P (Fabricated and Induced Illness: Fact-Finding), Re [2026] EWFC 112 (B)

[2026] EWFC 112 (B)

Case No ZE25C50110

IN THE FAMILY COURT

Date 23 April 2026

SITTING AT EAST LONDON

11 Westferry Circus

London

E14 4HD

Before

Her Honour Judge Reardon

Re P (Fabricated and Induced Illness: Fact-Finding)

Hearing Hearing dates: 12, 13, 16, 17, 18, 19, 20, 23, 24, 25, 26 and 27 March 2026, 23 April 2026

Fiona Munro and James Nottage (instructed by the local authority legal department) for the local authority

Gemma Taylor KC and Zoe McGrath (instructed by Charles Allotey & Co) for the mother AP

Jo Brown KC and Neil Fry (instructed by Myria Pieri & Co) for the father BP

Fareha Choudhury (instructed by Campbell Chambers Solicitors) for the children through their children’s guardian

Judgment

.............................

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.

[1]These proceedings concern two children, C aged four and D aged two. Their parents, who married in 2025, are AP and BP (“M” and “F”). They are both in their twenties and have been in a relationship since their late teens. M is currently pregnant with the couple’s third child.

[2]On 4 March 2025 M was arrested on suspicion of harming D by inducing illness and fabricating her symptoms. At the time D was an inpatient at the R Hospital (a specialist children’s hospital in London). She was 16 months old and had been subjected to a range of medical investigations and treatment over the course of her life, the primary presenting issue being persistent weight loss and failure to thrive. She had been fed through a naso-gastric (“NG”) tube since December 2023 when she was about 10 weeks old.

[3]Both children were taken into police protection on the day M was arrested, and were subsequently made the subject of interim care orders. C was placed with his maternal great-grandparents, MGGM and MGGF, and D joined him there on her discharge from hospital on 26 March 2025. They have had supervised contact with their parents throughout the proceedings.

[4]D’s condition improved swiftly after her mother’s arrest. Within about a week she was eating a normal toddler diet, and the NG tube was removed on 13 March 2025. Her presentation has been transformed since she has been in her great-grandparents’ care and it is not now suggested that she has any significant health issues; her development is age-appropriate and she has required no ongoing medical oversight or intervention.

[5]The local authority alleges that over a period of about a year, between March 2024 and March 2025, M fabricated symptoms which D did not have; resisted medical advice; and “medicalised” D by treating her as a seriously unwell child when this was not the case. Most seriously, the local authority alleges that on two occasions, in 2024 and 2025, M failed to follow D’s feeding plan and/ or tampered with her feeds. This led to D failing to gain weight and, on the second occasion, suffering from ketotic hypoglycaemia (“KH”), a condition in which the body has used up all of its stored glucose reserves and begins to break down fat.

[6]M does not accept that she caused D to suffer any harm by either fabricating or inducing illness in her. It is her case that her actions should be seen in the light of D’s diagnosis, in March 2024, of a rare genetic microdeletion, and the lack of information given to the parents about what to expect from this. The mother accepts that she became very anxious about D’s health and prognosis, but argues that her response was a natural one in the circumstances. She says that she described the symptoms she saw and that the prolonged use of the NG tube, and the other medical interventions which D experienced, were the result of genuine uncertainty about her condition on the part of professionals, and on occasion poor liaison between different health care providers.

[7]M does not accept that she provided a false account of D’s symptoms. She has formally accepted that she posted some exaggerated statements about D’s medical condition on social media, her case being that this was an emotional coping mechanism. In her oral evidence, however, M did not go quite as far as this, conceding only that she did not “word things very well”.

[8]F does not believe that the allegations against the mother are true. He was not himself closely involved in D’s medical care and when she was admitted to hospital it was either M or M’s grandmother (D’s great-grandmother or MGGM) who stayed with her while he looked after C. He, like M, says that the improvement in D’s condition from March 2025 onwards is attributable to factors unrelated to M’s care, including a change in her milk formula.

[9]The children’s guardian explored the evidence during the course of this fact-finding hearing and submitted, at its conclusion, that the court should make the findings sought by the local authority.

[10]All parties were represented at this hearing, as they have been throughout the proceedings. The parents, who have some additional communication needs, were each assisted by an intermediary. The hearing was listed with a time estimate of 14 days. This judgment was circulated to counsel in draft on 7 April 2026 and handed down at a hearing on 23 April 2026. B The applicable law The threshold criteria and the fact-finding process

B The applicable law

[11]The local authority seeks findings of fact to establish the threshold criteria under CA 1989, s31. S31(2) reads: (2) A court may only make a care order or supervision order if it is satisfied— (a)that the child concerned is suffering, or is likely to suffer, significant harm; and (b)that the harm, or likelihood of harm, is attributable to— (i)the care given to the child, 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; or (ii)the child’s being beyond parental control.

[12]When the court is making findings of fact the following principles apply. I have kept this summary as short as possible and for the most part have not cited authority, because the relevant law is well known and not in dispute:a. The burden of proof is on the party which makes the allegation;

b. The standard of proof is the balance of probabilities;

c. The courts may find only that something happened or that it did not happen. The law operates a binary system and there is no room for a finding that something might have happened.

d. The court must not reverse the burden of proof. If a respondent fails to prove an affirmative case they have set up by way of a defence, that does not itself establish the applicant’s case. In such circumstances, the question for the court is not, “has the alternative explanation been proved?”, but, “in the light of the possible alternative explanation, can the court be satisfied that the applicant has proved its case?”: Re X (Children)

[2015] EWHC 3651

e. Findings must be based on evidence, including inferences that can properly be drawn from the evidence, and not on suspicion or speculation.

f. The court may take into account the inherent improbability of an allegation, but it should be careful not to give too much weight to this factor (it is highly improbable that any one person will win the lottery, but someone does win the lottery every day).

g. The court surveys a wide canvas. It must take into account all of the evidence, and consider each piece of evidence in the context of all the other evidence.

h. Expert evidence in particular must be considered in context. Experts must confine their evidence to their own discipline. The role of the court is different from that of the expert. The Judge, unlike the expert, has access to the full evidential canvas and it is the Judge and not the expert who makes the final decision. For that reason it is not usually helpful for an expert to express a view about causation on the balance of probabilities, although it may assist the court for the expert to give his opinion as to the relative likelihood of different explanations.

i. It is essential that the court forms a clear assessment of the credibility and reliability of the parents and lay witnesses. Their evidence is extremely significant and the court is likely to be place considerable weight on their evidence and the impression it forms of them. Demeanour is not a reliable guide to credibility, and a Judge will not reach conclusions as to a party’s credibility on the basis of demeanour alone; but the assessment of demeanour may properly include the impression made upon the court by the witness, giving due allowance for the pressures of giving evidence.

j. It is common for lay witnesses to tell lies during the course of the investigation and hearing. A witness may lie for many reasons unconnected to the facts of the case. The fact that a witness has lied about some matters does not mean that he or she has lied about everything, and the fact that a lie is established does not prove the reverse of that lie: R v Lucas

[1981] QB 720

. The approach to the Lucas direction within family proceedings was considered in Re A, B and C (Children)

[2021] EWCA Civ 451

. The court is required to consider how and when the witness’s lack of credibility should be factored into the equation when determining an issue of fact. In order to do so it should ask itself the following questions, tailored as necessary to the circumstances of the case. First, whether the witness has told a deliberate untruth, i.e. the lie did not arise from confusion or mistake; secondly, whether lie related to a significant issue; and thirdly, whether there is any other reason which could explain the lie such as the witness’s shame, misplaced loyalty, fear, or distress.

Fabricated or Induced Illness in Children (“FII”)

[13]FII is an umbrella term that covers a wide range of conduct. The Royal College of Paediatrics and Child Health has issued guidance, Perplexing Presentations (PP) / Fabricated or Induced Illness (FII) in Children (March 2021) which is intended for the use of clinicians responding to a situation where a child’s symptoms may have been fabricated or induced by the carer. The guidance describes a shift in approach since the term “Munchausen’s Syndrome by Proxy” (now discarded) was coined by Professor Roy Meadow in the 1970s. The aim of the guidance is:

“to recommend early recognition and intervention in order to explore the possible causes of a perplexing presentation. There is a need to establish whether perplexing presentations are fully explained by a verified condition in the child, or whether there has been some element of exaggeration or fabrication of illness with consequent physical, emotional, social or educational harm to the child. RCPCH guidance, Perplexing Presentations (PP) / Fabricated or Induced Illness (FII) in Children (March 2021), p.5 ”

[14]The guidance sets out signs which, as part of a perplexing presentation, may alert clinicians to the possible presence of fabricated or induced illness. A number of those features were present in this case, including symptoms which only appear when the parent/ carer is present and/ or are only observed by the parent; an inexplicably poor response to treatment; and new symptoms which are reported as soon as previous ones have resolved. However these features are a diagnostic tool, not a pathway to a court finding. The role of the court in a case involving allegations of FII is the same as it is in any other case: to examine the evidence and to make findings of fact. As Ryder J observed in A County Council v A mother and others

[2005] EWHC 31

“175. The terms 'Munchausen Syndrome by Proxy' and 'Factitious (and Induced) Illness (by Proxy)' are child protection labels that are merely descriptions of a range of behaviours, not a paediatric, psychiatric or psychological disease that is identifiable. The terms do not relate to an organised or universally recognised body of knowledge or experience that has identified a medical disease (i.e. an illness or condition) and there are no internationally accepted medical criteria for the use of either label. 176. In reality, the use of the label is intended to connote that in the individual case there are materials susceptible of analysis by paediatricians and of findings of fact by a court concerning fabrication, exaggeration, minimisation or omission in the reporting of symptoms and evidence of harm by act, omission or suggestion (induction). Where such facts exist the context and assessments can provide an insight into the degree of risk that a child may face and the court is likely to be assisted as to that aspect by psychiatric and/or psychological expert evidence.”

[15]In Re BR (Three Families: Fabricated or Induced Illness: Findings of Fact)

[2023] EWFC 326

Poole J observed:

“116. I have not found it useful for any expert to give an opinion on whether a child is a victim, or an adult the perpetrator of, FII. Firstly, it is for the court to determine what harm has been caused to a child, by whom, and how. Secondly, the term FII covers a multitude of more or less intentional behaviour that may or may not have caused actual harm to a child. The label FII must not be used as a substitute for an analysis of the facts in each case, see A County Council v A Mother and others [2005] EWHC 31 (Fam), above. Hence, I have treated with some caution the parts of the schedule of agreement reached by four of the core expert witnesses following a joint meeting which set out "factors pointing to" and "factors pointing away from" FII in each case. I acknowledge that the experts were endeavouring to be helpful to the court, but I have to be mindful not to confuse evidence of fabrication with evidence of induction of illness, and not to conflate evidence of induction of vomiting, say, with evidence of induction of sepsis. My focus has to be on the particular behaviour alleged.”

[16]Dr Ward, who was the expert witness instructed in this case, was also one of the experts in Re BR. It was apparent that she had taken on board Poole J’s observations because she was scrupulous, as I will explain, in distinguishing between the expert’s role in evaluating the medical evidence and the court’s in determining whether or not illness had been fabricated or induced.

[17]In the same case at [161] Poole J said:

“As I listened to and read the statements of witness after witness I was struck by the extent to which underlying assumptions about the mothers' involvement in their children's illnesses affected the way in which many of them presented what they had seen and heard to the court. For example, a mother's report of vomiting could be interpreted as a sign that their child genuinely could not tolerate oral feeding, or as an example of the mother fabricating illness. The prism through which the facts are viewed affects the observer's perception of those facts – whether it is the prism of FII or the prism of innocence. The same evidence may lead different people to view the same event in different ways according to their pre-existing beliefs about FII.”

[18]I have heeded that warning, and have tried to remain alert to signs of confirmation bias in the evidence, particularly that of the witnesses involved in D’s care at the R Hospital in March 2025, after safeguarding concerns had been raised.

[19]Finally, the role of the court is not to evaluate the care provided to D by individual medical professionals, or by the various health care agencies; it is, as I have tried to emphasise, to make factual findings about M’s conduct and any consequent harm to D. In my analysis I will from time to time need to express a view about the professional responses to D’s presentation, but where I do so this is purely for the purposes of setting M’s actions or omissions in a proper context. C The evidence The clinical witnesses

C The evidence

[20]Over 50 medical witnesses of fact provided witness statements, and of those 20 were required to give oral evidence.

[21]The key medical witnesses were Dr L, who was the consultant paediatrician overseeing D’s care in the community and at the S Hospital; Dr N, who was the lead consultant in the metabolic team at the R Hospital; and the speech and language therapists and dieticians who supported D’s feeding both in hospital and the community.

