London Borough of Bexley v M & Ors (No 1)

2. Previous Proceedings

3. Findings Sought By The Local Authority

4. Implications of Previous Findings

5. The Law

6. Case Management Issues

7. Evidence & Witnesses

8. The Background 8.4. 2017 – Late 2018 8.8. The PEG-J, Pump & Weight Profile 8.13. Late 2018 – November 2019 Hospital Admission 8.56. Hospital Admission 20 Nov – 11 Dec 2019 8.127. 12 December To Hospital Discharge 8.140. Subsequent Progress

9. The Family Members 9.1. Mother 9.32. Father 9.67. Paternal Grandmother

10. The Videos & Witnesses X & Y 10.4. X & Y 10.41 The Flushing Videos 10.56 The Squeezing Video

11. Nurses 11.1. Generally 11.5. Criticisms 11.20. The Wards & Nurses

12. Clinicians 12.1. Dr U 12.14. Dr V 12.29. Dietitian DM 12.43. Dr F

13. Expert Evidence 13.1. Paediatrician - Dr Knight-Jones 13.20. Gastroenterologist - Dr Campbell

14. Discussion & Allegations

1. INTRODUCTION 1.1. This case involves three little girls: A, B and C. They are the children of M and F. M and F are not married, have not lived together full-time and are now separated. 1.2. All three girls were subject to previous care proceedings running from 2018 to mid-2019, which concluded on an agreed basis following the LA changing its position after hearing expert and professional evidence. No final orders were made. 1.3. B and C are 5 and 6 years old and are thriving and in general good health in the care of their F and PGM with whom they went to live in March 2020. Until the precipitating events of these proceedings in December 2019 they had lived together with A in their M’s home where F and PGM were regular and frequent visitors. They then moved in mid-December 2019 to the care of their step great-grandfather and his partner, before moving to their PGM’s home where their F also lives. 1.4. A was placed in foster care following discharge from hospital in late January 2020. A was born in early 2017, and suffered an Acute Life Threatening Event in her parents’ care at 6 weeks old. This has left her suffering from a range of physical and neurological disabilities and medical issues. 1.5. A posed a number of very worrying concerns for her health and had a number of hospital admissions in 2019, leading up to late November 2019 when she was admitted to hospital in what all agree was a very poor condition. 1.6. Members of the nursing team then recorded a range of observations, and were also alerted in December by two carers of another patient on the same ward to further observations, some of which had been filmed on their mobile telephones. This led to M’s exclusion from A’s care, an interim care order and M’s arrest. 1.7. Since that point, A has made remarkable progress in almost all aspects of her presentation and development. 1.8. This judgment concludes a lengthy fact-finding hearing relating to A alone. The findings sought by the LA are set out below under section 3, and cover allegations of M harming A by exaggerating or fabricating illness in A (referred to for brevity hereafter as FII – but see below for clarification on the use of this term). 1.9. In summary, I have concluded that most but not all of the findings sought by the LA against the M are established.

2. PREVIOUS PROCEEDINGS 2.1. This is the second set of care proceedings before me in respect of all three children. The first was issued in 2018 and concluded in mid-2019, with the Threshold Criteria being agreed in May 2019. 2.2. In the previous proceedings, those criteria were found to have been met in respect of A and B, but not C. Regarding FII, no findings were eventually sought by the Local Authority and none were made. More specifically, while FII allegations were raised and then withdrawn regarding B, no FII findings in relation to A formed the basis of the LA’s case before the court. 2.3. While the consideration of such issues and the children’s care generally formed part of the expert, Dr Ward’s, initial analysis dated October 2018 of all three children’s records, they did not form the subject of findings sought by the LA regarding A nor therefore the issues examined in detail in the course of the court’s investigation of the evidence; as far as care of A was concerned, findings were only sought and detailed evidence heard regarding A’s hypoxic collapse at 6 weeks old. General observations only were made as to the parents’ general care of A. 2.4. Eminent expert assessment (in particular Dr Ward’s October 2018 report, some key extracts of which are set out under section 9 below) informed the range of the findings sought by the LA regarding A’s care. Further expert evidence, in the form of Dr Ward’s oral evidence, plus additional medical and social work evidence, led the LA to withdraw key allegations relating to B and alleged FII, and relating to A with regard to the cause of her hypoxic collapse. The LA proposed modified findings for agreement by the parties, and for the approval of the court, at the point in the case prior to hearing evidence from family members. 2.5. The then allocated Guardian (there having been a re-allocation of CG part way through the 2019 fact-finding hearing) supported the consensus reached, as did the court, having considered the primary, expert and limited oral evidence. 2.6. The concluded position in those proceedings in relation to B is set out in full in Annexe 1. In summary, it was agreed that M’s behaviour did not amount to FII, but M accepted that she had been overly anxious about B’s health and if that pattern had continued without the implementation of the May 2017 Safety Plan it would have led to the likelihood of B suffering significant harm. 2.7. In brief, the behaviours referred to in relation to B included: unjustified assertions of B suffering from seizures/convulsions, including febrile convulsions; seeking specialist baby feed, barium swallow testing and other physical interventions that were not necessary and had not been prescribed; an inconsistent and anxious pattern of M’s reporting of B’s feeding difficulties, combined with failures to follow professional advice, that led to a perpetuation of those difficulties and had a negative effect on B’s feeding abilities; and M’s use of emergency and alternative services instead of the GP, in combination with poor communication to and from professionals, led to a risk that B would be prescribed unnecessary anti-biotics. 2.8. With regard to A, the only finding sought was that A had suffered inflicted harm in her parents’ care by way of suffocation or smothering, but the concluded position in those proceedings is set out in full at Annexe 2. In summary, the LA agreed that A had suffered a catastrophic ALTE by way of an accidental upper airway obstruction when placed by her M into the parents’ bed where her F was also lying. This had been the clear conclusion based on detailed analysis by Dr Ward. 2.9. The recitals to the May 2019 order included the following: ‘ AND UPON the court requesting all professionals to proceed on the basis that no findings have been made of Fabricated or Induced Illness conduct by the mother in relation to any of her children. She is not to be treated as such by professionals working with her and the children. AND UPON the court requesting that no professional will refer to the hypoxic event sustained by A on 7.4.17 as 'suffocation' or 'smothering'. It was an upper airway obstruction (in the terms attached in Annexe 2) with no evidence of intentional parental physical obstruction. The court heard and accepted evidence that the care all three children are receiving from their parents is positive and the children are thriving.’ 2.10. The case finally concluded with no final orders sought by the LA in July 2019.

3. FINDINGS SOUGHT BY THE LOCAL AUTHORITY 3.1. The amended Schedule is set out in full at Annexe 3. In summary, the findings fall into the following categories: a) M depriving A of sufficient feed leading to gross malnourishment, vulnerability to infection, and lack of developmental progress; b) M exaggerating A’s difficulties relating to excess salivary secretion, wheezing and recurrent respiratory infections; c) M seeking the unnecessary implementation of Total Parenteral Nutrition (TPN); d) M grossly exaggerating the extent of dystonia suffered by A, and seeking to blame dystonic episodes for the pump occlusions; e) M manipulating the PEG-J feeding tubes at both Hospital 1 [H1] and Hospital 2 [H2] so as to cause the pump to stop (occlude) and to interfere with the passage of feed and Dioralyte, leading to obscuring A’s true condition, frustrating her treatment, prolonging her hospital stay, and subjecting her to unnecessary and harmful procedures; f) M interfering with the PEG-J tubing to introduce fluid and squeezing A’s stomach so as to cause what appeared to be A suffering significant gastric fluid losses into her gastric bag; g) M interfering with A’s PEG-J tubing during supervised contact on 20.12.19 so as to introduce fluid, and again on 13.1.20 so as to open a tubing port. 3.2. Amendments were made by the LA to remove allegations made against F and PGM of collusion and/or failure to protect as the evidence developed, and to focus upon the medical issues rather than the state of any party’s home. 3.3. In particular, allegations as to the state of the PGM’s home, which was significantly cluttered in late 2019 and early 2020, have been dropped. The PGM successfully made and has maintained significant and satisfactory changes to her home (where the children had not originally been living) and the LA accepts that there is no child protection concern arising. 3.4. Allegations as to the state of the M’s home are not pursued at this hearing. The allegations of FII are of far greater significance and concern. The allegations are not dropped, but are not currently pursued here, and may or may not need to be considered by the court in due course. 3.5. The LA, due to the development of the evidence, no longer pursues findings against M relating to: a) Inducing recurrent chest infections by inappropriately feeding A by mouth – there was insufficient evidence to sustain this allegation; b) Failing to provide A with stimulation – there was clearly evidence of a variety of appropriate efforts by M to provide toys, sensory experiences, outings, and appropriate nursery or group activities for A; c) Inappropriate referral to the palliative care team – there was evidence to clarify that this is not considered to be an ‘end of life’ service only, but that it provides significant support and co-ordination around the multiple services, agencies and advice that children with multiple and possibly life-limiting disorders may need. 3.6. I did not permit the expansion of the allegations to include an assertion that in fact A’s PEG-J device (gastrojejunostomy) had been unnecessarily fitted (in September 2018) and that A had since then been unnecessarily subject to jejunal feeding and to the required interventions to maintain and replace parts of the PEG-J (December 2019). This further allegation had arisen following the clinicians’ evidence, when with hindsight and upon being asked to consider A’s current progress, they were asked to comment upon the need for the PEG-J and jejunal feeding. This request by the LA was supported by the Children's Guardian. 3.7. I accepted the objections raised by the Respondent parties, and in particular on behalf of the M. The initial PEG-J surgical intervention clearly predated the analysis of Dr Ward in the 2018-19 proceedings, in which she concluded that A suffered from the requisite problems that justified such a step. Clinicians at the time considered it to be necessary based on A’s difficulties, including an unsafe swallow, gastro-oesophageal reflux, and naso-gastric tube feeding. If it had been included in the Schedule of findings sought that was proposed in the early stages of case management in these proceedings, it would have prompted: firstly, a close analysis of the proportionality and propriety of examining the conclusions of the expert’s analysis provided at an influential early stage in the previous proceedings; and secondly, consideration of a range of different evidential steps to examine the nature of the information and decision-making at the time and any part M’s behaviour had played. Accordingly, it would have been disproportionate, unfair, and impossible to meet the forensic demands of this fresh allegation at this late stage. 3.8. I permitted the inclusion of two allegations relating to the alleged tampering by M with A’s PEG-J tubing on two occasions of supervised contact in December 2019 and January 2020. This ensured that these potentially relevant matters, which centred upon the comparatively narrow evidence of three witnesses to the events and an expert’s opinion, were properly considered and the burden of proof squarely accepted by the LA.

4. IMPLICATIONS OF PREVIOUS FINDINGS 4.1. During the early course of the management of these proceedings, the LA confirmed that it was not seeking to go behind the threshold findings of those earlier proceedings. 4.2. However, over and above the question of the findings sought, it was also asserted on behalf of the M that it would be unfair for the court to take into account references made to historical matters which predate May 2019 that were considered and commented upon by the experts as part of A’s history in these proceedings. This is of particular relevance to Allegation 1 and A’s failure to gain weight from September 2018 leading to a malnourished state by November 2019. I have, for example, obviously been referred to A’s weights since her birth, and their relevance in understanding her trajectory from the provision of her PEG-J in September 2018, then through 2019 and to date. 4.3. Reliance was placed upon the reference in the May 2019 order to: “ The court heard and accepted evidence that the care all three children are receiving from their parents is positive and the children are thriving.” This could be said to be the apex of the M’s assertions on this issue. However, given the limited finding being examined before the court in relation to A, it is not sustainable to assert that this was anything more than an observation of overarching generality. 4.4. Additionally however and by contrast, also on behalf of M and in support of her case, I have been referred to, for example: documentation of her concerns arising as to A’s health in late 2018 and early 2019, including in relation to A’s failure to gain weight; and that M was supervised in hospital in February 2019 due to the then ongoing proceedings, so that I am therefore encouraged to draw certain inferences in her favour in relation to hospital records relating to that admission in February 2019. Both positions cannot be properly or fairly maintained. 4.5. It was further suggested that the court should ignore and reject any expert evidence that referred back to such earlier information on the basis that it was somehow casting back to issues that were supposedly closed by the previous proceedings. However, firstly, these issues were not included in the threshold findings relating to A in the previous proceedings. Secondly, this is artificial and unsustainable; any consideration of weight or failure to thrive must consider a child’s overall trajectory over time and matters relevant to the topic. And given that it is said on the M’s behalf that the M herself was at all times extremely concerned at A’s lack of weight gain, it becomes impossible to consider the issues relevant to A’s weight or even the M’s own concerns without considering the child’s history. 4.6. On behalf of the LA, and supported by the Children's Guardian, it was pointed out that the Schedule of findings sought in this case does not include allegations that go behind the limited threshold findings made in the previous proceedings. The issues in the Schedule were not pleaded before the court in the previous proceedings and so were not the subject of its scrutiny. Indeed, it is clear that they relate to issues that took place or crystallised later in 2019. 4.7. It was conceded by the LA that certain particulars which the LA asserts to establish the context of Allegation 1 (failure to provide sufficient feed) contain references to matters that predate May 2019. However, the LA points out that these references were clearly set out in the LA’s Schedule well ahead of this hearing and so all parties had plenty of notice that they were pleaded as relevant context. The LA submits that this prevented any alleged unfairness. 4.8. Two such references (Allegation 1, Particulars a. and c.) are to the facts of the provision of her PEG-J in September 2018 which supported jejunal feeds that should have adequately fed her thereafter, but her weight remained much the same over the subsequent year and by November 2019 she was grossly malnourished. These are not issues which are disputed by M, and so it does not follow that it is improper to refer to them under this allegation in the Schedule. What is disputed is whether the M was responsible for that malnourishment. 4.9. Two further references (Allegation 1, Particulars d. and e.) refer to A’s admission to hospital in February 2019 when she gained weight over 1 week and no cause for inadequate weight gain was found. The LA asserts that the court must consider the weight to be given to this evidence and, in the context of the whole of the evidence, what if any inferences may be drawn from it, and consider any expert opinions expressed about it. The LA rejects any assertion made by the M that such material is prohibited from the court’s review. 4.10. On behalf of the F it was pointed out that these matters related to issues that were not covered by the previous proceedings and that there was fresh evidence in this case that would justify looking at matters from that earlier period, but that caution may be required. 4.11. On behalf of the PGM it was asserted that this was a straightforward matter of looking at the relevant background information and medical history that applied to these allegations in these proceedings, which were different issues than those before the court in the previous proceedings. 4.12. I reject the submissions on this issue put forward on M’s behalf, for all the reasons discussed above. I note however, that I have little detail before me as to the February 2019 admission and therefore must consider with caution whether it is safe or appropriate to place weight or draw inferences from matters said to arise from it whether that is asserted by either the LA or the M.

5. THE LAW 5.1. The principles that apply in findings of fact hearings are well known and I rehearse them below for completeness. In briefest summary: the standard of proof is the civil standard, i.e. the simple balance of probabilities; and where I describe events or make findings, I have applied that balance of probabilities, the burden of proof being on the party seeking the finding. In making any findings I have considered all the evidence and submissions, even if every potentially relevant factor may not be specifically cited. This is necessarily a long and detailed judgment, but it would be unrealistic and disproportionate to include and refer to every possible factor (cf. #37 and 39 per Black LJ in Re T-B-N (Children) [2016] EWCA Civ 1098). 5.2. The law was helpfully summarised by MacDonald J in respect of cases where FII is alleged in East Sussex County Council v SV and others [2017] EWHC 536 (Fam) at #46 of that judgment (with my additional observations alongside set out in square brackets): ‘i) The burden of proving the facts pleaded rests with the local authority. In cases of alleged induced illness, it is for the local authority to establish on the balance of probabilities that the illness was induced. There is no requirement on the parents to show that the symptoms exhibited by the child were genuine or have some alternate explanation to the case of induction advanced by the local authority. Where a respondent parent seeks to prove an alternative explanation but does not prove that alternative explanation, that failure does not, of itself, establish the local authority's case, which must still be proved to the requisite standard (see The Popi M, Rhesa Shipping Co SA v Edmunds, Rhesa Shipping Co SA v Fenton Insurance Co Ltd [1985] 1 WLR 948 at 955-6). [In relation to this aspect of the legal framework, I note also the following: - the burden of disproving a reasonable explanation put forward by the parents also falls on the local authority (#10, Re S (Children) [2014] EWCA Civ 1447 ). - where a set of circumstances calls for an explanation and none is forthcoming it is not a reversal of the burden of proof to expect the carer to provide a satisfactory explanation ( Re M-B Children [2015] EWCA Civ 1027 ).] ii) The standard to which the local authority must satisfy the court is the simple balance of probabilities. The inherent probability or improbability of an event remains a matter to be taken into account when weighing the probabilities and deciding whether, on balance, the event occurred (Re B [2008] UKHL 35 at [15]). Within this context, there is no room for a finding by the court that something might have happened. The court may decide that it did or that it did not (Re B [2008] UKHL 35 at [2]). iii) Findings of fact must be based on evidence not on speculation. The decision on whether the facts in issue have been proved to the requisite standard must be based on all of the available evidence and should have regard to the wide context of social, emotional, ethical and moral factors (A County Council v A Mother, A Father and X, Y and Z [2005] EWHC 31 (Fam) ). iv) In determining whether the local authority has discharged the burden upon it the court looks at what has been described as 'the broad canvas' of the evidence before it. The role of the court is to consider the evidence in its totality and to make findings on the balance of probabilities accordingly. Within this context, the court must consider each piece of evidence in the context of all of the other evidence (Re T [2004] 2 FLR 838 at [33]). v) In this context, and self-evidently, I am not limited to considering the expert evidence before me. Rather, I must take account of a wide range of matters that includes the expert evidence but also includes, for example, my assessment of the credibility of the witnesses and inferences that can be properly drawn from the evidence. Accordingly, the opinions of the medical experts need to be considered in the context of all of the other evidence. vi) When considering the medical evidence with respect to the child's presentation, the court must bear in mind, to the extent appropriate in the given case, the possibility of an unknown cause for that presentation (R v Henderson and Butler and Others [2010] EWCA Crim 126 and Re R (Care Proceedings: Causation) [2011] EWHC 1715 Fam). [I also note here that Re U (Serious Injury: Standard of proof) 2 2004 EWCA Civ 567; 2004 2 FLR 263 sets out considerations emphasised by the judgment in R v Canning that apply to care proceedings: i. Cause of an injury or an episode that cannot be explained scientifically remains equivocal ii. Recurrence is not of itself probative iii. Particular caution is necessary in any case where the medical experts disagree, one opinion declining to exclude a reasonable possibility of natural cause iv. The court must always guard against the over dogmatic expert, the expert his reputation or amour propre is at stake for the expert who has developed a scientific prejudice v. The judge in proceedings must never forget that today’s medical certainty may be discarded by the next generation of experts or that scientific research will throw light into corners that are at present dark.] vii) In respect of the medical evidence, it is vital to avoid blurring the important distinction between treating clinicians and experts (Re H-L (A Child) [2013] EWCA Civ 655 ). Where it is proposed to seek an overview opinion from one of the doctors who has treated a child, then that proposal must be expressly raised with the other parties and with the court. If permission is given to instruct one of the treating clinicians as an expert, then that instruction and all that flows from it must be conducted in accordance with the rules and established practice in exactly the same manner as it would be for an 'expert' who is brought into the case and who has not treated the child (Oxfordshire CC v DP, RS and BS [2008] 2 FLR 1708 ). viii) The evidence of the parents and carers is of utmost importance and it is essential that the court forms a clear assessment of their credibility and reliability. The court is likely to place considerable reliability and weight on the evidence and impression it forms of them. In this regard, it is important to bear in mind the observations of Leggatt J in Gestmin SGPS SA v Credit Suisse (UK) Ltd Anor [2013] EWHC 3560 (Comm) at [15] to [21] and, in the context of public law children proceedings, of Peter Jackson J in Lancashire County Council v M and F [2014] EWHC 3 (Fam) that: "To these matters I would only add that in cases where repeated accounts are given of events surrounding injury and death, the court must think carefully about the significance or otherwise of any reported discrepancies. They may arise for a number of reasons. One possibility is of course that they are lies designed to hide culpability. Another is that they are lies told for other reasons. Further possibilities include faulty recollection or confusion at times of stress or when the importance of accuracy is not fully appreciated, or there may be inaccuracy or mistake in the record keeping or recollection of the person hearing or relaying the account. The possible effects of delay and repeated questioning upon memory should also be considered, as should the effect on one person of hearing accounts given by others. As memory fades, a desire to iron out wrinkles may not be unnatural - a process that might inelegantly be described as "story-creep" may occur without any necessary inference of bad faith." ix) As to the issue of lies, the court must always bear in mind that a witness may tell lies in the course of an investigation and the hearing. The court must be careful to bear in mind that a witness may lie for many reasons, such as shame, misplaced loyalty, panic, fear and distress. The fact that a witness has lied about some matters does not mean that he or she has lied above everything (R v Lucas [1982] QB 720 ). Within this context, it is important to note that, in line with the principles outlined in the R v Lucas, in seeking to determine whether a person is a perpetrator, or should be included within the pool of possible perpetrators, it is essential that the court weighs any lies told by that person against any evidence that points away from them having been responsible (H v City and Council of Swansea and Others [2011] EWCA Civ 195 ). [I note also, with relevance to this issue, the guidance of the P in Re H-C (Children) [2016] EWCA Civ 136 , and I further direct myself in accordance with R v Lucas that where a person has told a deliberate, relevant lie, this can support the truth of an allegation against him. However, it cannot of itself prove the allegation, as was emphasised by McFarlane LJ (as he then was) at #97-100 of his judgment in Re H-C . The court must bear in mind that an innocent person may lie for other reasons. Where lies have been told, it is necessary to consider all the possibilities before reaching a conclusion about their significance.] x) It is also important when considering its decision as to the findings sought that the Court takes into account the presence or absence of any risk factors and any protective factors which are apparent on the evidence. In Re BR [2015] EWFC 41 Peter Jackson J sets out a useful summary of those factors drawn from information from the NSPCC, the Common Assessment Framework and the Patient UK Guidance for Health Professionals. xi) It is in the public interest that those who cause injury to children be identified (Re K (Non-accidental Injuries: Perpetrator: New Evidence) [2005] 1 FLR 285 ). The court should accordingly endeavour to identify on the simple balance of probabilities the person or persons responsible for inflicting the injuries in question where it is possible to do so. xii) The Court should not, however, 'strain' the evidence before it in order to identify on the simple balance of probabilities the individual or individuals who inflicted the injuries. If it is clear that it is not possible on the evidence before the court for the court to conclude on the balance of probabilities who the perpetrator of the injuries is, or perpetrators of the injuries are and the court remains genuinely uncertain, then the court should reach that conclusion (Re D (Care Proceedings: Preliminary Hearing) [2009] 2 FLR 668 ). …’. 5.3. The Court must survey the wide canvas of evidence, including the expert and lay evidence, and should assess each part of the evidence, and the credibility of each of those giving evidence, when reaching a conclusion: Re U (Serious Injury): Standard of Proof [2005] Fam 134 . 5.4. Butler-Sloss P in Re T [ 2004] 2 FLR 838 at paragraph 33 said this: "Evidence cannot be evaluated and assessed in separate compartments. A Judge in these difficult cases has to have regard to the relevance of each piece of evidence to the other evidence and to exercise an overview of the totality of the evidence in order to come to a conclusion whether the case put forward by the Local Authority has been made out to the appropriate standard of proof" . 5.5. Accordingly, the opinions of the medical experts, as well as other witnesses, need to be considered in the context of all the other evidence. This principle was particularly important in Re X (children) (fact-finding: fabricated induced illness) [2018] EWHC 4020 (Fam) , where Knowles J made findings against a mother that constituted fabricating and inducing illness and causing the child to suffer unnecessary medical interventions, and in doing so placed reliance not on the report of the single joint expert consultant paediatrician, instead preferring the evidence of the treating clinicians and nurses. The roles of the court and the expert are distinct, and it is only the court that is in the position to weigh up the expert evidence against or bearing in mind the rest of the evidence. 5.6. I must assess the primary evidence from the nurses, X and Y, the parents and the paternal grandmother. The parties have had the fullest opportunity to take part in this fact-finding element of these proceedings, and I place considerable weight on their evidence and the impression I have gained: Re W and Another (A Child : Non- Accidental Injury) [2003] FCR 346. 5.7. In assessing and weighing the impression which I have gained of the lay parties, I must also keep in mind the observations of Macur LJ it Re M Children [2013] EWCA Civ 1147 at #11-12: “Any judge appraising witnesses in the emotionally charged atmosphere of a contested family dispute should warn themselves to guard against an assessment solely by virtue of their behaviour in the witness box, and to expressly indicate that they have done so.” 5.8. The caution of Macur LJ has been repeated by the Court of Appeal in Sri Lanka v the Secretary of State for the Home Department [2018] EWCA 1391] and draws attention (per Leggat LJ at #40-41) to dangers of over-reliance on demeanour and the research base to support that danger. The family court expressly considered the issue of demeanour at #23 of A Local Authority v Mother and Father [2020] EWHC 1086. I accept and consider that these warnings are particularly pertinent here given the M’s vulnerabilities which I discuss elsewhere. 5.9. In Lancashire CC v R [2013] EWHC 3064 , Mostyn J summarised the relevant legal principles in respect of cases of this nature and continued in this way: “The assessment of credibility generally involves wider problems than mere 'demeanour' which is mostly concerned with whether the witness appears to be telling the truth as he now believes it to be. With every day that passes the memory becomes fainter and the imagination becomes more active. The human capacity for honestly believing something which bears no relation to what actually happened is unlimited. Therefore, contemporary documents are always of the utmost importance: Onassis and Calogeropoulos v Vergottis [1968] 2 Lloyd's Rep 403, per Lord Pearce; A County Council v M and F [2011] EWHC 1804 (Fam) [2012] 2 FLR 939 at paragraphs 29-30”. 5.10. THE TERM ‘FII’ – While I have also reminded myself of the guidance issued by the Royal College of Paediatrics and Child Health entitled Fabricated or Induced Illness by Carers - A Practical Guide for Paediatricians (RCPCH 2009, review date 2012) and the Government guidance entitled Safeguarding Children in Whom Illness is Fabricated or Induced - Supplementary Guidance to Working Together to Safeguard Children (DCSF 2008), I also remind myself that I am simply determining whether or not I am satisfied on the evidence as to the matters that the LA has set out in its Schedule of allegations. 5.11. I note that FII is not a diagnosis in itself nor a psychiatric nor psychological disorder. It is perhaps best understood as a descriptor term to refer to a “syndrome,” and is a convenient label for a series of incidents or behaviours that share the common feature of fabrication, exaggeration or induction of illness ( A County Council v A Mother and A Father and X, Y, and Z [2005] EWHC 31 (Fam) ). Any use of it in this judgment is therefore simply a shorthand label to conveniently refer to the combination of issues which the LA sets out in its Schedule and which it considers meets the description of FII. 5.12. Any findings I make will be the subject of future expert analysis and risk assessment. There may follow diagnoses, labels and/or identification of patterns, motivations or syndromes. That is not for consideration by me in this judgment at this stage in these proceedings.

