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	England and Wales Family Court Decisions (other Judges)
You are here: BAILII >> Databases >> England and Wales Family Court Decisions (other Judges) >> C (Fact Finding), Re [2014] EWFC B212 (10 October 2014) URL: http://www.bailii.org/ew/cases/EWFC/OJ/2014/B212.html Cite as: [2014] EWFC B212

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IN THE MILTON KEYNES FAMILY COURT

		10th October 2014

1. The court is concerned with a fact-finding hearing relating to child "C" whose date of birth is 5^th November 2013. He is currently placed in foster care under an interim care order to BCC. His guardian is Jane Lesley who appears through Counsel Leanne Murphy.
2. The mother of C is CS. She is 16 years old. She appears through Miss Sheff of Counsel. She is expecting a second child in December 2014 who will be a full sibling to C.
3. C's father is CH. He too is just 16. He appears through Miss Helen Little of Counsel.
4. Five intervenors were joined in the proceedings at an earlier Case management hearing before Her Honour Judge Brown. The first intervenor is the maternal grandmother who I shall refer to as "S" is. She appears by Mr McDonald of Counsel.
5. The second intervenor is the paternal grandmother who appears through Mr Yeung. I shall refer to her as "A" throughout this judgment.
6. The quasi-maternal aunt is the third intervenor who shall be referred to as "K". She appears through Miss Wentworth of Counsel.
7. The fourth intervenor is the paternal grandfather "AS". He does not have representation. He has appeared and given evidence; travelling some considerable distance to attend this court. He has not been able to attend court every day.
8. The fifth intervenor is "Z". He is the friend/boyfriend of the maternal grandmother. He too has appeared without representation. He has attended court each day throughout this hearing and he has conducted himself impeccably at all times.
9. Progress of the trial was impeded at the outset by the delay in the Legal Aid Agency reaching a decision on the grant of funding for the first intervenor. The pace of the trial has also been affected by the age and vulnerability of both parents. Expert assessment indicated that CS required regular and frequent breaks to enable her to participate in the proceedings. Furthermore both parents have had the appropriate support of an independent advocate throughout the hearing.

Summary

10. Baby C was referred for x-rays by his GP on 28^th May 2014 following the discovery of a lump to his chest. The x-rays revealed he had a healing fracture of the right eighth rib. X-rays taken on 3^rd and 6^th June and a skeletal survey undertaken on 9^th June revealed a further four fractures to the fourth, fifth, sixth and seventh rib on the left hand side all of which are considered to predate the fracture to the right hand rib. No other fractures, marks or bruises were noted on baby C.
11. Baby C was accommodated by the local authority under a Section 20 agreement on 10^th June 2014.. Care proceedings commenced on 24^th June 2014 and an interim care order was granted on 10^th July. The matter was subject to tight case management to enable the case to be listed for an expedited fact-finding hearing. The matter came before this court for the first time on 8^th September.
12. The parents have provided a series of possible explanations for the injuries to baby C none of which are considered plausible by the medical experts.
13. Fortunately baby C has made a full recovery from his injuries.

Criminal Investigation

14. Both parents have assisted the police with their enquiries on a voluntary basis providing a full police interview under caution.
15. This court has not been advised as to the progress of the criminal investigation or the likelihood/timeframe for any criminal prosecution.

Findings Sought by the Local Authority

•    Between approximately 25^th April 2014 and 27^th May 2014 C suffered a fracture of the anterolateral arc of the right eighth rib.

•    Between approximately 11^th March 2014 and 6^th May 2014 C suffered fractures of the left fourth, fifth, sixth and seventh ribs.

•    The fractures were caused as a result of compression/squeezing of the chest.

•    At the time of the injuries, C would have shown signs of distress.

•    The injuries to C are non-accidental in origin.

•    The injuries were sustained whilst the child was in the care of: (a) one or both parents, or (b) the maternal grandmother.

.

•    The maternal grandmother, the mother and father and must have known about the injuries and failed to protect C from suffering harm.

•    The mother, father or maternal grandmother failed to seek timely appropriate medical attention for baby C.

•    The local authority does not invite the court to identify the perpetrator as between the mother, father or maternal grandmother.

•    Having heard all the evidence the local authority no longer invite the court to find that intervenors two – five are possible perpetrators of the injuries to baby C nor that they failed to seek timely appropriate medical attention for him.

The Position of the Parties

Mother and father

17. The mother and father say that they love baby C very much and would never hurt him; they have never caused any harm to him and have never heard him scream in pain or cry for extended periods.
18. They do not know how the injuries were caused. They initially posited a series of possible explanations for the injures namely:

(a) Baby C fell off his parents' bed onto the floor.

(b) Baby C rolled off his parents' bed and got wedged between the bed and a radiator.

(c) Baby C tipped forward in his baby bouncer.

(d) Baby C fell out of his car seat which was balanced on top of his pram.

(e) C rolled back from his father's lap whilst father was sitting on the floor.

(f) C fell out of his baby buggy.

(g) C was crushed by K on 11^th March whilst rolling over onto him in bed.

19. The mother and father have since come to accept the expert assessment of Dr Stephen Chapman as to the nature of the C's injuries and his assessment of the clinical data which is that the explanations offered by the parents do not provide a plausible explanation for the injuries sustained.
20. The father further asserts that, whilst baby C has clearly suffered an injury, the local authority is unable to establish the rib fractures were deliberately inflicted.
22. The First Intervenor- S
23. The maternal grandmother SS accepts that she shared in the primary care of baby C. She makes clear that she loves baby C very much. She asserts that she did not cause the injuries to baby C and did not know who caused the injuries to him. She further refutes the suggestion that she colluded with the parents with respect to the injuries. She acknowledges that the baby sustained injuries to the rib consistent with compression/squeezing but asserts the local authority have failed to establish that the injuries were inflicted by her or either of the parents.
24. Whilst accepting that there was no medical evidence of an underlying organic explanation for the injuries. The maternal grandmother submits through counsel that the court should be reluctant to accept that positive assertion absent a DNA test for Osteogenesis Imperfecta
25. The Second Intervenor- A

A says that at no time did she have sole care of baby C. She found the lump on the right side of C's ribcage on the occasion of his first overnight visit to her home on 12^th May 2014. On discovery of the lump C did not appear to be in pain and showed no signs of distress. A advised father to tell mother and maternal grandmother. A accepts that she did not tell mother or maternal grandmother herself and accepts, with hindsight, that she should have taken steps to refer the child for medical treatment and advise members of the immediate family of the lump.

A is clear that at no time did she cause injury to the child. She did not observe anyone else cause injury to the child or hear the child cry or exhibit distress such as will be consistent with an injury.

26. The Third Intervenor – K

K denies causing any injury to baby C. She last had care of baby C on 11^th March 2014 where she noted him to be unsettled and grisly but observed no localised pain or discomfort around his torso.