[22]There was very limited factual challenge to the evidence of any of the medical witnesses, or indeed to their decision-making and approach. Their direct recollection of the family varied, as one would expect, and most relied heavily on the notes they and their colleagues had taken at the time. These notes were also available to the court. Overall I am satisfied that the evidence of these witnesses presented an accurate picture of events. There were of course occasional errors, most of which were picked up during the evidence and readily accepted by the witness. However I was impressed by the detail and accuracy of the recording across all healthcare settings, each of which had clear systems in place for notes to be taken and recorded swiftly, and invariably before the end of the note-taker’s shift. At the R Hospital, in particular, a very high priority was given to the accuracy of recordings, both because of the perplexing presentation which meant that glucose readings were checked and re-checked, and because of the context in which D was admitted. Dr N explained that where there are safeguarding concerns, that “makes you careful with note-keeping, clear with what you say to families, and careful that you are getting good information from the family”.

[23]M’s case, at least in part, is that her responses are likely to have been affected by her particular vulnerabilities, including OCD and associated anxiety, and possible neurodivergence: these issues may have increased the likelihood that she misunderstood advice she was given and affected her ability to form constructive working relationships with healthcare professionals. That may be so, but this aspect of the evidence needs to be considered alongside the experience most of these professionals had. As skilled specialists in different forms of paediatric care at large London hospitals they were familiar with a wide range of parental presentations and I had no sense at any point of any sense of frustration or a lack of understanding on the part of the clinicians; on the contrary, they attempted a variety of different approaches, repeatedly gave M the benefit of the doubt, and were consistently sympathetic to the family’s needs. In particular, the dieticians and SALT team both in the community (Ms O) and at the R Hospital (Ms Q) were extremely patient with M’s resistance to oral feeding, and creative and flexible in the strategies they employed. I do not think that any further flexibility or adjustments on the part of medical professionals could reasonably have been expected in this case.

[24]I was struck in hearing the evidence of the medical witnesses by the extent to which they relied, in treating children, on the history given by the parent. Dr N said that the assumption in paediatric health care is that the parent is reporting genuine concerns. Dr L said that he saw his role, in part, as an advocate for his patients and he would always start by assuming that the parent is working in the best interests of the child, so if a parent raised a concern he would advocate on their behalf (as he did in several discussions about D’s perplexing presentation in January and February 2025). Other witnesses, including Dr Ward, spoke of a shared responsibility in paediatric care between the doctor and the parent. Dr Ward observed that “much of what we treat or diagnose is based on what we are told, not upon what we see”. In this case, although there was a safeguarding referral in 2024, the primary concern at that stage was that M needed support with feeding, not that she was fabricating symptoms or knowingly limiting feeds. The suspicions about fabricated or induced illness only arose in 2025, relatively late in the medical chronology. This meant that the prism through which clinicians viewed D’s presentation was, for the first year and more of her life, the usual paediatric one of acceptance and reliance on the history given by the parent.

[25]This approach makes sense, because a parent will know their child best and will be able to alert medical professionals to any unusual presentation. However it does rely heavily on the accuracy of parental reporting. In this case, as I will come to explain, there were times when the mother’s reporting, not just of D’s symptoms but of the diagnoses and treatments she had had, was inaccurate. The records of different health care agencies are, of course, held separately. Clinicians at the S Hospital and the R Hospital had access to each other’s systems, but not those of the GP or community teams. The London Care Record now allows for a basic overview across different healthcare providers but is not, at least according to the witnesses at this hearing, a comprehensive record of each interaction. This meant that when the mother reported decisions that had been taken about D’s care – for example, by saying that she was on the waiting list for a particular test, or that a diagnosis had been made – there was no quick way of verifying this information. As a result misapprehensions and confusion persisted for longer than they should have done.

The expert medical witnesses

[26]Dr Robinson is the expert paediatrician instructed by the police. He gave oral evidence at this hearing as an expert witness, but not a Part 25 expert. He was not instructed jointly by the parties through an agreed letter of instruction and there was no mechanism for written clarification questions or an experts’ meeting. Importantly, because the police investigation seems to be less far advanced than these proceedings, Dr Robinson had not had access when he wrote his report to the comprehensive bundle of medical records that is now available to the parties and the court in the care proceedings.

[27]Dr Ward produced a written report and a short addendum, and gave oral evidence. She was very careful to remain within the scope of her instruction and to distinguish between the role of the expert and the role of the court. She accepted that on the issue of responses to medical advice there was room for different opinions as to how a reasonable parent would act. She also accepted, and indeed emphasised on a number of occasions during her evidence, that she and the court were looking at the history with the benefit of hindsight (through the lens of D’s recovery) and with the huge advantage, not available to any of the medical professionals at the time, of having full access to medical records from all clinical settings for the relevant period. Her report and her oral evidence were balanced, fair and thorough.

[28]On the central issue of the cause of D’s hypoglycaemia in January and February 2025 there was no significant difference between the opinions of Dr Robinson and Dr Ward.

The parents

[29]M has a diagnosis of motor tics, which impact her life to the extent that she does not travel on public transport, and obsessive compulsive disorder: she feels an urgent need to plan in advance and becomes anxious and stressed if plans are disrupted. She is awaiting an assessment for autism and ADHD. There were indications from time to time in M’s evidence that she might present with some rigidity of thinking, and I have had the possibility of neurodivergence well in mind.

[30]M presented as warm, engaging and devoted to her children. She had a traumatic childhood herself, having been excluded from school at 13 and spent time in local authority care, and she was clearly delighted to have been able to build, at quite a young age, a new family unit with her partner and now husband.

[31]Perhaps because of some underlying issues of neurodivergence, M’s evidence was not entirely easy to evaluate. At times, as I have set out below, M’s account of events differed quite significantly from all the other evidence. In reaching conclusions about her credibility I have taken into account the emotional pressure she was under at the relevant time and remains under. There remain in my judgement a number of occasions when M’s misrepresentation of a medical event or diagnosis is so gross that it cannot be explained by a misunderstanding. In her evidence M often appeared untroubled by these differences and was firm in maintaining her position. When asked about Dr Ward’s explanation – surely beyond challenge – of the relative nutritional content of infant formula milk versus junior milk she said, “I’m not going to deny her view but I also have my own view”. It may well be a feature of M’s functioning that she tends to form fixed views and struggles to adapt her thinking to accommodate the views of others, however well-qualified.

[32]On at least one issue I am satisfied that M has told a deliberate lie. That is the issue of her access, during the proceedings, to the Tiktok account which she was using from D’s birth (and possibly before) until March 2025. After Dr N raised concerns about M’s social media posts she deleted them; at an early stage in these proceedings she was asked to provide the email address associated with the account so that it could be recovered, but said that she had forgotten it. I cannot accept that: M used the account for a long period of time and it is just not credible that she forgot the login details as soon as concerns were raised. Dr N copied some of the posts which had concerned her and exhibited them to her first statement. She described some other posts which have since been deleted and do not form part of the evidence. I find that M deliberately withheld the email address to avoid the deleted posts being recovered. I have no idea, and M may not have either, whether recovery would in fact have been technically possible.

[33]No findings are sought directly against F and his evidence was quite brief. The local authority did try to explore, in the light of evidence that emerged during the hearing, whether F was open to the views of the medical professionals and experts and whether he thought there might have been any issue with M’s feeding of D. F was firm in resisting this suggestion.

[34]I was troubled by F’s evidence when he was asked questions about D’s presentation at home, and in particular the breathing difficulties and distress after feeding that M consistently reported. F’s evidence about this was vague and while he was firmly supportive of M’s account, and said in his witness statement that these events occurred regularly, he was unable in his oral evidence to give any clear or convincing account of having witnessed similar episodes himself although one would expect, if he had, that they would have been quite memorable.

[35]There was a hint from time to time in the evidence that the parents may have inaccurately presented C as a child with additional needs. Dr N said that she believed that M also had a social media account in C’s name which was heavily geared towards autism and the experiences of autistic children. C does not have a diagnosis of autism but he is still very young, and the two nurseries he has attended have each written a letter in which quite different views are expressed about his presentation. It does not seem to me that this evidence is secure enough to carry weight in my decision-making at this hearing.

The maternal great-grandparents

[36]MGGM and MGGF, the maternal great-grandparents and the children’s current carers, both gave evidence at this hearing. They are devoted great-grandparents who played a significant role in caring for the mother when she was a child and went on to provide considerable emotional, practical and financial support to the parents in caring for C and D. For much of 2025 the children stayed with them for the full weekend every other week, and they were the obvious choice for the children’s interim placement.

[37]MGGM and MGGF were emotional at times when they reflected on what they had been told by the mother in D’s first year of life about her prognosis and needs. It was not disputed that the mother had told them that D would have a short life expectancy and might never be able to walk. This brought back memories of their own loss of a child in infancy, due to a genetic heart condition. Both clearly suffered considerable anguish in the first year of D’s life, which was followed by bewilderment as well as joy as she improved in their care and was transformed into a healthy, active toddler.

[38]The range of emotions MGGM and MGGF have experienced over the past two years seems to have affected them in different ways. The special guardianship assessment of them sets out how their relationship with M has been affected by their feelings of hurt and betrayal. MGGM was clearly gripped by powerful emotions during her evidence in the witness box: at times this led her to “shut down,” and despite breaks and gentle questioning she struggled to give full answers and when she was asked to clarify some quite minor discrepancies in her evidence she reacted defensively. I have no doubt that this was a trauma response, and do not criticise her at all; I considered her to be an honest witness who for reasons outside her control was unable to give her best evidence to the court. MGGF too became angry at times in the witness box, but found it a little easier to re-group and to express how he was feeling. He was clear that whatever has happened he will remain committed to supporting M in whatever way possible, but his priority was plainly the safety and welfare of the children: he did his best to assist the court by giving his recollection of events and, with very little access to the detail of the medical and expert evidence, was open-minded about the possible outcomes of this hearing. At the end of his evidence he went over to his granddaughter and gave her a hug.

[39]There were one or two disputes of fact between the mother’s evidence and that of MGGM and MGGF. In their written evidence they said that when D stayed with them at weekends they would feed her exclusively through her NG tube because the mother told them that the dietician had said she was not allowed oral foods. They said that D would stare at them when they were eating food and they felt sorry for her, so they ate separately and when C had his meals one of them would supervise him and the other would play with D in a separate room. The mother firmly challenged this account, producing in support a text message from MGGM sent in the summer of 2024 with a picture of D eating solid food and a description of her meal.

[40]Having reviewed all the evidence, as set out below, it is reasonably clear that there was a shift in the mother’s approach to D’s intake of solid foods in the autumn of 2024. MGGM and MGGF both remembered explicit instructions from the mother that D was not to have solid food in their care, and their descriptions of how they managed this issue were detailed, consistent and compelling. I find that while until about September 2024 D was eating a range of solid foods, there came a time when M decided to restrict her intake; from this point what she ate at home became more limited, and M gave firm instructions to her grandparents that D was not to take anything orally during the weekends when she was in their care.

[41]MGGM, who attended several medical appointments with the mother and sometimes stayed with D in hospital, was asked about her own observations of symptoms reported by the mother, and whether she shared the mother’s concerns. Although there are occasional records in the evidence of MGGM backing up her granddaughter’s account and challenging medical staff, it is clear from a review of the evidence as a whole that she, like MGGF, took her lead from the mother and had no reason to doubt the information she was given by her. When she spoke up in support of M she did so in good faith, believing that her granddaughter was giving an honest account of D’s symptoms. D The timeline: D’s medical trajectory 2023: M’s pregnancy and D’s birth

D The timeline: D’s medical trajectory

[42]M experienced some early bleeding during her pregnancy with D but this settled and the pregnancy was otherwise unremarkable. Two days after the due date M underwent an emergency caesarean section because of foetal tachycardia after a failed induction, and D was born in October 2023. Her Apgar scores were good and she did not require resuscitation. She was on the 50th centile for weight and the 69th for length. Her head circumference was on the 2nd centile. A heart murmur was heard at an initial examination but not detected on review by a paediatrician.

[43]M has reported to clinicians from time to time that throughout her pregnancy with D she was told that the baby had tachycardia, and in her first statement in these proceedings she said that D had “constant tachycardia at all [prenatal] appointments”. In fact the only record of this that I have been able to find in her maternity notes occurs right at the end of the pregnancy, after the attempt at induction had commenced.

[44]D required no special care and was discharged home on day two of life. The parents were then living with M’s mother, D’s maternal grandmother, in South-East London, but this relationship was strained and M was on the waiting list for her own housing.