6. CASE MANAGEMENT ISSUES 6.1. COVID – Inevitably, this case has been afflicted by the difficulties posed by the measures taken to manage the coronavirus pandemic. Other than the few initial hearings that took place prior to public health social distancing requirements that began in March, all interim hearings have been conducted fully remotely. 6.2. The final hearing has also been remotely conducted by many of the participants, and on some occasions fully remotely by all. Certain days were conducted on a hybrid basis to hear oral evidence in court from all the nursing staff and most of the clinicians, due to the need for them to describe and demonstrate their observations. This was particularly important given the references made to the PEG-J feeding pump tubing and mechanism, and a set was provided by H2 at court for this purpose. The M and her intermediary and leading and junior counsel attended court on every such day, and leading counsel for the local authority also did so, occasionally supported by junior counsel. I encouraged, and all parties agreed, that those others who could join via remote video platform should do so, in order to maximise social distancing capacity in the courtroom and preserve adherence with public health advice. 6.3. Additionally, mindful of the President’s guidance in Re P [2020] EWFC 32 , the M also gave her oral evidence in court rather than remotely, and thus the court had the benefit of the most direct observations and interactions during her evidence. 6.4. Although the same method had been mooted for the F’s and PGM’s evidence, they each gave evidence from a remote location. F from counsel’s chambers and PGM from her home. No party resisted this step and I was happy to approve it, particularly in the light of the LA’s amended position, whereby it no longer sought to establish findings against either of them, and where the PGM belongs to an older age group that is more vulnerable to severely symptomatic coronavirus infection. 6.5. All of the expert and some of the treating clinicians’ and professionals’ evidence was also entirely adequately dealt with remotely. 6.6. Two lay witnesses, X and Y, who had observed and filmed M in the EH, gave evidence remotely from their home. The M wished them to give evidence at court, citing the advantage the court would have in observing them directly, and that doing so would impress on them the gravity of their contribution to the hearing. However, it was clear from the information directed to be provided as to their circumstances and to explain their reluctance to attend, namely their 24 hour care for a highly disabled and physically vulnerable adolescent, justified their giving evidence remotely from their home, particularly during this coronavirus pandemic. It would have posed an unnecessary risk to them and their vulnerable child/grandchild, and would have been a disproportionate burden upon them to be obliged to make care, travel and attendance arrangements in order to come to court. Appropriate measures were established to ensure that they did not give evidence in each other’s sight or hearing. 6.7. The Cloud Video Platform has been used throughout, largely without difficulty. The main problem, and some occasional delay, being caused by local signal difficulties at attendees’ remote locations, and establishing clear audio reproduction from the court to those attending remotely. Additionally, a failure to pin down in sufficient detail with lay witnesses the exact arrangements that would be used to both access relevant parts of the electronic bundle and the remote hearing platform led to lost time. 6.8. The hearing suffered two interruptions due to Covid scares. On one occasion a leading counsel being too unwell for some three days to attend court, and on another occasion M’s intermediary also falling ill. Fortunately, in both cases not only had minimising court attendance, social distancing and mask-wearing in court prevented the knock-on risks of illness and isolation by other participants and further disruption to the hearing, but in both instances subsequent test results fortunately proved negative for coronavirus. However, in the latter case, M and both her counsel (who had inevitably been in close contact with the intermediary at court) had arrived at court but in the circumstances it was not considered appropriate for them to enter the building and the morning was lost as they made their way to appropriate venues to participate remotely for that day’s evidence. 6.9. DOCUMENTS & BUNDLES – In the circumstances, a sensible and proportionate limit was placed upon the amount of documents from the previous proceedings that would be included in the court bundle. Notwithstanding, and unsurprisingly given A’s medical history and the numerous professionals who cared for her, the medical records alone approached 9000 pages. The medical records were extensive and not necessarily well-ordered. 6.10. I am grateful to the LA who agreed to fund the use of Caselines as a platform for the documents in this case. It did, however, take many valuable weeks and numerous requests to prompt the LA to see how vital this step was and to take the necessary steps to resolve it. 6.11. A medical chronology was commissioned and prepared at an earlier stage in the proceedings when the bundle and records were still in pdf format, and thus was hampered and reduced in its usefulness due to the inadequacy of the document references, and then failing to match up with the Caselines pagination. 6.12. I have no doubt that this type of platform with a degree of enhanced functionality is essential in a case of this sort, and simple adherence to the current minimum guidance relating to electronic bundles would have been strongly detrimental to both the parties’ and the court’s abilities in managing this hearing. Caselines, with its search facility among other functionalities, made far easier the challenging task of the navigation and comprehension of the medical records. 6.13. Disclosure was, inevitably, copious. It was unfortunately also sporadic and tardy. Two such important examples were: key nursing notes and a video filmed by one of the carers of another child on the ward. Despite comprehensive disclosure orders and chasing enquiries, the absence of the notes became apparent during final preparation for the hearing and were then provided by H2 following further chasing, just before the evidence began. Similarly, the absence of the ‘squeezing video’ became apparent during the evidence of X and Y, who described a particular observation of squeezing of A by M that had been filmed on one of their mobile phones and which had been provided by them to safeguarding staff at H2. Given the circumstances of the current pressures on hospitals, I do not criticise, but it added to the challenges of the case. Time had to be afforded to the parties to enable material that was provided in this way to be adequately considered. 6.14. Additionally in relation to X and Y, although the LA had checked the day before they were due to give evidence and were told they had two devices at their home, this was insufficient and inadequate to ensure that they had access to their statements and videos plus could access the remote hearing platform. This meant that the arrangements were not as good as they might have been if properly considered in advance and with attention to the relevant details. Then an attempt was then hastily made to send them access to Caselines without considering carefully whether and what access they might therefore have to other confidential material. 6.15. I have been assisted by the provision of helpful schedules and documents prepared by counsel. I note here that I am grateful to all the advocates and solicitors, who it is clear have worked extremely hard throughout, and in particular those representing M. I also note here that some criticism was made of the efforts made by and on behalf of the Children's Guardian to look with rigour into the issues before the court. I unhesitatingly note that the contribution made on her behalf has not only been appropriate (in accordance with the guidance in LB of Islington v Al Alas and Wray [2012] EWHC 865 (Fam) , and more recently in Cumbria County Council v KW [2016] EWHC 26 (Fam) ), but has been invaluable. 6.16. EXPERTS – I deal later in this judgment with issues arising in relation to the experts. 6.17. MOTHER’S VULNERABILITIES – I shall discuss M, her evidence and my impression of her in more detail below. This section addresses the management of her vulnerabilities. 6.18. M was assessed by Ms G (autism consultant) in January 2020 and by Mr Hutchinson (consultant chartered forensic clinical psychologist) in July 2020. 6.19. M has been diagnosed as showing symptoms and behaviours consistent with ADHD and Autistic Spectrum Disorder, and as a result of trying to manage or compensate for the effects of these disorders she experiences anxiety. She is also described as presenting with symptoms associated with complex post-traumatic stress disorder (flowing largely from her experience of A’s hypoxic collapse), anxiety, depression and low self-esteem, and according to Mr Hutchinson she demonstrates health anxiety related to A and at times when A is cared for by others this health anxiety appears to become exaggerated. It is argued on her behalf that the latter is hardly surprising in the circumstances, albeit Mr Hutchinson appears to analyse this more as a function of her disorders. 6.20. He writes: “ As a consequence of camouflaging her difficulties associated with ASD, M reported feeling anxious, which manifests in fidgeting. When she has to interact with professionals or persons whom she does not know, her anxiety levels increase. At such times, she can appear dismissive of professionals' opinions, in that she will ask questions to clarify her understanding. This may appear to professionals as being defiant or non-compliant.… Difficulties in social interaction, which is a core characteristic of an ASD, are reflected in M’s account of her personal relationships. She described feeling lonely as a consequence of being bullied at school, knowing that she was different from her peers and struggling to form and maintain relationships. As an adult, M reported having few close relationships. She has difficulties engaging in the give-and-take of relationships. She particularly avoids group interactions and finds it difficult to mix with others with whom she is unfamiliar. … Due to her slower processing speed for oral information, and working memory difficulties, M has difficulty comprehending orally presented information. M doubts her ability to comprehend and recall information presented if it is not explained in detail, and/or the explanation is not repeated. This may cause M to present as challenging and confrontational when interacting with professionals. … If account is taken of M’s neurodevelopmental difficulties, she can be enabled to comprehend information and express herself in a clear, coherent manner. All professionals should adopt an approach to oral and written communication that is based upon 'easy words' and easy read'. This is particularly necessary if M feels herself to be under stress or anxious.” 6.17 I did not hear oral evidence from Mr Hutchinson. M had an intermediary assessment earlier in the proceedings, and support from an intermediary during each day of the hearing whether at court or on screen with a private link during remote hearing days. Although M had more than one intermediary, I was glad to see that there was sufficient continuity between them, and I benefited from their feedback directly in court and also by way of written reports. 6.18 Not only were they able to ensure that advocates were swiftly reminded and assisted as to the need to avoid complex questions, but I was able to consult them as to the need for, frequency and duration of breaks required by M to manage her anxiety and seek support and clarification from her intermediary and legal team. I was also able to seek direct input as to the efficacy of the intermediary support process. This was further assisted by the feedback reports sent to the court which directly reassured me as to M’s ability to cope and understand and participate. 6.19 Overall, I was entirely satisfied that appropriate measures were successfully in place to meet her needs to participate as a vulnerable party. I was sensitive to the need to receive and implement feedback from the intermediary and requests from her legal representatives for sufficient time to explain the evidence and issues and to take instructions. 6.20 It did mean, however, with so much evidence to cover, in combination with M’s tendency to full and detailed responses to questions and her earnest wish to give evidence and convey in detail the information she wanted to provide, plus the need to take frequent breaks, that M gave evidence over some 4.5 days, and that I requested her to assist me with a few further answers when the opportunity arose after the PGM’s evidence, as I had not felt it appropriate to pursue those matters with M on a late Friday afternoon. I did not require her to remain on oath in the intervening period, so that she was able to discuss her case as necessary and seek support from friends. M was keen to provide her answers, and to give evidence. She was keen, if necessary, for the court day to be extended to permit her to complete her evidence. I took full account of her vulnerabilities, the intermediary’s advice, the steps that it was possible to take to support her in hearing her evidence. I balanced this against the critically important nature of her evidence in this case, both as her opportunity to explain or challenge what she wanted to and for the court to understand that evidence. 6.21 TIMINGS & DELAYS 6.22 Most unfortunately, due to clashing commitments in another case that became listed part-heard across the dates for this hearing, M’s originally instructed leading counsel had to withdraw from the case approximately one month before this hearing was due to begin. I am grateful to the legal team representing M that Ms Campbell QC was instructed as swiftly as possible. 6.23 However, it meant that I was properly obliged to accede to the loss of some days at the outset of the hearing to give sufficient time for preparation, and the occasional further loss of time during the course of the hearing. Firstly, to accommodate a date where Ms CQC had a longstanding prior involvement in another case where her attendance would be required, and secondly and importantly, where the lack of time beforehand meant instructions and preparation were further required. In the circumstances, I considered that these were necessary concessions to ensure that M was properly represented when facing such important allegations. 6.24 This case was originally listed to hear the evidence and submissions from early October until mid-late November, including various non-sitting days to accommodate various participants’ leave and hearing commitments. After Ms CQC’s instruction and case preparation there were inevitable disruptions to normal pre-trial case management, and I was presented shortly before the start of the hearing with a witness template that appeared to me to be significantly unrealistic, particularly given the need for regular breaks to support the M’s participation. The template was adjusted and further time listed. 6.25 For additional reasons, some mentioned already, some avoidable and some unavoidable, the hearing eventually took some 35 days to complete the evidence and submissions, stretching from 8 th October until 16 th December. 6.26 I have already mentioned the reasons of change of representation, the occasional technological breakdown, the impact of illness and in particular Covid scares which required particularly careful management, the impact of late receipt of source evidence, and the regular frequent breaks for M. Additionally, the further extension of dates brought difficulties with leading counsel being listed part-heard in other matters in late November and December. 6.27 However, I am obliged to criticise the LA for two particular areas of failure which contributed unhelpfully to the loss of time. Firstly, there was a failure to ensure technical and practical arrangements were properly checked with the lay witnesses X and Y. This had two implications: access to the remote hearing and access to their statements, videos and any other limited documents they might be referred to. This caused delay and disruption not just to the case but to the witnesses who were anticipating giving evidence, and I have already referred to the concern as to confidentiality and data protection. Secondly, there was a repeated failure to ensure witness’ attention was drawn to updating evidence which was buried in the various indices in Caselines. In the example of Dr Campbell this led to a significant loss of time set aside for his evidence to be heard, and the strain of an inevitably longer and more pressed day of evidence the following day. These were avoidable failures.

7. EVIDENCE & WITNESSES 7.1. I have considered the following in coming to my decisions in this case. 7.2. The documentary evidence is set out in the electronic bundle, alongside numerous videos and images. The videos include the videos of M’s arrest and police interview, six videos filmed by X and Y on the ward at H2, numerous videos and images taken of A mainly by M, some by F and one by PGM, with some recent videos while in foster care, videos and images of equipment including elements of A’s feeding pump and tubing in use, and instructional videos relating to the feed pump. 7.3. The documentary evidence includes statements made within these proceedings, police disclosure, expert reports, contact records, medical records and a variety of miscellaneous documents. I have included in my consideration statements and records by those who have not given oral evidence but that are included in the bundle. 7.4. I have had the unique and important advantage of hearing oral evidence from the following witnesses: Dr V – Treating Paediatric Gastroenterology Consultant (H2) Dr U – Treating (lead) Paediatric Consultant (H1) Dr F – Treating Paediatric Neurology and Neuro-disability Consultant (H2) Ward Sister AS Senior Staff Nurse EDC Senior S.N.ZS Senior S.N.IBE Staff Nurse AA S.N.MF S.N.SM S.N.PMDC S.N.ST S.N.NH S.N.SP S.N.XG S.N.NK S.N.IBY S.N.MG S.N.FA S.N.PM S.N.KS S.N.AH S.N.SB S.N.ELB Safeguarding Nurse Specialist BM Children’s Community Dietician DM Dr Campbell – jointly instructed court expert – Consultant Paediatric Gastroenterologist Dr Knight-Jones – jointly instructed court expert – Consultant Paediatrician Lay witness X Lay witness Y Contact supervisor Ms Ola Mother Paternal Grandmother Father

8. THE BACKGROUND 8.1. This is not intended to be nor can it realistically be a complete chronology, but I set out here certain key elements and events. 8.2. F is 27. F’s parents split up when he was 8/9 and he remained living with his mother (the PGM) with weekly contact with his father. He met M in 2011 and they became engaged in 2013. They have from time to time lived together but never married. The pattern in recent years has been that the F lived with the PGM for most of the week, but stayed at M’s home with the children from Sundays to Wednesdays as he was not undertaking his night shift work on Sunday to Tuesday nights. They now describe themselves as separated. 8.3. M is 26. The M has a more complex history. She has never been cared for by her mother whom she experienced as rejecting her, and her father left her in the care of her paternal grandmother and partner when she was very young although they remained close. She has reported an unusual mental health history as a child and adolescent, involving hallucinations, anxiety, perpetrating and experiencing bullying, self-harming and suicide attempts. She did well at school obtaining 10 GCSEs and 3 science A-levels, and recalls an autism diagnosis and extra support being provided in her early mid-teens. In mid-2013 aged 19 she was pregnant, caring for her terminally ill grandmother, and at college. She attempted self-harm and stated suicidal thoughts and experienced a miscarriage. There were concerns about M’s care of her numerous pets. Her grandmother died and by the end of 2013 she had left college, and was again pregnant. She had her first child C in 2014, with some obstetric and medical complications, and was supported by a Child in Need plan given her mental health difficulties. Child B was born in late 2015. Concerns were first raised in 2016 as to her levels of anxiety regarding B’s health needs. Additional concerns relating to neglect, home hygiene, mental health, self-care and coping skills were raised. 2017 - LATE 2018 8.4. A was born in early 2017. She was admitted to hospital in March of that year with laryngomalacia (a soft rear palate, with a tendency to collapse in), and on 7.4.17 suffered an hypoxic collapse as I have already referred to above. This was a catastrophic event in the life of this family, with profound consequences for A. 8.5. In 2017 to 2018 the extent of A’s disabilities became apparent. Her hypoxic brain injury has caused her to suffer from dystonic spastic quadriplegic cerebral palsy and a range of its associated complications: developmental delay, severe cortical visual impairment (registered blind), recurrent chest infections/episodes of aspiration pneumonia, gastro-oesophageal reflux, an unsafe swallow and there were concerns as to possible seizures/epilepsy. 8.6. In the 17 months prior to September 2018 when her PEG-J was fitted, A had several assessments in relation to her sight, numerous admissions and further community treatments for respiratory tract infections/pneumonia (approximately 10+ noted in the records and set out in the schedule of chest infections prepared by counsel for the Children's Guardian), thought to be secondary to aspiration. She underwent video fluoroscopies which identified an unsafe swallow. There were physical signs of reflux in her trachea on assessment, and she was fitted with a naso-gastric tube to assist feeding and to avoid the risks associated with her swallow and reflux. There was a single complaint about the feed pump for the naso-gastric tube in March 2018 when M found the pump was occluding and alarming due to the tubing being kinked in the bottom of the pump bag. In early September 2018 her naso-gastric tube was removed, a gastrojejunostomy was performed and the PEG-J fitted. 8.7. The first care proceedings were begun in April 2018, and in October 2018 Dr Ward reported as follows in relation to A’s various medical issues, as a result of which conclusions the LA pursued no findings in relation to and there was no further detailed examination of A’s current health status, feeding, weight or care: ‘Several factors contributed to A's feeding difficulties: cerebral palsy impaired oromotor function. We have evidence from the video fluoroscopy that although A is capable of feeding orally she has limited sucking and swallowing skills and is at risk of aspiration when taking fluids. On the other hand, she does not have a totally unsafe swallow, and it was reasonable to offer thickened fluids and tastes of solids. However, it was not realistic to expect her to achieve her full nutritional requirements by the oral route. This was acknowledged by clinical staff. It is not uncommon for children with cerebral palsy to feed reasonably well in early infancy and for progressive feeding difficulties over the first and second years of life [due to] the impact of gastroesophageal reflux and gastrointestinal problems. Gastro- oesophageal reflux undoubtedly adds to the feeding problems of a child with cerebral palsy. Vomiting, discomfort and the potential for aspiration are all factors affected by gastroesophageal reflux. The ENT investigations (micro-laryngo-bronchoscopy) revealed evidence of the impact of gastroesophageal reflux with changes in the upper airways associated with gastroesophageal reflux. It was, therefore, appropriate to maximise anti reflux treatment aversive feeding patterns - a child who experiences feeding as unpleasant or associated with discomfort, is likely to develop an aversive feeding pattern whereby the child avoids feeding. A showed aversive feeding patterns in turning her head away from the bottle, arching away from the bottle and biting on the teat. It is likely that periods of tube feed, discomfort from gastroesophageal reflux and possible aspiration all contributed to the aversive feeding pattern. This combination of factors illustrates the importance of supporting the family in dealing with the complex process of feeding in cerebral palsy. On one hand, one does not wish to deprive the child from the pleasure and social benefits of feeding as a result of increasing aversive behaviour. On the other hand, one wishes to avoid the risks of aspiration, recurrent respiratory infection and psychological distress associated with forced feeding. In my opinion, the mother's wish for a gastrostomy was not unrealistic and prolonged [naso-gastric] tube feeding carries its own risks and frustrations. For example, the need to replace the tube which may distress the child, irritation to the facial skin as a result of the adhesive tape required to keep the tube in place, social factors and the visual appearance of the tube. A has been appropriately investigated and the demonstration of dysfunctional feeds and the impact of gastroesophageal reflux has justified the need for a gastrostomy.… Pulmonary disease in patients with cerebral palsy results from different mechanisms that often occur together: recurrent aspiration - recurrent aspiration may result from gastroesophageal reflux and oropharyngeal dysphagia. Gastrostomy tube feeding provides direct enteral access and reduces aspiration during swallowing but does not address aspiration of oral secretions or stomach content from gastroesophageal reflux and, in fact, may exacerbate gastroesophageal reflux (see above); scoliosis - curvature of the spine and chest wall deformity are common in children with cerebral palsy and may result in restrictive lung disease respiratory muscle discoordination - weakness and/or poor coordination of the respiratory muscles may result in hypoventilation and ineffective cough and clearance of pulmonary secretions In A, recurrent respiratory symptoms have become prominent in the second year of life. There has been concern that there may have been exaggeration on the part of the mother and that clinical signs have not always correlated with the mother's reports. However, she has undoubtedly been observed to be wheezy with crepitations in her chest and x-ray changes which support the likelihood of recurrent aspiration. Weakness and poor coordination of respiratory muscles is likely to be another factor given the extent of neuromuscular involvement. An additional factor or co-morbidity in A, is the likelihood of asthma, a chronic inflammatory condition associated with increased IgE production. Asthma results in hyper reactive airways, inflammation in the respiratory tract and increased mucus production. Asthma is a genetic condition and there is a strong family history of asthma in A’s family.… A is a child with significant and complex medical needs, associated with evolving cerebral palsy and its associated complications. The mother's suspicions of oromotor difficulties leading to feeding problems and aspiration, severely impaired vision, delayed motor milestones, gastro-oesophageal reflux and recurrent respiratory problems related to aspiration and/or asthma are not fabricated and have been supported by investigations and known association with cerebral palsy.… In my opinion A has not been subjected to unnecessary investigations and use of tube feeding, use of a feeding pump, treatment for gastro-oesophageal reflux, asthma and prophylactic antibiotics and referral for gastrostomy are all justified.… This is not a case in which the child has been frequently and repeatedly presented with fabricated symptoms.’ PEG-J, PUMP, & WEIGHT PROFILE 8.8. I include at this point in the overview of the background a description of the PEG-J and pump mechanism. This will be the subject of further discussion later in this judgment, but it is useful to set out a brief explanation of it at this point. (Annexe 4 is a simple diagram of a PEG-J device originally provided by Dr Campbell as an appendix to his August 2020 report.) - The PEG-J is a device that is inserted through the stomach wall and is fixed in place by the inflation of a small balloon just inside the stomach. - Outside the body is a small unit, often referred to as a ‘button’ bearing two ports to which tubes can be attached. One port leads through the button directly into the stomach, the ‘gastric port’, and can support both the insertion of liquids (medicines, feed, water) and the drainage of gastric liquids, referred to as ‘gastric losses’. The other port runs through the button and the stomach, out of the pyloric sphincter and down into the jejunum, the ‘jej port’. This jej port can only support the insertion of liquids. - From September 2018 until the very end of 2019 A was fed jejunally via her jej port. Tubing was attached that ran from a bag or bottle of milk feed, through a feed pump which would be programmed to run at a certain rate and which delivered the feed through the tubing directly into her small intestine. - When A was additionally treated with Dioralyte rehydration remedy, this was also being pumped through as above via a separate pump. Once the feed and Dioralyte had passed through the tubing that was within the respective pumping mechanisms the two tubes would join at a Y connecter. - This is a small plastic connection device with three ports. The two tubes bearing each fluid were each connected to the two further ports of the Y connecter, the two fluids then combining into the single tubing that left the third port of the Y connecter, which tubing was in turn connected to the jej port on the button. - The pumps are designed to deliver a constant rate, despite differences in pressure that they have to infuse against. The system of using a Y-connector and two infusion pumps is common practice. - The tubing running from the feed through the pump to the Y-connector can also be termed the ‘giving set’. In addition, the term ‘extension set’ is used to describe the tubing that runs from the button to a Y-connector to extend access to the ports. - The gastric port had tubing attached which could be used for gastric feeding, but through which medicines and water were also occasionally flushed. In A it was primarily attached to a gastric bag that was used to collect the drained gastric losses. - Each stretch of tube could be clamped to prevent the flow of liquid, so as to permit detachments and attachments. The ports and connection points all bear a standard thread that matches with the nozzles of syringes that are designed for the purpose of treating those who have a PEG-J fitted. 