K fell out with the maternal family on 16^th March and consequently took no responsibility for baby C's care either solely or with others within the timeframe identified for the second injury to the eighth rib right hand side. K asserts that she should be discounted from the pool of likely perpetrators since baby C suffered two separate but similar sets of injuries . She cannot be responsible for the right rib fracture and it is inherently unlikely that C would suffer two similar injuries inflicted by two separate people within a relatively short space of time.

Furthermore K relies on the expert analysis of the clinical data which discounts the baby sustaining rib fractures through an adult rolling onto baby C in his sleep as suggested by the parents, S and Z.

27. The Fourth Intervenor – AS

AS did not make formal submissions but had no case to answer after the local authority accepted he did not have sole care of baby C at the relevant time nor observed baby C to be injured or in pain whilst in the presence of others.

28. The Fifth Intervenor – Z

Z says that at no time did he have sole care of baby C. He did not injure baby C nor observe anyone else to do so. He accepted that he spent a considerable amount of time in the home of the maternal grandmother with whom he had enjoyed a long relationship between 2007 and 2011.

The local authority having heard evidence from Z sought no findings against him. He is clear that he caused no injury to the child, observed no injury to the child and did not see the child in distress for an extended period.

The Hearing

29. The fact-finding hearing was conducted over nine days of court time. I have read the four court bundles and heard evidence from all parties and intervenors. I further head evidence from Dr Stephen Chapman consultant paediatric radiologist via video link. I

The Expert Evidence

30. The court has been assisted by the written evidence of Dr Halliday paediatric radiologist (G5). Dr Halliday provided a second opinion to the clinical team at Stoke Mandeville Hospital who were responsible for taking films of baby C on 3^rd and 6^th June and skeletal survey on 9^th June. The court has also had the benefit of two reports from Dr Chapman consultant paediatric radiologist whose first report (E38) was supplemented by his addendum of 5^th September 2014. The court also had the benefit of the transcript of the expert's telephone meeting of 3^rd June 2014.
31. The doctors are agreed that:-

(1) The injury to the eighth rib (RHS) and the fourth, fifth, sixth and seventh rib (LHS) was sustained on at least two separate occasions.

The injuries were caused by squeezing/compression and there was nothing radiologically to distinguish between a compression or a squeeze.

The radiological films revealed no other old or recent bony injuries. There was no evidence of an underlying medical condition that would predispose to fractures. In particular there was no radiological evidence to support a diagnosis of osteogenesis imperfecta and no radiological evidence of rickets.

The injury to the eighth rib (RHS) was sustained between four and six weeks before the/film taken on 6^th June 2014: that is the injuries were sustained between 25^th April and 9^th May.

The injury to the four ribs (LHS) are approximately six to twelve weeks old: that is they were sustained between 14^th March 2014 and 25^th April 2014.

32. The doctors did not consider there to be any significant issue between them as to the nature and timing of the injuries. Both doctors acknowledge that dating of the older fractures to the fourth, fifth, sixth and seventh rib (LHS) was more difficult. Dr Chapman considered the fractures to be two to three months old that is eight to twelve weeks old. He considered that they presented as healed fractures but not yet re-modelled so not yet a full three months old. Dr Halliday expressed caution in the dating. She preferred to give a wider window for the older injuries of six to twelve weeks.
33. So far as the later fracture to the eighth rib (RHS) is concerned the doctors agreed that the lump to the rib discovered by the paternal grandmother; having been described as hard and not tender, would suggest that the injury was already two weeks old and possibly even older. Whether the lump was discovered on 23^rd May or on 12^th or 13^th May as asserted in the differing accounts of the family the eighth rib fracture was at least four weeks old on 6^th June or at least five and a half weeks old on 6^th June.
34. Dr Chapman was clear in both his written and oral evidence that the incidents described by the parents as put forward both in their police interviews and in their written statements did not explain the injuries to C as the mechanisms proposed were not consistent with the nature of the injuries. The fifth intervenor asked whether an adult "playing aeroplanes" could cause or contribute to the injuries to C This was discounted as was crawling/tummy time.
35. Dr Chapman opined that he would expect a child to show distress when the fractures were sustained and that C's initial distress would probably have lasted tens of minutes. Thereafter a child might present as miserable for hours or days (because of the pain associated with breathing) or might have been relatively normal particularly when not being handled. The child might have exhibited greater distress when held by hands around the chest. Simple pain relief such as Calpol may diminish the child's distress.
36. Dr Chapman considered it possible for a 15 or 16 year old young adult with slight build to have been capable (physically) of causing this type of squeezing injury.
37. Dr Chapman stated that the bones of children are soft and springy and very often bend rather than break and that the pliable presentation of the bone makes it more difficult to break than a long bone or a bone of an adult. He opined that the level of force required to cause such injuries would be considerable that is as much or greater than the force required to conduct CPR.
38. Dr Chapman stated that the degree of force required was greater than that of normal rough handling and that the individual who perpetrated the injuries would have been aware that they had done something that could possibly have caused harm. There are two separate incidents of harm caused by a similar mechanism.
39. He acknowledged that rib fractures are not usually noticeable to any lay observer and that it is unusual for a lump to be noticed.
40. There is no medical evidence to rebut the conclusions of Drs Halliday and Chapman as to the absence of underlying organic cause. Dr Chapman robustly articulated that there was nothing in the child's medical presentation that would have warranted or justified DNA testing for OI. Furthermore, the court has received no reports to suggest that the child has been further injured over the past four months since being moved to foster care.

Events Leading up to Protective Measures Being Taken

41. The mother and father were just 14 years old when they met. It seems that the slept together on one occasion whilst mother was still involved in a two year relationship with another young man. When she discovered she was pregnant she notified the father by text. Immediately after the baby's birth she sent photographs to the father. After some initial uncertainty the father came to accept that he was the probable father of baby C as has been confirmed by subsequent DNA testing.
42. When the mother first came pregnant social services were alerted and the family were allocated a specialist community nurse with the Buckinghamshire Family Nurse Partnership. The nurse allocated to the family was Lesley Penn. Her initial contact was with the family during the mother's pregnancy. On discharge from hospital the baby and mother lived with the maternal grandmother S who shared in the care of C. The father and mother decided to see whether they could make their relationship work and so father enjoyed regular visits to the baby at the maternal grandmother's home. In January the father was bailed for a criminal offence. He was not permitted to continue to reside at his own family home. By agreement between the grandmothers, father moved in with mother and the baby at the maternal grandmother's home: developing his childcare skills and relationship with the mother and wider family. The maternal grandmother was actively involved in supporting her daughter in her care of the baby and that provided by the father. She was intermittently responsible for the sole care of the baby and on one occasion took baby C to Liverpool on her own.
43. The paternal grandmother and members of the wider paternal family visited the maternal grandmother's home to see the baby from time to time. By agreement of the mother and maternal grandmother the father was allowed to take baby C to stay at his mother's home overnight for the first time on 12^th/13^th May.
44. The paternal grandmother says that on lifting baby C, with her fingers under his armpits and hands around his rib cage she noted a lump on the right hand side. She later asked the father if he had seen the lump and where it had come from. It is her case that she advised the father to speak to CS and S when he took baby C back home.
45. There was a second visit by the father with baby C to the paternal grandmother on 15^th/16^th May. The father accepts that he was questioned by the paternal grandmother as to whether or not he had mentioned the lump but he deliberately misled his mother by saying that he had spoken to CS. His case is that he did not in fact speak to the mother until he returned home on 16^th May and that so far as he is aware the mother did not tell the maternal grandmother until 23^rd/24^th May.
46. There is an issue between the maternal grandmother, the mother and the father as to how and when the information concerning the lump was relayed.
47. Lesley Penn visited the family on 27^th May at 1515. During the course of the visit she was asked for her opinion of the "lump" on the side of the baby's chest. She noted the lump. She recorded seeing no redness or bruising. She found that baby did not react when touched and no history of injury or accident was shared by the family. Lesley Penn advised the parents to see a GP for review.
48. Dr Chapman accepted that the wait and see policy adopted by the maternal and paternal family was entirely understandable in the circumstances since the time the lump was noted whether it be on 12^th, 15^th or 23^rd May appeared to cause no distress or pain to the child.