[45]In common with most newborns D lost weight initially but regained it by the time she was 10 days old, and remained between the 25th and 50th centile for the next few months.

October – December 2023: D’s first three months

[46]D was bottle-fed from birth. She was taken to the GP on a few occasions in her early weeks with reports of minor feeding problems and congestion, and was given Infacol for colic. A high heart rate was noted at two GP appointments and by the health visitor, and she was referred for a paediatric review. At a home visit the midwife noted that the home conditions were not good (there was a smell of cannabis), but that M appeared to be doing her best; the health visiting team were asked to consider additional support.

[47]At her eight-week check in December 2023 D was noted to be feeding well, and her examination was normal. However M reported that she had episodes of shortness of breath and also eye-rolling and vacant appearance.

[48]On 18 December 2023 D was brought to the GP with a history of taking only half her normal feeds and a small amount of vomiting. She had been taking Gaviscon but this had not improved her symptoms. On examination she appeared well and was not dehydrated. The mother was advised to trial syringe feeding for 24 hours, and omeprazole was prescribed. 27 December 2023 – 1 January 2024: the first S Hospital admission and the insertion of the NG tube

[49]On 27 December 2023 D was admitted to the S Hospital with a history of three weeks of vomiting after feeds and reduced oral intake. She tested positive for adenovirus. A nasogastric tube was inserted in the emergency department and D was given a tube feed, but this was followed by a large vomit. She was admitted to the ward, kept nil by mouth and started on fluids. An abdominal ultrasound was carried out to rule out pyloric stenosis, and an abdominal x-ray which was also normal. The vomiting subsided when D’s milk was switched to a non-cow’s milk protein formula, Neocate LCP, so the working assumption was a cow’s milk protein intolerance.

[50]During D’s admission the plan was to re-introduce bottle feeding, but this was not successful. On occasion D would take a small amount by bottle but at other times she would gag and push the teat away. The mother is recorded as being worried about pushing D to take more in case it made her sick. The mother was trained in tube feeding and D was discharged on 1 January 2024 with the NG tube still fitted, an ongoing prescription for omeprazole and a plan for an outpatient referral for speech and language therapy (“SALT”). The reason for the referral was recorded as “oral aversion after a prolonged week of vomiting; unable to tolerate oral feeds”.

[51]It is clear from all the evidence that the expectation when D was discharged in January 2024 was that the NG tube would be in position for a finite period of time. The first NG tube fitted was a short-term one, intended for use for no more than 7-10 days; this was replaced in February 2024 with one designed for longer-term use. The medical evidence differed as to whether tube feeding was intended as a very short term remedy, to boost D’s calorie intake through a short-term period of illness, or whether the plan was to take a more cautious approach and to support oral feeding at a gradual pace until the tube could be removed. The consensus seemed to be the latter, but in either case there was clearly no expectation that D would remain tube-fed for over a year, let alone – as the mother subsequently suggested – that she would be dependent on either a NG tube or a PEG for life.

[52]The mother initially tube-fed D with gravity feeds (the milk feed is connected to the tube and held up by the carer, so it flows by gravity into the tube and then into the child’s stomach). After discharge from the hospital she requested a feeding pump, which controls the flow and allows the carer to administer the feed hands-free after making it up and connecting it to the pump. M was not initially trained in inserting the tube, so when it fell out or D pulled it out – a common event with tube-fed babies – she would have to go to the hospital to have it re-inserted. Insertion, according to all the witnesses, is an uncomfortable and sometimes painful process for the child who will usually gag as it passes down the throat; with young children there is the additional feature of the child having to be restrained in order for the tube to be inserted.

[53]Throughout the period when D was tube-fed her feeds were made up and administered in accordance with a feeding plan prescribed by either the hospital or the community dieticians. The volume, make-up and concentration of each feed was calculated with reference to D’s age, weight, calorie intake from other sources (eg solid foods) and estimated energy expenditure. It could be easily adjusted if there were concerns about her weight gain and growth. For the most part, D’s feeds were administered three- or four-hourly, although the pump could also be set to administer continuous feed at a pre-set rate.

January – March 2024: D at home; failure to thrive

[54]In January 2024 M was allocated temporary housing in South London, and the parents moved in together with both children. The allocation of housing in a different borough, when the hospital where she had been treated, her GP surgery, and the associated community dieticians and SALT practitioners were all based in the previous area, made oversight of D’s health more complicated. M was reluctant to change GP because she was hoping to be allocated permanent housing in her former borough. Therefore what tended to happen in practice was that home visits would take place at the maternal great-grandparents’ home; when this was not possible contact was made and advice given by telephone.

[55]On 8 January 2024 the community dietician, Ms O, carried out a home visit to D at the home of her great-grandparents. M reported that D’s vomiting had resolved, but she was worried about D gagging when offered a bottle or teat. Ms O said that as far as she was aware the NG tube was in place because there was some uncertainty about whether D had a safe swallow; as a dietician she would rely on the SALT team to assess that. In most cases she would try to do joint visits, but that was more difficult in this case because D was living out of borough.

[56]On 15 January 2024 D had an outpatient review at the S Hospital with Dr Q. D was gaining weight, but M reported that she was refusing bottle feeds. Dr Q was concerned that a SALT appointment had not yet taken place and wrote to the community dieticians and SALT team to emphasise that this was “key” and needed to happen as soon as possible. The emails show Dr Q pushing for a plan for review of the NG tube, and consideration of oral intake. In the meantime she discussed D with a paediatric gastroenterologist who suggested that as D was not vomiting and was gaining weight (and therefore did not appear to have a gastroenterological problem), the aim should be to transition back to oral feeds with possible early weaning onto solids at four (rather than six) months.

[57]M spoke to Ms O by telephone on 2 February 2024. The notes say that M “is unhappy with the plan [provided by the hospital] as they want to wean D. Mum is not happy as she thinks D cannot swallow so does not want to give her food and is still being sick…. Still vomiting after or during most feeds but only a small amount”.

[58]On 7 February 2024 an initial SALT assessment took place by telephone. M told the SALT, Ms T, that she was not sure if D had a swallow problem but felt that she got out of breath when feeding and that this was possibly related to her heart; she had a cardiology appointment in March or April. M said she was not offering anything orally; she was advised to try dummy dips (a dummy dipped in milk, to encourage the child to suck) and offering the bottle to allow assessment and avoid aversion later on.

[59]On 9 February 2024 D was brought to the emergency department at V Hospital after a 111 consultation. She had a high temperature and tachycardia; it was subsequently confirmed that she had a urinary tract infection, which responded to antibiotics. She was seen by Dr U who was concerned about sepsis and said that D needed to be admitted. M, who was accompanied by MGGM, was highly resistant to this: she said she wanted to get home to her other child, and that D was already under investigation at the S Hospital for tachycardia and she did not believe it was an acute issue. Dr U did not have access to the S Hospital records to confirm this, but felt that regardless of the history D’s symptoms were concerning and said that she was “very certain” that the admission needed to happen. M eventually agreed, although not until Dr U had told her that if she attempted to remove D she would have to call the police. D remained in hospital until 12 February 2024; she was treated with antibiotics and recovered.

[60]On 12 February 2024 M told Ms O about D’s admission in a telephone call. She said that she had been told D was more susceptible to colds (no reason for that was given) and would need [hospital] admission when she became unwell.

[61]On 13 February 2024 there was a joint in-person consultation with Ms O and the community SALT, Ms T. M said that she had not really been offering D a bottle as she was not sure what to do. D accepted dummy dips actively and sucked well; when offered the bottle she allowed the teat into her mouth but did not suck, and after a few seconds pushed the teat away. A swallow assessment was not possible as D did not take in sufficient liquid. D was weighed; she was now on the 9th centile and Ms O recorded that her weight gain was slow and she was not really gaining weight prior to the recent illness. Her feeds were increased and M was advised to continue the dummy dips and to offer a bottle 2-3 times per day but to follow D’s cues. The plan was to consider weaning in a couple of weeks.

[62]By this time D had been tube-fed for about six weeks and, in Dr Q’s view, a review of her ability to take food orally was now urgent. In her oral evidence Dr Ward observed that, with hindsight, perhaps this was the time to escalate the case by admitting D to hospital so that her feeding could be observed closely and a swallow assessment carried out. All medical witnesses agreed that the longer tube feeding continues, the greater the risk that the child will become aversive to oral feeding.

[63]D continued with weekly dietetics reviews, although these were not always in person. She was not seen again by a SALT practitioner until late April. Ms O did not formally assess D’s swallow but observed some of M’s attempts to feed; she did not see anything that concerned her about the swallow, or any real evidence of an aversion to food. She said that in her mind there was a plan to progress and to move away from tube feeding, but that she was looking for a period of about four weeks of stability before that could be attempted, and that never happened because new issues kept emerging.

[64]On 18 February 2024 D again attended the emergency department at the V Hospital and was diagnosed with a UTI. Dr Ward’s view was that the frequency of UTI infections over this period and throughout the rest of 2024 was due to insufficient fluid intake.

[65]On 21 February 2024 Ms O saw M and D in person at MGGM’s home. Ms O’s notes indicate that it was not clear why D was not gaining weight and that she discussed concentrating the feeds. The same day (it is not clear whether before or after the appointment), M told Ms T on the phone that she had trialled a small bottle feed which D accepted, but that she then vomited. The notes read, “unclear if this is aversion response or other difficulty”. M was invited to send videos of D attempting the bottle so that they could be assessed, but it does not appear that she did so.

[66]Towards the end of February there were discussions by email between Dr Q, Ms O and Ms T. Ms O reported that D: “has been on a lot of milk due to her lack of weight gain [details given] and still not gaining weight. She has lost weight this week as she has been vomiting and we trialled a period of Dioralyte, which she kept down but vomits when her milk is reintroduced. She remains on Gaviscon on every feed and 10mg Omeprazole. Today I have concentrated her feed to reduce the volumes per feed to see if this helps. I am unsure why she is requiring so many calories and not gaining weight and I [am] running out of ideas to try and improve her vomiting. Do you have any further suggestions to help manage this baby?”.

[67]Dr Q was alarmed by D’s weight, which had remained static in real terms since her admission in January and had therefore crossed from the 50th to the 2nd centile. In her oral evidence she described this as a “catastrophic” weight loss, explaining that at this age she would expect a child to be gaining about 120g per day. She consulted with a paediatric gastroenterologist, who suggested an echocardiogram to rule out cardiac abnormality. Dr Q then telephoned the mother to arrange a hospital admission for a full failure to thrive work-up. 3 – 9 March 2024: the second S Hospital admission

[68]D was admitted to the S Hospital on 3 March 2024. The doctor who admitted her, Dr W, felt that genetics screening should also be undertaken in the light of what he saw as D’s subtle dysmorphic facial features and short stature. Dr Q put in the request for a genetic microarray on 4 March 2024.

[69]D’s weight on admission to the S Hospital was 5kg, 250g less than her weight on 8 January 2024. She was examined by Dr Q who thought she appeared well. The mother had raised an issue of asymmetric leg creases and so Dr Q arranged an ultrasound of her hips. A cranial ultrasound was done to rule out hydrocephalus, and blood tests were carried out to screen for endocrine issues and metabolic disorders. An echocardiogram and electrocardiogram (“ECG”) were performed on the afternoon of D’s admission. The results of all these tests became available over the next few days. The ECG showed a patent foramen of ovale with minimal left to right shunt, which is a variant shared by 25 – 30% of the population; otherwise, the results of all tests were normal. On 7 March 2024 D was given a barium swallow to facilitate an x-ray of her oesophagus; this showed no signs of gastro-oesophageal reflux disease or obstruction of the upper gastro-intestinal tract.

[70]On 7 March 2024 Dr Q informed the mother and MGGM of D’s normal test results. She said that it was difficult to know why D was not gaining weight. She explained that when weight gain is observed in hospital after a period of failing to thrive doctors will worry that feeds are being missed at home. This possibility had also been suggested by Ms O in an email on 5 March 2024 to the hospital dietician, Ms X, but this was the first occasion on which it was put to M. M responded that she was giving all feeds in accordance with D’s feeding plan, and denied that any were missed; she said that she believed the difference was that in hospital D was given a smaller volume of more concentrated feed which she was better able to tolerate. Both M and MGGM were unhappy with the suggestion that the feeding plan was not being followed.

[71]During D’s admission she was switched to continuous feeding via the NG tube, with a four-hour break every 24 hours, and then to continuous feeding at night with bolus feeding (measured tube feeds, either by gravity or by a pump, at fixed intervals) during the day. Immediately following her admission D began to gain weight (she had what Dr Q described as a “huge” gain of 290g in the first 24 hours), and after six days she had put on a total of 670g, more than 10% of her body weight.