8.9. The pump that I have seen, and had the benefit of handling and seeing others handle, is manufactured by Nutricia. I understand that it is for all necessary purposes the same as the pumps used in A’s recent hospital admission, but slightly although not greatly different from those used for A at home. It is supplied to NHS patients via a firm named Abbott who replace broken or malfunctioning parts and pumps and can be contacted to troubleshoot issues. The small electronic unit has buttons and a screen which permit certain flow rates and functions to be programmed, and the screen can show a number of pieces of data such as flow rate, delivered amount, and error messages. The unit also includes an enclosed section with a small cover, into which the tubing is placed where it runs around a revolving mechanism that thereby pushes fluid through the tubing. If the pressure in the tubing builds up, the pump can slightly compensate, but if it becomes too great the pump will stop and alarm. If it is a blockage running from the feed or fluid source to the pump it will state on the screen: occlusion in. If it is a blockage running from the pump to the PEG-J it will state: occlusion out. 8.10. The hope and expectation of the treating clinicians at this point in A’s treatment, was that the PEG-J would improve the deteriorating picture in terms of A’s feeding and weight gain. She had sunk from her weight being on the 75 th centile at birth, to the 25 th centile in June 2017 some two months after her ALTE, then it had risen back to the 50 th centile by August 2017. From September 2017 her weight hovered between the 50 th and 74 th for a further 5 months until February 2018 when it dropped to the 25 th centile. In November 2017 a feed pump had been introduced. By late April/early May 2018, notwithstanding two overnight admissions from A&E for chest infections in April, she had gained weight and reached a high of 9.3kg on the 50 th centile, but had then dropped again to the 9 th centile by June 2018, to the 2 nd centile by July 2018 and then to the 0.4 th centile by the date of the PEG-J procedure in September 2018. There was then a slight recovery to the 2 nd centile by October 2018. 8.11. However, for the following year, save for two occasions, her weight dropped and tracked along at below the 0.4 th centile. When she was admitted to H1 in late November 2019 she was noted to be significantly below the 0.4 th centile at 7.9kg, being described then by Dr U as marasmic, in a state of severe malnourishment. 8.12. Those two occasions when her weight notably improved are as follows: a) A four day admission to H2 in February 2019 when her weight increased by approximately 0.5kg and she returned to the 2 nd centile at 8.4kg on 21.2.19. Due to the ongoing care proceedings, M was supervised during this admission. b) A week long admission to H1 from 9-15.7.19 when her weight increased by over 1kg from 7.48kg to 8.53kg. This admission was also noteworthy for two features: M took a short holiday with the F from 12-15.7.19, leaving PGM caring for A for the last four days of her admission until she was discharged, and her drainage bag was removed with no ill-effects. LATE 2018 – NOVEMBER 2019 ADMISSION 8.13. A seemed to rally after the PEG-J was fitted, happier and cooing, according to her parents. In September 2018 A had a consultation with Dr U, who observed excessive active drooling, to discuss the implications of drooling/secretions and A’s recurrent respiratory infections. A prescription to reduce drooling was begun. 8.14. In mid-November Consultant gastroenterologist Ms R had prescribed the use of a drainage bag based upon the accounts given of A suffering from bloating and wind, in order to vent wind at night. Ms R requested that M record the amount of any liquid also lost into the bag at night or by syringe during the day. And by late November Dioralyte was then prescribed to replace gastric losses. The normal rate of loss being up to 20ml/kg/day or approximately 100-150 ml/day for a child of A’s size. 8.15. In December 2018/January 2019 a short phone video was taken by the parents due to the pump not pumping through the feed. The pump screen can be seen to state that it is priming, but there is no feed being pushed through the tubing to emerge from the open end of the giving set. This was reported to dietitian DM: ‘ Parents reported that on Friday they realised pump had not been delivering full dose. No alarms and pump moving but no feed administered. Dad annoyed about this. Do not know how long this has been a problem for. Have 2 new pumps from Abbott. Loose stools did start with new pump so ? was not receiving full feeds before.’ 8.16. A had a two day admission 21-22.1.19 following a five day history of a cough/chest infection. On 22.1.19 PGM raised with the H1 dietitian that the hospital pump had been occluding and a query was raised as to whether it meant A would be receiving her full feeds, and PGM was requested to alert staff if the pump occluded in hospital. 8.17. In January 2019 the dietitian DM was raising concerns with the treating consultant Ms R about M’s concerns of high gastric losses of 350-450ml per 24 hours, and of A’s weight loss which the dietitian was trying to treat by increasing feed concentration to 140% of requirements. 8.18. M was at this time referring to Dr F in her discussions with the dietitian DM and saying that it was his view that A was not gaining weight because of her movements and tone. DM did not see A as a child with such an energy expenditure problem. Her physiotherapy assessment in mid-February noted no spasms or involuntary movements, and the physiotherapists provided explanations to the family to help with an understanding of the presentation of A’s movements. 8.19. A was admitted to H2 on 18-22.2.19 to review her gastro-intestinal, movement and respiratory issues. During this late February hospital admission M was noted by S.N.KS to express her concern about the numerous chest infections that A had suffered in recent months, and that her salivations lead to chest infections and that suctioning may be the answer to this. She complained at having to wait until April to see the consultant on this issue and that A may have more chest infections and may die. 8.20. Dr V oversaw the gastroenterology treatment during this admission. Gastric losses of 750ml/day were recorded initially, which were then reduced to 150ml/day by clamping A’s drainage bag and reducing the amount of Dioralyte that was provided. This approach was then reversed and a large loss of 8-900ml was recorded on the day she was discharged. Dr I’s discharge letter set out a plan of increasing clamping of the gastric tube so as to wean A off the need for a drainage bag. No clear cause for failure to gain weight was identified during this admission. 8.21. In a letter to Dr U in early November 2018, A’s GP confirmed three episodes of respiratory infection on clinical examination and requiring antibiotics. In each of November 2018, January, March and April 2019 A had respiratory distress or infection, and three of the four occasions led to hospital visits or admission. Suctioning was taught to the family and its use permitted from April. It involved using a small suction device to remove saliva or vomit from A’s mouth, but did not involve any deep suctioning into her throat which it was explained needed to be done by trained nurses. There appeared to be some abatement of chest infections from this date until late summer, noted by M to Ms O’L (specialist paediatric gastroenterology dietitian) in late June, and by her GP in relation to a request by M for a referral for a second opinion to a respiratory consultant at Hospital 3 [H3]. Records indicate approximately one chest infection serious enough to require anti-biotics prescription in each of May, June and July. 8.22. On 28.3.19 the dietitian DM recorded as follows: ‘ Mum reported is getting full feed most days but still having a problem with pump. Pump saying feed is being delivered and it is not. ’ 8.23. There were some 15 days of evidence heard in the previous proceedings in late April to late May 2019, leading to the agreed threshold conclusions that I have discussed above. 8.24. At a consultation with the dietitian at the end of May, A was noted to be tracking her height and weight along the 0.4 th centile, although she had put on some 0.3kg over the previous month and appeared otherwise well. DM reported this presentation positively to the core group meeting that day. M reported gastric losses of 600-700mls/day, and the appearance of a substantial gastric loss into the gastric bag was noted during the meeting. 8.25. There was a significant consultation on 28.6.19 with Dr V. She was referred due to her ‘faltering growth’ which is clearly a reference to her poor weight gain and consequent minimal growth. ‘Problems: 1. Referred in view of faltering growth 2. Gastrointestinal dysmotility 3. Global developmental delay secondary to cardiac arrest at six weeks of age 4. Epilepsy 5. Unsafe swallow 6. PEG-J fed - inserted in September 2018 7. High gastrostomy drainage 8. Episodes of significant distress on a daily basis 9. History of Inspiratory stridor and recurrent respiratory tract infection - currently on antibiotics 10. Severe dystonia 11. Constipation … Medications: … 9. Dioralyte to replace gastrostomy drainage - average 600ml per day 10. Feeding regimen of Neocate Junior which is concentrated to 1.26 Kcals per ml for the last 7 months- 750ml per day via pump at 37ml an hour for 20 to 22 hours (that would amount to 120 Kcal/Kg per day) Plan: 1. Discuss with parents that her calorific intake looks sufficient generally for growth. However, since there is ongoing faltering growth, we would aim to Increase the calorie content of her diet further (I asked the dietitian to discuss further concentration of feeds). 2. Reassured parents that the symptoms are not suggestive of any calorific loss (no vomiting or diarrhoea) …7. May need an inpatient admission in view of the faltering growth. … She is a two-year and four-month-old girl with the above-mentioned issues. The main issue according to mum has been these intense episodes of distress which continue to be ongoing and is sometimes associated with a worsening dystonia which tends to happen almost on a daily basis. She does not vomit however on days when the gastrostomy is clamped then she does vomit on those days and has worsening of her gagging. Her gastrostomy is generally kept on free drainage except on days when the gagging is better. She drains on average about 800ml per day, which is replaced with Dioralyte via the jejunal tube. She opens her bowels about twice a week and the stools are between type two to type five on the Bristol stool chart. On examination, her weight is 7.7kg, which is below the 0.4 centile and her length is 39cm which is on the 0.17 centile. There is no evidence of faecal loading on abdominal examination. I have discussed with her mum that given that she continues to falter growth, we have increased the calorific intake and that we can do this by increasing the rate of feeding or by increasing the concentration and hence l have asked the dietitian to have a chat with mum.’ 8.26. Shortly after this consultation on 2.7.19 A was admitted to hospital as she was unwell. She had been experiencing apparent episodes at home over the previous few weeks of very low blood sugars, the GP having provided blood sugar testing strips, following M using her own grandfather’s diabetic testing kit to have ascertained this problem. She was found to have low blood sugar on this date (albeit I understand that no lab tests to confirm were undertaken, and that strip tests are considered unreliable). It was thought it might be either metabolic or linked to her brain injury. The dietitian recommended using glyco-juice to raise her blood sugars but this would require gastric delivery and clamping the gastric drainage tube to assist absorption. 8.27. In late June/early July a further video of the pump was taken by the PGM, showing a third occasion when it should have been pumping feed through but was not working properly. This was raised by M at H1 when A was briefly admitted on 4-5.7.19, and again with her community dietitian DM in a telephone conversation on 5.7.19: ‘ Mum also advised the pump does not work well with Neocate so may be contributing to low [blood sugars] and a liquid feed might be better. Advised cannot change feed because of the pump and has had low [blood sugars] even when the pump was working so this is not a factor.’ This was the last time concerns being raised about the pump are documented before the November admission. 8.28. I note at this point that a pre-mixed liquid feed was used (Peptamin Junior) from September to December 2018. However, due to A’s apparent lack of tolerance, the dietitian recommended a change to Neocate due to its easily-digestible formula. Neocate is a powdered feed that requires mixing with cold water so as not to harm its constituents. This makes it highly prone to poor mixing, lumps and sediment. A remained on Neocate until shortly after she was admitted to hospital in November 2019 when her feed was changed to Pediasure Peptide on about 22.11.19 due to suspicions it may have been contributing to tube blockages. 8.29. A’s problem with low blood sugar recurred and she was treated at H1 on 8.7.19. Due to M claiming that A could not tolerate any clamping of the gastric drainage, the advice as to glyco-juice was changed to delivery via the jej port. Low blood sugars were not seen on the ward on 8.7.19. Further low blood sugars led to A’s admission on 9.7.19, with two such episodes on 9 and 10.7.19. By 11.7.19 her dietitian noted that the drainage bag had been removed and A was not experiencing the problems that M anticipated if it was removed, the low blood sugars resolved, her feed was tolerated well without gastric drainage, and during this week-long admission she was generally settled and gained over 1kg in weight. It was particularly notable that A did not experience the drastic symptoms described by M to Dr V only two weeks before at the consultation on 28.6.19. 8.30. The PGM was A’s sole carer from 12-15.7.19. A was discharged on 15.7.19 with a plan that her gastric tube would remain clamped and no further gastric drainage would be implemented. 8.31. There is controversy over the period immediately following this discharge home, which I will discuss in further detail below. But PGM described A as ‘in fine fettle’ on discharge on the evening of 15.7.19, and she then left A to be cared for by M and F. F returned home with A and M to spend the next two days there as was his routine when not working. A experienced some uncomfortable stomach distension that evening, recorded in a video by the parents. M contacted the GP the next morning claiming A had suffered vomiting and reflux due to removal of the bag, and told me in oral evidence that she had vomited on multiple occasions. F does not recollect any issue beyond the distension and considered that A largely returned to the state she had been in before her admission, but not worse. 8.32. M and PGM took A to the GP on 18.7.19, showing videos of distension albeit A was not presenting as uncomfortable at the time of the appointment, and M reported an increase in vomiting. The GP contacted the dietitian DM by telephone during the consultation, who reassured the GP that, as A had tolerated her feed and gained weight without the bag, she should not be put back onto gastric drainage. The GP referred the matter on to Dr V at H2. The GP also prescribed an anti-biotic due to a suspected upper respiratory tract infection. 8.33. M took A to A&E on 19.7.19 due to her concerns regarding low blood sugars, frequent vomiting, distension, pain and claimed that this was due to the drainage bag having been removed. During this same week A had three appointments with physiotherapy, portage and OT who did not report witnessing these concerns. 8.34. M also contacted the Ellenor palliative team liaison nurse for support in this same period, complaining as to the above, which led to an email from the Ellenor nurse to Dr V. Although the exact date is not clear, Dr V then approved the drainage bag to be reattached and the gastric tube unclamped, approximately one week after A had been discharged. By 30.7.19 her dietitian DM expressed disquiet at this change and the situation and noted that A had not gained weight since the bag was reattached, and raised this further with Dr V on 31.7.19. 8.35. On 19.7.19 the first proceedings came to a formal end with no orders, the principal issues having been resolved at the end of May. I note here that for a substantial period of those proceedings a safety plan had been in place whereby a support worker from the LA, predominantly Ms WF, had been assisting M at most, but certainly not all, appointments in order to assist with M’s vulnerabilities, diminish the risks of M’s anxieties and to ensure there was no failure to record or communicate the issues clearly at each appointment. She would attend many planned clinic or home appointments, but not all and not short notice GP or A&E attendances for example, nor assist with the numerous telephone calls or email messages that M made. I have seen her notes of the appointments she attended. Hereafter her involvement ceased. 8.36. An anti-biotic was prescribed for an infection in A’s PEG-J site on 7.8.19. 8.37. On 9.8.19 at a consultation with Dr V, M again asserted that vomiting had taken place with her gastric tube clamped and that vomiting was worse if clamped, and that currently (unclamped free drainage) she vomited at least twice per week. Dr V was sufficiently concerned by A’s low weight and failure to gain weight that he recommended 24 hour feeding at 38ml/hour (amounting to some 1150 calories per day) instead of the 20 hour daily regime. 8.38. On the same date a pH study was undertaken, requiring a naso-gastric probe to be inserted into A’s stomach, and (for some reason that it is not clear to me) M chose to film some of this procedure on her phone and I have seen footage of A with the tube visible down her nose, crying, passing wind then producing a substantial yellowish liquid vomit while lying down. 8.39. On 13.8.19 the Ellenor nurse was conducting a home visit when A became unwell and she advised A should attend A&E due to a suspected chest sepsis (it appears that this term was used by the Ellenor Nurse to refer to chest infection). This led to a short admission and IV antibiotics. 8.40. At a neuro-disability clinic on 29.8.19 and set out in his letter dated 2.9.19 Dr Q raised concerns that A had made no progress since April 2018. M reported as follows: ‘ The mother has on-going concerns about A's Irritability. There are times when she is fine and times when she is distraught. She describes that her legs go in a funny position and go stiff. She feels that A is having cramps and is in pain. She feels that she may also be getting distressed due to the stomach issues and bloating. She feels that A suffers from separation anxiety from her. A spends most of the time either being held by the mother or lying down. The mother is concerned that if she cries she vomits leading to chest infections and a vicious cycle, therefore she does not leave her lying down for long’ and ‘ A has a tendency to vomit often. The mother reports that the frequency of the chest infections has reduced and she is currently having 1-2 chest infections a month requiring antibiotics. She has had 4 Hospital admissions over the last 5 weeks .’ 8.41. In September 2019 B and C’s cases were closed to the LA’s Family Support and Child Protection Team. 8.42. A had a consultation with Dr F on 4.9.19. M gave a history consonant with severe dystonic spasms, pain, and disrupted sleep, and showed some tightness in her leg muscles, which prompted Dr F to promote A to the head of the waiting list for intramuscular botox A injections to rectus femoris and medial hamstring muscles on both legs, which took place under local anaesthetic on 12.9.19, and to prescribe Baclofen (an antispasmodic drug indicated for the treatment of abdominal pain) for general discomfort. 8.43. In late September A’s GP chased up a referral to the Metabolic team at H2 given the ongoing low blood sugar scares. She included in her concerns: why, if A is on 24 hour feeds, is she suffering low blood sugars; and why A has not gained weight over the past 12 months despite being on a high calorific feed? Ultimately this referral never bore fruit before the events later in the autumn that overtook it. 8.44. In late September another GP at the practice also expressed concern that M was using Phenergan (sedative anti-histamine), ‘ for drooling and ?vomiting’ , and asked M to check with the gastro-enterology team at her forthcoming appointment if it did actually help with vomiting and if it risked making A more sleepy. 8.45. To the Ellenor nurse on 1.10.19, M reported that due to increased salivary secretions she had bought Phenergan on the advice of the GP and pharmacist. 8.46. A suffered a further episode of chest infection with anti-biotic treatment in early and again in late September. Then, after attending a second-opinion respiratory consultation at H3 on 7.10.19 and following a vomit on the way there, she rapidly developed breathing difficulties and was admitted with aspiration pneumonia. An abdominal scan ruled out an obstruction as a possible cause of the vomiting. A remained at H3 until transfer to H1 on 13.10.19 and discharged home on that date. 8.47. On 8.10.19 M informed the dietitian DM during a long conversation that ‘ Dr F thinks that [A’s] gut becomes temporarily paralysed due to her dystonia and that is why she is not absorbing ’. DM advised M that A does not show signs of malabsorption (a particular diarrhoea presentation), and that other children with dystonia would still normally grow at this level of feed. M also informed DM that Dr F had mentioned TPN. DM advised that it was a last resort and that if it were tried (by the gastroenterology team) she would only recommend it to provide gut rest for a few weeks due to the many risks. DM stressed that the abnormal gastric drainage and low blood sugars needed addressing to promote weight gain. No concerns were raised in relation to the functioning of the feed pump. 8.48. Due to increasing concerns by a number of the professionals involved in A’s care a multi-disciplinary team meeting was called for by the Ellenor nurse and took place on 15.10.19. 8.49. On 20.10.19 M found her own father (MGF) deceased in his flat. He was her only direct relative and it was clearly an important bereavement. She was responsible for his funeral arrangements, and as the death was sudden and unexpected there was the added strain of a coroner’s inquest, the conclusion of which remains outstanding. 8.50. On 21.10.19 A’s GP raised concerns with dietitian DM about A failing to gain weight over the last year as with a high calorific feed the failure is ‘tricky to understand’. DM responded: ‘I share your concerns regarding her weight gain and hypos and I am also concerned about her drainage. With regards to her weight, she should be gaining weight with the significant increase in calories she has had. M states dystonia as a reason for no weight gain but I have never seen a child with this excess of calories being administered and not gaining weight. I cannot increase the feed any further as she is at her maximum carbohydrate. This was discussed with Dr U. Dr U and Dr V have increased the feed further themselves …’ 8.51. On 4.11.19 A was taken to hospital but examination showed no respiratory symptoms and she was prescribed anti-biotics for an ‘?early aspiration pneumonia’. 8.52. A further set of concerns was raised by A’s GP by letter to Dr F dated 11.11.19: ‘ A was brought into surgery by her mother because in the last 2 weeks she is having episodes of extensive extreme crying which she does not settle to. This is associated with the limbs, in particular the legs becoming very flexed and cont[r]acted or conversely fully extended and rigid. A usually settles by being picked up [by] her mum, but not on these occasions. The episodes can last 15 minutes or hours. It is reported as being particularly bad at night … She has been unwell in the last week with another chest infection, attending PAU at H1 and receiving antibiotics. On review today I witnessed one of these events of intense extreme distress. I have not seen A like this, even when unwell. At time[s] both legs crunched up tightly and other times they were extended and rigid. She appeared to be in distress on me touching her limbs… I am wondering if this is dystonia and if there is anything we can do? Or if this a phase/cycle which will resolve.’ (I note that this was less than two months after the treatment for dystonia provided by Dr F in mid-September.) The GP approved the use of ibuprofen, and not Phenergan as was claimed by M to the Ellenor nurse three days later. 8.53. Dr F replied by email to the GP as follows: ‘Generally a fluctuation in dystonia is secondary to a variety of other co-morbidities. The most usual is Gastro - constipation or reflux. Then Musculoskeletal pain. Then Anxiety / behavioural. I wouldn't necessarily increase background dystonic medication, but simple measures addressing these [other issues] initially.’ By telephone he also emphasised that he felt it was more likely to be due to reflux/constipation/ muscle pain/anxiety than dystonia, and that nothing should be done as he would arrange a review, noting that A was on maximum doses for those issues. 8.54. On 14.11.19 M brought A to A&E claiming A was in pain from increased dystonic episodes over the past two weeks. On observation she was found to be clinically well. M said she had given A Phenergan beforehand as advised by her GP which appeared to have settled her. 8.55. On 19.11.19 A’s GP prescribed anti-biotics to combat another chest infection, likely due to aspiration of vomit. HOSPITAL ADMISSION 20 NOVEMBER – 11 DECEMBER 2019 8.56. In summary: A was admitted to H1 on 20.11.19, and then transferred to H2 on 29.11.19. She remained jejunally fed via her PEG-J (save for a short initial period when additional maintenance IV fluids were provided as feeds were intermittently withheld due to various issues). The pattern of family members’ attendance at H2 was that M would visit from about late morning/lunchtime until about late afternoon/early evening due to her routine with the older girls at home. At all other times PGM was present, including overnight. PGM would often take an extended break during the afternoons when M was present. A significant number of nurses recorded observations of M’s behaviour during this first part of A’s H2 admission. Then on 11.12.19 after two other carers of a child on the same ward reported their observations and shared videos of M and A taken on their telephones, M was excluded from H2 and A’s care from that date. 8.57. On 20.11.19 A was taken to A&E and admitted to H1 with a three day history of lethargy and fever, two vomits the day before, cold hands and feet, irritability. On initial examination by the Specialist Registrar crepitations were reported to be heard in her lungs. She weighed 7.9kg, significantly below 0.4 th centile. 8.58. There is a significant recording by Dr U of her assessment and plan on 21.11.19 as follows: ‘ A was admitted as directed by me because Mum b/c M complaining of dystonia +++ with frequent episodes at least 3 x 1 day and for most nights lasting hours. Mum had procured Phenergan and says she’s administering 20 mls each time in order to “settle A”. She said she was told by the team at [hospital] during her last admission that this is okay to do. Seen by Dr U. Mum previously attended last week Thursday (on my advice) to assess A for the cause of her distress Reg Abd found to be settled in the 4 hours or so that she was in the PAU. On assessing A yesterday, she looked malnourished with prominent spinous processes, lax skin and lanugo hair. No respiratory distress. Hips stable but hip x-rays requested as mum reported that A cries and goes into one of her dystonic episodes. … Examination: Settles and handles ok (no dystonia movements). Nan showed me photos/videos and I do not think these are significant dystonia episodes. Pale, dry lips/tongue, stomatitis. Marasmic and muscle wasting. Lanugo hair on back…. Plan: 1. Continue Abx. 2. Daily refeeding bloods. 3. Continue IV fluids but feeds once PEG/J checked. 4. Abdo x-ray to check PEJ- if in place and no signs of bowel obstruction restart feeds. 5. Stop gastric drainage once feeds started and start strict Input/output chart. 6. Optimise anti-reflux meds. 7. Feeding to go with Dietitian plan and pump should only be accessed by nursing staff and 1-2 hourly during each shift. 8. BM checks twice daily with PRN checks if symptomatic. 9. Daily weight. 10. Review input/output every 6 hours in the next 24 hours as previous concerns with urine output.11. Plan to keep in hospital for 2-3 weeks to allow thorough assessment of feeds and movement problems. 12. Mum gave permission yesterday for staff to video episodes if she is concerned or dystonic. If you capture these episodes they should be sent to and discussed with the neurology on call at H2.