Evidence of the Parties and Intervenors

Mother

49. CS was only 14 when she conceived baby C. She is now only 16 and soon to have her second child. She has a statement of special educational needs and from the ages of 9 to 11 was placed away from home in a residential school. She has been diagnosed as having ADHD. Her statement of special educational needs describes her as a troubled young lady who can be verbally and physical aggressive towards peers and verbally aggressive towards adults. Her PNC record reveals that she was reprimanded for ABH on 12^th May 2011 when she was just 12. She received a further warning for common assault committed on 7^th December 2011. She has three convictions relating to ten offences, eight of which were against the person. The two most recent convictions relate to assaults on teachers at the Unity College School she attended in Wycombe.
50. She was assessed within the criminal youth offending arena initially as a medium risk to others but the risk reduced with the progression of her pregnancy and the subsequent birth of baby C.
51. All maternal family members and CS herself describe her as a young competent mother who has changed since the birth of the baby.
52. When she was questioned about her offending behaviour she demonstrated little insight as to the nature and seriousness of the offences she had committed particularly in the assaults upon her teacher. She sought to explain her conduct by blaming it upon the school regime and the staff. While she may have had a very good reason for being so cross and critical of the teaching staff at the college she attended she demonstrated no remorse, insight or understanding as to why her behaviour was inappropriate.
53. Throughout most of the court hearing she has been quiet and respectful. She found it difficult to listen to the evidence of the paternal grandmother who expressed concern about the mothers ability to manage her behaviour. CS is young. She is very young for her years and I commend her for the way in which she managed her temper throughout most of the hearing. Nonetheless there appeared to be a theme running through the evidence of the wider family as to mother's temper and her difficulty in managing that temper.
54. K describes mother as screaming at the maternal grandmother. Z said that CS would usually get her own way with S. Z described the mother as a normal teenager who generally got her own way by dogged persistence rather than anything else. He considered that the maternal grandmother was like CS's best friend.
55. In the father's statement of evidence (C52, paragraph 13) he described the mother as "screaming" on learning of the lump although he retracted that assertion in his oral evidence.
56. CS did not accept that she found looking after baby C difficult at any time. She acknowledged that she became tired from time to time but that this was understandable in view of her age and the usual sleep deprivation that follows with the birth of a baby. She did not accept that she was "stressed" or overwrought when she asked K to take baby C on 11^th March. She accepted that she had sent a text saying that she was "stressed" but asserted that this was really just a way of trying to persuade K to take C and give her a break. There is no evidence to suggest that CS was stressed on 11^th March although it is noteworthy that C had his second round of inoculations that day. K saw nothing of note in mother's demeanour when the baby was brought over at 9pm on 11^th March to suggest that she was not coping.
57. All witnesses have attested to the enormous love of and care for C demonstrated by mother despite her underlying youth, lack of experience and previous behavioural problems. She has made clear through her evidence the strength of her affection for the baby and the sense of loss she experienced on his removal into foster care in June.
58. Much time was spent during the course of this hearing in examining the date or dates on which the lump to C's right eighth rib was noted. The relevance of this evidence assists the court in understanding and interpreting the radiological findings, provides potential assistance in dating the injuries and understanding the chronology of events around the awareness of family members of the existence of the injury and the consequential actions taken.

All family members accept that father took baby C to stay with the paternal family on three occasions, the first being on 12^th May, the second being on 15^th May and the third being on 21^st May.

59. In mother's statement of 10^th July she describes learning of the lump for the first time on 23^rd May. Saying this (C30),

"I only discovered about the lump on [baby C's] chest on 23^rd May 2014 when he was returned back from (paternal grandmother's home) as he had been there since 21^st May 2014, he had been there overnight and returned later on 22^nd May. I had never seen this lump prior to [baby C] going with [CH] to his mother's home. On 22^nd May 2014 [ CH] told me he was going to bath [baby C ] with his 3 year old cousin and he would change him. I told him not to as I wanted to do it, then he called me back and said OK he would not bathe him. However when he came home late, he was dropped off by his mother and his stepdad, [baby C] had been fed and was in his babygrow so was ready to sleep. I finished the rest of the feed and changed his nappy and he went to bed. I woke up and gave [baby C] his feed again and changed his nappy about sevenish the next day 23^rd May. Later on in the morning about 10.30 to 11am I was just about to change him when [ A ] called me and said she had found a lump on his chest, I was shocked, [CH] had not said anything about the lump to me, when he came home the night before and his mum had dropped them off. I was shocked as to why [CH] had not told me himself or his mum on 22^nd May 2014; his reply was he thought I would accuse him of doing it. I was so annoyed with him and told my mother what had happened and [CH] just went home".

.

60. In her interview with the police on 11^th June which began at 12.32pm she said this:

Page reference H0 CO

CS It was quite a while back. It was before 13^th May and then 13^th May when he came back, he said "Listen, the baby had a bump. My mum's noticed it."

Page reference H0CS

CS I don't know. I was just like, "What is that?" sort of thing. "He ain't had a bump with me so it must have been him' sort of thing and then I felt down his dad's sides and it felt like he had a bit of a lump there too, promise you. And then I was like "Oh must be just off you" sort of thing. And then I left it for, like, two, three weeks, I'm not even going to lie. That's how I know that it ain't two, three weeks ago it's happened because I left it for two, three weeks. I know that sounds bad."

Page reference H0CU

CS I did think, like, "Well, what is this?" But then, once I felt his dad's side, he was like "I've got that little lump" when you put your arm up like that, you can feel like a little thing there in it?" So I was like "Oh, it must be just his body, because seriously he ain't had a fall" I was like, "So there's nothing that I can come to some sort of conclusion here, so, seriously, you need to either speak to your family or come up with something what's happened with him."