[72]D was discharged on 9 March 2024. Dr Q explained that the weight gain she had experienced in hospital was reassuring, and the results of all tests were normal. The feeding plan on discharge was the same as had been in place prior to admission. The plan was to bring D back within the week as an outpatient for an appointment with the paediatric dietician to look at weaning. 15 – 31 March 2024: the third S Hospital admission and first safeguarding referral

[73]D returned to the S Hospital, six days after she had been discharged, for a planned appointment with the hospital dietician, Ms X. On her arrival the NG tube was out and M explained that D had pulled it out that morning and therefore missed her early morning feed that day. Rather than gaining weight as she had during her previous admission, D had lost 100g. M was adamant that no feeds had been missed other than when the tube was out. Dr Q said that D had to be admitted again; M was “teary” but said she understood.

[74]The following day Dr Q had a conversation with M and MGGM; she explained that she found D’s weight loss worrying given the previous gain while she was in hospital. She said that she would continue to look for causes of D’s faltering growth but at the same time would make a referral to social care. In her evidence Dr Q said that she had been very worried on D’s first admission, especially when she reviewed the communications from Ms O about the lack of progress D had made. She said that she made the referral because she thought that medical professionals needed help from someone who could look into the family situation. M was unhappy about this, and requested a change of consultant.

[75]D remained in hospital for about two weeks. M was encouraged to try offering the bottle, but not to pressurise D if it was not accepted. D was now over five months old and the suggestion of weaning was repeated, but M was not keen to try purees and on 22 March she is recorded as saying she was not continuing with bottle feeds as D sounded chesty, and there was an increase in her vomiting. She declined overnight feeds as she did not want D to be woken.

[76]On 25 March 2024 Ms X had a discussion with M. M gave a history of large vomits after bottle feeds, but the only vomiting observed by nursing staff was recorded as milky dribble/ possetting. Ms X emphasised the importance of taking photos if D vomited a significant amount.

[77]A gastroenterology review took place on 28 March 2024. It was noted that D had had a normal barium swallow and was gaining weight on NG feeds, so it was not likely that she had a gastrointestinal problem. The plan was recorded as “continue with NG feeds for now, dietician and SALT follow-up”. If the issue had not resolved in three months a further gastroenterology review was offered.

[78]Dr Y, a paediatric cardiologist, examined D on 29 March 2024 following the results of the ECG and echocardiogram. She appeared “pink, warm, and well-perfused”. Dr Y noted normal heart sounds, and no murmurs.

[79]The results of the genetic testing were received on 30 March 2024. A genetic microarray had identified a 1q44 deletion, which had been identified as a “likely pathogenic variant” – in other words, a genetic abnormality capable of causing symptoms. Genetic counselling was recommended and the parents were put on the waiting list, but this had not taken place by the time that these proceedings were issued.

[80]On 31 March 2024 the local authority, LB Croydon, closed the case on the basis that they did not consider any support or intervention was required.

April 2024 – Jan 2025: D at home

[81]D remained at home from April 2024 until January 2025, without any further hospital admissions. She did, however, have quite frequent contact with medical professionals, partly because of the ongoing monitoring of her feeding problems and partly as a result of new concerns raised by M. Throughout this period Dr L, a consultant paediatrician at the S Hospital who had taken over responsibility from Dr Q at M’s request, had overall responsibility for her care and he saw her three times, in April, July and October. D’s appointments with the community dieticians and SALT also continued. D was weaned onto solid food in July 2024 and a form of stability was achieved: her weight returned to the 50th centile and remained stable, and she consistently appeared well when examined by medical professionals. M continued to report vomiting, and occasionally sent photographs; but as D was gaining weight these did not cause any professional concern.

[82]In the meantime, the parents were digesting the news of D’s genetic condition. Without any prospect of genetic counselling on the horizon they conducted their own research. They found the website of an organisation called Unique, set up by parents of children with 1q4 microdeletions to provide information and support. Dr Ward confirmed that the website is legitimate and the information on it is provided in good faith; but pointed out that, perhaps inevitably, its focus is on those who have been most severely affected by their genetic condition. I have spent some time considering the information available to the parents from this source. It seems that possible outcomes for children with 1q4 deletions include learning disability, heart conditions (although usually minor), feeding problems and hypotonia. There is a suggestion in the information leaflet that children with deletions nearer the end of the chromosome, at bands 1q43 and 1q44 (D’s deletions) may have a better outlook, and Dr Ward pointed out that the literature deals only with children who have undergone genetic testing, which those who present with no obvious abnormalities may never do. Nevertheless, it is entirely understandable that the parents will have been anxious about D’s future and how her condition might manifest itself.

[83]At the first appointment with Dr L on 8 April 2024 D’s progress was reviewed and her weight gain noted. On examination she seemed well and healthy. M said that she felt D was doing well other than that she was experiencing some “blank episodes” when she would stare without blinking and appear to lose focus. Dr L reviewed some videos M provided and said that he believed D’s presentation was normal for a child of her age. Overall he recorded his impression of being reassured by the weight gain and happy to review D in three months, with a view, if she remained on a stable growth trajectory, to considering a longer period between reviews.

[84]Dr L was aware that D was on anti-reflux medication (Gaviscon and omeprazole) and it was his understanding that she remained tube-fed because of presumed GORD. He knew that she was under the care of the community dietician and SALT team and that solid foods were being introduced. It is reasonably clear that he saw his role as reviewing D’s growth and development, and overseeing the one outstanding referral for a gastroenterology review. He was content to leave the management of her feeding to the dieticians and SALT team, and expected that the NG tube would be removed once they considered that it was safe to do so.

[85]M began introducing D to purees in May 2024. She reported to Ms O that D took the food well and appeared interested, but after eating she would seem uncomfortable with “non-stop crying” and was often sick. M also described “weird breathing” after D was given food. On 8 May 2024 M requested a GP appointment; in the econsultation form she wrote: “My daughter has been having a breathing problem since she was a newborn but it’s progressively getting worse and becoming more often… talked to her paed about it and they said it’s fine and normal but I disagree”.

[86]A GP appointment was arranged the same day; the notes record, “videos seen on [M’s] phone – do not look concerning”. D appeared well. Just over a week later M again requested a GP appointment, writing in the form: “My daughter was seen last week in regards to my concerns about her breathing/ sleeping he said it’s common in babies until 12-18 months she’s struggling most of the day hands and feet go blue often she sucks in at the ribs whilst it happens she's pale cyanosis when sleeping cries painfully and sleeps after for hours I've raised concerns of laryngomalacia and sleep apnoea due to her showing symptoms and got pushed away I’d like to be taken seriously I'm watching her most nights so I know she's safe…. She has other health conditions which makes everything heightened.”.

[87]A GP appointment was arranged and took place on 21 May 2024. The notes record, “alert and active warm and well perfused chest clear no recession no respiratory distress agreed ref[erral] to paediatricians”. The referral was made, but was rejected because D was already under paediatric review.

[88]Ms O observed D eating on 15 May 2024; she took about 1/3 of a pouch of puree, feeding herself from a spoon. Ms O thought that she appeared happy throughout with no signs of distress and no signs of altered breathing; M said that D usually had a breathing change after feeding, but it might not be immediate.

[89]On 18 June 2024 M sent an email to Ms O to say that D was bringing up clear liquid after feeds, “aspirating or like a gargle cough noise and clear fluid”. Ms O suggested changing the “flushes” (small amounts of water fed down the tube before and after each milk feed). M replied: “Okay will try this she still has been doing it was sick after this and last feed but think it’s where she’s still poorly we’re waiting for a referral for neurology for suspected focal seizures she’s been having a lot of episodes lately one thing after another lately”.

[90]The reference to “focal seizures” appears to relate to the “blank” episodes reported to Dr L. He had watched M’s videos and reassured her, and had not at that stage made any further referral. This is perhaps the first example of M providing a medical professional with information that is undoubtedly false (as opposed to exaggerated).

[91]On 11 July 2024 Ms T undertook a SALT review by telephone. M reported that D was accepting smooth purees and licking “bite and dissolve” foods (for example baby wafers). M expressed a concern that D was choking, and Ms T confirmed with her that D’s airway was not blocked; she explained the difference between choking and gagging or coughing. Ms T suggested offering thickened fluids from an open cup.

[92]Dr L saw D again on 17 July 2024. At this appointment M again raised a concern about “blank” episodes and Dr L agreed to consider an EEG; no referral was, however, made at that stage. M reported that D was constipated and Dr L chased the referral for a gastroenterology review. He recorded his overall impression as being reassured by D’s weight gain, and arranged the next review for four months’ time.

[93]On 23 August 2024 M described “fluidy loud breathing” after eating in an email to Ms O.

[94]On 12 September 2024 D was taken to the GP. M said that she had been experiencing breathing difficulties the previous day when M was at work (it was not clear from the evidence who had been caring for D; MGGM, who would often look after D if M was working and she herself had a day off, could not remember this incident). On examination D looked well and was a healthy colour, with no signs of respiratory distress, but in light of the history given the GP arranged an urgent paediatric referral and D was taken to the emergency department at the S Hospital. The history given by M, as recorded by the hospital, included “? laryngomalacia” (a weakness of tissues in the larynx which causes noisy breathing). On examination D seemed well and there was no noisy breathing or recession (sucking in of the skin around the ribs). M reported her concerns about D’s breathing and provided videos showing this and, it seems from later hospital correspondence, the “blank” episodes. A chest x-ray was conducted which did not show any findings of concern. D was kept in for about five hours for observation but then discharged with safety netting advice.

[95]There was a focus in the evidence on what M was told on this occasion about the results of D’s chest x-ray. From this date onwards, M regularly told medical professionals that D had been diagnosed with aspiration or micro-aspiration, a condition in which small particles of food are taken into the lungs (“aspirated”); over time this can cause chronic infection. M’s evidence is that she had the impression from Dr Z, the radiologist who reviewed the x-rays, that it was possible that there were signs of microaspiration. On reviewing the clinical evidence, including the written and oral evidence of Dr Z, it seems highly unlikely that anything said to M could reasonably have given her that impression. All the medical witnesses agreed that there was no evidence of aspiration on the chest x-rays. Dr Z’s notes record that the x-rays did not disclose any findings of concern; he believed he would have conveyed this to M and it is highly likely that he did.

[96]On leaving the hospital M left a voicenote for F in which she told him that the doctors had said that D was “micro-aspirating”. This voicenote was created very soon after D’s attendance at hospital. Although I do not place very much weight on this, M’s tone in the voice message is curiously matter-of-fact and I do not detect any significant concern about what might have been quite a troubling diagnosis.

[97]On 16 September 2024 emailed Ms O: “Hi just to let you know Ds going into hospital later got to get the letter from the doctor to take her in soon due to her breathing issues [….] She is out for now she will go back next week or week after a lot going on she’s microaspirating worse when she’s eating food awaiting ent and laproscopy within week or 2 being referred to a bunch of other teams for help and neuro for seizures etc”.

[98]In a telephone consultation with the new dietician, Ms A, the following day M is recorded to have said that “x-ray completed and microaspiration was discovered.”.

[99]M, MGGM and the children went on holiday to Lanzarote from 29 September to 13 October 2024. It was both M’s and MGGM’s evidence that although D was still receiving her milk feeds through the NG tube on this holiday, she was also eating solid foods (both remembered her eating chips in a restaurant).

[100]On 19 October 2024 D turned one. M posted a series of updates on Tiktok. Amongst the posts were the following:

“Accepted for DLA; starts her wheelchair process soon Going on PEG list Possibly requires lung surgery and other surgeries next year More disabilities added to her list More medical professionals added to her teams Still proving them wrong still fighting Sleeps 14+ hours of a night and naps 3+ hours of a day.”

. Going on PEG list Possibly requires lung surgery and other surgeries next year More disabilities added to her list More medical professionals added to her teams

Still proving them wrong still fighting

[101]In her oral evidence M accepted that much of this was untrue. However she said that the sleeping hours she asserted were an average, and did not accept that by using the “+” sign she had meant to suggest that D was sleeping more than this.

[102]Ms A, the new community dietician, first saw D in person on 22 October 2024. According to her note M reported that D was having difficulty with infant meals with a high liquid content “and appears to aspirate or vomit either due to the size of the pieces or the fluid content of the meal… she has no observable issue with her wafers”. M also reported that D was awaiting a neurology review, and referred to seizures. Ms A suggested that M stop giving baby meals and give tolerated snacks only until SALT could review.