13. Upcoming appointment with Gastro - Dr V arranged. 14. Please run all plans by Dr U in the coming weeks.’ 8.59. On 22.11.19 the Ellenor nurse recorded that M was unhappy about Dr U admitting A to review her feeding as ‘ they are not doing anything different from home ’. M also reported to H1 dietitians that (Neocate) feed occluded the pump tubing often at home and she was concerned that A had not been getting her full feeds. She requested a different feed brand. M and PGM drew a nurse’s attention to ‘dystonic movements’ where A’s left leg was bent and slightly stiff but easily moved. PGM’s own note refers to the pump alarming both with Neocate powdered feed and with an alternative liquid feed, and refers to a change of feed regimen (from this point on A is fed with a pre-mixed liquid feed Pediasure Peptide, other than a single occasion on 29.11.19 when the hospital could not source Pediasure Peptide and Neocate was given as a replacement). 8.60. On 25.11.19 M asked about TPN and was advised that they do not give TPN to children at H1. 8.61. On 27.11.19 the Ellenor nurse visited the ward and spoke to PGM who mentioned that there had been issues with the feed pump for some time. She then spoke by telephone with M to query that she had not been made aware of this by M who said she had liaised directly with the dietitian and Abbott (supplier of pump). I note that M’s last such discussion noted by the dietitian was recorded on 5.7.19. 8.62. M again asked A’s named consultant – meaning Dr U – about TPN on 27.11.19, and asked a dietitian on 28.11.19 saying that Dr U had discussed giving half TPN and half PEG-J feeds. The dietitian repeated the advice previously given that H1 does not treat with TPN. 8.63. On 28.11.19 the nursing records state that A had a settled morning with gastric losses of 150ml to 12.30pm, but that there was a further loss of 380ml at 14.30 when M was present. M reported two vomits by A that afternoon. Nursing staff recorded that A’s feeds appeared to be free-flowing in the morning and evening when M was not there, but that problems arose when M was present and likewise in terms of gastric losses. This was raised with the safeguarding team. 8.64. PGM’s own note refers to ‘alarm going off’ at 7.30pm. It is not clear which alarm (IV/Dioralyte/milk feed/probe monitor) or what problem if any was found when inspected and restarted. 8.65. A was transferred to H2 on 29.11.19 for ‘management of her occluded jejunostomy’ (PEG-J). Her weight remained at 7.9kg. A nurse practitioner assessed her PEG-J on arrival and recorded being able to flush water into the jej port with ease and without any obstruction, and aspirating fluids from the stomach via the gastric port she removed gastric aspirate only with no sign of the water that had been flushed into the small intestine. 8.66. Staff Nurse (S.N.) JC, from whom I did not hear oral evidence, cared for A thereafter on 29.11.19. She reported repeated occlusions occurred shortly after starting A’s feed and Dioralyte which had no clear cause, and when she checked the tubing and flushed it there was no problem. This problem was observed in M and PGM’s presence and with a consultant and registrar. It was then planned to directly introduce a bolus (using a syringe to introduce feed directly into the jej tube) and the nurse reported: ‘ it was decided to give bolus of 30mls milk every hour despite not usually giving bolus via jejenostomy. I tried by gravity first half went through before she got distressed and it came back up the tube. I checked with [the consultant] who was happy for me to give a push a slow bolus over 5 minutes, I started to do this but noticed it went from going easily to suddenly having high pressure, it is as if the tube suddenly got squ[i]shed shut, then back to flowing easily this happened a lot during this feed. A also got very distressed. She then went for an xray, not yet seen the report. The next feed at 19.15 went through with no concerns and I was able to give 10mls flush.’ 8.67. There were no occlusions/alarms noted overnight with only PGM in residence with A on 29-30.11.19. S.N.CBD, from whom I also did not hear oral evidence, was on duty the following day, 30.11.19. PGM was noted to be present all day and M from about 12.30-2pm. S.N.CBD noted: ‘ At approx 13:00 feed pump occluding continuously therefore 35mls given as boluses via syringe. A unsettled whilst feeds given via syringe and resistance felt continuously through feed ?A tensing. Mum reported that she believes that Jej issues are to do with A having inner dystonic episodes. She reports that she feels A tensing throughout feed which is causing pump to occlude constantly.’ 8.68. In PGM’s own note she recorded the pump working intermittently on this day, and that a nurse who had worked in neurology ‘also felt that it could be dystonic contractions that might influence the tube and cause the occlusions’. 8.69. Later that afternoon A had a tubogram, (an x-ray scan following the injection of a contrast medium in order to check patency and position) which showed no blockage and correct position, and both the contrast beforehand and flush water afterwards were introduced easily. The surgical team concluded that there was no mechanical issue with the jej feeding tube. 8.70. Again there were no issues with alarming or occlusion recorded overnight with PGM only in residence 30.11.19 to 1.12.19, nor during the morning of 1.12.19. M arrived at about 12pm on 1.12.19 with Child C. 8.71. S.N.CBD noted that from about 1pm A’s feed pump was continuously alarming saying ‘occlusion’ and she queried whether A’s apparent ‘dystonic episodes’ were causing it. She described A as in M’s arms at the time and so repositioned her onto the bed in the way she had been lying in the morning when there had been no problems, but the occlusions continued even with the removal of Dioralyte from the mix, and so a decision was taken to start IV fluids instead of feed and restart the ml for ml fluid replacement (Dioralyte). 8.72. Again there were no issues overnight with the feeding system alarming while PGM was resident 1-2.12.19. A was prescribed Alimemazine (a sedating anti-histamine) from the morning of 2.12.19. M arrived at about 11am/12pm. 8.73. S.N.AdAd (from whom I did not hear evidence) noted that: ‘ Losses of 612mls by 1700 this afternoon. …. Mum arrived at 1200 and sat in bed with A and since mum arrived pump was alarming frequently through the day due to blockage. … Mum stated that she thought beeping and blockage was due to spasm in muscle from being dystonic.’ 8.74. This led to A being reviewed that afternoon by the paediatric neurology team and Dr S recorded: ‘ In regards to her dystonia mum reports worsening over the last 6 weeks with frequent periods of leg flexion at the hips, knees and dorsiflexion of the feet associated with distress and crying. Mum reports that these are happening several times per day with no obvious triggers. However, mum feels that when feeding is stopped (A is on 24 hours jejunal feeding) then dystonia might be less’. 8.75. On the same day, 2.12.19, S.N.FA told S.N.AdAd (who recorded S.N.FA’s account in her own note as she was the nurse charged with A’s care on 2.12.19) that a concerned parent on the same ward had seen M behaving suspiciously: ‘ Staff nurse [FA] reported that parent opposite bedspace from A stated that she was unsure if mum was doing anything to the child as she saw mum with syringes of water pumping it in A. Earlier on in the shift there was a pool of water under A's bed which unsure where is came from.’ . This was clearly very concerning and it was reported to the Nurse In Charge, but does not appear to have gone any further as it should have done. S.N.FA also told the court that the alarming was constant every few minutes over hours. 8.76. A kink in the tube was also noted by the nurse on duty and drawn to the attention of a Dr D due to it appearing as if it had been deliberately squeezed. He noted finding it in the tubing and that it was odd. 8.77. In PGM’s own note she recorded that the ‘pumps alarming all pm and evening.’ On the evening of 2.12.19 at about 6pm A was moved to Beach ward from Mountain ward, and there were again no issues raised as to alarms overnight while PGM was in sole residence with A 2-3.12.19. 8.78. On 3.12.19 large gastric losses of 783ml over the previous 24 hours were noted at the morning ward round. M then attended hospital at around 11am and S.N.PMDC noted that the pump kept alarming both in the period before A went to theatre as her PEG-J tubing was replaced on the afternoon of 3.12.19 under general anaesthetic, and within about an hour of starting her feeds on her return, alarming every few minutes but without any visible dystonia. The nurse saw nothing to explain the alarming despite checking. 8.79. S.N.PM came on duty for the evening shift at 7.30pm, and M was still present to stay later than normal due to A having had surgery that afternoon. The nurse said that the pump was alarming when she came on shift and occurred repeatedly. She would check and restart, and then it would alarm again as she walked away from the bedside; it did not occur when she was at A’s bedside. M told the nurse that she thought the occlusion problem would have been fixed by the new PEG-J insertion that day, and mentioned dystonia as causing cramps that were responsible for the occlusions. 8.80. During a conversation with the hospital dietitian M claimed that the community dietitian team (DM) had recommended TPN for gut rest. 8.81. Again no alarming was noted overnight when only PGM resident 3-4.12.19. 8.82. At a review by the gastroenterology team on 4.12.19 M again asked about TPN and it was explained that it was still too early to consider this option. High gastric losses continued to be noted and a plan to replace losses was in place. Figures for that day later showed input of 793ml but gastric loss of 955ml. The hospital dietitian attending with the gastroenterology team noted that there were no reports (it is assumed she was referring to nurse reports rather than M’s) of increased dystonia when the pump was alarming. 8.83. S.N.NK was on duty on 4.12.19. M and PGM raised concerns that A had been dystonic and that this was causing the repeated alarms on this date. The nurse could find no cause for the occlusions, but at one point in the afternoon M claimed that A was dystonic and the nurse saw A’s left leg flexed at about 45 degrees with her left foot slightly bent in. She noted that the pump alarmed only when A was lying on M. 8.84. At a neurology review M claimed that despite the Alimemazine leading to less spasms and vomits and better sleep, that there were still times when A was showing more marked dystonia and she linked that to the blocking of the jej tube. This review led to A being started on Gabapentin (an anti-convulsant, anti-spasmodic drug that can also be used to treat neuropathic pain or epilepsy.) 8.85. In PGM’s own note she recorded the ‘ alarm going off again every 30 secs on av for 4 hours, kept tally’ . Again, after M left the ward no alarms are noted overnight with PGM resident 4-5.12.19 and S.N.NK noted no signs of dystonia in A. 8.86. On 5.12.19 A was transferred back to Mountain ward. The pump was noted to alarm an unspecified number of times during the period that M was on the ward. M reported to the nurse that she felt A was holding her breath. 8.87. On this date A’s medication to ease reflux, Omeprazole, was changed to Esomeprazole. The latter is an isomer of the former, chemically identical, but delivered in a different form, namely soluble granules instead of a liquid. 8.88. Again no occlusion alarms were noted overnight on 5-6.12.19 with only PGM resident. A had an apparent low blood sugar episode overnight but when the bedside test was checked by a laboratory blood test it did not show hypoglycaemia. 8.89. Events on 6.12.19 were significant. S.N.FA reported to the safeguarding team that she had seen M fiddling under the blanket over A and found the tubing to be clamped or kinked on numerous occasions following repeated frequent pump alarms for occlusion, and disconnecting the tube to allow it to run briefly into a tissue. She had a telephone call with Safeguarding Nurse Specialist BM who recorded that S.N.FA informed her of observing M removing a syringe from her clothing and inject something into the PEG-J, the occlusions and kinking issue and the disconnection issue. S.N.FA was asked to discuss with M that she was not to disconnect tubing or alter the pump, and that A should be nursed lying in her bed rather than in M’s arms under a blanket. An action plan was put in place that M was to be closely observed with visual contact on A at all times, inspection of the tubing if there was an occlusion, all witnessed concerns to be documented and a record kept in relation to any occlusions: time, attendees, A’s position, outcome. 8.90. Following her first call to BM, S.N.FA recalled that A was moved to a bed closer to the nursing station and she gave M clear advice as directed. She said that M was unhappy that A was in bed by herself and that M was blaming dystonia for the problems. She observed a kink in the tubing and asked a member of the gastroenterology team to inspect it. 8.91. A was moved to Savannah ward from Mountain ward in the late afternoon and the nurse handover took place from S.N.FA to S.N.NH. On Savannah ward S.N.SP noted frequent alarming which puzzled her as there was no obvious cause on inspection. M referred to there having been issues with the pump on Mountain ward and a log kept, and that M explained that it was A’s dystonia causing the problem as it made A tense her stomach which blocked the milk flowing in. She pointed to A’s legs and asked the nurse to observe as it was dystonic, but S.N.SP saw her legs had low tone and did not appear dystonic. 8.92. During the evening S.N.NH was on duty and in the period before M left the ward (about 6.45-7.15pm) the nurse could not find any cause for the occasions when she noted the pump had alarmed. 8.93. Later that evening S.N.FA reported to BM that she had witnessed clamping and kinking by M and that she had seen M lean her elbow on the tubing. In light of directly observed interferences BM contacted the Lead Nurse Safeguarding Children and the LA’s OOH Social Care duty team. A letter was sent to Social Care by a member of the nursing team: ‘ It has been reported that on 06/12/2019, when A was on the paediatric general ward another parent in the bed opposite reported she witnessed A's mother getting out a syringe out from under her shirt and injecting something to the PEG/JEJ. Nursing staff report that when mother is present on the ward the feeding pump continually occludes which is not reported when mother is not present. Today (06/12/19) she was witnessed by nursing staff to be disconnecting the feed and allowing it to run into a tissue. In addition, she was reportedly witnessed to clamp the line, kink the line and apply pressure with her elbow This was raised immediately with our safeguarding team’. 8.94. No occlusions were noted overnight after M left and when PGM was resident with A on 6-7.12.19. There was a low blood sugar alert which resolved on later checking. 8.95. Events on 7.12.19 were also significant. S.N.ST noted two occlusion alarms first thing in the morning when PGM was sole resident with A. One was the IV line which was caught in A’s bent arm and the other was the Dioralyte line that was found to be coiled into a kink and the nurse straightened it out. 8.96. M arrived on the ward shortly after noon. The feed pump occluded once before PGM left the ward at around 1pm. Between then and M’s departure that evening at some point after about 5pm there were repeated feed pump alarms. S.N.ST repeatedly noted a kink mark in the same area of the tubing that was under the blanket in the section nearest to A’s body. She also saw M replacing her hand under the blanket then removing it as soon as the pump alarmed. She saw M appearing startled when she and the student nurse went over after one observation of M kinking the tube, and M covering the tube lines with the blanket despite after each tubing check the nurse placed the lines over the blanket so that they could be seen. She also stated that she noticed M actually kinking the tube with her hand which prompted an alarm, and on another occasion saw M hold the Dioralyte line down behind the bedside rail – then when the pump alarmed M moved her hand and the nurse saw a visible kink where M had been holding the tubing. She was clear that there was no sediment in the tubing and would not expect it with this feed and so she was surprised that M claimed to have been clearing sediment. 8.97. S.S.N.EDC assisted from time to time as the pump alarmed so often and found no explanation on checking the lines. She too encouraged M to leave the lines visible above the blanket to see if anything was wrong and said that M could have been in no doubt about this request, but it would only last a few minutes before M would cover the lines over again. S.S.N.IBE also observed M put her hand under the blanket near where PEG-J tubing was and seconds later the alarm sounded. Then when S.N.ST stood up to attend to the alarm she (IBE) saw M remove her arm from under the blanket. S.S.N.IBE also sat with M and A for half an hour to chat after dealing with a feed pump occlusion alarm at around 2.30pm, during which time M’s hands were visible and there were no occlusion alarms. 8.98. Between 12-2.20pm A’s gastric losses amounted to 675ml. During this period a student nurse working with S.N.ST saw M repeatedly move her hand in and out of her top, and both S.N.ST and S.S.N.IBE observed M unscrew the gastric bag and hold it out to the side. S.N.ST noted that at 2pm she measured a gastric loss of 310ml, then recorded that at 2.10pm she aspirated the PEG-J gastric port (that is to say, she used the suction from a syringe to withdraw any stomach contents) and obtained only 2mls of fluid. She recalled in oral evidence seeing M massaging A’s stomach. Ten minutes later at 2.20pm, after she had returned from drawing up medications in the drug room, the bag contained a fresh gastric loss of 365ml. S.N.ST also noted M applying pressure to A’s stomach at around 4.20pm and when she saw she had been noticed she stopped and asked the nurse to vent her stomach using a syringe (via the gastric port). S.N.ST went to fetch the syringe and at that point the pump alarmed and on uncovering A to check the tubes the nurse saw that the jej tubing clamp was closed, therefore blocking the tube. There was neither aspirate nor air on attempting to vent with the syringe. 8.99. S.N.ST also recorded that M had been asking several questions about TPN and stating that it was her opinion that this was the best option for A. 8.100. No events or alarms were noted that evening and overnight when solely PGM was resident with A on 7-8.12.19, other than a low blood sugar which had recovered on rechecking later, and an IV pump alarm as it was the end of the infusion and not an occlusion. 8.101. M attended the ward at 12.30pm on 8.12.19, and PGM left at 12.50pm and was recorded as being absent until about 4pm. The same pattern was observed as on previous days with numerous inexplicable pump occlusions. S.N.SP noted a kink or dent in the tubing, and S.N.XG heard a click like a clamp being closed as she approached the bed on one occasion. Both noted repeated fiddling by M’s hands under the blanket. Once PGM had returned to the ward S.N.XG sat and chatted with the family for about 1 hour from 4-5pm and recorded times in the record that was being kept of significant events. No alarms were noted during this period. Shortly after 5pm she recorded M removing the blankets from over herself and A and she left the ward at 5.30pm. 8.102. S.N.XG also recorded that after draining gastric losses each hour at between 12mls and 80mls of a pale green aspirate that had a pH of 8-9.5, at 2.45pm it was suddenly full within a few minutes of her last having looked at it with 200mls of a much paler, clearer liquid that was not body temperature nor room temperature but cold to the touch. She tested its pH which was 7. She said she had never felt a gastric loss liquid that cold before. She noted that M had a cold drink in bed with her, and that may have been lying in the bed near the drainage bag. 8.103. From this date, 8.12.19, there were no longer any pump occlusion alarms. M’s suggestion to explain this is that the Gabapentin that was prescribed on 4.12.19 had worked in stopping the dystonia stomach spasms that she had said was the cause of the blockages. M claimed that the neurologist had told her that it would take a few days to work. 8.104. Again no events or alarms were noted that evening or overnight or the next morning while PGM was the sole resident 8-9.12.19. M arrived on the ward at about 11am, and PGM left for her break. The time PGM left is unknown although it is likely to have been after 11.45am when she is noted to be present during a gastroenterology ward round and before 1pm when M is noted as the carer present on the significant events record sheet from 1-4pm. PGM is noted to be back on the ward by 5pm on the same document. 8.105. S.N.KS recorded having seen M moving her hands around under the blanket and repositioning a large white drinks cup so that it was near the drainage bag and then put the blanket over it all. She also noted the following: ‘ A mother in the opposite bed mentioned that A was very cute but small, and that she saw mum be quite rough with her, I asked if she saw anything but this mother only mentioned she'd seen mum squeeze A's stomach and nothing else ’. (As will emerge later in this judgment, this mother is likely to have been lay witness Y.) 8.106. S.N.AA noted an unusual pattern of gastric losses with 56ml draining from midnight to about 11am and then once M was on the ward until she left at about 5.30pm the gastric losses reached a total of 560mls. The initial aspirates from the morning were yellow/green and pH of 8, whereas a large loss that M drew the nurse’s attention to was clear and appeared fizzy with a pH of 7. Ward Sister AS was shown this bag of gastric aspirate by S.N.AA and confirmed its appearance with bubbles in the bulk of the liquid not simply at the surface. 8.107. That afternoon Ward Sister AS noted M removing the drainage bag and AS then reattached it. She also noted repeated hand movements under the blanket. She removed the blankets when she became concerned that M had seemed to remove something from her top and hold it under the blankets. She did not see anything however. This was also observed by S.N.AH who documented it. Her evidence expanded on this to recall that she observed what looked like a screwing action under the blanket. 8.108. Again PGM was the resident carer overnight with M leaving shortly after 5.40pm, and no particular events were recorded overnight 9-10.12.19. 8.109. M arrived on the ward at about 12.30pm. S.N.AA recorded M moving an object that seemed to fit in her hand from behind her, and down in front of her leg. A’s observations monitor then alarmed and M appeared flustered and red in the face when the nurse removed the blanket to check the probe was still in place. A similar moment of M appearing flustered was noted by Ward Sister AS who walked around a corner to the bed space and saw M appearing to remove something from her top, some sort of purposeful movement from her jumper then her hands went back down by her sides. 8.110. An important observation was recorded by S.N.ELB who, in addition to seeing M fiddling her hand under the blanket covering A, also saw her squeezing A’s stomach hard. Her description was of both hands, one at each side of the stomach with fingers at the back and thumbs in front, with a strong in-out squeeze with the fingers and thumbs, which she said stood out because it seemed strong and A was tiny and it was over the top for a child of her size. 8.111. Slightly later that afternoon S.N.ELB recorded as follows: ‘ Myself and another nurse [S.N.AH] in the bay witnessed mum place her hand under the blanket and it looked like she was doing something underneath it. She then used her other hand over the blanket and it looked like she was unscrewing something. She then did this again a few minutes after. She said to the nurse she was letting the air out. - 15:27 I witnessed mum put her hand under the blanket and fiddle with something underneath it while A was laying on her chest. She then pulled her hand out and looked like she put something in her jumper. She then took the blanket off and placed A back in the bed. The drainage bag is now nearly full with clear fluid.’. She confirmed that the fiddling she saw here was down M’s left side and A’s right (A lying on M) where the drainage bag and tubing were, and she thought it was strange for M to be keeping a cup in bed with her. 8.112. PGM was then noted to arrive at about 15.40. Again no notable events occurred with PGM in sole residence with A overnight on 10-11.12.19. A was noted by both S.N.SB and S.N.ELB to have had a large bowel movement on the former’s night shift. This is also remarked on in PGM’s own note as A having had a ‘ good poo’ . (This is relevant to M’s answers in her police interview that her actions were partly explained by a need to hydrate A due to constipation.) 8.113. A professionals’ meeting was convened by the LA at H2 on 11.12.19, where it was considered that M was intentionally blocking A’s feeding tube and concerns were raised about lack of weight gain. A’s weight was 8.08kg. 8.114. M arrived on the ward at 12.20pm and S.N.ELB noted M to immediately cover A with a blanket, with A on her chest in bed. By about 12.50 PGM had left the ward. 8.115. Four nurses each record observations of M on 11.12.19. S.N.SB noted M moving her hands under the blanket, although not suspiciously in itself but she was looking to see where nurses were while doing so. S.N.NH noted M’s hands moving under the blanket, with what appeared to be one hand moving and the other still, and that she kept looking over to the nurses desk, looking back and away repeatedly. 8.116. S.S.N.ZS noted M to have an empty 500ml clear plastic bottle which she would fill and then pour into a paper cup, and was constantly fiddling with the cup moving it back and forth between hands, bed, bedside table. In the afternoon she noticed constant movements and repositioning of the bag, the blanket, the tubing. At about 2.35pm she saw her unscrew the drainage bag with one hand, and described that as extraordinary behaviour. At another point in the afternoon she saw M give A four or five short squeezes to her stomach and explained that you would not need to prod with such force to vent air from A’s stomach, but also noted that there was no reason for this as she saw this take place within 10 minutes of S.N.ELB having removed the bag and emptied the contents which would have vented air already in any event. 8.117. S.N.ELB was A’s allocated nurse and noted a number of issues that afternoon. She noted that when there was no one else in the bedspace M continued to have a hand under the blanket and appeared to be fiddling and screwing/unscrewing, that she appeared to have a small solid object the shape of which was sticking out under her jumper, that she wanted to know the amount of gastric loss, that she handed the drainage bag out from under the blanket to the nurse (therefore already disconnected) and also indicated to the nurse which of the two ports (of a Y connector) the nurse should reattach it to. 8.118. Her note entry for 1.53pm recorded a gastric loss in the bag of 140ml of clear liquid, which she saw was also in the PEG-J extension (the tubing leading to the gastric port) whereas in the morning that liquid had been yellow/green. At 2.20pm she saw there was again a lot of fluid, 170ml, being clear with a slight green tinge. 8.119. Shortly before 3pm she requested that the blanket come off A as she had a slight temperature, however M put it back on shortly after. On removing it again the nurse saw that the drainage bag had again got clear liquid in it. Shortly after 3pm M was observed to have sat up and forward which slightly obstructed the view from the nursing station, but the nurse saw M continue to fiddle, to pick up and inspect the drainage bag and frequently look down at it. By about 3.45pm M asked the nurse to empty the drainage bag or it would start pulling (with its weight). It held 270ml of clear fluid with a slight yellow colour. 8.120. Shortly before 4pm S.N.ELB saw M squeeze A’s stomach three times ‘very hard’ in a row. And shortly before 5pm the nurse again emptied the drainage bag of 220ml. M commented on the gastric port smelling strange and the bag contents being ‘fizzy’. On returning to replace the bag she noted that the gastric tubing port was wet and M replied ‘oh the cap must have come off’. 8.121. PGM arrived at about 4.10pm and M left at about 5/5.30pm and no further large aspirates were noted from the drainage bag. S.N.ELB’s note then records: ‘ Written in retrospect of the past 30 minutes events: - I had been away from the bedspace with Safeguarding Nurse BM discussing A. I came back to the bedspace around 17.45 and was handed over from the other nurses in the bay that mum had left at 17.30. I went over to drain what was left in the bag as it was still the clear fluid. I used a 60ml syringe to drain the bag as there was only a small amount in there (15ml but amended to 24ml in subsequent note). I entered the sluice with the syringe and was followed in by the grandmother of a patient in the bedspace opposite A (Bed 30). She disclosed to me that she had been watching A's mum all day and had seen her use a syringe to give things to A. She also told me that she had recorded her doing this on her phone. She showed me her phone and has multiple videos that she has taken today. The one video she showed me showed A's mother clearly with a syringe in her hand giving something to A through her PEG. The video shows me then approaching the bedspace and A's mum hiding the syringe in her jumper. I said to her that I would have to tell someone about these videos and it is likely that other people will need to come and look at them. I then informed Safeguarding Nurse BM and Matron...’. This grandmother is witness X. 8.122. This is also reported by X to another consultant Dr K the same evening. The short phone videos were shown and forwarded at about 7pm to Safeguarding Nurse Specialist BM. 8.123. In brief: Video 1 – 59 seconds – M has A in her right arm facing over her right shoulder. With her left hand she is using a syringe to introduce a fluid into the gastric port tubing, placing the syringe into her waistband, removing it again some 20 seconds later, filling the syringe from a white cup tucked next to her leg, and introducing more fluid before again returning the syringe to her waistband. M looking left and right. Then S.N.ELB returns with an empty drainage bag. Video 2 – 19 seconds – M and A similarly positioned. M using a syringe to introduce fluid into the gastric port tubing, and placing the syringe into her waistband. M looking left and right. S.N.ELB again returns with an empty drainage bag. Video 6 – 40 seconds – M sitting up with A on her right shoulder, first squeezes A with one hand and picks up the drainage bag to look at it, then squeezes A twice with both hands and looks down at the bag. PGM sitting in the armchair to the left and behind M and A. M looking around and particularly towards the nursing station. Videos 3 & 4 – showing M, PGM and A – chatting, M handing over A to PGM. Video 5 is of poor quality, similarly showing M and A. 8.124. Witnesses X & Y provided both police and witness statements and oral evidence that will be discussed in more detail later in this judgment. Neither witness had any concern regarding PGM who they described as loving and attentive to A. Both denied having any motive for reporting what they had seen, and denied having been aware of the range of concerns that had been recorded by the nurses or held by the clinical team. In summary: - X described seeing the actions of M using a syringe to insert fluid into the gastric port numerous times, 20 times at least. She regretted not having filmed it earlier in the afternoon when she described it as ‘rampant’. Earlier in the afternoon, for 2 hours before the videos when no one was there with M, she was doing it more often, at times continuously. X was shaking and scared and felt sick to her stomach. She saw M squeezing A’s stomach some 6 to 8 times and afterwards examining the bag to see what was coming out. It was not massage but squeezing using thumbs on one side of her body and fingers on the other. She explained that M did not do it when PGM was there with her, and seemed to ask PGM to run errands to get drinks for her in order to get her out of the way, when she would then do it. She showed the videos to a nurse and to Dr K who expressed that she was glad the footage had been taken. - Y saw M squeeze A’s stomach really hard 3 times and she filmed that. Then she saw M check the drainage bag a lot. She explained that X (her own mother) had been watching more than she had. She recalled seeing clear liquid in the syringe earlier but thought she had seen a darker coloured liquid like cola later on. Y was not aware that the nurses were watching M. She recalled an odd conversation with M two days previously and had drawn the curtain around her child’s bed due to the stress of dealing with his degree of illness and not wanting to have personal discussions. She also recalled a discussion with a nurse about M two days beforehand. 8.125. PGM was in residence overnight 11-12.12.10 and no incidents were noted. 8.126. Late in the evening on 11.12.19 a strategy meeting took place at H2 and a joint section 47 investigation was initiated. On 12.12.19 a medical review took place. M was arrested and interviewed by the police. PGM left H2 after a late afternoon telephone call informing her of M’s arrest. Children B and C were placed with the maternal step-grandfather and his partner. 12 DECEMBER TO HOSPITAL DISCHARGE 8.127. A’s care was hereafter undertaken by hospital staff until she was discharged into foster care on 20.1.20. 8.128. Her weight fluctuated slightly in the first week of this period from 12-18.19, varying from 8.8kg on 12 th and 8.9kg on 13 th, down to what may be an aberrant weight of 7.9kg recorded on 15 th , followed by 8.75kg on 16 th and 8.45kg on 17 th . But from 18.12.19 at 8.8kg she followed a constant and rapid upward trajectory and reached a weight of 10kg on 13.1.20. An increase of 2kg in just over a calendar month. She was 10.2kg on discharge from hospital on 20.1.20. 8.129. Her gastric losses fluctuated over the almost ten days from 12.12.19 before settling into very low double digit figures from 21.12.19. Her gastric port began being clamped on 18.12.19, and was increasingly clamped thereafter during this period, until the losses were so low (within a normal range) that gastric feeding could be retried. Over the three days to about 6.1.20 A was successfully switched from being jejunally fed to being entirely gastrically fed. 8.130. By 3.1.20 the nursing staff reported: no concerns with secretions/drooling, no suctioning required, no saline nebulisers required, no chest physiotherapy required, no sleep disordered breathing, and that A had an effective cough. 8.131. An H2 physiotherapy and OT assessment was carried out through December and January (report dated 22.1.20) during which assessment sessions the therapists saw some extension but no dystonic symptoms and found it possible to encourage A to use and enjoy her chair for up to 2 hours and various therapeutic exercises. They commented that her presentation was very unlike that reported to them by the community therapists. 8.132. During this period and by the end of her admission on 20.1.20 A had the following prescribed medications ended on the following dates: - Buscopan – 23.12.19 – for stomach cramps/gut spasms - Melatonin – 23.12.19 – regulates hormone to encourage sleep - Salbutomol inhaler – 23.12.19 – for respiratory distress/wheeze - Clenil inhaler – 30.12.19 – also for respiratory distress - Azithromycin – 30.12.19 – prophylactic anti-biotic for chest infection risk - Alimemazine tartrate – 30.12.19 – sedating anti-histamine - Gabapentin – 30.12.19 – anti-spasmodic, anti convulsant - Glycopyrrhonium bromide – 30.12.19 – to reduce secretions/drooling - Baclofen – likely stopped on 1.1.20 (although there is a queried reference to doing so on 13.1.20) – anti-spasmodic, muscle relaxant - Midazolam – 20.1.20 – for seizures - Suction machine & Saline nebuliser – (unused during admission and so not replaced on discharge) – also for respiratory distress. 8.133. Alarms sounded on three occasions: on 15.12.19 a monitor alarm but unrelated to the feed pump which was functioning normally; on 24.12.19 the feed pump alarmed stating ‘occlusion in’ where it was an issue between the bottle and the pump as the feed had come to an end; and on 5.1.20 during F’s contact when the feed bottle tilted causing air to enter the line. 8.134. Each parent had supervised contact with A over this period, with a supervisor from an external agency. No concerns arose in relation to F’s contact. And PGM telephoned regularly to ask for updates on A’s welfare and progress. 8.135. M’s contact on 17.12.19 was uneventful. On 20.12.19 M had contact from 12-2pm. It took place in a side cubicle due to A having loose stools (gastroenteritic infection). A’s drainage bag was removed for the contact and her gastric tube was clamped, and she was clothed in a babygrow. On entering the room M drew the contact supervisor’s attention to a loose syringe that was lying on the floor under the bed. A nurse was asked to remove it. M asked to bathe her and the nurse attended to assist with this but A was too upset for it to proceed. A was undressed and weighed and redressed. The nurse was present for this exercise as was Ms O the contact supervisor. M played games with A and the OT attended to try A in her seat. At the end of the contact S.N.SM noted that one of the gastric port caps was open where it had previously been closed. The gastric loss taken at 6pm that day was 153ml and a dark green colour. Total gastric losses for this day amounted to 404ml and this issue is discussed further below. 8.136. M’s contact on 30.12.19 was uneventful. On 3.1.20 M was noted to express concern that A was ‘chesty’ and very ‘dribbly’ and that the hospital should restart her medications for this. These symptoms were not noted by the nursing staff that day, although A had been recorded as being coryzal and having a chesty cough a few days before on 28-29.12.19 although the doctors assessing her found no respiratory distress, no compromise to respiratory drive, no temperature, nor increased work of breathing. 8.137. On 13.1.20 M’s contact took place from 10.30am to 1pm. Shortly after 11am M asked S.N.IBY if she could take A out of her chair and the nurse removed the straps and checked the tubing extensions as she lifted her out and passed A to M. Within a few minutes (recorded as three minutes) M and the supervisor triggered the buzzer for a nurse and S.N.AA attended as M and Ms O had seen that there was dampness on A’s clothing and milk leaking. The tubing was checked and the PEG-J tube (presumably the jej tube) was found to be unclamped and leaking some of the milk from within the tube. This issue is discussed further later in this judgment. On asking for an update from S.N.IBY afterwards, M mentioned that she felt A was stiffer, more dystonic and doing more intense movements, and was dribbling excessively again. This was not observed by nursing staff. 8.138. During this period after exclusion from the ward, M claimed to the SW that she had been instructed to carry out flushes every 4-6 hours and claimed to the Children's Guardian that A’s poor weight gain was due to chest infections. The dietitian DM confirmed that her last advice prior to A’s admission was for flushes before and after feeds (therefore the jej tube, but that as A was on 24 hour feeds this would not be necessary), and with medication. 8.139. At a multi-disciplinary team meeting and LAC review on 13.1.20 the following was noted by the dietitian DM: ‘ Mum reported that she is pleased with A's progress but that she was making progress prior to her being arrested. She reported that A gained more weight in her care in hospital than she has after. She reported a new drug was started prior to her being arrested which has made the respiratory changes. Did not name drug. Mum reported that A has had a couple of hypos during this admission and she is being referred to GOSH for investigation. Mum reported A is still having spasms as medication has been stopped. Reported on full gastro feeds with ? 8 hour break. Mum reported that they wanted to try these treatments before such as blended diet but were not allowed. ([I] did not mention this was due to the excessive drainage which resolved out of Mum's care).’ SUBSEQUENT PROGRESS 8.140. The Children's Guardian visited A in foster care on 12.2.20 and noted the following: ‘ When I arrived, A was initially sitting in her specially adapted seat, but was also seen playing on the floor. She was happy, laughing and smiling throughout the visit. This was a very different presentation to the one that I had seen at home in the previous proceedings, when A was often distressed or sleeping in her mother's arms.’ 8.141. She additionally noted in relation to A’s health: • A has put on 2kg since being placed in foster care, as well as 2kg in hospital, bringing total weight to 12.7kg. • No chest infections • No use of suction • No feeding tube blockages • No feeding tube alarms • Tube feeding reduced from 24hrs to 15 hrs per day [feeds orally 2x day] • No signs of dystonia, feet and right arm/hand relaxing • Sleeping well through night; rarely sleeps in day, save short naps • No seizures • No vomiting • Medication being reduced • No on-going concern about blood sugars so no regular testing needed • A’s medical team shocked at her progress and health improvements. 8.142. On 14.2.20 A’s PEG-J was removed and replaced with a PEG button, so that it no longer includes the tubing that extends through the pyloric sphincter into the small intestine, but simply into the stomach. 8.143. Following a clinic appointment with Dr U on 6.3.20, Dr U wrote to A’s GP: • “I was beyond pleased to see A in clinic today and was astounded by how well she looked and not just with her general weight gain, but also with how remarkably developmentally different and interactive she was, compared to the last time l encountered her on the ward.” • She has made “remarkable progress with her weight” (13.27kg – 34 th centile) • No seizures have been noted. • The foster carer has not noticed any dystonic movements or abnormal posturing. • She can hold objects • She is babbling and can play • Her sleep is good- she sleeps through the night • There are no concerns with bladder or bowel function • She looked very well on observation. • No dystonia or abnormal posturing when examined. And at this clinic Dr U ended the prescription of Domperidone (anti-vomiting). 8.144. By 5.6.20 all gastric feeds had stopped and A has since fed entirely orally. Water continues to be given via the gastric port due to A’s difficulties and/or aversion with swallowing. 8.145. A’s weight reached the 75 th centile at 16.1kg by mid-July 2020. Twice her weight of 8 months previously. Her intake has even had to be monitored and modestly reduced in order to ensure that she does not now gain too much weight. 8.146. As at this mid-July 2020 the only medications in use are Movicol (if required to ease constipation) and Esomeprazole (used to treat reflux). 8.147. I have seen recent videos of A in foster care where she is clearly physically active and responsive, understanding the words and encouragement of her foster carer to engage in various movements to strengthen and use her legs in her walking frame, babbling, and ‘chatting’ back. I have heard the evidence from the F in which he delights and marvels at A’s progress, clearly moved at her abilities: completing rhymes, trying out words, ’wonderful changes’ . It is truly a remarkably and astonishingly different presentation than the videos and images I have seen from 2019.

