusion of her report was that the most likely explanation for the constellation of findings, including not only the findings in the brain but also the spinal haemorrhage and trauma, and multiple fractured ribs, was of abusive head injury caused by rotational acceleration-deceleration or shaking forces. In her oral evidence, however, she emphasised that she was far from certain about this. She found it to be a very complex case:
‘at the far end of complexity’ amongst a cohort of cases which are rarely straightforward. She agreed that it does not fall comfortably into the published literature or accepted constellation of symptoms which help to make a diagnosis, whether in an accidental or non-accidental scenario. Either way, she agreed with counsel that the case would be considered an ‘outlier’
. Further, her opinion was based upon the constellation of findings, including injuries to the ribs and spinal cord roots. She was also mindful of the ocular findings.[53]She deferred to other experts, including Dr. Leadbeatter, as to the interpretation of the rib findings but made clear that if injury was present, this would fit and support the shaking hypothesis. She made a similar point about primary nerve root injury in the spine – subject to the evidence of the pathologists. She said that this case has become more, rather than less, complex as more information has been received. Several things had given her pause for thought, including the fact that there is a clear history (which she said was unusual in a non-accidental scenario, in her experience) and the fact that Z was two and a half years old, at the top end of the centiles for weight and height, meaning that shaking him would be considerably more difficult than it would be in a young baby without much head control. She stated – as it was put to her – that a freak accident was one of the range of possibilities for the court to consider in this case. Contemporaneous evidence[54]As I have explained above, there is a wealth of evidence from the mother as to what she says happened, captured in the 999 call, but also particularly on the police bodycam footage. The latter lasts for over two hours and I have found this to be particularly valuable in my assessment of the evidence.[55]In the 999 call, it is obvious that the mother is very, very anxious and distressed about Z. On that call, she says that she thinks he has fallen from the sofa onto some cars, and she describes exactly how he is presenting to her. She said that she came running into the front room as she had been making a cup of coffee. At one point during the call, she says ‘I literally see it happen and just come running’.[56]The 999 call concluded once the paramedics arrived at about 9am. For obvious reasons, they did not take contemporaneous notes, but did so later once Z had been taken to hospital. One of those paramedics recorded the mother as saying that Z fell onto his front and then turned onto his back.[57]The police arrived at about 9.50am and there is bodycam footage available from that time for several hours. There were a number of things that particularly struck me about the recordings. The first is that the mother appears to be a very talkative person and she spoke a very great deal about what she said had happened. She volunteered information about significant and seemingly insignificant matters and readily answered questions from the police officer. She was what I would describe as the opposite of guarded or defensive. She also asked if the police had news of Z on several occasions.[58]She physically demonstrated where Z was lying when she found him, angling her body to describe it, correcting her position as she looked towards the sofa. Her description and quick demonstration appeared utterly spontaneous, hardly more than an hour after the 999 call.[59]X herself is present in the footage. She was four months older than Z. Although the front room of the house was a bit chaotic in appearance, X appears well dressed and clean. She comes across as a delightful and curious child, happy, cheerful and talkative. She shows no fear of her mother, or anyone else for that matter. Her speech is indistinct in the way of small children, especially to adults who do not know her, but there is a lot of it. She was present in the room whilst the mother was describing events to the police officer, and that is something that I must bear in mind. She also, I noticed, seems to say ‘yes’ as a reflex answer to questions, which leads me to think that not much weight should be given to affirmative answers like that when she gives them.[60]Having said that, there is a point, probably no more than half an hour into the footage, when X was on the sofa and the police officer asked her an open question:
‘Did you see what happened to Z?’