[103]The next appointment with Dr L took place on 30 October 2024. An examination was normal and D appeared well. He noted that he was “very reassured” by D’s good growth, but noted that M was reporting constipation “with limited fluid intake due to restrictions with aspiration risk”. D was only eating baby snacks (“bite and dissolve” wafers), and no longer wet purees. Dr L told M that a colleague with a specialism in epilepsy, Dr W, had reviewed the videos sent and did not think the “blank” episodes were epileptic movements. However M continued to raise this issue and Dr L agreed to request a sleep EEG.

[104]The gastroenterology appointment previously requested had still not taken place and Dr L repeated this referral. He arranged to review D again in six months. The plan as far as D’s feeding was concerned was to continue with the current dietetic plan and ask the dietician to consider a higher fibre feed to address constipation. There was no discussion of the NG tube being removed and Dr L noted that M “is keen to discuss whether a PEG [percutaneous endoscopic gastrostomy] would be considered as [D] pulls out her NG all the time and she is not making much progress with other forms of feeding”.

[105]M’s note to herself after this appointment reads, “PEG approved by Dr L… Aspiration is there often and affects airways ent for February to decide on surgery or not. Aspiration is causing illness and inner infections hence why she gets poorly a lot but there’s nothing we can do about it”. M was adamant in her evidence that this note, which she wrote down immediately after leaving the appointment, reflected the advice she had been given. I have no hesitation in finding that it did not, and that Dr L’s note presents an accurate record of the consultation.

[106]On 13 November 2024 M requested a GP letter to assist with her claim for DLA. She said: “D has chromosome 1 deletion… micro aspiration central circulation problems absent and drop seizures breath holding spells apnoea episodes NG tube leg length discrepancies suspected scoliosis microcephaly raynauds frequent infections/ colds due to aspiration and floppy airway I need a letter to support her DLA claim to state she requires 24 hour care due to her disabilities and conditions.”.

[107]The surgery responded to say that they did not have the expertise to provide the letter sought and referred M to D’s paediatrician. When M was asked about this message she said that these were the conditions she believed D to have at the time. When D was in hospital in March 2024 M and MGGM had shown medical staff a picture of D curled up which they thought might show a curved spine, but D was examined and nothing abnormal was noted.

[108]On 30 November 2024 D attended the emergency department at Kings College Hospital. The notes record the presenting complaint as “generalised weakness – one week unwell. M noted her grabbing the back of her head and chest, ? seizure this evening. Nasogastric feeds, complex needs”. There was a lump in her left thigh and this was x-rayed; no abnormality was seen and this was later considered to be connected to a recent immunisation. On examination D was alert and well; she was discharged home.

[109]On 10 December 2024 there was a review dietetics appointment. Ms A recorded that D had had oral thrush and was unsettled, but her weight was stable and she was eating solids throughout the day.

[110]Around Christmas time M posted a picture of D on Tiktok with the following message: “She doesn’t know it but she doesn’t get a lifetime filled with spa days getting our nails done shopping trips girls days talking about boys or girls she gets a lifetime of less than 18 years filled with hospital trips tests treatments struggle suffering and if we’re lucky fun in between”.

[111]On 7 January 2025 D was brought to the emergency department at the S Hospital. The presenting issue was a cough and noisy breathing for the preceding week. The history given by M included “aspiration” and “seizures”. It is recorded that D had recently finished a course of amoxycillin for a UTI. She was examined and noted to be “active, smiling, playful, no respiratory distress”. However due to what M described as “similar episodes in the past” a chest x-ray was performed; this was normal. D was discharged with safety netting for worsening breathing, fever or seizures.

[112]In early January 2025 M asked her grandfather if she could borrow his blood sugar monitor, and began using this to check D’s blood sugar levels. The monitor required a finger prick to be done to draw blood for each measurement. M explained in her evidence that D was sometimes pale, with shaky hands, and sweaty on waking; there was a history of type 1 diabetes in the family and she was concerned. On 17 January 2025 M filled in a GP e-consultation form to say that she was checking D’s blood sugar levels, commenting that it had never occurred to her to do so “until the more frequent symptoms and troubles”. The GP replied that the levels reported did not sound overly concerning. Asked in evidence whether she agreed with this, M said that she was “not going to disagree when the doctor tells it, but there are other blood sugar problems other than diabetes.”.

[113]On 23 January 2025 D had a consultation with the dietician, the recorded aim of which, according to the notes, was “to observe D during a feed, both oral and via nasogastric tube for a prolonged period of time due to mums reported of aspiration”. Ms A noted that the videos provided by M did not clearly show the problems that M was reporting. D was observed eating puff pops (baby snacks with a bite and dissolve texture); the note records: “no issues were seen and she ate them quite quickly. Subsequently mum provided D with her feed there were no issues with breathing or gasping and no fluid like sounds in D’s voice. D was then observed for half an hour post feeding. There were no overt signs of aspiration during this period”. 28 January – 21 February 2025: the third S Hospital admission

[114]D was brought in by M to the S Hospital emergency department on 25 January 2025 with vomiting, a fever and a cough. She was seen and discharged home, but presented at the emergency department again on 28 January. On this occasion she was diagnosed with ketotic hypoglycaemia (“KH”), a condition in which the body’s glucose levels drop so low that the body begins to consume stored fats, converting them first into ketones. Ketones are usually produced by the body during times of illness or prolonged fasting. KH is not unusual in children during periods of illness. It is treated with a concentrated glucose solution given orally or, if that is not tolerated, intravenously, and usually resolves very quickly.

[115]D was treated with dioralyte and a note at 9.40am on 30 January 2025 records that the ketotic hypoglycaemia had resolved. D was kept in for observation and M was advised to feed normally every four hours. However at 1am D’s blood sugar was low (3.6mmol/L) and her ketones had risen to 2.3 (anything above 1 being concerning). M said that she had been worried that D might choke and was at risk of aspirating, so she had not given the full amount of feed. The feeds were adjusted and an attempt was made to cannulate D in order to administer intravenous fluids, but this was unsuccessful.

[116]From 31 January onwards, when the KH failed to resolve, the team at the S Hospital consulted with the specialist metabolic team at the R Hospital. The advice was to increase the calories D was receiving by adding Maxijul, a high-calorie formula, to her feeds and reducing other fluids. M was repeatedly resistant to the plan: she said that she did not want D to have milk feeds overnight, and then that she did not want to proceed with NG feeds until after the ward round. On 3 February 2025 she gave 60ml feeds during the night rather than 90ml. The nurses found it hard to obtain full observations overnight as M did not want D to be disturbed. D’s feeds were increased again, but M said she had been told by the community SALT team not to give more than 150ml in total because of the risk of aspiration. After discussion a reduced amount was agreed. An abdominal ultrasound was arranged.

[117]On 3 February 2025 D was reviewed by a dietician, Ms B. M said that the NG tube was in place due to concerns with D’s swallow, and a community SALT assessment was pending. Ms B was challenged and maintained her account that this information had come from M, and I find this account to be accurate: she had at that stage no access to the community records or contact with the community SALT team. She said that given that information, she would not have advised any oral intake as she did not know whether this would be safe or not. M told her that D received no significant oral nutrition other than the occasional melt and dissolve baby puff. Again, Ms B was clear that M was speaking about the period prior to D’s admission and not the current period, and I accept her account. It was noted that if D was not eating solid foods, neither her community feeding plan (110 mls per feed) nor the amount M said she had been giving (60 mls per feed) was meeting her energy requirements, but despite this her weight was tracking the 50th centile.

[118]In her evidence M denied saying that she was only giving D 60 mls per feed, but said that around the time of the hospital admission Ms A had sent through a new plan providing for 60 mls. The plan recorded in Ms A’ notes is that two of D’s feeds only (at 8am and 8pm) should reduce to 50 mls as a result of M’s reports of aspiration. In fact, Ms A noted, M had reduced all the feeds to 60 mls, which was “not meeting lower safe fluid limit”.

[119]I did not find M’s evidence on this point easy to follow. She said that she did not recall the conversation noted by Ms A, and that she had continued to give all feeds at the “normal” level of 110 mls. That is not what she said to Ms A shortly before D went into hospital, or what she told hospital staff she had been doing. M was fully on top of D’s feeds and fluent in explaining how they were made up; I do not think it likely that she was mistaken on this point. I find that prior to D’s admission she did reduce the feeds to 60 mls (against Ms A’s advice), and that she told the hospital that this was the level of feed she had been giving.

[120]Over the next two weeks the team at the S Hospital tried different methods of controlling D’s KH. M remained resistant to advice: on 7 February 2025 she admitted that she was not giving D her feeds in accordance with the feeding plan as 120 mls was the maximum volume allowed at each feed by the (former) SALT, Ms T. Ms T was contacted by the hospital and replied that she had not given any advice to limit D’s intake. M then agreed to follow the feeding plan, but when asked to allow observation during feeds she was unhappy about this, saying that she had already been through a safeguarding process and nothing of concern had been found.

[121]On 8 February 2025 the metabolic registrar noted that D’s results were “not making sense”: despite a significant increase in carbohydrate, she remained ketotic and with low blood glucose. The results of an abdominal and renal ultrasound scan were normal, and there were no records of vomiting. A conversation took place with M who said that she knew her child and how to feed her, so she did not need to be observed. Further discussions took place with Dr N, the metabolic consultant at the R Hospital, who advised a switch to continuous feeds, made up and administered by nurses. This was put into place on 8 February 2025; D’s blood sugar and ketone levels returned to normal the following day, and remained so for the following four days.

[122]On 12 February the team recommended a change from continuous feeding to every two to three hours. M was informed but did not agree: she said that two-hourly feeds had been tried before and were unsuccessful in maintaining normal levels. A compromise was agreed: D would be on two-hourly feeds during the day, and continuous feeds overnight. This was put in place on 13 February 2025.

[123]On 14 February 2025 a professional multi-disciplinary team meeting took place involving clinicians from both hospitals. There was a concern that D’s results could not be fully explained by a metabolic diagnosis, and that M’s narratives to professionals were inconsistent; “multiple breakdowns in relationships”, and a potential safeguarding referral, were discussed. The plan was to complete tests to exclude an underlying medical condition before D was discharged. In order to be safely discharged she would need to be on four-hourly feeds. Dr L was tasked with explaining to M that there were concerns about the feeding and therefore all feeds needed to be recorded. M agreed to the plan, but said she felt she was being victimised and not trusted.

[124]The continuous feeds were stopped at 10am on 17 February 2025, and an attempt made to move to bolus feeding, initially at a two-hour frequency. However the following day D’s blood glucose was down to 2.1 and her ketones had risen to 2.4. She was placed back on continuous feeds. The metabolic team at the R Hospital agreed to an MRI scan to rule out a pituitary growth hormone issue; in parallel with this a safeguarding referral would be made. Dr L had a conversation with Dr M at the R Hospital; Dr M queried the need for a transfer and suggested that the S Hospital could monitor M’s feeding first to make sure she was getting the full feeds. Dr L said that the team at the S Hospital were at the limits of what they could provide, and suggested transfer to the R Hospital for the specialist expertise of the metabolic team, and “a fresh set of medical and nursing eyes”. In oral evidence he said that he was aware that because of the ward layout at the R Hospital it would be much easier for nursing staff to monitor D’s feeding. The transfer was agreed.

[125]That day M sent a text to MGGM: “she’s still a mystery… possible PEG emergency list but could go home on continuous via ng while we wait as if that’s what her body needs then that’s that”.

[126]At around this time M posted the following on Tiktok: “So after 24 hours of being machine free she is now hooked back up by the looks of it her body physically isn't producing the fat- energy proteins on its own without constant support today took another traumatic turn her body has been pricked over 100 times this week her feet are so bruised you can barely touch them after waking up the other day she is still sleeping 20 – 22 hours a day she can't stay awake we've trialled so many different treatment plans this week even ones where I physically struggled to function but I'd try anything to help my girl fight another working my heartbreaking watching this happen I feel like I'm watching my little girl fade away in front of my eyes” and “We have scans on Friday for her liver and other organs to see how their functioning due to the ketone problems that aren't being resolved… currently as it stands the quality of life isn't great all she is doing is sleeping and functioning through a machine until her cells give up completely as she doesn't have the genes to regenerate them… I’m cherishing every moment she's awake because at the moment we don't know when the last time that could be her levels have been on death doors too many times this past week”.

and

[127]On 21 February 2025, just before D was due to transfer to the R Hospital, her feeds were stopped and she was sedated for the planned MRI. However she woke up before this could be attempted and it was decided that the attempt should not be repeated. M posted on Tiktok: “D went under sedation for an MRI during the sedation she suffered with desats tachycardia breathing difficulties seesaw breathing and aspiration… reports came back that she is developmentally/ physically six months old her brain is the size of a 5 month old”. 21 February – 4 March 2025: The admission to the R Hospital

[128]D was admitted to the R Hospital on continuous NG feeds. She arrived with her mother on a Friday, and was nursed over the weekend on the open ward. Nurses were aware that the KH was unexplained, but not that there was any concern about missed or tampered-with feeds. Initially there was no enhanced supervision and M was permitted to draw the curtains around the bed. D was switched to two-hourly feeds, but again developed KH overnight despite an increase in calories and carbohydrate.