9. THE FAMILY MEMBERS 9.1. MOTHER 9.2. FAMILY – I do not doubt that her children and family have been the centre of M’s life since her first child C was born and there are many important positives to note. I have seen the delight and affection shown by M, B and C in a video clip of their first meeting face to face again with M and with A after the initial lockdown period that prevented direct contact. The older girls’ cases were stepped down to Children in Need in summer 2019 and no concerns were noted until the incidents of December 2019. I note the evidence of the contact supervisor Ms Ola as to the emotional care she observed during supervised contacts with A in late 2019 and early 2020, and the positive observations of M’s supervised contact with the older girls noted by the LA throughout 2020 until supervision passed to F and PGM in the late summer. M has attended all contacts save those that clashed with other significant commitments. The foster carer reports M’s keen interest in A’s welfare and progress. 9.3. I have not heard evidence from the social workers as to the children’s presentation and relationship with M, due to a combination of their evidence in relation to M and her relationships being largely uncontested and less directly on the contested allegations I have to decide, and lack of time to do so. Nonetheless I have taken into account all the various positive observations brought to my notice on M’s behalf as to her conduct during contact, commitment and affection with the children and note these positive factors to her credit. She has also expressed appropriate gratitude, which is not always seen, for the care provided by F, PGM and the foster carer to her daughters. 9.4. I have no doubt as to the devastating impact on M and the family of A’s ALTE and consequent developing picture of her disability and many medical needs, not simply emotionally devastating, but also with profound practical implications in terms of meeting A’s complex needs. 9.5. On top of that, in 2018 M was the focus of intense child protection concerns preceding and during the previous care proceedings which included an examination of whether or not A had been subject to an intentional asphyxiation or had suffered an accidental hypoxic collapse. As discussed above this led to a conclusion of an accidental ALTE in A, and M admitting to a risky level of anxiety in relation to child B in May 2019. Then in October 2019 M’s father died suddenly, leaving her to deal with the consequential responsibilities and emotional impact. I do not underestimate the combined stresses of these series of events. 9.6. To M and the family’s great credit, notwithstanding all of that, there has been active and enjoyable family life in the form of, for example, riding lessons, park walks, playgrounds, allotment gardening, children’s parties, and sensory groups and water play therapy for A. I have seen a delightful scrapbook made by M showing a number of these fun activities, and a video showing the girls enjoying each other’s company with A laughing in bed while her sisters are playing around beside her. 9.7. M has been all three children’s principal carer throughout, and has been assisted by F and PGM in meeting the demanding routine required to care for A. I have seen a timetable that was created showing when F and PGM were also attending her home to help. This will be discussed further later in this judgment. In general terms, one or other of them was on hand most of the time to help during the days, and F was also there overnight on the three nights of the week when he was not working. It is quite clear that A’s care was a dominant element of every day and that she had numerous appointments, both planned and incidental, to attend on a frequent basis, and that F and PGM saw M as a devoted and caring parent attempting to meet and understand A’s needs. 9.8. INTELLIGENCE & ABILITIES – I have already discussed M’s particular vulnerabilities as identified in the assessments of Mr Hutchinson and Ms G. 9.9. It is worth observing at this point, that notwithstanding Mr Hutchinson’s analysis and M’s own anxieties expressed to him as to her ability to recall details, M exhibited a highly detailed memory, appearing to be able to confidently recall many and significant details of conversations, prescriptions, meetings, appointments, dates, interactions, conversations, measurements and so forth. While I entirely accept the impact of her disorders and do not doubt Mr Hutchinson’s diagnoses and analysis of her anxiety, which appeared to be well managed by the sympathetic intermediary support and frequent breaks (approximately every 45 to 60 minutes), I found her to be remarkably articulate and intelligent in her evidence. Alongside detailed recall, she used complex and expressive language both in medical and other matters. She was generally very quick to respond, rapidly grasping the relevance and import of questions or the document references to which she had been directed. I note that F described her in his oral evidence as intelligent when it comes to logic and learning, but that she is not good at reading people’s body language or meeting their eyes and finds social interactions difficult. 9.10. I take on board the submission that this evident level of intelligence and articulacy should not be seen without the co-existing issues that M struggles with. I note that she was unable to cope with continuing her degree course due largely to mental health issues alongside her pregnancy. I also note that she will have put her intelligence to good use in seeking out information, whether via online research or via second opinions. This will also have been fuelled by the health anxiety also identified by Mr Hutchinson. 9.11. I note that Mr Hutchinson refers to M needing to clarify any information presented to her. This, in combination with her anxiety and difficulty about comprehending orally presented information plus her difficulties ‘reading people’ due to her ASD notwithstanding her intelligence, would readily explain her persistence during clinical appointments. F and PGM recalled having to rein her in occasionally because of her sometimes inappropriate insistence on going over and over topics or returning to themes that concerned her or pressing one clinician on an area of concern that was not that clinician’s field. 9.12. I note that clinicians did not provide prompt written summaries as had been hoped and requested with this in mind at the end of the previous proceedings. Additionally, I bear in mind that clinicians’ notes of meetings or discussions with M may be very brief summaries of M’s voluminous enquiries and detailed discussions. I treat such notes with a degree of caution, but I also bear in mind that the accurate recording of history and parents’ input is central to paediatric clinical practice. I also bear in mind the clinicians’ and M’s own account of and response to various salient recordings. 9.13. I also bear these matters in mind when considering, for example, the extent to which M will have absorbed some of the nurses’ suggestions or requests during the November-December 2019 admission. 9.14. ANXIETY, PTSD & ASD – Dr Ward referred to M’s anxiety in her 2018 report and the need to repeat advice and be aware of the difficulty in coming to terms with parenting a disabled child. Mr Hutchinson analyses this further in his report, in particular in relation to M managing her ASD. I note that the plan at the end of the previous proceedings was for M to be supported in accessing support for her anxiety and the review child protection conference on 10.6.19 referred to M having referred herself to her GP but due to long waiting lists a counsellor via a LA resource was mooted but did not occur. I note that the LA states that M was not willing for the LA to commission a psychological assessment of her, and so the issue remained outstanding at the end of the last proceedings, and that M was planning to refer herself via her GP. Health professionals were concerned at a Serious Case Review meeting on 19.11.19 that M’s anxiety was not being addressed given its underlying importance. The social worker could not attend that meeting but sent a report. 9.15. In the CYP plan of support dated 4.7.19 M expressed ongoing anxiety that health professionals were not treating her in a positive way due to the then ongoing proceedings. This is indeed unsurprising given the date was only shortly after the resolution of painful and contested evidence relating to the allegations made in the previous proceedings, and shortly before their formal conclusion. The support worker assistance at clinic appointments did not continue following the end of the previous proceedings – the reduction and possible termination of that assistance had been anticipated during those proceedings, and the LA had agreed at the final hearing to try and provide a family support worker to accompany M to consultant appointments if F or PGM were not available. 9.16. The LA’s failures to take more action and follow a more supportive route with M is cited on her behalf as important in analysing allegations relating to exaggeration, understanding and communication. I bear this picture in mind, and consider that the absence of treatment for her anxiety and the withdrawal of the support worker may have added to M’s overall anxieties. 9.17. Mr Hutchinson further identified health anxieties as an element in his formulation of M’s difficulties: ‘ 3.96 While M does not present with Health Anxiety about her own health needs, she does present with health anxieties about A. Her health anxieties about A are likely to have become exacerbated due to a lack of support or management of her own symptoms of anxiety that she experiences as a consequence of ASD. 3.97 Health Anxiety in a mother with psychological or physical health issues is typically associated with them perceiving that their children have more emotional and physical symptoms compared to the perception of their children's health needs by 'healthy mothers'. Mothers with physical and/or psychological health issues report having a more negative illness perception and more health anxiety on behalf of their child, as well as discontent with their child's medical consultations, when compared to 'healthy mothers' (Thorgaard, 2016). 3.98 A parent with health anxiety may impose a Factitious Disorder on a child in their care by falsifying manifestations of an illness.’ ….. 3.102 Although there is no clear relationship between any specific mental disorder and abusive behaviour towards children (Adshead et al., 2004), it is common to see mothers who fabricate illness with somatising and 'borderline' personality disorders, as well as symptoms of anxiety and depression. 3.103 M does not demonstrate the factors that are indicative of an increasing risk of FII in her child. M does not have a personality disorder or somaticizing symptoms but does demonstrate anxiety and depression, primarily as a consequence of untreated comorbid neuro-developmental disorders, and stressors associated with meeting the care and parenting needs of her children. 3.104 M has legitimate health anxiety related to her daughter's physical health needs. The legitimate health anxiety about her daughter that M experiences increases when her daughter is in the care of others. 3.105 It would appear that M periodically has an exaggerated sense of anxiety about her daughter's health needs as a consequence of her own anxieties, and the post-traumatic stress symptoms that she experiences…’ 9.18. Again I note that I have not heard evidence from Mr Hutchinson. And while my attention has been drawn on M’s behalf in particular to paragraphs 3.96 and 3.103 in his report, I also note that in these paragraphs set out above Mr Hutchinson identifies anxiety/health anxiety which he states can be a factor in those who fabricate illness, but also states that she does not demonstrate factors indicative of such risk. In that respect it is a somewhat confusing series of statements, and they are made prior to the determination of the allegations considered at this hearing and in this judgment (which should assist in a consideration of the NICE guidance list of signs and issues relevant to FII that he also sets out at his paragraphs 3.99-100, and which should properly inform any such opinions). I confine myself here to deciding the facts, and other than acknowledging that M is undoubtedly considered to experience anxiety as explored in his report, I will not include in the analyses required in this judgment the opinions of Mr Hutchinson as to risk factors. 9.19. M is to be credited for undertaking therapy for her complex PTSD and I note the benefits that she has achieved as a result. I note the impairment of emotional, interpersonal and occupational functioning that Mr Hutchinson identifies. This also ties in with M’s impaired social functioning as a result of her ASD. 9.20. M describes herself as really disliking visiting a hospital, due in part to the experiences when A suffered her ALTE. The F and PGM’s evidence to me was that M is uneasy and dislikes hospital. I bear this in mind, and that this would have been enhanced beyond that experienced by any parent of a sick child partly due to M’s inherent vulnerabilities, but also due to the knowledge that she had been accused of FII in the previous proceedings. I also note the F and PGM’s evidence that they were sometimes concerned as to how to strike a balance that met health anxieties for A, met M’s anxieties to raise issues and ask questions, but did not seem to be pushing for too much. They both described, to assist with these anxieties, that they would as a group try to work out a list of topics or questions to be raised at forthcoming clinic appointments. I also note, however, that they did not agree that one or other of them attended medical appointments with her to ‘protect her from allegations or misunderstandings’ as is claimed on her behalf, but in order to provide support and to hear what the clinician had to say. 9.21. Notwithstanding her vulnerabilities, and including the fact that they were undiagnosed in 2018 when she was first accused, it certainly can be said that she engaged with professionals throughout those previous proceedings, and has continued to seek appointments, advice and action from professionals since their conclusion. She also continued to parent the children, with active support from F and PGM throughout. 9.22. POLICE INTERVIEW – The first point to note is that this was undertaken without any intermediary support for M although she had her solicitor present. It took place on the evening of 12.12.19 from about 8.30-10pm, the day following the precipitating events in this case. M and her solicitor had not been shown the flushing video in advance, and so these were her first responses to seeing that recording. The interview did not deal with the squeezing video as this had not reached them, for the reasons discussed elsewhere in this judgment. 9.23. I am asked to bear in mind that this would have been a distressing situation and that M answered all the questions asked of her freely. I am asked to note that M showed that she was trying to manage her feelings and compose herself, for example by putting her hands together. On viewing the DVD she did appear to be remarkably composed in the circumstances. 9.24. I note that many of M’s answers are attempts to explain A’s conditions, various procedures and equipment to the officer, and how palliative care services may be different to the end of life services for adults. She ascribed the pump alarming to dystonic symptoms and denied adding fluid to increase gastric losses save for providing gastric flushes and/or water to hydrate. There are several points or explanations made that M consistently maintains over the course of these proceedings, such as that she was never told not to use syringes, that she was looking around but not to check if nurses were around or watching but because it was a busy ward and she was anxious, and principally that she had not acted to harm A. 9.25. However, there are a number of concerning responses provided by M, that were either inconsistent or untrue or that she has subsequently dealt with differently, for example: a) In relation to why the pump alarms had sounded so frequently she said ‘ But it only happened when she was in dystonic posturing position… And then when she was relaxed and asleep, when there was no contractions, it didn't do it .’ – This was untrue as many if not most occasions of the alarm sounding took place while A was peacefully lying on M, and showing no signs of posturing, distress or dystonia. b) In relation to her use of the tubes in the hospital (and it is important to note that this comment comes before she is made aware of the flushing videos): ‘DC STEVENS: Are these required to be used in the hospital by you? M: On occasion I have been asked to use them, yes. DC STEVENS: Okay, to do what? M: To either give water flushes. I've been asked to give Movicol as well through the tube. And venting, which means delivering, like, taking air away. DC STEVENS: Okay. M: You connect it to the tube and the air comes out. DC STEVENS: So you've been asked whilst at hospital. M: I have been asked, yes. A couple, not regularly, but a couple of times, yeah. DC STEVENS : Okay. Do you recall the occasions you've been asked to do that? M: It was mainly, it's been asked a couple of times, but mainly, once or twice by a student nurse. There was one nurse called P [?] particularly who I remember, who gave me a bottle of Movicol and a syringe. And she said to me, 'Could you deliver this to her'? Which I did. And I told her as soon as I'd done it. ’ – the clear impression given is that she was asked to undertake particular activities, including flushing, on a couple of occasions only, not regularly, and that she reported back to the nurse immediately in the example she gives relating to Movicol. c) Later in the interview M is shown the 59 second flushing video (Video 1). Like many of us on our first viewings of the clip, the officer did not spot that in the first few seconds we can see M is already administering water. He then asks what M is doing subsequently when she goes into her waistband and uses an item in the cup in front of her and fiddles her hands under A’s blanket. M answered that she was ‘ flushing ’ and confirms that she was using water from the cup and that she had drunk water from that cup and that she returned the syringe to her waistband because she did ‘ not have any pockets ’. She is then shown the 19 second video (Video 2) and the officer brings up her initial explanation that she would have ‘occasionally’ been asked to undertake tasks including flushing to which M responds: ‘ DC: Do you recognise when that was then? Because you say that you flushed occasionally. M: No, the flushing is not occasionally. The Movicol was the one that I was talking about’. – This response contrasts unconvincingly and inconsistently with her earlier assertion. d) M claimed that PGM would not leave the ward leaving her alone until about 3pm: ‘ Usually it's not until about three o'clock’ , and in response to the officer explaining that he was going by the timings in the records she further bolstered this with: ‘ No, I'm just telling you, normally, normally, because I usually allow her about an hour or so for Nan to go and get something to eat and stuff like that ’. But in her evidence in chief she had to correct this and acknowledge that PGM would normally be gone from the ward much earlier than that to take a break, usually in fact shortly after M’s regular arrival time in the late morning. This was evidently a regular occurrence of which M must have been clearly aware. This answer came directly after the officer had faced her with recorded timings of when she was alone on the ward without PGM earlier in the afternoon. Accordingly, this was a lie used in an attempt to deflect the suggestion that she was alone on the ward during that afternoon period, to minimise the time when she might be considered potentially culpable, and to deliberately place PGM there at critical periods of time. It became untenable in the light of the time recordings in the nursing records, and also in the light of the PGM’s further recent statement which itemised her pattern of attendance on the ward. e) She claimed that both she and PGM had sent videos of pump malfunctions off to the ‘feeding company’ – M wished to correct this in her evidence in chief, saying she was not 100% sure she had sent the videos but that she had meant to. She later said it was possible to check her emails to confirm this, but she has not provided anything to confirm this assertion. (I note here that this is not any reversal of the burden of proof, but an opportunity M wished to take in the light of her claim to the police.) PGM denied any involvement in or knowledge of sending videos of the pump to Abbott herself, as suggested by M. In the circumstances, and if I accept (as I do) that it was a false assertion that PGM had also done so, it appears highly likely that this was also a false assertion on her own behalf. She was asserting this to underline her own virtuous actions, to recruit the fictitious actions of another person to emphasise her innocence, and to try to emphasise that the pumps were to blame. This not only undermines her credibility generally, but also raises the question as to why she should seek to lie about this in this manner. f) In response to the officer raising the concern that another fluid is being added to A’s stomach waste products to make it look like the amount lost is larger, and which is also made before M is shown any video footage, M’s first response was: ‘ But they are also, just to let you know, they are also meant to be flushing the tube regularly with water as well, so you have to bear that in mind’. This is a telling response. The reference is to ‘they’, meaning the nursing staff. It is an assertion that water flushes provided by others need to be included. There is no mention of ‘we’ (nurses and M) nor ‘I’ (M alone) performing these flushes. Given that M later explains that she was providing water flushes herself, why did she not say so at this point rather than deflecting onto ‘they’? This statement also indicates a keen awareness of the impact of water flushes on the amount of gastric losses. So if, as M later asserted, she was providing regular flushes and further hydration, but she was also expecting the nurses to be flushing the gastric tube regularly as per this response, then there would surely have been a risk – of which she was aware as is made clear by this statement – of there being an excess of water inserted into A’s stomach given that M accepts that she never told the nurses nor the PGM what amounts or when she was inserting water into A’s stomach. But she never mentioned it to the nurses, claiming that it did not occur to her to do so. g) She emphasises more than once, when explaining how she would administer a water flush, that she would ‘ clamp it off’ ‘ so it doesn’t come out’ and ‘in about half an hour you would unclamp it’. This does not fit with her subsequent acceptance in oral evidence that she performed a second insertion of liquid only a few seconds after the first seen on the video, and then also not telling the nurses anything about it, so that when S.N.ELB reattaches the drainage bag there is no explanation given as to any need for the tubing to be clamped for any period due to M having just given two amounts of water into A’s stomach. h) When M is asked whether she has ever added any fluid to the drainage bag she replies: ‘No. They're actually using different bags to what I'm used to using anyway. So I don't even know how to use them.’ Again, M sought to correct this in her evidence in chief. Her evidence was confusing. She began by saying she could not remember which bags, then she said at first they were using bags from home and when those ran out the hospital bags were used, but from 9.12.19 it changed back to the bags from home when she had brought some more in, and finally she said she was pretty sure the bags had changed back (to the bags from home). So her first comment to the police was therefore a strange assertion on two fronts. Clearly she was aware that the more familiar bag type was in use at H2 both at the start of the admission and after 9.12.19, so why did she say they were using different bags and were unknown to her? Secondly, the bags are very similar indeed with very basic functionality. The principal difference is in the colour (white/purple) of the components at the top and bottom, and the white bag (of the type used at home) has a longer piece of tubing leading out of the top of the bag and has no threaded unit at the end of the tube leading out of the base. Otherwise on both bags the threading at the end of the top tube is identical and marries up with the gastric port tubing connector or Y-connector in the same way, the soft semi-transparent plastic bag with black print showing approximate measurements up the side is in both cases very similar to collect the drained liquid, and the short tube at the base of the bag which is used to empty the bag have a clamp and a stopper on each version. In answer to the first question begged above therefore, this appears to have been a false and misleading statement to the police, particularly in the light of her own recent effort to bring in her own bags and given what are evidently almost identical devices, attempting to artificially distance herself from any knowledge of the hospital bags and to suggest that she was incapable of using or manipulating them, when in fact on her own evidence she would have known that at least since 9.12.19 they were in fact the familiar type she had brought in from home. i) In further explanation of her activities in the flushing videos, and after having seen the second flushing video showing a further occasion of the insertion of water, M answers as follows: ‘ M: That was, that particular, as I explained earlier on, there's flushing and there's giving water to hydrate. DC STEVENS: Yeah. M: As long as you clamp it afterwards, it doesn't cause a problem. DC STEVENS: Okay. M: We've been trained to do that since we've had the tube. DC STEVENS: Right. M: And as she was getting dehydrated, it's, I didn't think there was anything wrong with that .’ – This is a development from M’s earlier explanation of flushing, to include a further reason for giving water which was to hydrate A on the basis that she was getting dehydrated. It is also the third mention of needing to clamp afterwards, which refers back to the observations I have already made above. In her written statements there is only mention of a single 10ml flush and that she could not remember whether or not she had given water for constipation. Additionally, there was no attempt to check A’s hydration levels with nurses or PGM, no explanation to nurses that she had just hydrated her and so the tube needed clamping, and no actual clamp of her gastric tube afterwards in accordance with the hydration she claimed she was undertaking. 9.26. M’s WITNESS STATEMENTS & EXHIBITS – M provided four written statements in January, March, April and October 2020. I have referred already to the variety of video clips and still images M has provided, which have been most helpful in understanding some of the key issues. Attached and referred to in her October statement was also an extract from the pump handbook referring to ‘Gastric Compression’ (to be conducted by leaving the gastric port open and using gravity drainage (into the bag or syringe) or low suction (via syringe)), and from which M cites and relies on its advice that flushes should be conducted every 6 hours. Detailed issues arising from M’s statements will be addressed further when considering the separate issues and allegations. 9.27. M’s ORAL EVIDENCE – Again I do not intend to run through details arising from M’s oral evidence here but will do so when considering individual issues and allegations. 9.28. However, I note the following points. M attended court every day in person or remotely unless she had to attend a contact visit. She was keen to give evidence and often provided highly detailed, precise and rapidly delivered answers. Sometimes her speed and precision were unhelpful in that she would hit upon a particular small element of the question rather than always addressing the overall point, but it was possible to return to the overall point with further questions or clarifications. 9.29. Despite several interruptions and requests by the intermediary to avoid particular forms of questions, particularly tag questions, it was clear that M almost always reached a very quick and accurate understanding of the meaning and import of a question. Corrections and clarifications were appropriately pursued with the help of the intermediary where necessary. 9.30. While it is always a stressful and fatiguing experience to give evidence, I appreciate that M will have found it particularly so given the mental energy required to manage her anxiety, to concentrate, to assimilate information and manage her social and communication vulnerabilities. It was clear that frequent regular breaks, and being guided by the intermediary in that respect were of particular help in managing her difficulties. 9.31. My overall impression was that M was trying extremely hard to answer all the questions. However, while bearing in mind all the positives and her vulnerabilities and related caveats that I have set out above and heard in submissions, I was also driven to conclude, through a number of inconsistencies and more reluctant or less plausible responses, that she was not a reliable witness. And for reasons that will be expanded upon further in this judgment, I found that where her evidence conflicted with those of another witness I have preferred the evidence of that other witness, whether from her family or a professional. 9.32. FATHER 9.33. F has attended every day of these proceedings via remote link either from home or his counsel’s chambers. He has done so by using up all his paid leave and also obtaining unpaid leave, and has continued to assist PGM in caring for his two older daughters. 9.34. He has provided three statements in these proceedings and signed a police statement in early September 2020. Although he had available to him the case papers and videos throughout the proceedings, he did not have full access in that PGM had to buy him a laptop shortly before the hearing in about September so that he could access Caselines and see the documents coherently and see the videos. 9.35. In his statements, he repeats his overall position which is to attempt to understand the vast amount of evidence and to be led by the expert medical evidence and any findings made by the court. 9.36. He repeats in his statements his regret at saying ‘ We will beat the fuckers’ on the occasion of M’s arrest in December 2019. He says it was to reassure PGM and because of his shock and upset at the turn of events. 9.37. He provided his police statement over the telephone during the initial lockdown period in the second quarter of 2020, and was asked to sign it electronically in early September. In that statement he said that M was a brilliant parent and that he could not fault her, and in relation to the flushing video he said this: ‘ It appears to me, as if [M] is putting a flush to the tubes and flushing it out. Also, [M] does not have great mobility when she is sitting down, so she would have placed the syringe in her waist band or in her bra as she had no pockets to put it in. This was a common practice for [M] to keep her belongings such as phone or keys in her bra as clothes for her size didn't usually have pockets! Therefore, I can see how a lay person would watch that video and be of the view, that some kind of foul play may be taking place. However, because I know [M] and of the procedures that we have been allowed to perform ourselves, I am not concerned by her actions on the videos I have been access to view.’ 9.38. I note that F would not have seen the squeezing video as it was not yet produced, and that his comments appear to indicate that he had not looked so closely at the longer flushing video to see that it in fact shows M carrying out two occasions of inserting liquid into the gastric port within a few seconds of each other. 9.39. What is of particular note is the development of F’s position over time and the clear impact upon him of having seen and heard the evidence of the nurses, the clinicians, the experts, the lay witnesses X and Y, the M, and having seen the videos played carefully and queried closely, and having had the opportunity to consider A’s remarkable progress in foster care in that context. 9.40. It was complained of on behalf of M, and also in submissions, that it was wrong for an advocate to explore with a witness their opinion of the evidence and that such evidence should be discounted. However, I am bound by the case law to attend very closely to the evidence of family members. In this case, the F’s position appears to have shifted from loyal (police statement) or very much on the fence (care proceedings statements), to upset and deeply concerned that the evidence he has seen and heard had changed his overall understanding. In the circumstances where he was intimately involved in M’s and the children’s lives, and where such a shift has emerged, it appears to be central to an understanding and analysis of his evidence to comprehend the nature and provenance of such a shift, and it would be artificial to try and do so without asking his opinion of key areas of the evidence. 9.41. The following is submitted on F’s behalf in relation to the M’s submission that it is wrong for the parties to be asked their opinion on certain evidence, as it suggests that everyone is proceeding only on the basis that the evidence in question is true: ‘ This is very far from accurate in the case of the Father. For a long time, he championed and defended the Mother, understandably believing her to be wholly blameless. As the body-worn camera footage shows, the Father was shocked by the Mother’s arrest and, as is necessary in the case of suspected FII (and consistent with Royal College Guidance) he had not been alerted by any professional to any of the concerns. It is the weight of the evidence, and his careful reflection upon it, which has driven him to a different position; this has been and is a very sad and painful process.’ 9.42. This sad and painful process was noticeable during the course of his oral evidence, in which he pointed out aspects of the evidence that had caused him to pause and reflect and to feel upset at what he was seeing, hearing and being made to think. When challenged about his shift in position, he described that he had not then seen all the evidence, that he was ‘ very much in shock and trying to rationalise .’ He admitted that he had not seen that the longer flushing video was two flushes, for example. And it was only during this hearing that he heard X’s description of multiple uses of the syringe to insert water on the afternoon of 11.12.19. 9.43. He cited the various discomfiting oddities about the behaviour shown by M in the flushing videos with striking puzzlement in his oral evidence, and I list them in detail below under the section addressing the flushing videos in paragraph 10.54 below. 9.44. He was also particularly disturbed by what appeared to be M’s ability to try and pull him (and PGM) into lies about their care of A at home. 9.45. It was submitted on F’s behalf that he is particularly concerned that M tried to press a schedule of timings on him (and PGM) before it was sent to the other parties, and when he declined to agree it as it did not reflect the position accurately, it was nonetheless put forward and has been relied on by M: ‘ It is quite clear that the schedule was designed to be exculpatory of the Mother, by establishing that the bulk of the feeding was carried out by the Father or Paternal Grandmother. Although the Father and the Paternal Grandmother had a good deal of involvement in the making up of feeds, this does not, as the Father realises, exculpate the Mother; neither he nor the Grandmother would sit and watch the feed go through.’ 9.46. M was also quick to call F a ‘liar’ when it was put to her in cross-examination on his behalf that her account of the regime at home was inaccurate. This, as F said, angered and concerned him. 9.47. He had no recollection of the extensive vomiting that M claimed to the court had taken place after A was discharged from the July H1 admission. When M was asked about her email sent to the GP on the morning of 16.7.19 the day after A’s discharge the evening before, she claimed that A had vomited on the night of her discharge on 15.7.19, and that F was lying about how ill A had been. 9.48. He remembered that A left hospital with her gastric bag off, that she was able to tolerate that and was thriving and putting on weight and was well. He recalled she was playing, laughing and happier when discharged on the evening of 15.7.19. Later on she became more miserable he recalled, with the distended stomach which was filmed on that occasion, and that her PEG-J site was infected and uncomfortable. But he was quite clear that she was not seriously ill as M suggested but simply appeared to return to a similar miserable state as she had been before the admission, albeit she no longer had the drainage bag attached. This picture is substantiated by the source documents such as the note on discharge and the video. 9.49. He was only aware of the two occasions when the pump failed to push the feed through, the one he recorded in early 2019 and drew to Dietitian DM’s attention because he was so upset and worried about it, and the second which PGM recorded in late June. He was unaware of any others, let alone the two full feeds per week that M claimed were not being delivered by the time she gave her oral evidence, nor had M informed him of these pump/delivery failures. His evidence was striking and emphatic, and I have no doubt that he would have recalled such serious failures if he was made aware of them, given the actions he had taken in relation to it himself. He said with some exasperation: ‘ if there was that much left that often I don’t know why we did not take more videos’ . And I note that no such concerns in relation to frequently undelivered full feeds were raised with any professional. 9.50. I deal further below with his concern and disgust in relation to M’s squeezing of A’s stomach seen on the squeezing video at paragraph 10.68 below, and her attempt in her oral evidence to suggest that he had seen her do it that way at home, and when he was cross-examined to suggest that he had often done it that way himself. 9.51. The evidence he gave in relation to these critical realisations and conflicts that these issues threw up for him was impressive in terms of its vivid and natural unease and upset that it caused him. 9.52. It is submitted on F’s behalf (and which he expressed albeit in more immediate and less formal ways during his oral evidence), that it was this ability of M to show that she could ‘fabricate’ such issues in relation to their shared care of A during the course of this hearing that gave him particular cause for concern. Firstly because it calls into question her credibility, but secondly because it was attempting to exculpate herself by drawing him and PGM into her behaviour or her thinking. 9.53. I note that it adds a third concern in relation to the feed and pump issues, namely that it begs the question as to why M would want to press these issues, contrary to F and PGM’s experiences? These were issues relevant to the question of the proper feeding of A at home. 9.54. He was particularly concerned that the overall picture from the medical evidence in relation to A’s weight loss at home, subsequent progress, and the ruling out of various possible explanations for it, in combination with the concerns raised as to M’s credibility and her fabrications in relation to matters that he was able to give direct evidence of himself, led him to conclude that M was responsible for A’s malnourishment and consequent discomfort and unhappiness. This was clearly a painful realisation for him. 9.55. In terms of his general observations as to the H2 admission in November-December 2019, F was never there due to his work commitments, caring for the older girls and the distance. He was reliant on any feedback from M and PGM. He confirmed that he could not recall M had raised with him that she felt the nursing staff were watching or suspicious of her (although he accepted when cross-examined that this is something that M might have said at some time). Nor did M raise that the nurses were not performing gastric flushes and she was having to do them herself. He also said that he could not see why the nurses would lie about what they had seen because it did not affect them in any way. He thought they were obviously going on what they had seen and he thought they were telling the truth. 9.56. In terms of general observations of home life and A’s presentation, F recalled that M appeared to be a devoted and caring M, albeit anxious and beset by the worries and demands of caring for A and the two older children. His description was of a home that was always extremely busy. Supervision of M had been by way of a presence in the home rather than constant oversight. She had, for example, spent time with one or other of the children in another room while he was busy with something else, and had A sleeping in her room every night without another adult present, save that he slept there on three nights per week. 9.57. With regard to the feeding regime, he described this as a shared activity. He acknowledged that Neocate was a difficult milk to mix and that he may possibly have been at fault there himself in adequately mixing it. He would not watch feeds going through. He considered there may have been opportunities for M to interfere, and that he was not always there with her. Fairly, he accepted that he had not himself seen any direct interference by M with A’s feeding or in relation to gastric losses at home. 9.58. He slept Sunday night through to Wednesday mornings at M’s home. He might make the 8am feeds on the Tuesday and Wednesday mornings that he was there, but could well have handed them to M to fit them as he was making breakfast or dealing with the older girls. He explained that on Monday mornings he would sleep until 2pm, and so not be responsible for morning or midday feeds, but on Monday and Tuesday nights he would deal with the night-time (4am) feeds. From Wednesday through to Monday he would be able to help with the 4pm feeds (or 8pm on Weds due to his later work start) but would leave for his night shift on Wednesday to Sunday before the feeds would have gone through. He would then be working through the night Wednesday to Sunday and sleeping at his/PGM’s home during the next morning before rejoining the family the next afternoon. 9.59. He described periods when the alarms would go off, that they would then remedy and fix it. There were a number of reasons why the pumps could alarm at home: a feed sediment blockage; the end of a feed; air having got into the system; the system being paused for more than a few moments. On other occasions the problem persisted and the cause was unclear. He recalled their caravan holiday which was affected by a persistent alarm problem that kept going off despite him trying everything. He recalled occasions when the pump alarmed while A was upstairs in bed and M downstairs. 9.60. He assumed that the feed was running through if it was not alarming. He described that you could hear the pump humming when it was working, that the screen was backlit if there was an issue such as an alarm or priming, but otherwise remained dark. He confirmed that whoever did the midnight feed could see how much had been delivered over the previous 24 hours if they checked the screen, and in doing that feed would restart for the next 24 hour period. He did not notice discrepancies in the amounts that should have been delivered. He confirmed that if the feeding tube was disconnected but permitted to run out elsewhere then it would not affect the figures. 9.61. He confirmed that regular large amounts of gastric drainage were inconsistent with his experience at home. They sometimes saw little or no losses, and then large losses which could happen ‘ quite quickly and sometimes when I was out of the room’. 9.62. He acknowledged witnessing episodes of extensive drooling, of vomits, and of vomits leading to apparent chest infections or respiratory distress. He accepted that A did not have severe dystonia, as he understood that to be so severe as to lead to for example fractures, but considered she had occasional mild or moderate experiences of it. 9.63. He acknowledged the level of M’s anxieties and difficulties dealing with professionals and described the joint process they attempted to put in place with a limit on the number of questions, but also described how it remained difficult to rein M in and answers would lead to further questions and she would experience a great deal of frustration and upset in the car on the way home as a result. 9.64. Overall, I found the F’s evidence to be straightforward, thoughtful, direct, considered, candid, fair, and given with a vivid natural quality. It was largely corroborated by the evidence of PGM and by such source documents as applied. Where it conflicts with that of the M I overwhelmingly prefer that of the F for the reasons discussed. 9.65. I consider that his shift from the view expressed in his police statement was an entirely valid and explicable shift in the circumstances that are discussed above, and demonstrated an ability to think through difficult and unpalatable information with intelligence, adaptability and rationality. 9.66. It is argued on M’s behalf that both he and PGM were affected by their fear that they might lose the care of the older girls, or the chance of having A returned to their care, if they did not tow the LA’s line. PGM accepted that she had some concern that the answers she gave might mean she and F would not be able to look after the girls. While I consider that this type of fear must always arise to one extent or another in care proceedings, I clarified for all parties the oversight of the court and the various stages that such a case passes through. It was also firmly rebuffed in their evidence that this fear or concern was however actually making either of them answer in cagey or artificial ways, and indeed I picked up no such guarded or influenced responses. F was refreshingly open, natural and immediate in his responses, and I reject this submission. 9.67. PATERNAL GRANDMOTHER 9.68. PGM has also attended every day of this hearing via remote link from home. 9.69. She was a teacher for 24 years, and a qualified SENCO and dyslexia tutor who became self-employed recently, carrying out assessments and tutoring for various educational agencies, schools and private clients. Because her arrangements were more flexible as a self-employed person she was able both to work throughout the time after A’s accident, and assist M and F with A’s and the older children’s care. She arranged her commitments around her son’s availability; A’s hospital, clinic, and doctors’ appointments (44 in 2019); and her in-patient stays (50 nights in 2019); and the many family activities and duties in which she helped and participated. There are no historic concerns relating to PGM and she is police checked due to her working responsibilities with children. 9.70. All the professionals with whom she came into contact, ranging from nurses to the expert paediatrician instructed in this case, described her as appearing devoted and caring. I heard and saw no evidence to the contrary, but found that their impression was borne out by her own and other’s accounts. She came across, throughout these proceedings generally and during her own evidence, as a kind, trusting, conscientious, committed and thoughtful person, who does not find it easy to think ill of others. 9.71. On occasions during her oral evidence she very fairly acknowledged when she could not remember a specific matter. I found this reassuring in terms of her clear recollections that she did provide. Other than the submission made on M’s behalf, namely that fear of losing the children is making PGM tailor her responses and which I have discussed above and not found borne out by any evidence, there has been no issue raised to suggest I should not accept PGM’s evidence as truthful and that she is a reliable witness. 9.72. She has clearly been very shocked by the evidence she heard. Like F, she also described A with a sense of awe as ‘ like a different child… she can sit up and use her right arm… she is copying songs and words and understanding .’ 9.73. She described herself as stunned, in tears at points, and that it was awful to hear some of the evidence. She described the worst shocks as seeing the videos of M and hearing X and Y’s evidence, plus the amount of nurses who had made notes of concerning things they were witnessing. 9.74. She made a critically important point with this in mind. She said how she felt ‘totally confused about M because I never saw anything like that at home or anywhere else, so I was shocked when I saw any of that. … I was disappointed that someone I had known for so long has done this sort of thing and that person could have duped you all that time …. I’m just really shocked by it – it’s almost unbelievable, but then you see lots of it here…’ . PGM’s clear and shocked impression was that M had the ability not to openly demonstrate that behaviour in front of her at home, but to act this way when PGM could not see it, and was filmed doing so. 9.75. PGM filed two statements in these proceedings, the first in October shortly before the hearing began, and the second in late November which went into some detail as to her regular and sometimes lengthy absences from the H2 ward each afternoon during that last admission while M was there alone. 9.76. Attached to her October statement are a number of delightful photographs; a timings schedule that reflected the typical pattern leading up to July 2019 when F and PGM had agreed that there would always be one of them at M’s home with her and the children; some typed notes made by PGM of issues she noted from the H1/H2 admission in November-December 2019; and a tally sheet kept in August and September 2019 which she made in order to keep track of low blood sugars. This last document also showed data for vomits and anti-biotics and other issues such as chest infections. PGM clarified that the number of vomits was derived partly from her own observations but also when M reported that it had happened. It records 9 vomits in August, and 15 in September; three chest infections, being the chest/sepsis in mid-August spotted by the Ellenor nurse, and two infections in early and late September . 9.77. She signed a police statement in March 2020. She clarified the comment in that statement in relation to alarms in that it reads in a way which appears to inaccurately elide events at the two separate hospitals, H1 and H2. She explained that the alarms she described as going off in front of nurses and doctors took place at H1. In terms of alarms at H2 she explained that these occasionally sounded in the evening or early morning when M was not there, and that she was not woken by alarms at night. It was further clarified that the alarms that are recorded as sounding in solely PGM’s presence on 6.12.19 were of the IV and the Dioralyte pumps, and in one case was due to A’s bent arm blocking the tube and in the other case to it having become coiled up while she was sleeping. 9.78. When she was asked about the occasion on 4.12.19 in her note when she recorded many frequent alarms, she recollected that she was sitting next to M who was lying on the bed with A on her stomach. She suggested that laying A down might improve it. A was then lying on the bed between M’s legs as M was still on the bed. The alarms continued with A in that position. 9.79. Her observations of home life very much reflected the evidence of F. 9.80. In terms of feeding, she confirmed that for each feed they would actually make up extra milk in excess of the amount required. M confirmed this. This was to have some in hand in case there was any delay in being able to start a new feed, and this would prevent either A missing out on feed if there was a delay, or would prevent a blockage because if the milk ran out it could leave a residue in the tube that would be likely to cause a problem, or it would prevent air entering the system which would cause an alarm and needed a troublesome fix to clear it from the system. 9.81. She said that every time there would therefore be a slight amount of feed left because of that ‘over preparation’, but it was never measured. She stated that it was probably never a large amount nor a whole feed left because she was so astounded on the single occasion that occurred in June when the pump malfunctioned and she filmed it. She confirmed that she never observed a full feed left undelivered once or twice per week as alleged by M and she was absolutely certain that there had only been one such occasion that she had witnessed. M had not informed her of any other such incidents : ‘I was never told of other problems like that. I would have taken more videos and shown them to the GP and [Dietitian DM]. It would have been unacceptable and worrying’. 9.82. She was equally clear about M’s assertion that she had sent videos to Abbott: ‘I never talked to M about sending videos to Abbott. I would have got on and done it straight away the same day and I would have remembered. They are good at getting replacement pumps to you.’ 9.83. In terms of the pump occluding and alarming at home, she described how they would check for clamping, kinking, sediment, finished feed and would then prime and restart and if that did not work they would sometimes put on a new giving set or remake her whole feed. She confirmed that she did not mention A’s behaviour as a cause of the alarming as she had not noticed that as a possible cause at home. She confirmed that even these problems did not have a significant effect on the volume of feed reaching A as it would only take a few minutes to sort it out each time. 9.84. Like F, she confirmed that although she set up a number of feeds at particular times of day on certain days, she would not necessarily be there to see if it had gone through. I note that other than Tuesday night on M’s schedule, PGM was said to be responsible for all other midnight feed preparations when the full amount delivered would have been showing. She described making it up at about 11pm and then A would go to bed and she would return to her home to sleep. She confirmed that although you could see the amount of feed that had gone through on the pump she never checked it as there was no need to, that they had no reason to doubt each other, and that she would reset the tally on the display at the midnight feed. 9.85. In relation to the H1 admission in July 2019 she recollected how much better A was in the last few days when she was caring for her alone. She took her to the hospital fete and around the garden. She had put on weight and was ‘ very happy’ and ‘ moving her right hand a bit more’ . 9.86. Having cared for A for several days she then returned to her own home after she was discharged on the evening of Monday 15.7.19 to her parents’ care, and went to work on the following days (Tuesday and Wednesday) and did not think she had any care of A during those days. She could not remember any discussions with M about the effect on A of having no drainage bag in those days following A’s discharge, but she told the court that because of the controversy over what M had been saying about A’s condition, she had checked her mobile phone and she had been texted by M on the afternoon of Tuesday 16.7.19 that A had ‘ nearly vomited three times’. I note that this is not an account of A actually vomiting (as per M’s oral evidence), nor does it match with the account given by M in her email to the GP on 16.7.19. 9.87. PGM then accompanied M to the GP on Thursday 18.7.19, which is the consultation that led the GP to contact the dietitian DM. Although it has been suggested repeatedly on M’s behalf in both written and oral closing submissions that they were both urgently seeking to have the drainage bag reinstated, PGM did not remember it this way. She had not been involved in A’s care at home since she was discharged from hospital, she said she would therefore have accepted what M was saying about A’s presentation, but she was not pressing for any particular outcome, but was simply there to support M. 9.88. Her description throughout has been that M was very much in charge, could be a forceful personality, knew more about A’s detailed history and presentation, and was the person who engaged with the clinicians during appointments. She might gently suggest if she thought M had got something wrong, but gave no examples of doing so. She described M as not very confident but she was intelligent, knowledgeable, strong-willed and could become fixated on something. I find this to be a telling description from someone who knew her so well, which fits with the impression given by M herself during her evidence and from others’ accounts and in the papers. 9.89. PGM was aware that A was grossly underweight and she was worried by it. She said she had not been aware that A’s feeding plan prescribed her about 40% more calories than would normally be required. She accepted, given A’s malnourishment, that A would have been hungry and this may have explained her pain and distress during those months before her November admission. She agreed with the medical evidence she had heard that it could have hindered her development, made her more prone to infection and may have led to the low blood sugars. 9.90. She had noted occasional extensive drooling and vomits, and chest infections that appeared to arise from aspiration. 9.91. She described seeing what she believed were painful spasms, which she believed was dystonia, with A’s legs stiffening in a frog position or her feet would twist and legs become rigid. She thought it tied in with what she thought Dr F and a nurse had said and could be causing gut spasms that made the alarms go off. 9.92. During the H2 admission it was quite clear that PGM had not noticed that M or A were being observed by the nursing staff at all, and she too confirmed that M had never mentioned any worries or anxiety that she was being watched in hospital. This was notwithstanding that she recollected seeing a note in red saying ‘Alert’ on the front of A’s paper file when she was being taken for her operation on 3.12.19 and when she asked about it she was told it related to safeguarding. Clearly this did not lead her to consider or notice that the staff were trying to keep an eye on A. 9.93. She could not think of an explanation as to why there was a pattern of so much more gastric losses when M was present on the ward. She noted that A was sometimes more upright and active with M and did more lying down with her. 9.94. In terms of flushing/hydration, the flushing videos, and the squeezing video, I set out her telling concerns and observations in the relevant section dealing with the videos below at paragraphs 10.55 and 10.72. I note here that she made similar points as F, and with the same sense of puzzled outrage and concern. 9.95. She did not recall M mentioning any difficulties or observations of sediment in the tubes at H2 to her, and she explained that you use both hands to smooth out sediment and she had never seen M doing that at H2. 9.96. Overall, I found PGM’s evidence to be consistent, fair, straightforward and convincing. For all the reasons discussed, I have no hesitation in accepting PGM’s evidence over that of M’s where it conflicts.