61. Mother repeatedly asserts during the course of the police interview that she did not tell anyone about the lump because she did not think it was a broken rib. She confirms that she told Lesley Penn the family partnership nurse of the injury when she attended on 27^th May and when asked whether she told anyone else she said this "Well, the fact that I mentioned it to my mum and that but the thing is like we didn't know if that lump was there, because he is not saying a story. We ain't got no story, so I was thinking that lump was just already there."
62. She continued (H0CX)

"And then I was like, 'no', after two weeks. I think it was two weeks. I am just saying three just in case, yeah? and then, like, it got to a bit bigger and I was like "Nah, that ain't right", and obviously lumps can mean cancer, anything, yeah so I was like 'Let's just go down, simple as.' I know for a fact that I ain't done nothing, but every time I seem to say to (father) 'Can you just please speak to your family?' he gets in a mood. Like, if he was asking me to speak to my family, I'd be like, 'Yeah, I will speak to them' do you know what I mean? 'I will try and get somewhere' but he's like 'Nah, it's not my family. Don't even try saying that'."

63. It is noteworthy that this interview was completed shortly before father was interviewed by the police and there was little opportunity for the couple to consult.
64. During the course of her oral evidence mother resiled from the position presented in her police interview instead asserting that she did not hear of the lump until the paternal grandmother telephoned the maternal grandmother to speak to father. She described father bringing the telephone into the bedroom and then said she overheard father explaining to A that he hadn't said anything yet. Her oral evidence was thus that she didn't learn of the lump until the 23^rd or 24^th May, just a few days before Lesley Penn's visit on 27^th May and that at no time did she believe the lump to be anything serious.

Father

65. Father came over as a very shy young man who found it difficult to speak in front of others. Like his partner he is very young and vulnerable and presents as being markedly younger than his chronological age. A psychological assessment prepared by Dr Farhy revealed that he has difficulties in verbal comprehension and that his ability in this domain falls on the seventh centile.

All lay witnesses spoke of the father's gentle manner and responsiveness to the baby. He had only ever been seen as being kind and sensitive and there are several examples in the notes of Lesley Penn commenting on how sensitive and responsive to the baby he is. There is further no evidence of temper or volatile behaviour towards those close to him.

66. Disclosure from the Youth Offending Services reveals six convictions in respect of nine offences, one of which related to an offence against the person. He joined the mother's household at a time when he was on police bail and unable to live with his own birth family. No action was taken with regard to those criminal matters and the court understands that the father has not been in trouble with the police in relation to any other matters since the birth of baby C.
67. The father's account of how he came to learn of the lump to baby C is at odds with the account of the mother's. In his police interview of 11^th June he told the police that he had his first overnight visit with his own family on 12^th/13^th May where he says this (H0W):

"She took him out of the car seat, but she didn't tell me then, but she said to me after she felt it then. But she took him upstairs and I was in the front room with all my other family, because they are all there. I said hello to all them. She called me up and said 'There is something on him' but I just didn't think nothing of it. But obviously I should have but ..."

He continued,

"If he put his arms up like you could see there was a little lump there, but not really like that, because he has got his arms there, but when he is like that, if he moved like that then you could see a little lump."

He accepted that he had spoken to CS although initially was not going to say anything. He acknowledged that he told her because he had to. "Isn't it – just in case it was anything."

68. He did not give a date to the occasion on which he told mother but when asked how she responded he said (H0AA):

" … was just like me; she didn't think anything of it, like ... because he weren't in no moods or nothing he was just cool all the time."

69. He explained to the police how he had felt his own ribcage and satisfied himself that the lump he had found on the baby was not anything.
70. In his statement to the court he gives a rather different account explaining how the lump was discovered by his mother on 12^th May and her urging of him to tell baby C's mother and maternal grandmother. At paragraph 11. C51 he says:-

"11. Despite what my mother had told me, I was very nervous about telling [CS] about the lump because I was fearful that she would blame either my mother or me. For the same reason I didn't tell social services. I realise now that I should have done so immediately.

12. I took [C] to stay with my mother again on 15^th May 2014 for the night. Again I went by taxi with [baby C] in his car seat. I told my mum that I had told [CS] and her mum about the lump and so my mum did not question me any further.

13. I took baby to stay with my mother again on 21^st May. I travelled there by taxi and my mum's partner [MB] took us both home again the following evening. I didn't tell [CS] or her mum about the bump until the morning of 23^rd May. As, anticipated, [CS] immediately blamed me screaming at me that either my mother or I must have caused the lump. [S] then tried to contact her GP surgery for an appointment but could not get one immediately and so [baby C] was not seen until 28^th May 2014."

The father stated that he found it difficult to speak in front of others. The maternal family and the paternal grandmother agreed with this. The paternal grandmother noted that father was different at home where he felt more relaxed. It was clear that he was uncomfortable when giving evidence and was, in my view, watchful of the responses of his partner. Nonetheless in giving his oral evidence he was prepared to take issue with the evidence of CS as to the timing of his disclosure as to the lump making clear that he advised CS after his second visit on 15^th/16^th May. He described how the couple checked his ribcage after noting the lump on the baby and agreeing that it was a finding of no great consequence. He was confident that this recollection was accurate because he was clear that there had been a markedly longer period between the date on which he shared the information for the first time with mother and the date on which the lump was referred to Lesley Penn. It is noteworthy that his account given to the court in oral evidence is largely supported by the mother's own account to the police as to the lengthier period between which she first learned of the lump and the occasion on which the lump was revealed to Lesley Penn.

71. Both father and mother gave evidence that the lump changed in shape and size over the period before which the medical and social agencies were informed.

The maternal grandmother- S 1^st Intervenor

72. In giving her evidence to the court S was polite, respectful and concerned to reassure. It is apparent that she loves her daughter and her grandchild very much. She had welcomed baby C's father into her household even before she had come to know him.
73. In the early stages of the mother and father living together it is apparent from the evidence of all lay parties and from the notes of Lesley Penn that the maternal grandmother took on a significant role in providing care and support for baby C. The role of the mother and father increased over time as the maternal grandmother was advised to "back off". It is apparent from the records of Lesley Penn that she did indeed "back off" allowing mother and father to assume more of the primary care for the baby.
74. However all agree that there were many occasions where the maternal grandmother provided effective support and respite usually when the couple were very tired. Regrettably however there is no accurate or reliable account from mother, father or maternal grandmother as to any occasions on which they openly acknowledged the stresses and strains arising within the household. Indeed the account of family life within the maternal grandmothers household is that everything ws fine. This sits uncomfortably with the observations of Z , K and A of inter family relationships.presented by CS, CH and S.
75. It is clear from the evidence of the maternal grandmother that she remained primarily responsible for arranging all medical and other formal appointments on behalf of both mother and father even up to the point that baby C was removed into care. Furthermore the maternal grandmother was responsible for facilitating father's trips to stay with the paternal family on 13^th, 15^th and 21^st May.