[129]At the R Hospital Dr N took over responsibility for D’s care. She met her for the first time on Monday 24 February 2025. She noted the discrepancy between M’s reported feeding of D and her weight prior to admission to the S Hospital. During that admission D had had no solid food, and had lost 500g of weight despite a significant increase in calories. Dr N spoke to the nurse in charge of the ward and the hospital safeguarding lead, Dr C, and said that she was concerned that the only explanation was feed tampering. A plan was made for increased observation, but D developed adenovirus and for infection control purposes had to be moved into the side room, making observation difficult. Instead, the plan was that nurses would observe the start and finish of each feed.

[130]On the nights of 24 and 25 February the mother cleared the feed pump after feeds, meaning that the volume that had passed through was not recorded. She was instructed not to do so.

[131]Over the next week the intervals between feeds were extended.

[132]An EEG was carried out on 26 February 2025; no abnormalities were seen.

[133]On D’s admission to the R Hospital M reported that she had an NG tube because of feeding and breathing difficulties, and that she had an unsafe swallow. She said that D did not have solid food; she had previously had purees until July or August 2024, and then bite and dissolve snacks until December 2024, but this had all stopped because of respiratory problems. Dr D, the respiratory consultant to whom M provided this information, was challenged on her evidence but maintained it, and I accept her evidence: she said she had specifically asked M to confirm the dates because it was unusual for a child’s development to go backwards. She said that M had initially given the impression that she had been advised to stop feeding by the community SALT team but when pressed M said that she herself had taken the decision, because the SALT team had gone by the time the issue became apparent.

[134]M told Dr D and other medical staff that D would sleep for 20 hours a day. This became an issue as M did not want her to be woken for feeds, saying that she needed rest. It was put to Dr D that M had said that D slept like that only when unwell but Dr D was clear, and I accept, that M was saying that was her regular pattern. Dr D was concerned about the impact of this on D’s development and suggested that if D had slept for more than 16 hours she needed to be woken, but M refused to agree.

[135]Dr D found it hard to obtain clear descriptions of D’s behaviour from M. M would say that she could not feed D “because she has micro-aspiration”, but when Dr D tried to encourage her to describe what symptoms she had seen she found it difficult to say.

[136]On 27 February 2025, after D had been at the R Hospital for six days and her glucose and ketone levels had stabilised, Dr D suggested that this was an ideal opportunity to progress D’s feeding. She reassured M that she had reviewed D’s x-rays and examined her, and there was no evidence which suggested a risk of aspiration. M remained anxious but appeared to accept this advice.

[137]The first stage in progressing feeding was a SALT swallow assessment, which had not yet taken place despite D having spent more than a year on the NG tube. It took some time before this could take place. The SALT therapist at the R Hospital, Ms Q, was a specialist in acute paediatric Speech and Language therapy and dysphagia (problems with eating, drinking or swallowing). She saw D for the first time on 24 February 2025. M reported that D was “nil by mouth”; Ms Q’s understanding was that D had not taken in anything orally since the NG tube had been fitted at 10 weeks. M said that there had been some unsuccessful attempts at eating but D would become breathless and tired. She said that it was difficult to feed D because she slept a lot, for up to 23 hours a day. It was put to her that M was talking about the newborn period but Ms Q believed M was talking about the present day and in the context of the conversation (and M’s Tiktok post quoted above), that is much more likely.

[138]Over the following week Ms Q tried on multiple occasions to observe D’s eating. M said first that she did not want D to eat as it would cause her pain; then that she had had a “dangerous breathing episode” during the night (this was not reported to nursing staff); then that D was asleep and should not be woken. On 27 February 2025 Ms Q had brought a small pouch of puree with her. D reached out for it and she put the unopened packet in her mouth. She did the same with a wrapped cake slice. M refused to allow D to eat, saying that she had never had any concerns with her swallow, the problem was that D would be in pain after eating; she said also that she did not want D to have processed food, although she had not taken up the opportunity previously offered to bring in food for her. Ms Q tried to give reassurance and explained that a swallow assessment would need to be done at some point. M said that D would “always be NGT as she has a 1 in a million genetic disorder and all children with this disorder are tube fed”; she would not allow D to have food as she said she would deteriorate. Ms Q was challenged on this part of her account but confirmed that she had recorded what was as close as possible to a verbatim note of what M had said because she felt it was so important, and I accept her evidence.

[139]The following day, 28 February 2025, M told Dr E during a ward round that D’s feeding ability would regress and she would be solely dependent on NG feeds one day; she said that she had already looked at blended options. She told a nurse, Mr F, that the inevitable next step would be a PEG; Mr F documented this as he did not think there was anything at the time to indicate that D would regress.

[140]Over the weekend of 1 – 2 March 2025 M was not present in the hospital as the family had been offered accommodation in their former borough and she and F were moving house. MGGM stayed in hospital to care for D. On 1 March 2025 Dr N had a conversation with M over FaceTime on MGGM’s phone. Dr N said that D was sleeping too much, more than normal and M replied, “she’s not normal because she has a chromosomal disorder”. She went on to list D’s problems which she believed to be linked to her genetic condition and Dr N asked who had told her this because there was nothing in D’s medical notes to support it. M said that was because doctors did not want to do the research. Dr N said that it was good to get support from parent groups but to be careful because not all children will be affected in the same way. M became agitated and angry.

[141]On Monday 3 March 2025 Ms Q was able to conduct a swallow assessment after M brought in foods from home for D to try (baby wafers and purees). D appeared highly motivated to eat and fed herself using her hands and a spoon; she sometimes stuffed the food into her mouth and required pacing. However there were no signs of aspiration and no problems with her swallow. Ms Q recommended normalising mealtimes (three meals a day) and to try a sippy cup.

[142]Ms Q returned the following day; she was hoping to review D and carry out an assessment of her ability to manage liquids. M was not present and asked Ms Q not to feed D until she arrived. Once M arrived at the hospital she declined any further attempt at oral feeding, saying that D had been in pain the previous night due to eating. 4 March 2025: strategy meeting, M’s arrest and police protection

[143]Dr N had remained in overall charge of D’s case since her admission to the R Hospital on 21 February 2025. She said in evidence that throughout that period her major concern was that M had been tampering with D’s feeds. She could not think of any other explanation for the blood glucose and ketone levels which had improved at the R Hospital once M was more closely monitored. Through extensive testing all possible medical explanations had been excluded. Dr N was familiar with the RCPCH guidelines and discussed the way forward with the hospital safeguarding lead, Dr C. She said that her own view was that M’s resistance to oral feeding and her unsupported fears about respiratory problems were concerning and could potentially amount to false beliefs, but the primary and most urgent concern was the risk of illness induction and the investigations carried out at the R Hospital had not provided any reassurance that that concern was unwarranted.

[144]A referral had been made to the local authority by the S Hospital on 20 February 2025, raising a query about the family’s need for support. M declined the services offered and the local authority was in the process of closing the case when it received another referral from the R Hospital, shortly after D’s admission, raising concerns about fabricated or induced illness.

[145]A strategy meeting took place on 4 March 2025 attended by the police, local authority, Dr N, the safeguarding lead Dr C, Dr L and other clinicians from both the R Hospital and the S Hospital. Dr C had prepared a chronology setting out the history of D’s medical interventions. The hospitals reported their concerns about induced illness, fabrication of symptoms (including in M’s social media accounts) and excessive sleeping. At that stage there was a concern that D might have been medicated to induce sleep and toxicology tests were being carried out. The initial samples were, however, inadequate and subsequent testing did not support that conclusion; no finding is now sought by the local authority.

[146]At the strategy meeting Dr N made clear her view that because of the concerns around induced illness, and despite the improvement in D’s glucose levels, she could not guarantee D’s physical safety on the ward while M remained in control of her care.

[147]The strategy meeting took place in the morning. Later that day the police attended the hospital and D was taken into police protection. M was arrested and removed from the ward and D’s care was taken over by medical staff. C was also taken into police protection and placed with his maternal great-grandparents. The police noted clutter and some hygiene issues in the family home, but the parents later explained that this was because they were in the middle of moving house, and the local authority does not pursue this issue.

Events after 4 March 2025

[148]Following M’s arrest and removal from the ward Ms Q continued to assess D’s feeding and her speech and language development. She carried out several swallow assessments with a range of food textures and fluids. It was clear that D did not know how to use a cup so she initially drank from a straw beaker. She consistently showed no signs of aspiration or ongoing dysphagia. Her speech and language was delayed (at the 3-6 month level) and she was not regularly babbling or making speech sounds, but over the period of her stay she began to do so and to catch up to her milestones.

[149]D’s milk feeds via the NG tube were reduced as her oral intake increased. The overnight feeds were stopped on 11 March 2025 and on 13 March 2025 the NG tube was removed.

[150]On 26 March 2025 D was discharged from hospital to the care of her great-grandparents. She was by then eating a normal toddler diet and drinking fluids from a cup. She was discharged from the community SALT service on 8 May 2025. Dr N saw her as an outpatient on 7 July 2025 and discharged her from the metabolic clinic. She recorded that she was eating and drinking well, her weight was stable and her development appeared appropriate.

[151]For a period following D’s removal from their care both parents frequently expressed concern that what they saw as her significant medical needs were not being met. On 15 May 2025 they jointly wrote a letter to the IRO describing D’s “long and complex medical history” and raised particular concerns about her left-side movement, saying that D “walks with a visible limp or wobble and falls often” and asking for a referral. Around the same time M raised a concern about the food being given to both children during contact. In relation to D she said that she “does not eat crisps and chocolate and may only tolerate something like a yoghurt…. She requires fresh textures and safe food options”. She concluded by saying that D was “still a child with known vulnerabilities, and her needs should not be minimised”.

[152]The parents’ contact with the children has been supervised since the interim care orders were made. They are currently seeing the children twice a week.

E The opinions of the experts

[153]Dr Ward’s conclusions can be summarised as follows:a. D’s early feeding difficulties, irritability and vomiting may have been due to gastro‑oesophageal reflux and/or non‑IgE‑mediated cow’s milk intolerance, both common infant conditions that typically resolve with time.

b. No medical cause was identified for the reported respiratory gagging, noisy breathing or shortness of breath.

c. A neurological assessment, including video review and EEG, found no evidence of a seizure disorder to explain the episodes described by the mother.

d. No medical cause for faltering growth was identified during 2023–2024. In the absence of underlying disease, faltering growth indicates inadequate caloric intake.

e. D’s genetic variant may have contributed to early feeding difficulties or developmental delay but is unlikely to have played a significant role in her later presentation. The marked improvement in feeding, responsiveness and development in March/April 2025 suggests environmental and caregiving factors were more significant.

f. No metabolic, endocrine or other medical cause for the ketotic hypoglycaemia in 2025 was identified despite prolonged admission and extensive investigation. While an initial infection with reduced intake may have contributed, the recurrent hypoglycaemia and ketosis were inconsistent with prescribed dietary intake or any metabolic condition. Significant improvement occurred when feeds were prepared and administered by nursing staff. This pattern suggests the hypoglycaemia was a starvation response caused by failure to administer the prescribed feeding plan. Failure to follow the feeding plan placed D at risk of recurrent ketotic hypoglycaemia, with potential long‑term physical and developmental harm, including to the brain.

g. Prolonged tube feeding without appropriate oral trials limited development of normal feeding skills.

h. Extended hospitalisation related to a perplexing presentation restricted D’s normal life experiences and developmental opportunities.

[154]In her oral evidence Dr Ward accepted that there was room for different opinions as to the reasonableness or otherwise of M’s responses to medical advice in D’s early months. However from March 2024 onwards she considered that a picture was building of M becoming increasingly resistant to the views of professionals. She agreed that the information M had had about a possible cardiac issue, followed shortly after that was ruled out by the news of a genetic condition, was, likely to have raised her anxiety even if her concerns were not objectively justified. She was very clear that in late 2025 M’s presentation of D on social media “crossed a line”, creating a picture of disability beyond anything that had ever been suggested by medical professionals.