10. THE VIDEOS & WITNESSES X & Y 10.1. I now turn to some of the further critically important primary evidence, namely the evidence of witnesses X & Y, the video evidence, and M’s and the family members’ responses to this evidence. 10.2. Although there are issues that touch on A’s medical conditions, it is not necessary to examine the medical evidence in detail at this point for this material to be considered. These were central, precipitating events, witnessed and recorded by neutral outsiders, the interpretation of which inevitably provides a critically important contribution to the analysis of the case. Determining the facts here is dependent upon my impression of the evidence and the witnesses and not upon complex medical issues. 10.3. Given that X and Y are outsiders to the issues and history, being simply carers of another child who happened to be on the same ward as A in December 2019, it is worthwhile and important to explore their evidence and its implications in some depth. 10.4. X & Y 10.5. X is the grandmother and Y is the mother of a 16 year old boy with severe disabilities. They live together, and X and Y provide for his 24 hour care needs. On 9-11.12.19 he was hospitalised on the same ward as A. He required an operation on 9.12.19 and was significantly unwell on that date, and Y described him as suffering a very significant health crisis when he nearly died and was in great pain. Y was on the ward throughout, and was joined by X by about late morning or early afternoon on 11.12.19. They each gave police statements (X in February 2020 and Y in June 2020), the contents of which were repeated in their statements in these proceedings dated September 2020. They expanded on these written statements in their oral evidence. 10.6. They began to notice M’s behaviour with some concern on the afternoon of 11.12.19; X first, who then drew it to the attention of Y. They thought of taking videos due to their concerns and began doing so at about 4-5pm, and X recalled that the video she took was timed at 4.56pm when she looked at it when the police visited her. Between them they took 6 short videos using their mobile phones, while sitting together in the bed bay opposite but slightly to one side of A’s bed bay. 10.7. X’s statement reads as follows: 10.8. ‘4. …I cannot totally recall why I started looking at the woman, but [Y] had noticed something untoward was going on. I found it shocking and I did not like what I was seeing. It appeared to me like a crime was going on in front of us.