. In answer to that, X put her hand on the back of her head and said something (albeit indistinctly) that appeared to be that he had hit or hurt his head, and then said something about the sofa. She was then asked a series of leading questions by both the mother and the police officer which rather diminished the reliability of her subsequent answers. She appears to say that they had been on the arm of the sofa – she gestured to that. It was the wrong side of the sofa, albeit it was the one she was right beside when she said it.[61]I noticed that the mother did not hover around X when she was talking to the police officer, or appear to be worried that she would say anything untoward. If X had witnessed her mother losing her temper and hurting Z, she might well have said something about it in the course of her childish chatter.[62]I have watched all the extensive footage, some of it more than once. I cannot refer to everything in it without making the judgment unmanageably long, but there was nothing that the mother said, or did, within it which, by itself, would make one suspicious that she was hiding anything, inventing anything, or that she had lost her temper uncontrollably that morning. Quite the reverse. The same applies to the earlier 999 call.[63]The mother was then interviewed twice the following day, once at lunch time and once later on. She then filed a statement in the Family proceedings. In that statement, she repeats much of what she said in her earlier accounts (and I assume that at that point she had not seen any of the transcripts or footage of what she had said before), albeit she does add some details about Z not being his usual self in the days before 5th March, for example not eating his pancakes the night before he was injured, and urinating when his nappy was taken off.[64]She also gave oral evidence before me. The mother’s evidence generally[65]Ms. Keniston, for the local authority, has raised a number of inconsistencies and significant points in the mother’s evidence which she put to her in cross examination and referred to in her final submissions.[66]The first related to whether or not she had seen the fall itself. During the 999 call she told the operator she had ‘literally seen it happen’ when her evidence otherwise was that she did not. A second is that she said at some points that she went to Z immediately upon hearing the fall (e.g. to a police officer on the body worn footage) and at others that she finished in the kitchen, and spoke to the children from there before going over to them and realising something was seriously wrong. Ms. Keniston also states that the mother’s story as to what she did with Z after she discovered him to be floppy has ‘grown’ or developed as well. At some points she said she picked him up and put him on the sofa, and at others she added that she flung him over her shoulder and ran about the room. In her police interview on 6th March, the mother said that X had told her grandmother that ‘mummy was shaking him’. One paramedic recorded that the mother said that Z was found on his front and then rolled over onto his back. This is the only place where this is recorded, and it was not contemporaneous.[67]Ms. Keniston also draws my attention to what the mother said in her statement in these proceedings and her last police interview in February 2026. She made a number of observations about how Z did not seem to be his normal self in the lead up to 5th March, being lethargic, not happy about eating his pancakes on 4th March, and being a bit reluctant to walk down the stairs.[68]I am satisfied that there is nothing sinister in these points. The first thing that the mother told the 999 operator was that she thought that Z had fallen off the sofa, not that she had seen him do so. In the body worn footage, the ambulance crew are seen telling the police officer that the mother had not witnessed the fall. That history remained the same throughout the mother’s explanations during the course of the morning. In her oral evidence, she explained her use of the phrase ‘I literally seen it happen’ that she was exaggerating to show that she was very close when the incident happened. I would not describe this as exaggerating but I accept that she did not mean to say that she had witnessed the fall itself. She has never described it. I am clear that in saying ‘I literally see it happen’ she was not intending to say that she saw the fall itself but that this was a figure of speech. I am also satisfied that the account from the paramedic that the mother said that Z fell onto his front is not a reliable one, as the local authority properly acknowledges. It was written down later, and is not corroborated by the other paramedic who was with her.[69]Further, I do not find any material inconsistency in the evidence as to what happened immediately after the fall. It is true that the history has varied from the mother going straight over to the children to her finishing in the kitchen before doing so, but the lapse of time is extremely small – measured in seconds. The accounts of her picking up Z to find him floppy are absolutely consistent, with some accompanying detail about what happened in the seconds between that and connecting with 999 given at some times and not others. It is inevitable that a witness will not give an identical account each time a history is given, and that some details will be remembered or even change a bit as time goes on. The accounts do not contradict each other in any meaningful way.