[155]Dr Ward also remained firm in her analysis of the causes of D’s persistent ketotic hypoglycaemia in January/ February 2025. She agreed that when D was first admitted she may have become hypoglycaemic simply as a result of a viral illness. However there was no medical explanation for the failure to resolve the issue after D was treated with highly calorific feeds.

[156]Dr Robinson’s conclusions were essentially the same as Dr Ward’s. There was a slight difference in his approach to the prolonged period of tube feeding: he said that he would have expected the NG tube to be removed as soon as possible, and would have felt uncomfortable sending a baby home from hospital with an NG tube unless there were an underlying neurological diagnosis; if the baby did go home he would have brought it back within a week or two for a nurse to take out the tube, observe a feed “and all’s well”. He accepted that for an experienced nurse simply to remove the tube without a formal SALT assessment could be seen as an “old-school” approach, but pointed out, with some justification, that the chronology in this case included a lengthy period of tube feeding which subsequent events have demonstrated to be unnecessary.

F The local authority’s threshold pleadings

[157]My task is to determine whether or not the threshold criteria in CA 1989, s31 are met. It is important in all care cases, but particularly those involving allegations of this nature, to maintain a focus on the wording of the statute. The question for the court is, firstly, whether at the relevant date (4 March 2025) D was suffering or likely to suffer significant harm; and secondly, if so, whether that harm was attributable to the care being given to her by her parent(s) not being what it would be reasonable to expect a parent to give. Wording such as “at risk”, which appears occasionally in the local authority’s threshold document, is unhelpful: Re S-B (Children)

[2009] UKSC 17

[158]The local authority’s original schedule of threshold findings was an unwieldy 11 pages, with 45 paragraphs/ subparagraphs. There is sometimes a tendency in cases involving illness or injury to a child for a local authority to plead separately each building block of the medical evidence, even when much of it is not in dispute. This can obscure the central allegations, ie what it is that the parent is said to have done or not done. My observation along these lines at the conclusion of the evidence led the local authority to revise its document, but even after revision there were 15 separate pleadings. This judgment will be more comprehensible if the threshold is further condensed into the following four central allegations:a. The mother “medicalised” D: that is, she treated D as more unwell than she actually was. This meant that D’s ability to engage in normal toddler activities was limited and her development was delayed. [allegations 4, 6]

b. The mother unreasonably rejected medical advice. This led to D suffering, or being likely to suffer, significant physical harm. [allegation 5]

c. The mother fabricated symptoms which D did not have. This led to D undergoing unnecessary tests and treatment, some of which was invasive, risky or otherwise harmful. [allegations 1a, 1c]

d. In the period from January to March 2024, and again in January and February 2025, the mother restricted D’s food intake by failing to follow the feeding plan and missing or tampering with her feeds. On the latter occasion this led to D experiencing low blood sugar and high ketone levels (ketotic hypoglycaemia). [allegations 2, 3, 9]

[159]The local authority also alleges that C:a. Suffered emotional harm as a result of his mother and sister’s lengthy absences from home [allegation 10];

b. Was likely to suffer physical harm: the evidence relied on by the local authority being the mother’s actions in failing to provide adequate food to D [allegation 11].

[160]The remainder of the local authority’s schedule particularises the harm which D is alleged to have suffered. I will deal with that issue after I have made findings about what M did or did not do.

[161]F does not feature at all in the local authority’s pleaded threshold document. It is accepted that he attended very few medical appointments and assisted with D’s tube feeds only under M’s supervision. His oral evidence made it clear that he accepted what M told him about D’s medical needs without question. The issue of whether he was right to do so is one that is better left, assuming that these proceedings continue after this hearing, to the welfare stage.

[162]If the mother induced caused physical harm to D by tampering with feeds, not following the feeding plan or otherwise preventing her from taking in sufficient calories, it will be relatively straightforward to conclude that the threshold criteria are met.

[163]The allegations of fabrication of symptoms, over-medicalisation and the rejection of medical advice require a more complex analysis. The local authority says that the mother described a variety of symptoms that were not observed by professionals; it alleges therefore that the mother fabricated them. The mother’s case is that she reported what she saw, but she accepts that her anxiety about D’s chromosomal deletion, and the lack of information she was given about that, may have made her hypersensitive to what she observed. She was a young, possibly neurodiverse mother whose child had received a worrying diagnosis. Because she was in a state of heightened alert she may have described some symptoms as worrying which, viewed objectively by a medical professional, did not give rise to any significant concern.

[164]Returning to the wording of the statute, the focus of my analysis must be on whether, in the light of the information available to her at the time, the mother’s response was reasonable. If I conclude that it was, then even though with hindsight the treatment which ensued was unnecessary and caused D significant harm by keeping her away from her family and subjected to painful and distressing procedures, the threshold criteria will not be met.

[165]In any case where FII is alleged, the court has to face up at some stage to the inherent improbability of a parent choosing to act in such a way as to cause harm to their child. That means that any possible motivation the parent might have had for acting as they did becomes more relevant. The RCPCH guidelines suggest that parental motivation in these cases tends to fall into one (or both) of two categories: gain for the parent, whether financial or emotional, by way of increased attention and support; and a false and unjustified belief on the parent’s part that the child is unwell. There is also some overlap between motivation and context: the parent’s reasons for acting in a particular way may be relevant to the issue of whether the care they were providing was reasonable.

G Analysis

[166]Other than some minor feeding issues D was well in her early weeks and the treatment she received, including the initial fitting of the NG tube in December 2023, was necessary and appropriate. There were some small indicators of maternal anxiety, and with hindsight the seeds of later events may have been present. However D was not over-medicalised or otherwise harmed.

[167]After the NG tube was fitted, this became the most obvious and visible feature of D’s physical presentation. With hindsight, it is plain (and not, I think, disputed) that tube-feeding became unnecessary within a very short period – weeks, if not days – after the tube was fitted in December 2023. Dr Robinson identified an appointment on 8 January 2024 (at which it was recorded that D “would not take the bottle”) as the point when the tube should have been removed and oral feeding reinstated. Whether or not those involved at the time should reasonably have been expected to take that step, it is now clear that D required the tube only to get her through a short period of illness. She had no neurological condition preventing her from taking feeds orally; her swallow was not unsafe; she did not aspirate; and while there may have been some mild reflux this was adequately controlled by medication.

[168]From January to March 2024 D failed to gain weight. I deal with this period below, together with the later period of ketotic hypoglycaemia in 2025, because the two episodes have similarities.

[169]Over the period from April 2024 until January 2025 the medical evidence overwhelmingly suggests, even without the benefit of hindsight, that D was developing normally and that she was physically well. When examined (other than on the occasions when she was feverish or had other symptoms of a viral illness or infection) she consistently presented as a healthy baby: her colour was good, her chest clear and nothing of concern was noted. On the three occasions when Dr L reviewed her he described her presentation as “reassuring”. It was only M’s reports of persisting or sometimes new symptoms that led him to refer D for further investigation.

[170]Over the same period there is a pattern of M’s reports to medical professionals escalating. Since her early weeks of life M had occasionally reported breathing difficulties and “blank” episodes, but from the autumn of 2024 these reports escalated and the word “seizure” was repeatedly used, even after Dr L had passed on the reassurance given by the specialist that M’s video recordings did not appear to show epileptic movements.

[171]By late 2024, M was also giving accounts of referrals and diagnoses that simply had not happened. One clear example was M’s firm and repeated account that D had been diagnosed with micro-aspiration after the chest x-ray in September 2024. M also reported, incorrectly, that D was awaiting a neurology referral, a wheelchair assessment and a PEG.

[172]The evidence suggests that these reports obscured and caused a distraction from the fundamental issue, which was D’s feeding. Dr L was content to leave that issue to the community dieticians and SALT team, but he might well in my view have questioned the ongoing use of the NG tube if M had not persisted in the reports of seizure-type behaviour. Similarly, the SALT practitioners and dieticians were aware that D had a diagnosis of a genetic microdeletion, that she was under paediatric review and (at least according to M) that there were several investigations outstanding. In those circumstances they may have been less likely to give M the strong encouragement she needed to continue with oral feeding and wean D off the NG tube.

[173]A further complication was D’s location: it was difficult for the SALT team to see D as frequently as necessary because she was not living in the borough. D did not have any more face-to-face SALT appointments after April 2024. Dr L had a conversation with M about the challenges of having a GP in the borough and an out of borough address, but M was reluctant to change GP.

[174]The response of healthcare agencies is not the focus of these proceedings. Nevertheless it is appropriate to observe that there were systemic issues (not individual failings) that made it harder for medical professionals to give appropriate advice in D’s case. Over the course of 2024 the situation developed into what Dr Ward described as a “stalemate”, where none of the clinicians was directly engaged with the question whether the NG tube could be removed and normal feeding attempted. Dr Q said of this period: “I think I was just hoping SALT could help us help [M] to have the courage to bottle feed, not be worried about the gagging, that would settle down if we just persevered. Without SALT support, it was hard for us to push that further”.

[175]For their part, the SALT team and dieticians were waiting for the green light from the hospital, as well as a period of stability in D’s presentation, to progress the feeding. No one had direct responsibility for reviewing the ongoing need for NG tube feeding.

[176]In contrast to D’s generally healthy presentation and weight gain between April 2024 and January 2025, there were two distinct periods either side of that when she failed to thrive. The first was from January to March 2024, when she put on no weight at all over a period of about 8 weeks until she was admitted to hospital, and then lost weight again as soon as she was discharged. It is significant that this happened before D’s genetic condition had been discovered. The second was from January to the end of February 2025, when D’s weight again was static and her blood glucose levels dropped so low that she developed ketotic hypoglycaemia.

[177]Both of these periods triggered safeguarding referrals. On the first occasion concerns arose only after a period of extensive medical investigations, the initial assumption, appropriately, being that there was an underlying physiological cause. A referral was made to the local authority but not pursued when D gained weight and the issue appeared to have resolved. On the second occasion, because of the history and D’s failure to respond to treatment, safeguarding concerns arose much sooner and a “perplexing presentation” was identified well before the transfer to the R Hospital.

[178]The RCPCH guidelines suggest that where the child’s safety is not at risk, the clinical response to a perplexing presentation should be one of curiosity and support and, where possible, the clinician should have an honest conversation with the parent explaining the uncertainty around the symptoms. This may enable a health rehabilitation plan to be put in place and avoid the need for the type of intervention that ultimately happened in this case. Asked whether she thought there might have been a possible route back to health for D without the interventions that took place Dr Ward said that, with hindsight, a multi-disciplinary meeting might have been arranged to look at options soon after D’s transfer to the R Hospital; but this was a fairly tentative suggestion, and she had no criticism of the hospital’s application of the guidance in the light of the information available to them. Dr N’s view was that there was clear evidence of induction of illness through feed-tampering, over a period of some weeks; in those circumstances a robust safeguarding response was required and further attempts to work collaboratively with M would be too risky. It is always tempting to wonder what might have happened if, for example, the clinicians had asked M voluntarily to step away from D’s care for a period and allow them to try a different approach. However, taking into account the level of M’s resistance to advice around feeding, there is perhaps little reason to believe this would have led to a different outcome; and it was not unreasonable for the hospital to take a cautious approach given the nature of the risks to D. H Findings Medicalisation: allegations 4 and 6

H Findings

[179]This allegation needs to be seen in the context of D’s diagnosis of a genetic microdeletion, and the lack of information available to the parents about that. In March 2025, after these proceedings had commenced, a consultant geneticist at the R Hospital examined D and expressed the view, based on all the information available at that time, that her genetic condition was unlikely to result in more than a mild motor and cognitive delay. But that opinion of course was not available to the parents over the relevant period and they were relying on the information on the Unique website, some of which suggested that D might be severely affected.

[180]I acknowledge entirely that any parent presented with a diagnosis of a genetic abnormality will be fearful and perhaps hypervigilant. That response is not unreasonable, and a degree of overcaution in the interpretation of the child’s general health is to be expected. However what is striking about D’s case is the degree to which M perpetuated a narrative in which D was significantly disabled, with a very poor prognosis, even in the face of repeated reassurances by medical professionals as test after test came back normal. I have commented already on the dissonance between Dr L’s recorded impressions of D when he reviewed her over the course of 2024 and the accounts given by M of her multiple pathologies. In my view, M’s persistence in describing D as a “medically complex” child with multiple, very serious health conditions went far beyond what would reasonably be expected of a parent in her situation.