5. On Wednesday 11th December 2019 I looked across at this woman who I described earlier and noticed that she kept looking from her left to her right, in a shifty way as though she was looking out for anybody that might see her. I noticed that when nobody was around she was facing towards me, with the baby in her right hand and using her left hand she would put her hand into a pocket on her left side, in her leggings, and take something out, which I am sure was a syringe.

6. She would then put this syringe into a white plastic cup, held between her legs. She would draw whatever was in the cup, up, and then she would appear to unscrew/remove the cap on the feeding tube and then administer the contents of the syringe. She would then restore the cap and then replace the syringe into her left hand pocket. This all took place whilst she was seated on the bed.

7. I watched this take place all the time she was there. However, I noticed that she was asking her female relative to bring her more water/drinks, which gave her the time on her own. I noticed that if she was approached by a nurse etc, she became very chatty and engaged with them.

8. [Y] was with me, whilst we were watching this happen. I remember suggesting that we film what she was doing. I held my Samsung Galaxy 9 plus mobile phone in her direction, as though I was reading my phone. However, I was in fact recording her on video at around 4.56pm where you can see the actions I have just described take place. We don't know exactly why she was doing what she did, but it didn't look right.

9. A short while later, whilst [Y] and myself sat with [16 year old], his consultant, Dr K attended and [I] grabbed her hand and I was shaking. I said "M [Dr K’s first name], something awful is happening in the bed opposite." She told me to come outside and myself and [Y] went with her. I told her what I had seen and I told her that I had videoed it. She seemed quite pleased that I had videoed it. We then returned to [16 year old's] bed and sometime later, a couple of women came to see me and took me into a room. I told them what happened and I am sure that we were joined by a woman called 'B'. I then showed them the videos, and again describing what I have said earlier.’ 10.9. In her oral evidence X was emphatic and consistent on the key issues she was recalling, despite skilful and rigorous cross-examination. Her answers were not perfect and she occasionally corrected herself, for example she corrected her reference to M syringing into the drainage bag when giving an initial general comment, to referring to syringing into the tubing when she went into more detail to describe what she had seen. This was clearly a matter of mis-speaking and an openly acknowledged correction. The impression gained was of a witness doing her very best to be helpful and detailed, with unrehearsed recollection of witnessing something she had found very troubling. 10.10. In her oral evidence X stated: ‘I saw the woman in the bed opposite looking around, taking a syringe out of her top or leggings in her belly crease and drawing liquid from a cup then unscrewing the bag and pushing the liquid into the bag and then she would squeeze the baby’s belly and then she would shake the bag to see what was coming out. I saw her do that lots of times. I was shaking, could see it was not right. She was putting something in the baby and we could not see what, and if a nurse passed she would put it away and quickly chat and she would keep an eye on nurses’ desk and watch and take opportunities. I saw it 20 times at least… The video is only the tail end of it – only thought of that after I had seen it. I saw her take the syringe from the left side of her leggings, put it into a white cup between her legs and holding the baby in her right hand and she drew it [the syringe] up – it’s very easy to do with one hand – we do it all the time. I definitely saw her screwing it into a tube. She had a blanket. She kept shaking and studying the contents of the bag. The tip of the syringe went into the end of the tube, the PEG coming out of the tummy – not the end of the bile bag – the bag was off and it was going into the tube… She was sending [her relative, PGM] off to buy more drinks and things, to get her out of the way I think… She was looking very shifty and looking or watching to see and whenever anyone wasn’t there she was doing what she was doing… I know why I started looking at her – she was acting shifty, and pulling something out of her trouser top and pushing something into the baby’s tummy – things need to be sterile… I said I had wished I had taken the videos earlier when it was more rampant – like continual. Before we took the videos she was doing it during the day. A lot of times. In the two hours before the video maybe 20 times. I’m telling the truth. I told the hospital and the police. I remember thinking I’d wished I’d have taken the video earlier in the day when she was doing it a lot… [M used the syringe] sometimes three or four times in a minute if no one was around. She would put the syringe back in the cup and then back into the baby, then back in the cup, then baby, then cup, then baby, then back into trousers.’ 10.11. X was criticised for not mentioning in her statements this level of detail as to the numbers of times she had seen M behaving in this manner. I note she thought she had done so to the police officer, and that in both her statements it states: ‘I watched this take place all the time she was there. ’ This description, although not providing the detail, clearly refers to the behaviour she was watching having been taking place throughout the afternoon that M was there and X watching. 10.12. X acknowledged that there is no mention of squeezing in her statements, but said she thought she had told the police officer and accepted that it was an oversight not to have included it in her statement. At the time of giving her oral evidence, the parties and the court were aware that a video of M squeezing A had also been filmed, but it had not been seen by the parties. It was referred to in another member of the nursing staff police statement. It was presumed lost or unavailable given the challenges of developing events, as it had not been disclosed by the hospital or via the police enquiries. It became clear during X and Y’s evidence that they had not only taken this video but sent it with the others to the hospital safeguarding individual (probably BM). At the court’s request, given their confirmation that the videos they sent were probably still available on their devices, the squeezing video was then subsequently provided after their evidence had concluded. It will be discussed in more detail below. However, before it was seen or indeed X had any opportunity to remind herself of it, X provided in her oral evidence clear, detailed and emphatic descriptions of what she recollected. I note here that X was unaware of the oral evidence or written statements of the nursing staff who had described squeezing movements to me, and she had not had an opportunity to remind herself of the brief content of the squeezing video with which her oral descriptions were consistent (to the extent that the brief video clip demonstrates): ‘She would put fluid into the tummy and squeeze, but not every time. I saw her two hands around the tummy squeezing it, and I can imagine the baby’s tummy fluid coming out into the bag and then looking presumably to examine it. That’s what it looked like to me… She might do that [syringing fluid] three or four times, and then squeeze the tummy and look at the bag. I saw the squeezing maybe six to eight times, maybe ten… She squeezed, she did not massage. [16 year old] has a similar bag. I know what I saw and I saw her squeezing the tummy and looking at the bag and shaking it. It was not massage. I can only go by our [16 year old], I am not a medical person. You don’t need to massage air out. Air will come straight out. Fluid will come out if you press it. You don’t need to squeeze or push because air comes out naturally with the pressures of wind… Four fingers on one side of the body and thumbs on the other side. Both hands. The baby was always facing her when squeezing.’ X was not familiar with the idea of pressure being used to relieve gases in a child’s distended stomach. She described as ‘odd’, ‘weird’ and ‘unnatural’ M’s behaviour in repeatedly picking up the drainage bag and looking at it and shaking it. 10.13. In terms of flushing, X was quite clear that what she was seeing was not flushing. She explained her understanding was that it is not often appropriate to flush a gastric tube as the drainage bag is there and that you only need to flush it after administering medication. She asked, rhetorically: ‘ Why would you be doing it shiftily and looking around and hiding it? It would be above board and the nurses would be helping with it’ . And she added that if a child fed this way was constipated you would normally ensure they had water via a drip and ‘ not via the back door using a syringe in someone’s trousers’ . 10.14. X was challenged that she knew more about the situation that was concerning the clinical team at the hospital, and that they had a cosy relationship with the nurses and doctors, and were therefore somehow caught up in the ‘excitement’ of pursuing M’s alleged wrongdoing. Again she was very clear in her evidence. She described knowing the nurses’ faces but not many of their names, and during this line of questioning she volunteered that she had taken the videos on her own initiative and that ‘ nobody prompted ’ her. On behalf of M, weight is placed on this comment as somehow significant of X being aware of the issue of prompting. X was clear and consistent throughout her evidence: ‘ They did not ask me or tell me – they just asked me what happened and I told them about squeezing the tummy so contents coming out, and picking up the bag and looking and shaking .’ 10.15. She was unaware of any of the concerns held by the nurses and was quite clear that she was completely unaware that M was being observed in any way. She recounted a busy ward with four nurses tending to a number of patients and having no prior conversation or information from any nurse or doctor. She was equally clear that it was only after she had mentioned her concerns at what she was seeing to her daughter Y that her daughter told her about an awkward conversation she had previously had with M. And that it was only when she and her daughter mentioned what they were seeing to the consultant Dr K that she first became aware that the professionals had their own suspicions about M. Later in her evidence she recollected speaking to S.N.ELB briefly in the sluice room before she spoke to Dr K, but it was to say what she saw and it did not alter her clear evidence of not having been informed of any suspicions or concerns. 10.16. X was quite clear that M had done no harm to her, X, and that all she was saying was what she had seen; that this was ‘ not her forte’ ; when it was put to her that she had simply found it ‘exciting’, and that she was trying to ‘build up’ something, she firmly denied that; said that she wished the best for M; and that ‘ I gain nothing out of this’ . 10.17. Y gave a similar but briefer account than that of her mother’s, of seeing the use of a syringe to draw up fluids from a cup between M’s legs and insert it into the gastric tubing, then squeezing A’s stomach and checking on the bag. She had been understandably very much caught up in the anxieties of the health crisis her 16 year old son was facing on 9-10.12.19 and that her memory was not entirely clear. She described a conversation with M on probably 10.12.19, and which she found odd and intrusive. 10.18. She said she did not find M weird at first but that then M’s questions became a bit too personal. She explained that her son was in terrible pain and she did not want to deal with those sorts of questions and so she drew the curtain around his bed bay. She denied knowing M’s name, but that the conversation had taken place after she had offered to get M a drink and M had given her a large Burger King cup to fill. She found some of M’s comments inappropriate (asking about her son’s puberty) and others she disagreed with (M’s views on switching off life support if her child were on it). She was clear that there was no conflict or argument but she just did not like to speak to M as she did not have the inclination or energy to do so in her circumstances. Y explained that her son had almost died the night before and she simply was not up to dealing with pleasantries and she was not in the frame of mind to permit discussions of personal matters. She said she tried to be polite and patient but described having nothing in common save for a disabled child. 10.19. She said that she had noted M appeared to handle A roughly in picking her up and putting her down. She described the squeezing as ‘rough’. She confirmed this handling did not seem to be harming A and that she did see some cuddling and stroking also. Both she and X used the term ‘rag doll’ to describe how M was handling A. She recalled mentioning this handling to S.N.KS on a date prior to the events of 11.12.19, and being asked by that nurse if she had seen M feeding A. She did not recall until she was reminded in cross-examination, that she had mentioned seeing M squeezing A to S.N.KS, which appears in that nurse’s note of 9.12.19: ‘ A mother in the opposite bed mentioned that A was very cute but small, and that she saw mum be quite rough with her, I asked if she saw anything but this mother only mentioned she'd seen mum squeeze A's stomach and nothing else’ . 10.20. Like her mother X, Y was quite clear that no nurse had mentioned or done anything that made her start watching M or think they were suspicious about her, and that she ‘ did not dream anyone was watching M until I spoke to [Dr K] ’. In terms of her conversation with S.N.KS, she had sketchy recall but remembered mentioning the odd conversation she had with M and preferring to draw the curtains around the bed, but that overall she ‘ did not think anything of it ’ (in terms of any suspicions of M) as she ‘ had too much on’ . She described her situation caring for her son as ‘ go, go, go ’ and that she was ‘ so busy’ and ‘focused on her son ’. 10.21. On M’s behalf it is argued that their note of the following evidence from Y is significant : ‘So my mum noticed first. My son very sick so obviously not noticed at first. My mum mentioned. A few nurses mentioned stuff before so I started watching. Said let’s start videoing. Not as much footage as my mum got.’ (My own note is not in exactly these words). It is suggested that this is indicative of some campaign behind the scenes among the nurses, and/or that Y has concealed some level of knowledge about M. Given that Y had an earlier conversation with S.N.KS, which had involved Y referring to roughness and Y recalling the nurse asking something as to whether Y had seen M feeding A, it is not a surprising comment. And an important component of this answer, which fits entirely with the rest of Y’s evidence is that it was not her, but her mother X who had noticed M’s behaviour first on the afternoon of 11.12.19 and mentioned it. 10.22. She confirmed that she had encouraged her mother X to video what they were witnessing once X had drawn her attention to it. Prior to that Y explained that she had not been paying attention to M and had not noticed the repeated syringing, but she had been tending to her son’s needs. 10.23. Y confirmed that she had taken the video of squeezing on 11.12.19 and provided it to the H2 team, and that she had not seen PGM squeezing A but that PGM had been gentle and loving to A. 10.24. The only difference with X’s evidence is that Y believes that at one time she thought she saw M drawing up a fizzy drink like Cola and inserting that into the tubing. She remembers seeing M at one point pouring Cola into her cup, and indeed in the videos it is possible to see a Cola bottle on the table at the end of the bed. She could not remember exactly when and described herself as ‘almost positive’ she saw it drawn up out of the cup and into the syringe before it was inserted into the tubing. She described a dark fluid like Coke. The videos do not assist further on this point and a detailed analysis of the fluids was not undertaken that would identify such a substance. 10.25. OBSERVATIONS REGARDING X & Y : I note that they did not and do not know M, other than as a fellow parent on the same ward that December. They are in no way implicated in the history of the case, but are complete strangers to it and were uninvolved with any previous safeguarding concerns. They have not seen the medical records, nor read the statements of the nurses or other witnesses. At face value, this would mean that they have no reason or motive to lie, nor to interpret observations against M, nor have been influenced one way or the other. 10.26. They are familiar with flushing and venting, due to Y’s son’s disabilities, who is also tube fed and has been in and out of hospital his whole life, which gives them a degree of familiarity with and awareness of what they were seeing. 10.27. During cross-examination on behalf of M, it was suggested that X and Y were somehow caught up in some sense of excitement surrounding the nurses’ suspicions, and were somehow working under that excitement to achieve something against M. I did not hear anything to substantiate this suggestion from any witness. Wisely, neither in cross-examination nor in submissions, was it suggested that X and Y somehow stood to benefit from doing so in any way. In fact the clear impression given was that they were concerned, felt duty bound to raise their concerns, and that this whole process had been a worrying, difficult and upsetting experience. 10.28. In submissions on M’s behalf, it was asserted that X’s evidence was given in a way that was unsettling and odd, in that she volunteered she was not friendly with the nurses or under any instruction to video M; and that she lacked credibility given her extreme descriptions, and a failure to report immediately what she said was making her so scared as to shake with fear. 10.29. I do not find these submissions persuasive. I find it unsurprising that a witness should respond to questions relating to over-familiarity or friendships with nursing staff by clarifying the status of their evidence with an explanation of how she came to see, record and report her observations for herself ‘ off her own bat’ with ‘nobody prompting’. As for the description of her evidence as ‘extreme’, almost all aspects of her evidence are visible in the flushing and squeezing videos. Those aspects that are not seen in the videos relate to the frequency with which she saw fluid being introduced to the gastric tube and the frequency of squeezing being applied to A’s stomach followed by checking the bag. I find striking and persuasive her descriptions of the timing of her videos, her regret at not having thought of doing so earlier, the consistency of her descriptions of what she saw, the vivid and detailed nature of those descriptions, and her reference to it being ‘rampant’. These all bear the hallmarks of genuine recollections of M’s actions. 10.30. X is criticised for not reporting this earlier in the day given that she was so shocked and scared. Clearly it was, among other things, the repetitive and incremental nature of the incidents that X was seeing that caused concern, and will have led to increasing levels of alarm. I note also her evidence that she was the kind of person who was brought up to keep your head down and ‘ stay schtum’ . I also note that it is evident that she did in fact report it to S.N.ELB and to Dr K. While this was not ‘immediate’, as submitted, it was the very same afternoon, and straight after they had made the effort to try and record what had been seen which would therefore give some visual back-up to what would otherwise have simply been their words. 10.31. It was also suggested that X and Y have spoken together and thereby picked up on each other’s evidence, for example both using the term ‘rag doll’. Although they said they had hardly done so, it would have been surprising if they had not spoken together at some point. And I note that they clearly must have been doing so at the time on 11.12.19 in order to agree to sit and record what they were seeing. I do not consider that this observation undermines their accounts as outsiders reporting what they had seen. 10.32. I have borne in mind, as I have addressed in more detail elsewhere in this judgment, M’s accounts that she has given regarding the water she was inserting into the gastric tubing, the squeezing of A’s stomach, her movement of the drainage bag, the busyness of the ward. However, bearing in mind all the features of X’s evidence, and the circumstances and surrounding evidence, and all the submissions made in particular on M’s behalf, I can see no reason for disbelieving X’s accounts. Significantly, she has no axe to grind with regard to M. She was impressively straightforward and immediate in her answers, recounting congruent and appropriate responses to what she was seeing – both emotional, and in terms of her own familiarity with similar practical operations; she was open to acknowledging oversights, detailed, consistent in her own account and with the accounts of others. 10.33. Of particularly critical significance are X’s accounts of the frequency and types of behaviour she saw, which I accept. 10.34. I note Y’s own evidence that she found some of this hard to remember and had a great deal on her plate during her son’s admission. I do not consider I have sufficient evidence to take the question of her recollection of the Cola fluid any further. I note that this latter point is not the subject of any submissions by the parties. In other respects her account is borne out by the accounts of others: her mother’s, the nurses’ accounts of witnessing squeezing, and by the videos themselves. 10.35. She was a slightly more abrupt witness than her mother, at one point saying ‘I am not the bad guy here, I’m just trying to help a child’ when she felt pressurised by cross-examination. She was consistent and clear about seeing syringing and squeezing, and that she had suggested that her mother video what her mother had been seeing that afternoon. 10.36. I am persuaded, given the awful worries and responsibilities she described during that admission, that her attention would have been principally on her son and not on other ward attendees, and that she was not previously alerted to any significant suspicions about M. Her description of the conversation with M and her feelings about it ring true in her circumstances, and I do not find that this perception that M was a bit ‘weird’ or the desire for privacy around her son’s bed bay could amount to any significant negative intent towards M on her part. Indeed, I note that drawing the curtain around her son’s bed bay could hardly equate with having adopted any enhanced suspicion from the staff about M that Y was somehow keen to furnish with negative observations, given that it closed her away from any such observations. Equally, I see nothing in her evidence or the combined circumstances overall, and bearing in mind all the submissions made, that would indicate any time or inclination to provide some form of artificial account. 10.37. It appears that the squeezing video that Y took might not have been provided to the staff until the next morning, 12.12.19. It is submitted on M’s behalf that this is significant of a lack of importance that was or ought to be ascribed to it. Given Y’s responsibilities and her lack of awareness of the surrounding details of the case, I find that it was entirely reasonable and even comparatively prompt to provide at about 8am the very next day. 10.38. F himself, during his oral evidence, said he could not think why X and Y would make any of this up – ‘ they have a sick child taking their time and attention and I don’t see why they would make it up’ . Equally, the PGM was very affected by the impact of their evidence and did not see reasons to doubt it, but found it to be one of the most disturbing and persuasive elements of the evidence that she had sat through. 10.39. Both witnesses gave evidence in a compelling, vivid, cogent way. I remind myself to guard against being simply guided by demeanour. I found the congruence of their straightforward expression of their experiences compelling. Their language and evident reactions, both during their evidence and in describing their feelings at the time, were convincingly of a piece with the memories they were recalling and indicative of the genuine concern and shock they felt. 10.40. Of particular significance are the common features of their evidence that correspond with various repeated observations noted by the nursing staff, especially in their contemporaneous electronic notes: M looking around, the blanket, A sitting stomach to stomach on her M, screwing and unscrewing movements, the use of one hand, the syringe, a cup, squeezing A’s stomach, M lifting and looking at the drainage bag. This adds to their, and also to the nurses’, respective credibility. 10.41. THE FLUSHING VIDEOS 10.42. Video 1 is a 59 second clip made on the late afternoon of 11.12.19. It shows M seated towards the end of the bed with A supported in her right arm and leaning stomach to stomach on M and her head resting on M’s right shoulder. There is a pink blanket around A’s hips and over M’s legs. There is a small hospital table at the end of the bed in front of them. At about 5 seconds in as the image moves up to focus on M and A, M can be seen with her right hand holding something through the pink blanket and her left hand pressing the plunger down on a syringe attached to tubing in front of her. She then moves her left hand up to perform a twisting type movement on what may be a clamp that is close to the side of A’s stomach and the PEG-J button, before returning her hand to the syringe and unscrewing it. She then appears to wipe the connector with part of the pink blanket and lifts the syringe up to tuck it into the left side of her waistband and readjust her top at about 12 seconds in. During these actions she has looked to her right and left. She then fiddles beneath the pink blanket, and continues to look both ways until, at about 30 seconds in, she extracts the syringe from her waistband with her left hand, places it into the white paper cup that is balanced between her legs on the bed and draws up some fluid using only her left hand. She then moves the filled syringe beneath the pink blanket and screws it onto something beneath the blanket, using her right hand to again hold an item through the pink blanket. She then moves her left hand up to again undertake a quick twisting movement next to the side of A’s stomach and then brings it down in order to swiftly push the plunger in, then lifts it to repeat the twisting movement and lowers it to quickly unscrew the syringe and return it to her waistband. Again she is looking around, and she then picks up the white cup and lifts it as if to drink from it and rests it briefly against her chest. 10.43. It has been a notable feature of this case that it took several careful viewings, assisted by the pause, slow-motion and rewind functions, for many of those involved in the case to spot that Video 1 in fact showed two syringe-fulls of liquid being administered within a total of about 40 seconds. Most early viewings missed the first syringe-full. 10.44. Video 2 is a 19 second clip taken during the same late afternoon, and shows M undertaking the same movements with her left hand: pushing the plunger in, twisting movement near the side of A’s body, unscrewing the syringe and returning it to her waistband; and with her right hand she continues to hold the pink blanket and to hold onto something beneath it while she performs the screwing and pushing movements with her left hand. Shortly after she completes this manoeuvre, S.N.ELB is seen approaching with an empty drainage bag. 10.45. M’S RESPONSE: 10.46. I have already discussed above M’s explanation given during her police interview. In summary: she was flushing the feeding tubes and/or administering water to hydrate A. 10.47. She told F and PGM that she was carrying out a flush. 10.48. In her second statement dated 3.3.20, the mother said that she flushed A’s tube as standard procedure and was ‘ advised to give A small amounts of water to help with constipation, usually approximately 10ml at a time ’. The mother states that she did ‘ on a few occasions give small measures of water via the tube to [A’s] stomach ’. 10.49. In her third statement, dated 23.4.20, the mother stated ‘ I do not recall whether I was also administering flushes for constipation at this time in addition to the normal flushes.’ This is inconsistent with her subsequent oral evidence. Firstly she said that she did not know if she was administering water for constipation on the video, but later she asserted that the second flush on Video 1 must have been for constipation. 10.50. In her fourth statement, dated 9.10.20, the mother simply specifies that she was carrying out a flush on the videos. In neither the third or fourth statement, nor in the mother’s oral evidence, did she make reference to “ a few occasions ” again. 10.51. As mentioned earlier, she attached to that statement an extract from a pump handbook and cited it in her statement as showing that flushes should take place every 6 hours. This then became 4-6 hours, which I acknowledge is also referenced by F and PGM. But in her oral evidence she compressed this further to 2 hourly if A was constipated, then she added that this might take place as soon as 30 minutes later. When she was later obliged to look at the timing of only a few seconds between the flushes in Video 1, she had to further contradict this earlier version, saying: ‘ Sometimes that was the case but because the bag was taken away and off, a good time to do flushes together, just to save time. Sometimes do quickly, other times wait .’ This was a clear set of inconsistent statements, each one adapting to try to work around the implications or questions facing her. 10.52. In her oral evidence the mother said she believed that in the second flush in Video 1 she was giving water for constipation, but did not have a clear recollection (despite her otherwise very good memory). Whereas in fact: a) S.N.ELB recorded that A had a big bowel movement the night before, b) on 10.12.19 she was noted to have ‘ been passing urine and opening her bowels’ and later ‘ passed urine and bowels opened (loose)’ , c) PGM recorded A having a ‘ good poo’ on 11.12.19 in her own notes, d) there was no sign of pain nor discomfort all day on 11.12.19, e) M checked with no one about whether A was dehydrated or constipated, and conceded that ‘ she didn’t really know’ and that she should have asked. 10.53. Additionally in her oral evidence M provided a further series of unsatisfactory or inconsistent responses. In relation to Video 1: - Initially in cross-examination M demonstrated giving a flush using the equipment. She did this using two hands and looking down carefully at what she was doing. She also explained that ideally A would be laid down to do it properly and that no blanket was needed to carry out the procedure. This is clearly not the position or arrangement in place when she claims to have undertaken three such introductions of water to the gastric tubing on 11.12.19. - Only when challenged that the blanket was there to cover things up did she say it was there to catch gastric fluid – although I note that M had otherwise always explained that the blanket was there to be used as a warm cover for A. This is therefore inconsistent in two ways: either she did not need the blanket or she is saying it was needed to catch fluid; plus she is claiming to be using a cosy cover as a mop-up for gastric fluids, and I note she had also explained how unpleasant gastric fluids were and that you would not want to get them on yourself. - M said she did not want to ask the nurses for a tissue or leave A and go and get one. However, there were many nurses available, including the nurse bringing back the emptied drainage bag. I note that M is also seen smiling, interacting and talking with nurses in videos 2, 5 and 6 and so it is all the more curious that she found it inappropriate to ask for a tissue. I also note that M used tissues to catch milk emerging from the feed tubing on 2.12.19 as observed by S.N.FA. - M could not explain why she was looking towards the nursing desk just as she is first inserting water in Video 1. - She admitted that the port was open and accessible as the nurse was emptying the gastric bag. She said it was just a coincidence that the nurse was away when she was carrying out this flush. - She claimed that she could have been just looking around generally when it appears she is looking towards the nursing station as she puts the syringe in her waistband. - She denied looking towards the nursing station when checking to make sure that the cap was on properly, again she was just looking around generally. - She carried out this action under the blanket, and when she was challenged about it she then changed her account to say that she was not putting the cap back on under the blanket. She changed her account at a point when she was unable otherwise to explain why, if she was replacing the cap under the cover of the blanket, she was not looking at what she was doing as she had earlier demonstrated but was instead looking about. - When initially asked why she had put the syringe in her waistband for 19 seconds between flushes, if not so as to hide it, she did not answer the question. When I requested her to answer, she said she probably decided to give A more liquid ‘ for whatever reason’ – this did not answer the question posed to her about hiding the syringe. - M claimed the nurses were aware she was doing flushes as she had asked for syringes and told them. This is neither recorded in their contemporaneous notes, nor has any nurse given that evidence. M admits not telling S.N.ELB on the day when she was filmed inserting this water on three occasions. - M said that the sterilised water and cooled boiled water ran out frequently/quickly at H2 as an explanation of why she was using the drinking water in her cup. Again, although this is highly surprising in itself (given that the nurses variously told me that sterile water was used on the ward, and this is a leading children’s hospital with many such children fed enterally), it would appear appropriate to have asked for a further supply which she accepts she did not do. I also note that she insisted to the police that this was water she was drinking from the same cup. This was no longer therefore clean tap water, but tainted by her drinking. Again also, this is a cup into which M has repeatedly placed the tip of a syringe which has been screwed into a gastric tube port, which tubing has been used to drain gastric fluids into the bag. That port is therefore likely to bear the traces of gastric fluids which M herself emphasised to me were foul and unpleasant. The whole picture is entirely inconsistent and unlikely, and smacks of giving some sort of cover to having a large cup of water constantly available and in use by describing it as her own drinking water. - When asked why, when drawing water into the syringe at 33-36 seconds in Video 1, she was looking at the nursing desk and not down at the procedure, M said she thought her actions were clearly visible. This was not an answer to the question. - When moving the syringe to the cup she did not look down, but remained watchful. - At 37 seconds M is twisting the syringe to attach it but with a blanket over the port and her hand holding the port through the blanket. M struggled to explain this. Again, she claimed the blanket would catch any fluid coming out. - M could not explain why she would place a syringe in her waistband when this might be soiled with gastric fluid. She claimed she did not throw it away as those going into the stomach port should not be thrown away. She claimed it was hard to get up and put the syringe on the side. She agreed a nurse could have taken it away when returning the bag but she did not ask her. I note that she had a small hospital table with a wide range of items on it just in front of her which she could have used. - She could not explain why she did two flushes where on each occasion she returned the syringe to her waistband. - She accepted she had not told any nurse what she had done. In S.N.ELB’s e-note made at 16.58 on 11.12.19 (and therefore some two minutes after she is seen at the end of video 1 that was recorded at 16.56, and so it is reasonable to conclude that her note refers to a short discussion held with M at that point in the afternoon) she wrote: ‘ As I went to reattach the emptied bag. the PEG port was wet. Mum said 'Oh, the cap must have come off .’ It is astonishing in all the circumstances, if M were properly and innocently providing cleansing flushes or constipation flushes through A’s gastric port, that she did not simply say so at this point. She admitted that S.N.ELB would have been confused by the wet port as she had not told her what she was doing. In relation to Video 2: - M admitted she did not ask S.N.ELB about flushing because she regarded it as a minor matter. - M admitted that the blanket was not being used to keep A warm. - She also asserted that she was flushing the tubes in open view despite doing so under the blanket. - At 10 seconds M said this was her flicking open the clamp with one thumb. - When using the syringe, M admitted that she was looking at the doctors and nurses. - She did not discuss adding water for constipation as she did not think she was doing anything wrong. I note that there is no evidence that she was told that she should not be carrying out flushes/hydration, and her vulnerabilities may explain why she had not picked up on the situation at H2 where there was no obligation to carry out these duties. (PGM had realised this by contrast.) However, this would not explain the failure to tell anybody any information whatsoever about the fact that she was inserting water. As I have mentioned earlier, in relation to her police statement, she was clearly well aware of the significance of flushes for the overall gastric drainage total. 10.54. F’S RESPONSE: I set out here his alarm, concern, confusion, suspicions and queries raised in response to the evidence relating to the flushing videos: - He was very clear in his evidence that he could see no reason for multiple flushes. He said that he and M had been trained that it would be wrong to flush more than once at a time. - If a second flush (or extra water) was needed, you had to wait 30 minutes to allow A’s body to recover, and at home they never did flushes a few seconds apart. - If A was constipated they would leave the water for some time before giving any more. - He recollected flushing was only ever done every 4-6 hours at home using sterilised or cooled boiled water, or after medications or if A was constipated. - He did not recall ever seeing M use tap water. - Using a syringe taken from a waistband was ‘ dirty ’ and inappropriate. - If the syringe was wet it could then get dust or ‘ other nonsense’ on it, ‘fluff’ or ‘bacteria’ and then it would be inappropriate to reuse it on A. - Using water from a cup which M had been drinking from would be unhygienic and inappropriate. - The use of a dirty syringe or dirty water might have resulted in A requiring surgery to change her tube. - At home M would ask him for a clean syringe, and he said ‘I just don’t know why she did not ask for another syringe ’. - He could not see why M did not put the syringe on the bed or the hospital table, and it seemed odd to return it to her clothing – ‘ why put it away first and get it out again? – it does not make sense ’. - He could see no reason why M would be doing what she was doing under or through a blanket, and that he had never seen her do that at home, and that it was odd – why not do it openly if it was just a flush or water to ease constipation? - If doing a flush he said they would use tissues to catch the gastric aspirates (rather than A’s blanket as suggested by M), given the unpleasant nature of the aspirates. - He was certain that it would be very important to tell S.N.ELB that the gastric tube needed to stay clamped to stop the water coming out (if it was for rehydration/constipation), and if it were him he would have said he had done the flush and that it should be taken into consideration, and it was odd that M did not. Otherwise he said that the water would come straight out and could contribute to the overall amounts of gastric losses. - He said that when they flushed they would say when the last one was done so you could know in terms of the next one. - He was also shocked by the video of M squeezing A’s stomach as set out elsewhere. - He could think of no explanation for what M was seen to be doing other than that she was interfering with A’s feeding. 10.55. PGM’S RESPONSE: It is notable that both she and F reflected similar astonishment and concern at what they were seeing: - They always used cooled boiled water in sterile bottles and did not use tap water at home, and they had plenty of little bottles as M had bought many of them. - They did not re-use syringes as they had plenty of new ones available, and it was so much easier to use a new one than to try and clean out an old one using tiny brushes. - They did carry around syringes in case they were needed but did so in its sterile packaging, not in a pocket or handbag. - If flushing you would normally use sterile syringes in full view. - On considering that the thread of the syringe might become tainted by gastric fluids from the gastric tubing she said she was surprised that M then put it back into her clothing. - M never mentioned carrying out any flushing at H2 to PGM, and she would expect to be told as she would be the next carer. She said she found this suspicious. - She noted the failure to tell the nurses as suspicious. - She would not expect flushes to be administered over and over again as X and Y described, and twice within 30 seconds was suspicious. - She had not heard of M’s claim that flushes could be up to 30ml every two hours, but was familiar with the amount of only 10ml every 4-6 hours, and this was what they would do when A was admitted to H1 where they were expected to carry out more duties due to the busyness on the wards. - Although she acknowledged that no one at H2 had told them not to carry out flushing or hydration for constipation, she said that she would have challenged M if she had seen her doing it at H2 because she was not doing it and we were not involved in that care. She added that she was aware that the nurses were weighing A’s nappies and measuring gastric losses. - She confirmed that the entry ‘ good poo’ in her own notes for 11.12.19 meant that A would not have had constipation. She was also handing over nappies to the nurses and so if she was dehydrated or constipated the nurses would have detected it. She also said that she would have expected M to check with the nurses if she was concerned that A might be constipated. 10.56. THE SQUEEZING VIDEO 10.57. Video 6 is a 40 second long clip. For the first 15 seconds it shows M sitting on the bed with A peacefully lying in her right arm with her stomach on M’s stomach and her head on M’s right shoulder. PGM is just visible seated in the armchair behind and to the left of M on the bed. In effect M’s back is between PGM and A’s body. M has her right arm curled around A’s body and her left arm is free. At about 10 seconds M’s face is turned towards the nursing station and there is possibly something said by M although it is unclear to whom (whether it is to a nurse out of shot, or to the PGM over her shoulder who is just visible seated in the armchair behind M and to her left.) She strokes A’s hair and her upper back with her left arm. A’s position and demeanour does not change throughout, she lies passively as if asleep or extremely quiet against her M’s stomach and right shoulder. 10.58. Between about 18 and 24 seconds M can be seen grasping the side of A’s stomach that is nearest to the camera with her right hand. In effect her right arm does not change position much from encircling and supporting A, but her hand alters its function from gentle support to a tight closing around A’s right side. There is a first short grasp and then a second which lasts for several seconds. M then looks down towards the tubing and the drainage bag, which is just out of sight behind the table at the end of the bed, and at 26 seconds M picks up a light squareish item in front of her and in doing so also lifts sections of tubing leading to A’s stomach and where a tubing connector can be seen. While looking down at it she gives it a quick shake up and down before putting it back. She then immediately moves her hands either side of A’s torso, with her fingers of each hand on A’s back and her thumbs invisible but the position of the hands indicates the thumbs are at the front of A’s stomach on each side. There then follow two obvious deep squeezes applied by M’s hands before the camera moves away. It is possible to see the inward curving movement of the flesh on A’s sides just beneath her ribs as M presses her fingers towards her thumbs. This visible pressure is maintained and gradually changes as M’s hands then move and dip slightly upwards in a curving motion that would suggest a rotating pressure is being applied by the thumbs at the front of A’s stomach. During these movements M is looking around and also down to the position of the drainage bag. 10.59. M’S RESPONSE: 10.60. M’s explanation for the movements seen in this video are that she was attempting to make A more comfortable because of wind and to release air bubbles from her stomach. I note M also told the court that she would only use this method if other methods had not worked, but I consider it would then have been an important opportunity for M to explain what other methods had been tried and failed that afternoon. (This is not any reversal of the burden of proof, but a question of the degree of reliability as to the nature and coherence of the explanation put forward by M). There is no record of A suffering from wind, distension, pain, distress, or similar discomfort in any of the nursing records that day, nor did the PGM recall any such problem in her written or oral evidence relating to that day. 10.61. M agreed that if A was asleep there would be no good reason to squeeze her. She accepted that it ‘looked rough’, but said that this was not her intention. 10.62. M also asserted that she and the PGM were shown how to do squeezing in this way by the community nurse. This was firmly denied by PGM. 10.63. M also claimed that she had been seen using this type of squeezing at home, and that both F and PGM had witnessed this. Both firmly denied this. 10.64. At the point where F was being cross-examined on M’s behalf her case had expanded to put to him that he too had used this method. He was evidently appalled at this suggestion. 10.65. I note that in her October statement, M claims that she only used ‘ gentle pressure ’ to alleviate wind. This appears to be inconsistent with the above assertions that are M’s attempts to explain the squeezing seen on the video. 10.66. M admitted she was moving a tube and looking down towards where the drainage bag might have been, however she denied lifting the bag and denied being able to see the bag in the video. I found her denial that she was lifting the bag on this occasion to be absurd. It could not be another pale square-shaped item that on moving it also lifts tubing attached to A’s PEG-J. This was an obvious lie in oral evidence to evade a clear example of lifting and checking the bag, as had been seen and recorded on other occasions by nurses. 10.67. She denied that this was any attempt to encourage fluid in A’s stomach to enter the drainage bag that afternoon. She accepted that if F was to be believed, and that she had not done this at home, then her actions could be seen as likely to be associated with the flushes and gastric losses. 10.68. F’S RESPONSE: 10.69. F’s evidence on this topic was very striking. He was shocked by seeing this squeezing of A’s stomach, and said in cross-examination that if he had seen M doing this he would have said something and would have ‘ kicked off’ . He was adamant that he would never treat A in such a forceful way and that to do so was very wrong. He said ‘ Why would you do that? She was so little, it would hurt her.’ 10.70. He added that he was ‘ disgusted ’ at M’s counsel putting to him that he did this himself at home. His disgust, it appeared to me, flowed not simply from the notion that he would treat his disabled daughter so roughly, but also at being faced with such an untrue allegation by M. 10.71. I have seen another short video clip, said to have been taken shortly after A was discharged from hospital in mid-July 2019, in which she is crying and her stomach appears taut. The F’s hand can be seen gently stroking A’s stomach. He explained and demonstrated to the court the type of gentle massage he was shown to try and assist with the passage of wind that had built up in A’s stomach. By demonstration, he used a flat hand very gently rocking and smoothing over the front of his body and he described it as ‘ very gentle pushing ’. There was never any suggestion of grasping or squeezing any part, let alone double-handed repeated side squeezes. 10.72. PGM’S RESPONSE: 10.73. The PGM was very clear in her evidence that she had never seen M squeeze A at home in the way seen in the video, and that if she had seen it she would have intervened – ‘ I would have said what the heck are you doing! ’. 10.74. She clarified where she was sitting at that point, down and behind M to her left, and that she had seen nothing of it at all. She was unaware of M doing this and was clearly shocked that it appeared to have happened under her nose and that she ‘ sat there unaware’ . Her feelings of guilt at missing this were evident. It is clear from the respective positions of A, M and PGM in the corner behind, that it is likely that her view of A and of anything happening at the front of M’s body were obscured by the breadth of M’s back. 10.75. She agreed that M was facing the ward when she squeezed A’s stomach. 10.76. She was clear that she had never squeezed A like this herself - ‘ no way’ , nor been trained to do so, nor had seen any other parents in A’s disability group do so (as had also been asserted by M). 10.77. If A’s stomach was bloated and tight the PGM told me that they would never squeeze it, but that they would use a syringe on the gastric tube and gently push the air out that way. She described gently pushing down the body, giving a similar description as F, and that she had seen M performing a smooth downward push at home, but only using gentle pressure. 10.78. She said that it was an ‘ awful shock seeing the squeezing – her poor little body so thin – that was awful ’, and that this squeezing video was the most shocking. 10.79. In terms of venting, PGM said that they would use a syringe or careful squeezing of the air out of the bag, and they would use tissues to make sure no fluids leaked anywhere. She added that it would be no problem asking the nurses for tissues at H2. 10.80. CLINICIAN’S EVIDENCE - SQUEEZING: 10.81. No professional described the method M claimed to be using as an appropriate method to relieve gas trapped in a child’s stomach. At most, Dr V (A’s treating gastroenterologist) provided a very general response that removing the drainage bag and/or applying pressure could be methods used, but he did not go into detail as to the nature of the pressure that would be advisable. 10.82. Recognised methods of venting were referred to as follows: a) Attaching a syringe to the tubing leading to the gastric port, unclamping and removing the plunger, then raising the syringe up to permit the air to exit through the tubing and the barrel of the syringe. This would prevent leakage of stomach contents because it would be caught in the syringe. Dietitian DM described this in oral evidence. All three carers were trained in this method by a community nurse, as confirmed by the PGM in her statement. All agreed this happened at home. It is clearly demonstrated in a short video clip where gases can be seen escaping into the barrel of a large vertically held syringe and bubbling through traces of gastric fluids at the bottom of the barrel (video 9) . The H2 nurses also carried this out on Savannah Ward as did the paternal grandmother (under the supervision of S.N.IBY). b) Either removing the drainage bag to vent directly via the tube (without a syringe), or venting directly via the bag where gases collected. Removing the bag to vent via the tube was not recognised universally as a routine practice for venting. S.N.ELB for example said ‘generally with venting you attach a syringe to a PEG and get the air out … I have not seen the (taking drainage bag off method) before. I have never seen anyone unattach the tube and let the air out’. Others saw that that could be a way to vent via the bag: Dietitian DM accepted in oral evidence that, if the drainage bag was connected, you could ‘ let air out by undoing it at the top’ but went on to point out: ‘However, the problem with A was that when her drainage bag was on it was full of liquid. It would be very difficult to manoeuvre that volume of liquid in order to let the air out of the bag’ . Given that F also refers to it in his police statement by implication when he described ‘The drainage bag would also inflate with stomach gas which would need to be vented so that there was room for the liquid and to make A more comfortable’ it appears likely that this was a method used at home despite the risks of spilling gastric aspirate, which is described as very unpleasant. c) Using gentle pressure to assist in the passage of the air out of the stomach via the gastric port tubing, as described and demonstrated by F and PGM. This was recognised by S.N.ELB and S.S.N.ZS, although neither accepted that the squeezing or prodding that they had seen fell into this category. 10.83 The following are examples of evidence from professionals commenting upon squeezing or massage, or who witnessed M squeezing A’s stomach: a) Dietitian DM was asked about it, before video 6 was produced. She was asked (in cross examination on behalf of the children) whether she had advised or heard of the practice of putting adult hands around a child’s abdomen and squeezing and confirmed that she had not. b) S.N.ELB described what she saw on 10.12.19 in her contemporaneous note: ‘ I witnessed mum squeezing A’s abdomen hard and then looking at the free drainage bag’ . In oral evidence about this occasion she said this: ‘ A was on Mother’s lap, facing the Mother, holding her abdomen and squeezed tightly – not seen manoeuvre like that before - I have seen children being gently massaged but nothing like that. It was definitely an in/out motion. It stands out because it looked quite strong. And A was tiny. It looked over the top for a child of her size … on that occasion there were 2 presses … then Mother looked at the free drainage bag – almost at the same time she would turn and look … ’. I note here the H2o between this nurse’s evidence and what can be seen on the video and what was described by witness X. c) S.N.ELB also set out in her contemporaneous description on 11.12.19 at 15.57 (written a minute after her observation according to her e-note) was: ‘ Watched mum squeeze A’s stomach very hard 3 times in a row as she was sat on her lap’ . In oral evidence she said the mother was ‘ doing the same thing … the squeezing of the stomach’. d) S.S.N.ZS’s contemporaneous description (at 14.35) of what she says she saw on 11.12.19 was: ‘… Since Mum has been present with A, she is constantly fidgeting and moving A and moving the blanket to cover A. She prodded her in the abdominal region approximately 4-5 times pushing in approximately ¼ depth of her body .’ She confirmed her observations in oral evidence, describing ‘ 4-5 short sharp squeezes’ , and she was clear that what she had seen was not a gentle massage, and said it was ‘ extraordinary’ ; ‘ it was not a gentle massage … it wasn’t massage that mum was doing’ . She also demonstrated what she had seen – with her fingers on one side and thumbs on the other – as in the video; and when asked why she described it as ‘extraordinary’, her response was ‘ the force’ . She also said ‘ I cannot think of a reason as to why you would need to prod a child in the abdomen in the manner that [M] did’. f) S.N.KS told the court that, on 9.12.19, another mother of a patient on the same ward as A (witness Y) had seen and expressed concerns about M being ‘quite rough’ with A. She described Y had demonstrated what she had seen: ‘ She was squeezing her stomach and nothing else … don’t remember if one hand or two …’.