Issues as to the maternal grandmother's credibility have been raised through Counsel for the guardian. The maternal grandmother accepts that she misled the court and the local authority about her use of cannabis. She says that she had not appreciated the significance of her usage nor the fact that historic usage would be revealed through testing. She asserts that she no longer uses cannabis.

76. The maternal grandmother further asserts that she did not permit the parents to smoke cannabis at her home. Both parents accept that they have used cannabis. The maternal grandmother suggested that she could not tell that mother and father were using cannabis as they tended to smoke away from the house in the garden. It seems improbable that she did not notice their usage in such a small household since the smell of smoked cannabis would hang on the clothes of the parents as was indeed evident to the local authority social worker when she made an unannounced visit on 28^th August. Latterly the maternal grandmother accepted that she had known the mother smoked cannabis but had no wish to see her daughter get into trouble.
77. Concern is also expressed as to the reliability of the maternal grandmother as a protector of baby C having lived in the same household as the baby for the first seven months of his life. S is clear that she did not observe anything of concern in the conduct of either mother or father or anyone else with whom the baby came into contact and saw nothing in the child's demeanour to suggest that the child was harmed.

It is noteworthy however that S made no reference to any of the "incidents" referred to by the parents in her discussions with Lesley Penn. It is accepted that these incidents raise issues about parental supervision and protection and yet these "incidents"; some directly observed and some reported were not shared with Lesley Penn. The mother and the maternal grandmother were both clear that they are very close and share all relevant information concerning baby C. Thus it must follow that the maternal grandmother was aware of the "incidents" where baby C could have come to harm.

78. The maternal grandmother is criticised for her failure to be transparent about the nature of her relationship with Z. Nothing appears to turn on this and the court accepts that the couple remain very close but have rather different perspectives as to whether they have a sustainable permanent relationship. Issues of trust appears entirely plausible.
79. S is a very young grandmother and was herself a relatively young mother. She is understandably protective of her daughter but it was noteworthy that she found it difficult to be objective and provide any reasoned critical analysis of the daughter's behaviour. When she was asked in evidence how she felt about her daughters criminal convictions for the two recent assaults including one on her teachers and one on a taxi driver the maternal grandmother sought to explain away her daughter's explosive behaviour without showing any reasoned or critical assessment of that conduct. Yet it is clear from historic papers that the mother has had significant difficulties in managing her anger throughout a significant period of her childhood.
80. When the maternal grandmother was asked if there were ever any issues between her and her daughter she suggested that these were always resolved by agreement. She accepted that she tended to give in to the mother whenever she wanted something. She said that this was not because she was the subject of bullying or because she was frightened but rather because CS was just so persistent. This was echoed by Z (who has known CS since she was 6 or 7 years old) who said CS usually manages to get her own way.
81. The maternal grandmother was clear in her oral evidence that she was not told of the lump to baby C on 16^th May. She was quite emphatic about her recollection of events as on this occasion she had gone away with Z for the weekend to celebrate his birthday. Baby C had returned with his father from the paternal grandmother's home just a few moments before the maternal grandmother disappeared on her weekend trip. She describes snatching a cuddle. She is clear that she heard nothing of any consequence at that stage and Z endorses her account through his evidence to the court saying that if the paternal grandmother had picked up that baby C had a lump before they departed for the weekend it would have blighted their trip and indeed he was doubtful that they would have travelled at all.
82. The question of whether or not the paternal grandmother knew of the lump before 23^rd/24^th May was addressed in fathers police interview where he said this [H0AA]:

Father "It could be this bit anything – so I just said, 'There could be something wrong here' and at the same time, [S] didn't actually feel that; she felt this. Because she didn't properly look into it. She felt just that bit.

DC Crystal "But your"

Father "She thought I"

DC Crystal "Is it your arm you are indicating to now whereas the baby's lump was further down."

Father "She thought I meant that because that is a lump there. So she thought 'No, that's just that'. She didn't feel that so the next day she did feel that and she said 'I do know what you are on about now'."

83. In her police interview the mother was asked whether she had told S about the lump after it was found. At [H0CW] the mother says:

"Well, the fact that I mentioned it to my mum and that but the thing is like we didn't know if that lump was there because he is not saying a story we ain't got no story so I was thinking the lump was just already there."

When CS was asked whether she told her own mother her answer was "Yeah".

84. Under cross-examination CS denied telling her mother before 23^rd/24^th May. Z considered it improbable that his partner had been told of the lump and considered it wholly unlikely that CS would withhold information of this nature from the maternal grandmother with whom she was very close.
85. The maternal grandmother's asserts that the date on which she learned of the lump can be linked directly to a series of text exchanges which were exhibited to her written statement which S asserts support the mother's account namely that she heard, and shared, the information about the lump for the first time on 23^rd May.