[181]M’s presentation of D to medical professionals as significantly unwell was only one aspect of her medicalisation. Another was the NG tube itself. Several witnesses observed that M was unusual amongst parents of tube-fed babies, who typically would “hate” the tube and be desperate for it to be removed: Dr Q said that tube feeding, other than in cases where it was neurologically required, usually came to an end naturally because the parent was so strongly motivated to persist with oral feeding. M, the evidence demonstrates, never showed any desire for the tube to be removed and indeed pressed, from a relatively early stage, for it to be replaced with a permanent PEG. I am satisfied that despite the lack of coordination between services and medical oversight of this issue that the primary reason for the NG tube remaining in place for such a prolonged period of time was that M wanted D to have it and was highly resistant to attempts to progress her feeding.

[182]A further strand of this allegation is the excessive sleeping reported by M. If D was not being medicated – and that finding is not now pursued – the evidence is now clear that there was no medical basis for her to need 20 hours or more of sleep per day. One possibility is that by refusing to wake her and insisting she be left to sleep, M encouraged patterns of lethargy and inactivity which again reduced D’s energy levels. Another is that D was, in fact, awake for some of the time when M reported that she was sleeping. M was insistent through all hospital admissions that D should sleep in her pushchair rather than in her cot, with a cover over it; this meant that she could not be seen. On at least one occasion, towards the end of her admission to the R Hospital, a nurse drew back the cover to find that D was awake. It is possible that M left D for long periods awake in her buggy. Whichever of these possibilities was the case, D was being presented as a more unwell child than she actually was.

[183]Finally, M’s social media posts provide compelling evidence of the grossly misleading way in which M presented D to the world. I do not accept that in posting this material M was only seeking support, or an outlet for her emotions. The postings are consistent with the information M provided to her grandparents, who were devastated by the prospect of their great-granddaughter having a much reduced life expectancy. They are also consistent with M’s reports to medical professionals.

[184]I find that over the months leading up to the threshold date of 4 March 2025 M consistently medicalised D by presenting her as a very unwell child with a number of serious and life-limiting health conditions, when this was not in fact the case.

[185]As the harm caused by D’s medicalisation overlaps with the harm caused by M’s fabrication of her symptoms I deal with this under the next heading.

Fabrication of symptoms [allegations 1a, 1c]

[186]M has accepted, in her submissions following the evidence, that she exaggerated D’s condition; although she says that it was not unreasonable for her to do so in the circumstances, given her justified anxiety about D’s health, and therefore the threshold criteria are not met on this basis.

[187]I do not accept that M’s misrepresentations of D’s symptoms were limited to exaggeration (unwitting or otherwise). I find that M fabricated symptoms which D simply did not have. The following are examples of what became a persistent pattern:a. M’s reports of “seizures”: at most, D experienced periods of blank staring that were not, according to the medical advice M received, unusual for her age and developmental stage. No professional ever observed a seizure, nor did any of M’s home videos show seizure-type behaviour. Two EEGs were clear. Nevertheless M was reporting a history of seizures as late as February 2025.

b. M’s reports from the autumn of 2024 onwards of breathing problems or pain after D ate. This was not observed by any medical professional, including the community dieticians who were specifically watching for it and the hospital staff over the lengthy period of D’s admission in January – March 2025.

c. M’s report in February 2025 of “dangerous breathing”, unreported to nurses but raised as a reason not to agree to a swallow assessment.

[188]M’s fabrication of symptoms, alongside her presentation of D as an unwell and medically complex child, caused D to suffer very significant harm. She was subjected to an extraordinary number of medical interventions, including some (eg the x-rays) which carried a risk of long-term harm, and some (eg the blood tests and the NG tube) which would have caused her significant pain and/ or discomfort at the time. Further harm was caused to her general development: by persisting with tube feeding for so long and resisting oral feeds M caused D to be socially delayed and delayed in her speech and language.

[189]M also caused D emotional and psychological harm by fabricating her symptoms, medicalising her and prolonging her stays in hospital. Dr Ward observed that an NG tube is a very obvious and visible sign that the child is unwell: when a child has an NG tube taped to the face, it affects the way that people interact and all that time the child is learning that they are different from other children, and will come to believe over time that they are ill.

Resistance to medical advice: allegation 5

[190]The primary allegation pleaded by the local authority under this heading is that M did not, on her own account to nurses at the R Hospital, use the NG tube safely. On 26 February 2025 Hannah Collis was unable to get sufficient aspirate from D’s tube to test the PH and ensure that the tube was in the right place. She asked M if she could reposition D, who was asleep, but M declined. Ms Collis asked M what she would do in that situation; M said that she would check to see if the tube had moved and if not she would administer the feed. A similar incident took place on the 3 March 2025 when there were again difficulties obtaining an aspirate and M gave the same account. Parents who are used to undertaking medical tasks may occasionally take shortcuts; but there were serious risks associated with a misplaced NG tube which it was not reasonable for M to ignore.

[191]I would also include under this heading a finding that when M resisted Dr U’ attempts to admit D to hospital on 9 February 2024, conceding only when Dr U said that she would have to call the police, she was not providing D with the care it would be reasonable to expect a parent to give. The strong impression from M’s actions on this occasion is that she thought she knew best; but D had an infection and urgently required treatment, and M was not correct.

[192]These are just two examples of a repeated pattern of M declining to follow medical advice. Just as relevant are the occasions when M ignored the results of tests that indicated that D did not have a cardiac or respiratory problem, or the attempts by qualified doctors to reassure her that D was generally a well child. If M was regularly administering feeds without checking the positioning of the tube there was a risk that the feed would go directly into the lungs and D was likely to suffer significant harm as a result. She was also likely to suffer significant harm when M was refusing to agree to her admission and treatment for sepsis. However just as significant, if not more so, is the harm she suffered over many months as a result of M’s refusal to accept that she did not require extensive and ongoing medical interventions.

[193]I remind myself that there is no rule that a parent must always follow medical advice without question; indeed, sometimes it is a parent’s responsibility to challenge such advice. I remind myself also that there may have been times when M was in possession of fuller information than any one medical professional, and therefore better equipped to make a particular decision. However the incidents I have included under this heading are all occasions when M’s behaviour, in my judgement, fell well outside the bounds of a reasonable parental response.

Induction of illness: allegations 2, 3, 9

[194]The local authority says that the most likely, and indeed the only plausible, explanation for D’s failure to thrive in 2024 and 2025 is that the mother was not giving her sufficient calories. Because on both occasions when this happened D was entirely tube-fed, the local authority alleges that the mother deliberately missed or tampered with feeds.

[195]The mother denies that she tampered with or missed any (or any significant) feeds, either between January and March 2024 or during the period of D’s admission from January to February 2025. She suggests that the cause of D’s improvement at the end of February 2025 may have been the switch to a different milk formula; but the medical evidence was that this was impossible as the infant formula is in fact richer in calories than the junior formula, which is formulated on the assumption that the child is also taking in calories from solid food.

[196]I remind myself that the parents are not required to prove an alternative cause for D’s symptoms. It is, however, relevant to consider any possible alternative explanations which have been put forward for D’s presentation, while always bearing in mind the possibility of an unknown cause. During both admissions D underwent extensive investigations to try to establish why she was failing to gain weight and, on the latter occasion, why it had not been possible to bring her ketotic hypoglycaemia under control. The referrals went to specialists in cardiology, gastroenterology, respiratory disease, metabolic conditions and an extraordinary number of tests were carried out. The only investigation that could not be completed was the MRI scan to establish whether there was a growth hormone deficiency; but as Dr Ward pointed out, if this were the case it would not have resolved itself over the timeframe that D’s KH resolved.

[197]When one traces through the timeline of D’s blood glucose and ketone levels, as is done in detail in the medical evidence and in Dr Ward’s report, and as I have summarised above, the correlation between feeding and blood results becomes clear. In particular, there were no occasions when D became hypoglycaemic when she was on continuous NG feeds. Once M was under close observation and it was possible to be reasonably certain that the feeds were being administered correctly, D’s condition rapidly improved. This establishes a strong link between the milk feeds she was receiving and her medical condition, and makes it much less likely that there was any underlying and as yet unidentified metabolic or other physiological cause.

[198]The evidence also demonstrates M’s resistance, at least while at the S Hospital in January 2025, to the feeding plans developed by the hospital dieticians. M would repeatedly decline to increase feed volumes in accordance with the plan, raising a concern that D would vomit or saying, incorrectly, that the community SALT team had advised a maximum amount of feed. These issues were managed by the hospital and the feeding plans adjusted to take account of M’s requests, so this of itself did not result in D receiving insufficient calories. This evidence however supports the suggestion that M was, for whatever reason, anxious to reduce D’s calorie intake and makes it more likely that when she was unobserved M was in fact failing to give the full amount of feed, whether by diluting or otherwise tampering with individual feeds, disconnecting the tube or simply pouring the feed away.

[199]Finally, I have considered the possibility that M was inadvertently making up feeds in the wrong way, to the wrong concentration or volume. I have discounted this possibility as fanciful. M was experienced at tube feeding and knew how many scoops were required for each volume of feed; she was following prescriptive feeding plans; and she was observed making up feeds on very many occasions. It is simply not conceivable that an error in her method could have persisted over such a length of time without being noticed and corrected.

[200]I have set the medical and expert evidence on this issue alongside the other evidence, including that of the parents. It is inherently unlikely that a parent will seek to harm their child by withholding food and inducing what some of the medical professionals, including Dr Ward, described as a “starvation response”. However the medical evidence strongly supports that conclusion, and the evidence of M’s presentation over the period of the 2025 admission suggests that, for whatever reason, she was highly resistant to D receiving sufficient calorie intake and resisted and blocked clinicians’ attempts to ensure that she did.

[201]I have considered the evidence in respect of the earlier period in January 2024 separately and come to the same conclusion. D did not gain any weight between 8 January 2024 and her admission to hospital in early March. As soon as she went into hospital she gained a substantial amount of weight, but her weight gain ceased over the six days she spent at home prior to her re-admission.

[202]On this occasion D did not become hypoglycaemic; she simply failed to thrive. At the time, although a safeguarding referral was made, D’s weight did stabilise and the focus was still on providing M with support with feeding. Looking back at that period now having reviewed the full extent of the evidence, I am satisfied that the cause for D’s faltering growth between January and March 2024 was that M was not feeding her in accordance with the feeding plan.

Findings in respect of C [allegations 10 and 11]

[203]The two allegations pleaded by the local authority which are said to have caused harm to C are very different. In the first instance the local authority argues that C suffered significant harm because of the absence of his mother and sister from the home for lengthy periods of time. D’s repeated hospitalisation and frequent medical appointments would have been hugely disruptive of family life, and although C seems to have been well cared-for by his father, his mother’s absences and the concern in the family about D’s health will have caused him significant emotional and psychological harm. If D’s treatment had been necessary M’s response would have been reasonable and the threshold criteria would not be met on this basis; but in circumstances where I have found M’s actions to be unreasonable I agree that allegation 10 is made out.

[204]Allegation 11 is an allegation that C was likely to suffer significant harm of the same type as D, ie physical harm due to inadequate feeding. I do not find the allegation proved in those terms: for whatever reason, C’s calorie intake was not restricted although there were multiple opportunities for that to happen, suggesting that this particular harm was not something he was exposed to. However at the threshold date C too was a very young child about whose development and possible special educational needs M had begun to express some anxiety, and I accept that on the basis of the findings made about D there was a real possibility that he too would become the victim of some form of fabricated or induced illness. I find the allegation proved on that basis.

I Conclusions

[205]I have found the local authority’s allegations proved, and the threshold criteria met on the basis that:a. The mother “medicalised” D, presenting her as a seriously unwell child and thereby hindering her development.

b. The mother unreasonably rejected medical advice and D was likely to suffer significant harm as a result.

c. The mother fabricated symptoms which D did not have, causing D to undergo unnecessary and sometimes harmful medical interventions.

d. In the period from January to March 2024, and again in January and February 2025, the mother restricted D’s food intake by failing to follow the feeding plan and/ or missing or tampering with feeds. On both occasions D suffered significant physical harm.

[206]I have also found that C suffered significant emotional harm due to the unnecessary absence of his mother and sister from the family home for long periods; and that he was, at the relevant date, likely to suffer significant harm due to the fabrication of symptoms or illness induction.

[207]Although it has been necessary from time to time in this judgment to allude to evidence suggesting possible motivations M may have had for acting as she did, I have done so only where this evidence was relevant to the primary issue of what M did or did not do. A fuller exploration of M’s motivation, taking into account her possible neurodiversity and any impact that may have had on her understanding of D’s medical condition, will take place as part of the welfare stage in these proceedings. That evidence will allow the court, in due course, to form a view as to whether work can be done to reduce the risks M poses, and to decide whether it is safe for the children to return to their parents’ care.