[70]There are other factors too which support the mother’s account. Mr. Jayamohan pointed out that she (the mother) could hardly be expected to know that a fall on the back of the head has been rarely associated with a particularly severe outcome. Her demonstration to the police officer as to how he fell took place at about 10.30am that day. There are no searches of any note on her phone. I also have in mind what X said.[71]I should deal with the use of the word ‘shaking’ by the mother in her interview on 6th March. The mother told the court that, like all mothers, she had been warned by the health visitor of the dangers of shaking. She knew that it was dangerous and was adamant in her evidence that she had never done so, even when it was put to her by the Guardian that she might have done this in response to the fear of finding Z floppy and unrousable. I accept that the use of this word at this time could be significant, but I note that X has never repeated this anywhere else, and that she has said variously that he fell, and/or hurt his head and that he jumped on the sofa. The mother’s descriptions of handling Z after finding him floppy do include some force (albeit limited), such as throwing him over her shoulder and onto the sofa as she called 999.[72]Finally, I accept the mother’s explanation for setting out some relatively minor concerns about Z’s behaviour in her statement for this court. She was trying to think of any observations that could possibly be relevant and have some bearing on Z’s injuries. This is an understandable and, in my experience, very common response. Conclusions[73]In this case, I am faced with medical evidence on one side which points strongly towards Z having suffered an abusive head trauma involving acceleration/deceleration forces caused by shaking alongside what I find to be a very consistent and compelling account of an accident given by the mother.[74]Looking to the detail of the medical evidence, it is that which relates to the eyes and, to a lesser extent, the findings in the cervical nerve roots, which point to the likelihood of a shake as well as impact. Having heard from Dr. Leadbeatter, the local authority no longer pursues a finding that there were any rib fractures. Further, Dr. Leadbeatter was very cautious about ascribing causation to the findings in the spinal nerve roots. According to Mr. Jayamohan, the findings in the brain are consistent with impact alone if it was to the back of the head.[75]This all means that the medical opinion about shaking in this case relies very heavily, if not exclusively, upon the ocular findings although all of the doctors have said that injuries like this caused accidentally are outwith their experience. The findings of peri-macular folds and retinoschisis in Z’s eyes are rare and have only been associated with abusive head trauma in the literature and in the experience of Dr. McPartland. It is believed that these are sustained as a result of acceleration-deceleration shearing forces as she described during the course of her oral evidence, and fit with the very extensive retinal and other ocular haemorrhages. Whilst a finding of peri-macular folds in a child with leukaemia demonstrates that shearing is not the only possible mechanism, for this court to determine that they were caused in the course of a low-level fall would make this case unique to her knowledge.[76]On the other hand, Dr. McPartland herself advises that it is very important to correlate ophthalmic pathology with neuropathology, other clinical and autopsy findings and other features of the wider investigation. Shaking type injuries in a child of two and a half are unusual, albeit not rare. Looking at Dr. McPartland’s own experience, the number of cases which she has dealt with of children that age, are less than 10, possibly less than 5 amongst a cohort of 150. As Mr. Jayamohan and Dr. Ward said, it is hard to shake a child of this age who is bigger and has more head control. This mother is small and very slight in build, which raises a question as to whether she would be able to muster more acceleration/deceleration forces by picking Z up and shaking then throwing or pushing him than would be engendered by a fall from the arm or back of the sofa, whatever its components.[77]Further, I note what Mr. Jayamohan said about Z’s clinical response. Unlike many other fatal cases where shaking is believed to have occurred, Z did not suddenly stop breathing and have to be resuscitated. There is evidence, not only from the mother herself but from the clinical observations of the paramedics that Z’s neurological condition, whilst very serious from the start, then deteriorated which is more in keeping with an impact only injury.[78]As Dr. Ward stated, the medical picture here is a very unusual one, whether or not the injuries were caused as a result of abusive shaking and impact, or an accidental fall from the sofa. There is a limit to medical knowledge in these extremely difficult and complex cases, especially when the experts are required to grapple with explanations which are often inaccurate or incomplete. Medical knowledge, with the availability of better scanning techniques and more case reports, is developing all the time.