The Paternal Grandmother- A- 2^nd Intervenor

86. The local authority no longer invite the court to conclude that the paternal grandmother should remain within the pool of perpetrators on the basis that there is no real possibility that she was responsible for the injuries to baby C. Furthermore the local authority do not invite the court to conclude that she failed to take protective measures. The paternal grandmother acknowledges that on finding the lump on 12^th May she alerted her son to her discovery and took no personal steps to inform the maternal grandmother or the mother herself or to take the child for any form of medical intervention.
87. The paternal grandmother prepared a statement for the court which addressed the case she had to answer. It was not a statement in which she was invited to address the wider issues as to the dynamics of the parental relationship or inter family relationships.
88. I found the paternal grandmother to be an entirely credible witness. There was no challenge to her evidence that the first occasion on which the baby came to stay at her household was 12^th/13^th May. She described in graphic detail holding the baby with her hands around his chest as she lifted him upwards. Her realisation that he had a lump to the chest was described clearly and without embellishment. It is clear that she knew the lump was unusual. She described it as being visible to the naked eye whatever the positioning of the baby's arm. The paternal grandmother was unequivocal as to her observations of the lump to the baby's side. The circumstances in which she found the lump have not been meaningfully challenged.
89. On any view of the evidence the injury to the eighth rib was at least two weeks old on the occasion it was discovered by the paternal grandmother. It is apparent that the paternal grandmother did not have sole care or realistic opportunity to cause the injury to the eighth rib. Furthermore considering the evidence against the timeline the paternal grandmother cannot reasonably be considered to be within the pool of perpetrators in respect of the fourth to seventh ribs. The evidence suggests that during the window for these injuries which at its widest is 3rd March – 25^th April she was only permitted to have visiting contact at the family home by the birth family and maternal grandmother.
90. It was apparent that the paternal grandmother was appropriately distressed during the course of her evidence and as she listened to the medical summary given by Dr Chapman. She accepts that she should have had the lump investigated and that she should have done more to ensure that the mother and maternal grandmother were told or to have told them directly. Furthermore she accepts that she should have sought medical advice notwithstanding the opinion of Dr C at (E49) where he states, "In the absence of any obvious injury, it is reasonable for the carer to have adopted a wait and see policy and not to have sought urgent medical advice".
91. Her candid acknowledgement of her own shortcomings, her emphatic tone and her reflective and self critical presentation made her assertions that she did not speak directly to the maternal grandmother on the morning of 23^rd/24^th May about the lump she had found to baby C, .all the more credible. The texts appended to the statement of S do assist the court in determining the content of phone calls made. Essentially it falls for the court to consider the credibility of A and S and where their accounts differ I prefer the evidence of A. Her presentation further served to give a ring of authenticity to her assessment of the dynamics of the parental relationship. She was pressed by the Counsel for the guardian as to how she felt life for the father was within the maternal grandmother's household. Her response was thoughtful and considered. It was apparent that she recognised that her response was likely to give rise to difficulties with her own son and she called across the court "I told you I will not lie".
92. She described how on occasion the father had telephoned her to ask if he could come home when the couple had rows. The fact of these disagreements between the parents was alluded to by the maternal grandmother. The paternal grandmother however was able to give account of a telephone conversation she had had with the father when mother had been heard in the background clearly distressed and angry.
93. Her evidence as to those telephone calls and the probable tension within the parental relationship demonstrated by those calls had a clear ring of truth to it. The history vulnerability, age and immaturity of these two young parents would suggest such tensions to be predictable.
94. Concern was expressed on mother's behalf that the paternal grandmother went on to give extensive evidence as to an incident outside the paternal grandmother's home. I make clear that I take no note of that part of her evidence as the mother was not given an opportunity tof formally challenge it or give her account.
95. The challenging dynamics of the parental relationship as described by the paternal grandmother was consistent with the court's observation of the parents' interaction during the course of the proceedings. The father was ever watchful of the mother when giving his evidence. This did not deter him from contradicting her on occasion but it was clear he was uncomfortable and defended.
96. I note the paternal grandmother has had five children of her own and that hers is a household within which children are regularly present. It is however perhaps surprising that she is the only significant adult who observed or felt the lump to the baby's ribcage. The maternal grandmother shared primary care with two very young inexperienced parents and appeared to note nothing on the child at all.
97. It is noteworthy that a medical appointment with Lesley Penn fixed for 15^th May did not take place. There is no evidence before the court that would justify the court concluding that this appointment was deliberately missed. However one consequence of that appointment not taking place is that Miss Penn did not have the opportunity to check baby C at a time when, on the paternal grandmother's account, the bony lump to the right rib would have been evident to touch and sight.
98. I accept the local authority's assessment of the evidence and the basis on which they no longer seek to include the paternal grandmother in the pool of perpetrators.

Quasi maternal aunt – K -3^rd Intervenor

99. K was represented by counsel throughout the proceedings but she declined to attend for the first week of proceedings because of the difficulties that had arisen within the family relationship. It would seem that up until 16^th March 2014 K enjoyed a good relationship with all members of the maternal family and the father. She babysat for baby C on three occasions that is on 1^st February, 14^th February and 11^th March. The baby was unsettled on 1^st February and was returned home. He remained with K without difficulty on 14^th February and on 11^th March it is clear that he was unsettled and could not be pacified. K gave evidence that she found no external markings that would suggest that the baby had been injured. Eleventh March was of course the day the baby had his inoculations. This is the only occasion on which K had sole care within the timeline (or at the edge of therof) for the first set of injuries. Dr Halliday's timeframe for the first set of injuries is six to twelve weeks prior to the radiology images taken on 3^rd, 6^th and 9^th June. Twelve weeks prior to 3^rd June is 11^th March and three months is 3^rd March.

Dr Chapman's timeframe for these injuries is two to three months prior to the radiology images taken on 3^rd, 6^th and 9^th June. His oral evidence was that he felt the injuries were closer to three months than two months. The experts agreed that there was no distinction to be drawn between twelve weeks and three months.

100. The mother, the maternal grandmother, the father and Z all sought to suggest that K may have been responsible for some of the injuries to baby C asserting that she had slept in bed with the baby and being a woman of large frame had crushed him. All now appeared to accept that, having heard the evidence of Dr Chapman, such explanation is entirely implausible.
101. Miss K had fallen out with the maternal family by the middle of March it is apparent that she cannot have been responsible for the second set of injuries within the timeline agreed. The local authority no longer seeks findings against K and I accept their analysis of the evidence since it would seem inherently unlikely that baby C would suffer two similar sets of injuries inflicted by two separate people within a relatively short space of time.
102. It is noteworthy that the manner in which K gave her evidence appeared careful and cautious. She did not seek to cast blame on the maternal family and indeed seemed anxious not to further alienate them. I am conscious that she became rather agitated during the course of the paternal grandmother's evidence when account was given of the mother's explosive conduct. I have already made clear that I do not propose to take that incident into account in the course of my considerations and consider it inappropriate to speculate as to the source of K's obvious agitation.

The maternal grandfather –AS- 4^th intervenor

103. The maternal grandfather joined us for only a brief period. He gave his evidence in a respectful albeit perfunctory manner. I wholly accept the basis on which the local authority came to conclude that he too can no longer justly be considered as a potential perpetrator of the injuries to the baby. He had little opportunity to meet with the child and had no opportunity on which he assumed sole care.

Maternal grandmothers partner –Z- 5th intervenor

104. Z appeared without representation. He was intelligent and considerate in his participation of the proceedings and respectful at all times.
105. It is apparent that he is extremely fond of the maternal grandmother and has a longstanding relationship with the mother. It is apparent that he has little understanding of child development and on his own account has no idea how to change a baby's nappy or to do a baby's feed. As a consequence nobody in the family sought to leave the baby with him as sole carer.
106. The limitations on Z's experience in child development were demonstrated in his assessment of the mother and maternal grandmother's relationship. He described mother as a typical teenager. She is of course pregnant with her second child and has acknowledged use of cannabis. She has convictions for violence and has had a very troubled childhood including two periods away at school. Her vulnerability is evident and these have undoubtedly impacted on her family relationships.
107. Z sought to suggest that there was no conflict between mother and grandmother and that S managed the care of her young daughter by generally exceeding to her requests or demands. It is obviously the case that S loved and loves her daughter very much. She is an only child and a very precious one. The absence of parental boundaries in that relationship however is demonstrated through mother's behaviour which struggled with authority in the school and community college context. Z's suggestion that S is a friend to the mother further illustrates his limited understanding of healthy familial boundaries which require clear demarcation in the parent and child relationship and the imposition of clear consistent and child focused boundaries.
108. Z was asked under cross-examination when he understood the maternal grandmother had been told of the lump to baby C in May. He is clear that she was not told before the couple departed for their weekend away on 16^th May. He is certain that if she had thought that anything was wrong with the baby she would not have gone away. This analysis coupled with the oral evidence as to the very limited window of time that was available between baby C returning from the paternal grandmother's home on 16^th May and the maternal grandmother leaving leads the court to conclude that the maternal grandmother was not told at that stage. However Z's assertion that CS could not withhold information as important as that of finding a lump from her mother assessment is flawed because it assumes that mother understood the significance of the lump and further that she always maintained an entirely transparent relationship with her mother. It is clear that mother, like many teenagers, engaged in behaviour so she did not always share with her mother. Furthermore the mother's police interview makes clear that the maternal grandmother was informed on a date unspecified but that mother herself knew about the lump at least two to three weeks before it was seen by Lesley Penn.
109. I accept the local authority's assessment of the evidence on the basis on which they no longer seek to include Z in the pool of perpetrators.

The Law

110. The burden of proof is on the party making the allegations.

The court must decide disputed issues of fact by applying the civil standard of proof. A disputed allegation thus only becomes a proven fact if it is more probable than not that the disputed event occurred. Lord Hoffman said in Re B [2008] UKHL 35 at paragraph 13 "I think that the time has come to say once and for all that there is only one civil standard of proof and that is proof that the fact in issue more probably occurred than not."

111. In determining whether the local authority has satisfied the burden upon it Bracewell J observed in Re B (threshold criteria: fabricated illness) [2002] EWHC 20 (Fam) [2004] 2 FLR 200 that:

"[24] ... Although the medical evidence is of great importance, it is not the only evidence in the case. Explanations given by carers and the credibility of those involved with the child concerned are of great significance. All the evidence, both medical and non-medical, has to be considered in assessing whether the pieces of the jigsaw form into a clear convincing picture of what happened ...

[30] In the current case, it is correct that the evidence upon which the local authority relies is circumstantial. No-one saw the mother do anything suspicious and numerous nurses and other witnesses have testified that nothing the mother did put them on enquiry. The mother has made no admissions of any kind and has always denied harming her child. The cogency of circumstantial evidence depends on its quality. It can range from the peripheral and unhelpful to compelling and cogent, and therefore it is necessary to test the various elements."

The evidence of the parents and members of the wider family is of the utmost importance and to this end the court must make a clear assessment of the individual witnesses, credibility and reliability. In Re JS [2012] EWHC 137 (Fam) Baker J provides a helpful summary of the law relating to cases involving allegations of non-accidental injury which can be summarised as follows:

(i) The burden of proof rests with the local authority [at para.36 ...];

(ii) The standard of proof is the balance of probabilities [Re B [2008] UKHL 35];

(iii) Findings of fact must be based on evidence (Re A [a child] (fact-finding hearing: speculation) [2011] EWCA Civ 12) Mumby LJ in Re A stated that:

"It is an elementary proposition that findings of fact must be based on evidence, including inferences that can be properly drawn from the evidence and not on suspicion or speculation."

(iv) When considering cases of suspected child abuse the court must take into account all of the evidence and further consider each piece of that evidence in the context of all other evidence.

(v) The role of the court and the experts are distinct. It is the court that must weigh up expert evidence against other evidence.

(vi) The evidence of the parents and any other carers is of utmost importance.

(vii) The court may wish to give itself a Lucas direction R v Lucas [1981] QB 720. The court will be aware that witnesses may lie for many reasons such as loyalty, panic, fear or distress and that because they lie about one thing it does not follow that he or she has lied about everything.

(viii) The court must resist the temptation identified in R v Henderson and Others [2010] EWCA Crim 1219 to believe that it is always possible to identify the cause of the injury to the child.

(ix) The test of whether a particular person is in the pool of possible perpetrators of non-accidental injury is whether there is a likelihood or real likelihood that he or she was the perpetrator [North Yorkshire County Council v SA [2003] 2 FLR 849] in order to make a finding that a particular person was the perpetrator of non-accidental injury the court must be satisfied on the balance of probabilities it being desirable, where possible, for the perpetrator of non-accidental injury to be identified. However where it is impossible for a judge to find on the balance of probabilities that A caused the injury rather than B then neither can be excluded from the pool and the judge should not strain to do so [Re D (children) [2009] 2 FLR 668, Re SB (children) [2010] 1 FLR 1161].

112. Lucas Direction

I am particularly mindful that in this case there are two young and very vulnerable parents who have each been assisted by an advocate throughout these proceedings. They each have capacity and have been ably assisted by Counsel. I recognise that they and other members of the extended family who have given evidence before me may have lied from time to time about matters which they consider to be of importance in terms of the family relationships, for fear of reprisal, anxiety or confusion or other reasons which compel them. I remind myself that even where I find witnesses have lied they may not have lied about everything.

113. The Court's Findings

•    The radiological images of the 3^rd, 6^th and 9^th June indicate that baby C suffered a fracture of the anterolateral arc of the right eighth rib. Drs Chapman and Halliday are agreed that the injuries occurred between four to six weeks before 6^th June. When considering the evidence of the parties as to the occasion on which the lump was first identified I am satisfied that the account given by the paternal grandmother is accurate. Her account of the discovery of the lump on 12^th May has been clear, consistent and in my view honest. She is supported in her account by the comments of the mother in her police interview on 11^th June in the dating of the mother's own knowledge as to the existence of the lump. She is further supported by the oral evidence of the father and his comments in the police interview. I thus conclude that the fracture was sustained 5 and half weeks to 6 weeks before the film on 6^th June, that is at the upper end of the (of time identified by Drs Chapman and Halliday).

•    The radiological images indicate that baby C suffered fractures on the left fourth, fifth, sixth and seventh ribs. Drs Halliday and Chapman agreed that the window for injury is between six weeks and three months. Both doctors are agreed that these injuries occurred on a different occasion to that on which the eighth rib (right hand side) was fractured.

•    The court is satisfied that there is no underlying organic difficulty that would predispose, to such injuries.

The report of Dr Chapman made clear that there was nothing within the radiological images that were suggestive of osteogenesis imperfecta. Dr Chapman was clear that there were no markers that would have justified bone density testing or further DNA testing. No such reports are before the court and the suggestion that baby C suffered from OI or other medical difficulty is simply speculation. Furthermore it is noted that the child has experienced no breaks in the four months since his removal into care.

•    The injuries sustained were consistent with a squeezing/impression mechanism.

Save for the charge made on the maternal grandmother's behalf as to possible underlying organic difficulties all other parties accepted the likely mechanism as expressed by Dr Chapman.

•    At the time of the injuries baby C would have shown signs of distress.

Dr Chapman was clear in both his written and oral evidence that at the time the injuries were inflicted baby C would have shown signs of distress. Baby C is described by all members of the family as a happy baby. Nonetheless there were occasions on which it is clear he was capable of demonstrating distress such as the occasion of 11^th March when he stayed overnight with K. He is further said to have been distressed over the night of 1^st February when his planned stay with K was aborted. The maternal grandmother, mother, father and Z also commented on the occasion when baby C fell between the radiator and the bed.