[79]The strength of the medical evidence must be acknowledged, but so too must the very compelling, sustained and consistent account given over a lengthy period of time by the mother.[80]As the fall was not said to have been directly witnessed, and involved two children jumping on the sofa and then falling, it is simply not possible to know what mechanisms were involved. I am satisfied that Z fell onto the back of his head, which in some cases is associated with unusually severe neurological consequences. Nobody watching the bodycam or listening to the mother give evidence could be in any doubt about how traumatised she was, and is, by Z’s floppy state as she picked him up, and I also accept her evidence that he was extremely heavy as she put him over her shoulder before trying to find her phone and ring the emergency services.[81]I must look at the evidence as a whole, something that the medical experts have not been able to do, or at least not in the same level of detail. Having carefully considered all of the material before me, I have come to the clear conclusion that it is more likely than not that an accidental fall, and not an act of abuse, was responsible for causing Z’s injuries and subsequent death. It is possible that the mother’s actions after finding him on the floor, by putting him over her shoulder, running around and/or then putting him on the sofa when he was completely floppy were responsible for some of the findings more commonly associated with acceleration/deceleration forces, but that does not mean she should be regarded as culpable for what happened. It is also possible that the acceleration/deceleration type injuries came about because of the nature of the fall itself or something not currently understood.[82]It follows that I do not make the findings sought by the local authority that Z was the victim of any physical abuse.[83]The local authority has also alleged that the children are at risk of physical and/or emotional harm because of the mother’s cannabis smoking and the fact that she has left them alone for a few minutes at a time whilst going to the shop. There is no suggestion that the mother was under the influence of cannabis on 5th March, or indeed on any other occasion when she has been seen by professionals together with the children. The fact that she has left the children alone for short periods of time was only discovered by investigation of CCTV outside the house following Z’s death. This showed that the mother left the house for about five minutes.[84]For the sake of completeness, I accept the mother’s evidence that she told the social worker, when questioned, that she would ask her neighbour to keep an eye/ear out for the sleeping children as she popped out to the shop. The social worker was not as careful as she should have been in the way she presented evidence (for example about an alleged burn), and I had some reservations about the way she perceived the mother.[85]Even if I am wrong about the social worker’s evidence, I do not find that regular cannabis smoking or leaving the house for a few minutes to go to the corner shop whilst the children were asleep is sufficient, either alone or taken together, to reach the threshold required by section 31 of the Children Act 1989. In saying this, I am not suggesting that this is good practice for a parent, and I hope the mother will reflect. Nonetheless, there must be an element of realism as to the standards to be applied when judging parenting. It is obvious from all the other evidence that X and Y were well cared for children. Final points[86]This case has been extremely well prepared by all parties. Ms. Keniston and Ms. Navas, for the local authority, provided a detailed chronology, opening note and closing submissions, all of which were extremely helpful. I have also been greatly assisted by detailed written closing submissions by Ms. Branigan KC and Ms. Bath, for the mother, and from Mr. Howard and Ms. Flaxman-Ali for the Guardian. I wish to extend my grateful thanks to all counsel accordingly. The father[87]The father of the children who are the subject of these proceedings was not present on 5th March and so did not have any active part to play in this part of the proceedings. He did, however, express an understandable wish to attend the hearing in order to form a view as to whether the mother poses a risk to their children. He was represented, but his attendance was somewhat sporadic (he did apply to be excused from listening to some of the medical evidence because of his poor mental health). Just before the mother was due to give her evidence he objected to this happening without being able to see her face. Given that the mother had made allegations of domestic abuse against him, this was strongly resisted and counsel wisely withdrew the application. As it happened, the father did not attend the hearing when the mother gave evidence at all. I mention all of this without any particular comment as the reasons behind this were not explored before me. It is something that may fall to be considered if the father seeks contact with the children in the future.