Thus on the evidence of the lay parties baby C presents as a happy and bouncy baby and it seems probable in all the circumstances that his distress at the time of the injuries would have been noted as unusual even if he was crying at the time the injury occurred.

•    The court concludes that the injuries to baby C are non-accidental in origin.

In reaching this conclusion I remain mindful of the fact comments of Lord Justice Ryder in Re S (split hearing) [2014] EWCA Civ 25 paragraph 19:

"The term 'non-accidental injury' may be a term of art used by clinicians as a short hand and I make no criticism of its use but it is a 'catch all' that everything that is not an accident. It is also a tautology: the true distinction is between an accident which is unexpected and unintentional and an injury which involves an element of wrong. That element of wrong may involve a lack of care and/or an intent of a greater or lesser degree that may amount to negligence, recklessness or deliberate infliction."

The medical data and opinion is agreed that this child suffered two sets of fractures caused by squeezing or compression. There is an absence of plausible explanation from any of the main carers.

The type of injuries sustained by baby C required considerable force to be used. Force that a 15 year old adult girl or boy would be capable of applying.

As a child of a positive disposition it is probable that baby C's distress on injury would have been marked either at the time the injury was sustained or in the period immediately following. Dr Chapman was clear that the child would exhibit distress for tens of minutes and may be miserable for hours or days thereafter.

It is inherently improbable that this child would suffer two injuries of such similar nature within such a short frame of time, absent any underlying medical condition, save where the injuries were deliberately inflicted.

I accept the opinion of Dr Chapman that the individual that caused the fractures to baby C may not have intended to cause the injuries that were in fact sustained. However the level of force required to break the bones of a small baby which are growing, pliable and reflexive went beyond rough handling or normal care and the perpetrator would have been aware that they had done something inappropriate.

Thus on the facts of this case I am satisfied that the factures to baby C were inflicted.

•    The court finds that the mother, father, maternal grandmother and paternal grandmother failed to seek timely appropriate medical attention for baby C upon noting the lump to his right rib.

The paternal grandmother has acknowledged that she took no action after she discovered the lump and regretted that she had not taken direct action to notify the mother and maternal grandmother.

It is accepted by father that he was notified of the existence of the lump to baby C on 12^th May. There is some confusion about the date on which he advised the mother but on his case whether in the context of his police statement or his written statement and oral evidence to the court it was some significant time before 23^rd May but after 12^th May.

I found the father to be largely truthful in his account as to the period over which the mother had notice of the lump. He was clear in his oral evidence that he told the mother when he returned from his second trip to the paternal family on or about 16^th May. He is supported in this account in the mother's police interview where she describes having noticed some two to three weeks before the baby was eventually seen by Lesley Penn.

I accept that the mother's account as given in the police interview is more likely than not to be accurate in view of the proximity of the interview to the events in question and the fact that the couple had no opportunity to collude before their interviews were recorded.

Next mother and father described how when father reported the lump to mother she felt the lump on the baby and then touched the father's ribcage. She reassured herself that baby and father had a similar "problem". There is something rather tragic about this scene as described by both of them. They are young, they are inexperienced and have intellectual limitations. They appear to have convinced themselves and each other that the lump was not concerning. In her oral evidence the mother spoke of how the lump became larger between the period on which she was first advised of the existence of the lump and when a decision was made to refer it to Lesley Penn. It thus appears likely that mother was told on or about 16^th May and that on that date the grandmother was not present being away with her partner. At the time of first being advised of the lump mother simply did not understand its significance.

I further find that the maternal grandmother was advised of the existence of the lump before 23^rd May. In her police interview the mother accepts that she spoke to her mother about finding the lump. The father describes showing the lump to the maternal grandmother and her really making nothing of it confusing the site of the lump with the arm rather than the rib. It is common to both the evidence of the mother and the father that the lump became bigger. The period over which it became bigger was not tested with the experts but it is noteworthy that the maternal grandmother, an experienced carer, did not at any time appear to note the lump on the baby until it was expressly referred for her attention.

•    The court is unable to identify the perpetrator of the injuries to baby C. There is no direct evidence of any particular event consistent with the injuries sustained and no relevant circumstantial evidence that would entitle the court to conclude that there is sufficient evidence to positively identify the perpetrator or perpetrators.

The court being unable to identify sufficient evidence to make such a finding now has to go on to apply the test set out by Lord Nicholls as to whether there is a real possibility or likelihood that one or more of a number of people with access to the child might have caused the injury to him. The court cannot speculate as to what happened to baby C. It is clear from the evidence that mother, father and the maternal grandmother were the primary carers for baby C either solely or jointly during all or significant parts of the two windows during which the injuries were inflicted on baby C. Both mother and father present as very young and vulnerable. Mother has significant emotional difficulties and has had significant difficulty in managing her anger. It is apparent from the evidence of the paternal grandmother that the relationship between the father and mother has been fraught and that at the very least the father is wary of the mother as indeed is the maternal grandmother.

The father was criticised for his reluctance to share the discovery of the lump with the mother. His explanation for failing to do so was that he thought she would be very angry and blame him and his family. He was right to be so cautious and yet it remains of significant concern to the court that that was his primary concern rather than the health and welfare of his son.

The court remains concerned as to the maternal grandmother's collusion with the mother and father, her failure to note the lump as an experienced carer and the circumstances in which she learned of the lump. It is clear that she has lied in her evidence as to the circumstances in which she came to learn of the lump. I do not accept that a phone call was received from the paternal grandmother. I consider it significant that the mother accepted she had told the maternal grandmother of the lump. I further consider it significant that the father describes pointing out the lump to the maternal grandmother. The motivation for the collusion between the mother, father and maternal grandmother and the absence of a satisfactory explanation as to the cause of the injuries to the child leads the court to the view that it cannot exclude any of the three family members from the pool of perpetrators and I therefore conclude that there is a real possibility that each of them may have inflicted all or some of the injuries to baby C. I cannot exclude any of them from the pool of perpetrators. I am not able to attribute degrees of likelihood to any of the family members within the pool.

Acknowledgments

114. I would like to say thank you to the advocates for the way in which they have conducted themselves during this difficult hearing and to each of the family members. I recognise this has been a very difficult hearing for all family members and has caused them considerable distress.
115. I note that the guardian remains hopeful that even if baby C cannot remain in the care of his mother and father that he can remain within the family and it will now be necessary for the court to give directions to enable essential assessments to be completed.
116. It is regrettable that this judgment could not be handed down earlier. Sadly with the limited resources available within HMCTS extended pieces of work have to be sent out for typing. The contractual turnaround time is 10 days.

HER HONOUR JUDGE VENABLES 10^TH OCTOBER 2014.