11. NURSES 11.1. I heard evidence from 22 members of H2 nursing staff. I have summarised some of their key contributions in the history set out in section 8 above. I have been greatly assisted by and paid close attention to various schedules provided by the advocates in sifting through the volume of evidence both written and oral. I discuss their evidence in some further detail below, and in particular with attention to their contemporaneous documentation, as it provides some key insights into their observations at the time, and how their subsequent written and oral evidence may have added to the picture. 11.2. The nursing records are voluminous. Of particular help and insight has been the electronic noting records. Each nurse could make entries by computer in the ‘e-notes’ which would then show their name and the time and date. Some clearly followed a template with set headings, and others were simply briefer notes of particular incidents. I have been particularly impressed by the professionalism, detail and regularity with which these notes were kept. They gave a real insight into the events and practices on the wards in question. 11.3. The nurses also kept and explained to me various hand-written records. In particular, I was referred to and assisted by the following: - Fluids Charts, which showed regular recordings of weights, fluids in, fluids out, in a tabular format with entries under the relevant columns made against specific times. There was a column for any particular comments, used for example to describe the colour or other appearance of the gastric losses and each set of entries bore a set of initials to indicate the nurse who had completed them. - Feeding Pump Alarm Record/Significant Events Document. The entries begin shortly after 1pm on 6.12.19 after Safeguarding Nurse Specialist BM was alerted to the concerns of the nurses as to what was being witnessed on the ward, and put in place an Action Plan which included the need to systematically document all witnessed concerns. This record was completed by hand using a tabular format headed Date, Time, Position, Action, Comment. Brief descriptions were included and the presence of which family members or other notable features was often noted. Again entries were initialled. 11.4. There were a number of typed records of a wide variety to which I was referred. Some were simply of the usual type of medical and hospital records created, ranging from medication charts to ward round e-notes. Others were attempts to turn into typed format some of the information held in the hand-written documents. Some of the latter were more accurate than others. For example the ‘Fluid balance of PEG Aspirate covers 2.12.19 to 20.1.20 and has been referred to in short form as the ‘Aspirates Chart’. It is a helpful summary of some of the data from the Fluids Charts and has provided an understanding of what aspirates were measured when and which family member was present. The typed version of the ‘Significant Events Chart’ was less helpful. It had been created at speed by Safeguarding Nurse Specialist BM over a very short timescale between 6.12.19 when she was first informed and contacted the LA and 9.12.19, to assist with urgently called meetings. It clearly contained cut-and-paste errors which she acknowledged and which were comprehensible in the circumstances. They were clearly unintended errors due to haste and without sinister intent as the source documents were provided. I found the source documents more helpful and ignored this chart. 11.5. CRITICISM OF THE NURSES’ EVIDENCE – The principal criticism of the evidence provided by the nursing staff was posed by M’s submissions that: ‘the hospital was on “red alert” about A’, as shown by the red sheet that PGM saw on A’s paper file; ‘they’ refused to accept this and that this therefore undermines ‘their’ credibility; and because the professionals were somehow thwarted by the conclusions of the previous proceedings that they were intent on gunning for M at some later point and used this opportunity to do so in some artificial way. The suggestion was made that M’s history and the details of the previous care proceedings were known to the H2 staff due to M being under supervision for visits that took place during those proceedings. M claimed that her experience as of a range of medical staff appeared to be aware of this history, both prior to the end of the previous proceedings, and during the November admission. This all, it was submitted, led to a particularly negative attitude to M and hence to an ‘evidence gathering’ exercise based on confirmation bias. Negativity, gossip, lack of empathy and objectivity were, it was submitted, what led the nursing staff to read too much into what were innocent behaviours. 11.6. To fuel this argument I was provided with a comprehensive schedule by M’s representatives of almost all the comments made by all the nurses who gave evidence that touch upon this topic, to which I have paid close attention, but which I did not find provided the substantiation for this submission. I was additionally provided with a shorter table on behalf of the LA. 11.7. Most of the nurses were not asked about whether they were aware of the previous proceedings and safeguarding concerns. Of those that were: - S.N.s AA, and KS and S.S.N.ZS confirmed that they had some awareness. S.N.AA said she had been told about them at handover, she was aware that they had concluded but had no specific knowledge of what happened. S.S.N.ZS recalled being a nurse involved in A’s care in February 2019 and so was aware that there were previous proceedings but could not remember what information was shared with her, nor did she know the outcome. She wrongly thought that A had been in foster care and then returned to her M. S.N.KS was aware, through her care of A in February 2019 that social services had been involved but she was unaware of previous proceedings until M had been excluded from the ward in mid-December. - S.N.ST had previously briefly cared for A in February 2019 but said she had no recollection, and that even if she had remembered it would not have affected her account in these proceedings. - S.N.FA recalled that Safeguarding Nurse Specialist BM had told her on 6.12.19 that there had been previous court proceedings regarding another child but went into no detail save that the case was closed and there were no further safeguarding concerns. She said that this was mentioned to her at the point when she contacted SNS BM on that date to escalate her concerns as to what she had been witnessing on the ward. She made two calls to SNS BM, around the middle of the day and again that evening. It is further suggested that because of the recording made by S.N.NH on 6.12.19 when receiving A onto Savannah ward from S.N.FA there is reference to the previous proceedings and to A having been in foster care, and that therefore this information must have been passed on to S.N.FA by SNS BM for it to have been shared with S.N.NH. Neither S.N.FA nor SNS BM recall this piece of information. It is suggested that this proves that there was far more information circulating among the nurses than has been admitted to. - SNS BM said she was unaware of this family and did not know about the previous proceedings until these concerns were raised with her on 6.12.19. There is no evidence to suggest otherwise, save for a single email in May 2019 where she is responding to a request for email addresses of professionals to whom the outcome of the previous case needed to be sent. While the email suggests some awareness (it refers to ‘the [NN] case’ using the relevant initials), there is no indication that this meant she had acquired any detailed knowledge of the previous proceedings or of this family. Later in her evidence she said she only found out about the safeguarding concerns at the meeting held on 10.12.19. However, I note that in her statement she writes, and also stated in her oral evidence, between the two calls with S.N.FA she contacted the LA and spoke to the duty social worker and indeed passed on advice from that social worker to her safeguarding colleagues. It strikes me as possible therefore that S.N.FA may have correctly remembered being given a brief outline from SNS BM as to there having been previous proceedings (and possibly the information as to foster care), which outline was likely to have been given to SNS BM by the LA and passed on by her to S.N.FA during the second call between them, albeit that S.N.FA thought this was during the first of their calls. Equally, SNS BM is also likely to be correct that it was not until the meeting at which the allocated social worker attended on 10.12.19 that she would have learnt of the detail of previous safeguarding concerns. 11.8. In M’s submissions some emphasis was placed on the role played by SNS BM. She was the only member of the senior safeguarding staff to give evidence, although there were several others involved. This was primarily due to her having been the safeguarding nurse who received the initial referral from S.N.FA and then put the Action Plan in place and prepared the documents I have referred to above. It was suggested, albeit indirectly, that she bore some degree of responsibility or had some degree of control or influence over the conduct or attitudes of the nurses then charged with observing A and recording their observations. I note that few of them came into direct contact with her, and that she was more heavily involved in the administrative side of her safeguarding role: preparing the documents I have referred to, attending the meetings with the LA, and liaising with senior colleagues as to the appropriate plan. She clarified that the management of handover discussions was not her remit and she would not know what was done on a particular ward. She clarified the nature of handovers that could be conducted in various ways. She emphasised that ‘ all nurses are expected to adhere to the Nursing And Midwifery Council guidance where a number of standards are set out to maintain registration. These would cover confidentiality and sharing of appropriate information and which I would expect our nursing staff to adhere to. … Nurses are expected to share proportionate information to ensure safeguarding and regarding the direct care of a child .’ She was clear in her evidence about the plan advising nurses to document their observations clearly, but she had no discussions with the nurses as to how they should conduct particular interactions or conversations, save that proper guidance was given in accordance with the RCPCH guidelines that M and family members should not be alerted to any potential FII concerns. It was clear therefore and I accepted, that even if she had some degree of awareness of the prior proceedings and while she was the lead safeguarding member of the nursing staff to whom these staff nurses and senior staff nurses would go if the situation required it, that she did not direct or machinate their personal day to day observations and interactions, and that the clear message repeated to me by almost all the nurses was that they were to carefully observe and record in their e-notes any issues of concern, complete the fluids chart carefully, and fill out the feed pump alarm sheet as necessary. 11.9. It is another point of criticism within this submission made on M’s behalf to suggest that she was unfairly treated by the hospital. It was submitted that if the hospital’s concerns had been openly put to her she could then have readily explained that she was providing water for flushes or for constipation. Firstly, I note that this would have been contrary to national guidelines as mentioned above. Secondly, this might make sense except that the only occasion when M has accepted that she was flushing/hydrating was when she was filmed on 11.12.19. It is notable that throughout her evidence, when being asked to explain all the various observations by the first parent, by S.N.FA, by the nurses on Savannah ward, she has not once explained that the actions she was observed undertaking had anything to do with flushing/hydrating, nor did she volunteer she was doing so while on the wards nor openly undertake it. She has simply denied that any of her observed action have any such significance at all and that she was simply fidgeting or touching A or some other innocent movement. It is therefore, I am afraid, a specious point. 11.10. I do not doubt that PGM saw a red sticker on A’s paper file as she describes. Her evidence did not go so far as to recall who spoke to her about it and I have no evidence as to who would routinely see and handle the paper file. It was not a question raised with the nursing staff. The evidence I have heard from SNS BM is that there was no specific ‘alert’ on A’s file about these or past concerns. She explained the e-noting system, used by the nursing staff, and that there was a hospital protocol where standard parts of the e-noting file in the form of information boxes at the head of the file were completed as appropriate and were present on all patients’ files. These would refer to whether the child was a Child In Need, a Looked After Child, or on a Child Protection Plan, and would relate to the protocol for information sharing with a LA to inform them that a child had been admitted. She could not say what had been set out in that box on A’s file as she had not studied her records since this period. I note that the nurses on Beach ward who cared for A during the period she had that operation on 3.12.19 all consistently confirmed that they had no prior knowledge of any safeguarding concerns or of the previous proceedings. 11.11. Most of the focus of the questions put on M’s behalf to the nurses on this topic related to the degree of discussion between the nurses, and the degree to which they were primed or influenced to gather evidence. I note here that most of the nurses were firm and clear as to the propriety and necessity of handovers, and that these were the primary focus of their discussions with each other about A and any concerns. It was clear that other discussions would, necessarily, occasionally take place and that there were spaces it could be done discreetly. However, there was no sense whatsoever of loose talk, excited or exaggerated gossiping, inappropriate information sharing, nor any example of building up a case. One such example of treating information with discretion and lack of egregious gossip was S.N.ST recording numerous concerning observations in her e-notes on 7.12.19, such as directly witnessing M pinching the tubing, but not unnecessarily sharing that detailed information of her observations in chat with her colleague on the day shift S.S.N.EDC, nor in her handover to S.N.IBY. 11.12. It is notable that the nurses did not all work on the same wards and did not all know each other. One example is that Senior S.N.IBE from Beach ward was asked about S.N.FA and made it plain that she did not know her at all. Another particularly good example is S.N.FA, who worked on Mountain ward, and S.N.NH, who worked on Savannah ward and was the nurse to whom the former transferred A’s care on the evening of 6.12.19 after the concerns had been raised by S.N.FA. In accordance with proper procedure S.N.FA then had to provide a handover to S.N.NH, namely a formal discussion of A and any relevant issues. When being questioned about her knowledge of and discussions with others S.N.FA had to remind counsel that she did not work on Savannah ward. She also pointed out in this context, when being questioned about the handover information which S.N.NH had recorded in her notes, that she did not know S.N.NH at all and could not be responsible for her note-keeping. 11.13. I note that S.N.FA also openly explained during her oral evidence that the nurses on her bay had all noticed a pattern that the alarms were occurring when M was there and not when PGM was there. The note of evidence provided on M’s behalf reads as follows: ‘On 6 th , constantly occluding and noticed pattern. Not occluded throughout the night. Throughout the day constantly occluding. Odd behaviours of patterns. That [was] when contacted [BM] on 6 th . (Q: So were conversations about pattern?) Yes, about pattern rather than saying suspicion. I spoke with night nurse looking after A and they would give feedback in relation to how alarm go off. We would notice constantly occlude since M arrive and not overnight. (Q: Who is we?) All the nurses in the bay.’ Firstly, it is important to observe that handover and feedback were important elements of proper nursing care, and they had noticed a pattern. Secondly, all four nurses from whom I heard evidence from Beach and Mountain wards (S.N.s FA, PMDC, MF and NK) were clear that they had no prior knowledge of background information/safeguarding issues/previous concerns relating to A or M at this time. Thirdly, when asked, both S.N.PMDC and S.N.NK (S.N.MF was not asked) confirmed that they were not aware of the information that another parent on the ward had reported to S.N.FA on 2.12.19 (that she was worried about M’s behaviour using a syringe to pump water into A and which report S.N.FA passed on to A’s allocated nurse (S.N.AdAd)). From this can be concluded that: - not only was there no gossip passing between the nurses, - they had independently made their observations without having had any knowledge of safeguarding concerns or previous proceedings, and without the report made by another parent on 2.12.19 to S.N.FA being made common knowledge between them. 11.14. This becomes all the more important in the context of this submission, when one considers the important similarities of: a) the report and observations made initially on Mountain and Beach wards, b) then the subsequent observations made on Savannah ward, c) then as independently witnessed by X and Y, d) and then actually visible on the videos which I have analysed in depth above. This is an important point that is made on behalf of the Children's Guardian (also referred to in paragraph 10.40 above), which I entirely accept. In doing so, I also note that while there are corroborative thematic similarities, there was absolutely no sense that any of these witnesses had been copying or artificially repeating or reinforcing each other’s accounts – each witness had her own particular detailed observations, varying in small but natural respects, with their own mode of expression and demonstration. 11.15. Reliance was placed on comments made by S.S.N.ZS. She wrongly believed that A had been previously placed in foster care. She had been involved in February 2019. She agreed she had formed a negative view of M. She went on to describe the nature of ward safeguarding procedures and child protection priorities, and placed her views in that context: ‘in our profession it is very hard to understand why somebody could possibly want to cause harm or do something that might cause harm’ . She agreed that M was under strict surveillance by 7.12.19 and that she could not remember who she had talked to prior to 11.12.19 by way of doctors or nurses ‘because there was so many of them.’ I note that she firmly explained that these discussions were in the form of handovers and not gossip, and was about child protection. I consider the term ‘surveillance’ that she agreed with, as being a term she was content to use to describe the plan of observation and recording of any concerns that was in place. I do not consider it adds anything sinister. I agree that she came across as a less sympathetic witness than some and was more abrupt in her answers. However, I can see no criticism can properly be levelled at her for expressing a duty to protect the child given that patient safety is a nursing priority, nor can it be extrapolated generally to undermine the evidence of her colleagues. 11.16. Given the events of 6.12.19 and the inception of the Action Plan to log any concerning observations from that date, it came as no surprise to me that most of the nurses accepted that they were aware of the need to closely watch and document M’s activities on the ward, and that there would have been numerous handover discussions that must have included reference to these issues. This was what they had, in the circumstances, rightly been asked to do. I was consistently impressed at the dignified and professional manner in which they fielded rigorous and testing questions in this respect, explaining the nature of the plan and their tasks of observation and recording - a particularly good example of this was Senior S.N.IBE. More than one of them referred to their nursing code of conduct and professional standards, and to the need to keep discussions to an appropriate and professional minimum, and to keep as good and accurate records as possible due to medical records effectively being legal documents created by their respective authors. This was further borne out by the nature and tenor of their note-keeping which avoided emotive language despite some of the concerning issues they were recording. 11.17. It was certainly the case that several of the nurses found it difficult to comment in positive terms as to M’s mothering skills and caring behaviour generally. In circumstances where they have been recording concerning observations, which were then also independently witnessed and filmed, I am not entirely surprised that they found such questions hard to respond to easily, or to respond in an immediately empathic way. I do not find that this undermines the quality of their observations overall. 11.18. Reliance is also placed on a comment said to have been made by Ward Sister AS that nursing staff were likely to see what they expected to see. My note and recollection of her comment was in the context that she politely agreed with the proposal that one might notice things if you are approaching this with a suspicious mindset to look for things. She was a more mature witness, with a somewhat deliberate and very accommodating manner. She was the Senior Staff Nurse on Savannah ward on 9.12.19. It did not surprise me that she agreed with such a statement. I bear in mind at other points in her oral evidence that she emphasised the importance of considering safety issues, reassessing when a patient is new to a ward, the need to take care with any safeguarding issues as there is a need for evidence or something concrete or it may be unfair to them (carers), and that she was trying to provide objective documentation of what she saw. I note with approval that she said to the nurses on her ward to be careful because they might not know what M might be having difficulties with. While I am of course alert to the risk of confirmation bias among the nurses’ and their evidence, I do not think her comment relied on at the top of this paragraph goes any way towards establishing its presence here. Equally, her warning to her team of nurses and her own careful observations and mature presence on the ward is likely to have meant that their observations were all the more carefully made. 11.19. Accordingly, for all the reasons discussed above, I do not find that the criticisms made on M’s behalf of the nurses’ evidence are well-founded and I reject them . 11.20. MOUNTAIN WARD NURSES – 29.11.19-2.12.19 11.21. I did not hear from Staff Nurses JC, H, CBD, AR or AdAd . I have set out their involvement in the history above. The e-notes of nurses H and AR who were on duty overnight showed no alarms were recorded. S.N.AR noted periods of A being unsettled and dystonic during one night, but no alarms. When attempting delivery of a bolus of glycojuice/milk/Dioralyte directly into the jejunal port both nurses JC and CBD experienced difficulties, with A becoming upset, and a feeling of resistance or backing up of the fluid. M suggested to S.N.CBD that it was due to ‘inner dystonic episodes’ . And on both 30.11.19 and 1.12.19 S.N.CBD noted that at about 1pm which was about one hour after M arrived on the ward the feed pump alarm began going continuously. 11.22. I have set out the extract from S.N.AdAd’s e-note in the history above where she mentions the alarming beginning once M arrived on the ward, and which includes the report given to her by S.N.FA of what another parent thought they had seen. I deal with S.N.FA’s evidence below. 11.23. BEACH WARD NURSES – 2-5.12.19: 11.24. I did not hear evidence from Staff Nurses L or P who cared for A overnight on 2-3.12.19. An occasion of upset and dystonia was recorded – but no alarms were noted. I did not hear evidence from Staff Nurse M who cared for A overnight on 4-5.12.19. No alarms nor dystonia were recorded. 11.25. S.N.PMDC was a careful witness. She looked after A on the day of her operation to change the PEG-J on 3.12.19. Her e-note, although less detailed than many of the nurses’ notes in terms of her observations of the alarms was detailed regarding A’s medical needs that day. She gave the impression of a strong focus on the clinical needs of her patient and was somewhat less detailed in the surrounding observational issues. She noted extremely frequent alarming from about an hour after she restarted A’s feed at 4.30pm and going on throughout the afternoon and evening until she left her shift at 7.30pm. She noted no dystonia or any other cause such as kinking. M was present throughout. She also provided a helpful explanation of the function of the ports on the tubing and that it was possible to insert fluid via one of the Y connector ports even while another item might be connected to the other limb of the connector, and thereby, depending on which tubes were clamped, could direct fluid through either of the other limbs of the connector, whether that would be towards the PEG-J button, the drainage bag or other tubing. And she described, accurately in my judgment given my own opportunity to view the handling and nature of the tubing, that the purple tubing of the giving set is soft and easy to bend. 11.26. S.N.SM was the allocated nurse for the night shift on 3-4.12.19. Her e-notes had little detail as to the alarming but confirmed there were none overnight while A slept and no dystonia. Her statement and oral evidence expanded, and I found her to be a straightforward witness who tried to be helpful, but was somewhat less precise than some as to timings. M was still present on the ward when she came on duty in the evening due to the operation earlier in the day, and the alarms were still going. She recalled that it was every time she left the bedside it would start again: ‘Remember continuous: go to bedside, walk away, alarm go, walk back to bedside. Only alarmed when I left bedside…Me and mum discussed A having dystonia- was belly cramping, causing milk to go back down tube, but nothing else could think of…No experience of dystonia causing alarms but because M talking about it, sounded plausible .’ She recalled PGM arriving after she started her shift and M then leaving at about 8.30-9pm and that they were only there at the same time for about 15 minutes. She could not recall alarms when only PGM was there but clearly remembered PGM going to bed and A sleeping and no occlusions for the rest of the night. A ward round note the next day refers to the alarm beeping for 2-3 hours the previous evening. Despite these two nurses’ somewhat approximate timings, this would appear to fit within the parameters of an hour after A’s feed began(c5.30pm) until M left (c8.30-9pm), and not overrun into a period when only PGM was there. 11.27. S.N.NK was on duty during the day on 4 and 5.12.19. She was a junior newly qualified nurse at time, and she presented as nervous, open about what she could not remember, keen to get things right but significantly less precise than some of her colleagues. Her e-note for 4.12.19 notes M arriving at ‘approx 11’, and that she left at about 5.30pm. She noted alarms began constantly going from about 10.30am. In her oral evidence she clarified that ‘ I put in approximate times as it was very busy that day and I was not mindful of the times’ . She had never seen such frequency of alarming before throughout 3 years of training and subsequently, and she noted that it was only alarming when A was lying on M. She checked tubing, clamps and roller all the way from bottle to PEGJ on A, and the tubing was under a blanket. She thought it had occurred once when PGM was holding A, but then said in fact she could not remember that. She could not remember PGM being present but nor could she remember her leaving the ward (in fact PGM visited a supermarket and crossed […] bridge during her time away from the ward that day). She recalled that on two other occasions when she had been on overnight duty and only PGM was present, there had been no occlusions. She corrected her note to referring to A’s ‘foot’ rather than her leg being flexed on an occasion of an alarm, but otherwise saw no cause nor direct interference, and agreed that it was M who had raised the possible explanation of dystonia. 11.28. MOUNTAIN WARD NURSES – 5-6.12.19: 11.29. S.N.MF was allocated to A overnight. No alarms were noted. She had little to add in her oral evidence save that despite close quizzing as to background knowledge and gossip she was very clear that she knew nothing of the history nor of any discussions between the nurses about M. 11.30. S.N.FA is a significant witness. She is a young nurse. She responded to questions rapidly, and on occasions in a slightly more hasty, vague and excitable way than her colleagues. As I have discussed above she was unaware of any previous history about M or A at the time she was on Mountain ward for the events of 2.12.19 and again on 6.12.19. 11.31. In her statement and sustained in her oral evidence, S.N.FA described the pump alarming constantly alarm while M’s hands were over A but under the blanket, and that she saw a kink in the tubing. 11.32. She clearly gave an account to her colleague on 2.12.19 of a parent caring for a child in a bed opposite A’s where her colleague recorded in her e-note: ‘ Staff nurse [FA] reported that parent in opposite bedspace stated that she was unsure if mum was doing anything to the child as she saw mum with syringes pumping it into A. Earlier there was a pool of water under A’s bed which unsure where came from’. S.N.FA did not complete an e-note as she had given the information to the allocated nurse who had recorded it. That nurse reported it to the Nurse In Charge on the ward. It is worth noting at this point that, contrary to hospital procedure, it was mistakenly not then escalated to the safeguarding team, who therefore had no involvement with S.N.FA until 6.12.19 when it was escalated following her further observations. 11.33. In her filed statement dated 7.9.20 she wrote : ‘ On the same day [2.12.19], a concerned parent that was sitting opposite A's bed space, confided in me with confidentiality that [M] was doing something under the blanket and in her opinion [M] was constantly watching if anyone was looking at her. The concerned parent stated she has no knowledge of the situation but felt the need to report as [M] was deemed to be behaving in suspicious manner. The concerned mother described [M] to be holding a syringe and water leaking on the floor by the patient bed space, which I have witnessed and found it strange where the water was leaking from.’ 11.34. She has been criticised in relation to this account for subsequently varying her description of the water: pool, 40-50ml, massive leak, puddle. I note that the word ‘pool’ is not from her own note but her colleague’s and may have been what her colleague had noticed under the bed herself. She is also criticised in that, when taken to this account where it says ‘pumping’ and to another account of the incident that is recorded on 6.12.19 by a Dr D where it says ‘injecting’, she denied or could not recall using those words. She is criticised for the expansion in her statement of the inclusion of the blanket and ‘constantly watching’ and for saying in her oral evidence that she thought the water must have come from the syringe. 11.35. She told the court: ‘ Other parent said water was coming from syringe. Other mother described syringe as underneath something … remember her saying suspicious, hiding syringe under something – blanket or clothing … she was quite scared. Did not want to get into trouble … she said mother kept looking around at nurses. Whenever nurses were busy, that was when she would use syringe. She just mentioned about suspicious behaviour and fact M had a syringe underneath a blanket or some piece of clothing and that was where the water came from. Impression was pushing something in … did not specify exactly …’ 11.36. While I must and do remind myself of the hearsay guidance, I note that while there may have been some more excitable wording used as to the water, and she cannot recall using the words pumping/injecting to her colleagues at the time, there can be no doubt that she did pass on to her colleagues the bare bones of this report from another parent firstly on 2.12.19 and again on 6.12.19. And it has not been suggested that the e-note of S.N.AdAd who recorded this on 2.12.19 is in any way fabricated or false. Thus this initial account is important. It chimes significantly with what was seen and filmed by witnesses X and Y. That in itself provides corroborative support for S.N.FA’s account of the report. But it also undermines the suggestion made on behalf of M that she is a ‘manifestly unreliable’ witness in this respect. 11.37. In her e-note of 6.12.19 she wrote: ‘Contacted safeguarding and gastro team due to since Mum being present the pump for the jej feeds have occluded at an numerous amount due no factual or medical reasoning. I have found Mum clamp the line and kink the line during shift, I have informed relevant professionals such as NIC, Deputy sister, Senior nurses, Safeguarding B and Matron R. Since then we have followed protocol of moving A closer to the nursing station and only nurses are allowed to respond to the occulusion only and not Mother as Mother has been reported to respond to the occulusion by unwinding the tubes and allowing milk to leak through. We have placed the tubes away from Mum and recorded the time each time it occuluses. Reported back to Safeguarding that since the move the pump alarms have decreased. PEG is on free drainage, mum has been seen to unattach the free draiange and reattach it. I have asked her to leave it alone, she reported it has started to leak. No previous leak mention before . … Mum has been seen to be fiddling with the JeJ tubes to cause occuslion she has clamped the extension while the feeds were running through. I have asked her strictly to place A in bed so we can monitor the occultion and find the causes. Mum said she will comply however she said she wants to cuddle A and she shouldnt stay in bed all day. I informed her that isn't the case and it just to find the reasoning behind the pump occulusing. Contacted safeguarding’.’ (typos sic). 11.38. SNS BM recorded this in her own e-note: ‘ Contacted by SN FA who reported that she had been informed that on 02/12/19, when A was in the mountain ward another parent in the bed opposite reported A's mother getting out a syringe out from under her shirt and injecting something to the PEG/JEJ. Reported that this was escualted to the nurse in change, … SN FA reported that the feed pump has been occluding numerous time, she raised concern that when A was in her cot overnight there had been few/no occlusions. However reported that when mother has been present on the ward A has been in her arms with a blanket covering, during which time the pump has regularly occluded and nursing staff had concern that the tube may be being kinked. In addition reported that when the pump alarms mother has been noted to disconnect the time and allow the feed to run into a tissue. I have advised SN FA to have a discussion with A's mother and inform her that she must not disconnect the tube under any circumstances or make alterations to the feed pump. In addition nursing staff to assess the pump and line every time it occludes. Discussion to be undertaken with mother to advise that A is nursed in her cot rather than in mothers arms under a blanket…Action plan: Close observation at all times - Member of nursing staff to remain in the bay with visual contact on A at all times - If the pump occludes please inspect the tube and while line assessing if it has been kinked or clamped…’ , and following a further conversation with S.N.FA a letter was prepared and sent to the LA which I have set out at paragraph 8.93 above. That letter refers to the report from the other parent, the pattern of repeated occlusions when M is on the ward which are absent when she is not, allowing the milk to leak into a tissue, and the nurse witnessing M clamping, kinking and seeing M leaning on the line with her elbow. 11.39. S.N.FA’s filed statement referred to the fiddling, unattaching the tube, leaking milk into a tissue, and to finding kinking on the tube which was reported to a doctor, but like her police statement dated May 2020, it failed to mention clamping or leaning on the tubing. 11.40. In terms of the clamping, she said she had seen it on 6.12.19, she said that when checking the tubes because the alarm had sounded she found the tube clamp was clipped shut under the blanket. She was a little vague but thought she saw this more than 4 times. She did not see M actually performing the act of clamping it. She described finding it clamped shut when the alarm went off having only about a minute earlier checked the tubes and restarted the pump. She did not think it could be an accident given the movements required. It was not clear from her evidence whether the dent/kink in the tubing was as a result of the clamping or a separate observation, however she demonstrated on the tubing how folding it back on itself produced the type of kinks she found. Her regret at failing to include the details of the clamping issue in her police and witness statements was clearly heartfelt and frustrating for her – she said she wished she could go back in time to have made sure it was included. 11.41. In her oral evidence she initially thought she had not seen M leaning on the tubing, but later in her evidence when she had to return for a second day, she recalled it, explaining that being taken to the documents had jogged her memory. Her e-note does not refer to the elbow leaning albeit it was clearly mentioned on 6.12.19 so that it was included in the letter. Her recollection in her oral evidence was by her own admission slightly vague, but she recalled M was in the chair and leaning on the bed and when she checked the lines following an alarm she found M’s elbow on it and said she gently removed it and restarted the pump. 11.42. Her description of the milk running out of the tubing into a tissue turned out to be less concerning than it at first sounded. It was a very small amount she thought, maybe 5ml, and she demonstrated that M was holding the tube upwards in front of her and catching the small amount of milk in a tissue. M stopped doing this when requested. During M’s evidence she explained that she had previously been shown to do this by another nurse on some other occasion to release any pressure or to check the milk was flowing. S.N.FA had clearly found this to be a worrying action because there was concern to know how much feed and fluid A was receiving and she felt it was inappropriate. 11.43. In the circumstances of her description I do not consider it is appropriate to think of the elbow or the milk into the tissue as suspicious, as the description of the former could simply have been an innocent failure to see she was leaning on the tubing, particularly as M is a considerably large person. And the milk into the tissue was a very small amount and done very openly. 11.44. She could recall little of the OT’s visit to the ward which is referred to in the Feeding Pump Alarm Record. On that record the first entry made at 13.32 on 6.12.19 is by S.N.FA, with A noted as lying down. There follow four more entries between 13.35 and 14.15 indicating pump alarms with A lying down which are entered by nurse colleagues. At 15.00 a colleague notes that A was sitting up with the OT – and it is not suggested that this is an alarm. I note from the OT’s own e-note that it refers to an appointment time of 14.30, and M recollected this appointment took about 45 minutes, suggesting that the OT may have been there from that time until about 15.15. No occlusions are noted during this period. Thereafter, there are ten entries running from 15.22 until 17.10 showing that A was sitting in her blue chair and the pump had to be checked and restarted, five of which entries bear S.N.FA’s initials [FM]. 11.45. At one point in her oral evidence S.N.FA said, in reference to the pattern of alarms, that there were more when M was on the ward and suggested that there were a few or fewer overnight when PGM was on site. I have been unable to find substantiating records of this vague comment, and in fact there is evidence of the opposite as the other Mountain ward nurses who were on duty on the relevant nights (namely S.N.s H, AR and MF – referred to above) did not record any alarms at all. I note that SNS BM’s e-note records ‘ few/no’ overnight alarms in the account given to her. Given PGM’s evidence that she was never woken by an alarm I consider this was an example of S.N.FA’s imprecise approach and that there is no evidence at this time of overnight alarms. 11.46. I note that S.N.NH, a more experienced nurse and more stolid witness than S.N.FA, expressed a degree of frustration in her e-note at the vague nature of the handover information she was given. This would appear to be of a piece with her colleague’s slightly more slapdash approach. And it was at the point in S.N.FA’s cross-examination when she was being questioned about the nature of that handover and why the note did not contain a reference to seeing the tubes clamped that she was briefly in tears. It was clearly a frustrating and upsetting moment to have these problems pointed out to her. She collected herself, pointed out this was not her note, and was emphatic about having seen the clamping and that she thought she had mentioned it (it is in her own e-note). 11.47. I take into account when considering S.N.FA’s evidence that her memory and accounts were not always precise and had elements of an exasperated response to the events she recounted. She can clearly be slightly impulsive and slapdash from time to time. However, I found her to be detailed and cogent in relating convincing accounts of direct experiences of the initial report to her by the other parent, and of finding the tubes clamped shut on multiple occasions and feeling kinks in the tubing. 11.48. SAVANNAH WARD NURSES – 6-11.12.19: 11.49. S.N.NH received A onto Savannah ward on the evening of 6.12.19 and made the next three entries in the Feed Pump Alarm Record between 18.35 and 18.45. She recorded A was in her blue OT chair and M at her bedside (next to her). Her evidence to the court was that when she checked she could find no cause. The next two entries relate to a period when the feed was paused to resupply it, and then M went home and A was in PGM’s arms while the feed was restarted. 11.50. On 11.12.19 she recorded the following in her e-note at 14.19: ‘ Mum currently has A on top of her with a pink fluffy blanket covering them both. Mums hands were both underneath the blanket and could see Mum with left hand moving it a lot, whilst her right hand appeared still, both remained underneath the blanket. Mum kept looking over at the HDU desk and looking away, looking back and looking away again. I interpreted Mum to appear flustered in my opinion.’ I found S.N.NH to be a straightforward and direct witness. She stuck to her description noted at the time. It represents a remarkable similarity to the movements seen in the flushing videos where it is also the right hand that is holding an item still through the blanket and the left hand that is moving around, save that here both hands were under the blanket, accompanied by the repeated looking back and away. 11.51. S.N.IBY was the allocated nurse overnight on 6-7, 7-8 and 8-9.12.19 and noted no alarms or dystonia on those shifts. She was another straightforward, practical witness. She was clear that although alerted to fill out the fluid and alarm charts and watch for those problems, that she was just told to ‘ monitor any family members no one specific’, and that she had not been given gossip or unnecessary details by S.N.ST when she took over from her on 7.12.19. She made three entries on the Feed Pump Record Chart on the late evening of 6.12.19 to note that the feed was paused for medications, not alarms, and a fourth entry on the next evening of 7.12.19 at 21.15 to note that the Dioralyte pump was alarming as the infusion had finished and was not an occlusion. She then added and initialled on the chart ‘ No further events overnight .’ Nor were any alarms noted overnight on 9-10.12.19 by her colleague Staff nurse P nor on 10-11.12.19 by Staff nurse B , from neither of whom I heard evidence. It is in nurse B’s note, towards the end of her note made at the end of her shift on the morning of 11.12.19 that she notes ‘ Passed urine and bowels opened (loose) ’. This is the day when M claims she was hydrating A that afternoon as she was constipated. 11.52. S.S.N.EDC was on duty caring for two other patients that day. She is an experienced nurse and came across as a down to earth, practical minded witness. Unlike S.N.ST she did not make e-notes relating to any of her observations relating to A. She regretted this and accepted that she may not have exact recall. In her police statement and filed statement and oral evidence she did state she saw M fiddling under the blanket but accepted she did not know what that was and it could have been a stroking movement. She stated that M was reluctant to allow the tubing lines to lie over the blanket or for the blanket to be removed and that it was pulled up again shortly after the occasion she requested it should be down. She helped out with checking and resetting after it alarmed on several occasions and found no reason and saw no interference. She did point out the following: ‘I would press start and feed would run completely normal. Few minutes later it would beep again … only reason would be if clamp on or if line kinked. [Q: why is swift resumption of pump not consistent with it being the milk?] because if there is a clump or a problem with the line it would say occlusion again and prompt you to investigate further …’ – that is to say if there were a genuine blockage such as sediment or other impediment, simply switching it back on would not resolve it immediately, as was repeatedly the case here, as the problem would still exist. She also pointed out that it would take more than massaging a line to disperse sediment to produce a kink, and that it was possible to clamp and unclamp using one hand (indeed that is what M acknowledged that she can be seen doing on the flushing videos, and she also showed me how she can open a clamp with a slight push of her thumb). She expressed the opinion that she thought M was causing the pump to occlude by clamping the small white clamp on the tubing, and was then unclamping it. 11.53. S.N.ST was another important witness of contested events. Occasionally she showed the emotional strain and upset at the experience of giving evidence on such difficult issues, but her account remained contained, consistent and coherent. Her responses were straightforward and factual. There was no suggestion that she had remembered or been affected by any memory of her earlier role as one of the nurses who cared for A in February 2019. 11.54. She was absolutely clear in describing what she had seen despite thorough cross-examination. I have set out at paragraphs 8.95-8.98 a summary of her observations. She was particularly detailed about her direct observations of interference with the tubing. She demonstrated by using her thumb and forefinger to bend and pinch together a small section of the soft purple tubing, to show me what she had seen M do down beside her leg that led directly to an occlusion alarm: ‘ Observed M kink the tube … I was at nurses station, M & A on bed, on M tummy … I saw A’s feed pump hanging down and down the side of the bed. M looked over at the nurses station. M grabbed the tube and bent it round, kinked it and the pump then alarmed … no doubt that caused the alarm … caused block in the tube …’. I note that her e-note was brief and this was not referred to in her police statement, but her account was detailed, vivid, natural and she explained that this was what she referred to in her e-note. She is criticised on behalf of M for having failed to share details of her observations that day with her colleagues, and that she would have done if she had actually seen them. Given that she included in her various e-note entries that she ‘ observed M kinking the tube’ , ‘ unscrew the PEG free drainage bag and hold it to her side not visible from the nursing station’ , M covering up the feed line, putting her hand beneath the blanket and the alarm sounding, holding the Dioralyte line down the side of the bed and the alarm sounding with a visible kink seen after, and also finding the jej tube clamped, I do not consider this is a well-founded criticism. 11.55. M admitted moving the tubing back under the blanket, after S.N.ST had arranged it above the blanket. She claimed that it was so A would not pull at her lines, which she claimed was a frequent problem. I note this problem was not observed by the staff to be shown by A in hospital (save for a single cannula issue, and was seen on an occasion during a contact supervised by Ms O). M denied kinking the tubing or seeing any kinks. She claimed if she was seen touching the tubing it was due to smoothing out sediment in the tubing – although I note that both she and PGM demonstrated that two hands would be needed to do this by both sets of thumbs and index fingers pulling away from each other to smooth and squeeze the tube. 11.56. S.N.ST also clearly described finding the jej tubing clamp clipped shut when she pulled back the blanket. Notably, M having suggested in her oral evidence that the clamp may have been closed accidentally, she went on to add that it had probably been left closed by a nurse following the administration of medication. She afterwards accepted that this was misleading given that she acknowledged that no medication had been given at that time and that A was supposed to be receiving her feed through that jej tube at that time. 11.57. She was fair about the timings and what she had seen in relation to the gastric losses between 12 and 2.15pm (paragraph 8.98), accepting that the first loss of 310ml may have accumulated over some time, but that the gap between emptying that loss from the drainage bag and attempting to vent and aspirate, and the subsequent filling of the bag with another 375ml was only about 10-15 minutes. She was also fair about venting being a reasonable activity and the use of massage to assist with it if necessary, and that she saw no syringe or flushing of any tube. 11.58. She made numerous entries on the Feeding Pump Alarm Record. She made eight such entries between M’s arrival on the ward at about 12.15pm, running from 12.55pm to 14.31pm. It was at about that time that S.S.N.IBE spent about half an hour sitting next to M and A and chatting. During that half hour no alarms sounded. S.N.ST then recorded a further nine alarms on the chart running from 15.15pm to 16.50. PGM is shown as present with M for the first one at 12.55, then it is M alone until PGM is noted also to be present from 15.38. S.N.ST, recalled, like many of the other nurses that M had A under a blanket lying stomach to stomach during this period. A ward round took place at 5pm and no alarms took place then or thereafter, with M returning home and leaving PGM with A overnight. 11.59. I have already commented on S.S.N.IBE ’s clear and dignified explanations in relation to the plan of observation and recording above. I noted that while some aspects of her recall were more vague, she gave clear evidence that during the half hour when she was sat chatting with M on 7.12.19 that there were no alarms and both M’s hands were visible to her, and that this contrasted with the occasion when she observed M’s hand move under the blanket followed immediately by the pump alarm going off, and with the periods when other nurses were noting repeated movements of M’s hands in and out of and under the blankets during periods when the alarms were sounding. M accepted that no alarms went off during this period when S.S.N.IBE was sitting and chatting with her, by contrast with the frequent alarms that preceded and followed this period. S.N.IBE’s and S.N.SM’s respective observations relating to M’s contact visits on 20.12.19 and 13.1.20 are not dealt with in this section but are considered later in this judgment along with the evidence of Ms O the contact supervisor. 11.60. S.N.XG was another important witness, of events on 8.12.19. She was direct, careful and helpful. I have set out a summary of her account at paragraphs 8.101-102 above. The pattern of alarming being absent when only PGM was there and frequent when only M was there is apparent from her entries on the alarms chart, and she sat next to the bed for about an hour in the late afternoon and there were no alarms then, nor after M went home. Her descriptions of the repeated fiddling under the blankets was vivid, and I was struck by her account – also set out in the pump alarms chart – of hearing a click like a clamp when she approached the bed on one occasion of an alarm. (I note that the clamps can make a sharp light clicking noise as the curved plastic flange is pressed down and caught by the opposing clip edge, or when the clip edge is pushed away and the flange springs up from it). M denied manipulating the clamp. 11.61. She acknowledged a timing error in her statement due to two different times set out in her recordings (13.45/14.45) for dealing with a particular gastric loss, but dealt with this openly and with efforts to be helpful. I do not find that her overall recordings are undermined – this was a sole error, easily done, with otherwise great care taken in her evidence and recordings overall. Given the nature of the handwritten Feeding Pump Alarms chart in which she records this drainage bag issue it was more likely to be the earlier time of 13.45 as she wrote there, due to later times being written thereafter including another nurse’s entry a few entries later at 1400, and I am satisfied with the nurses’ evidence that these entries were made shortly after each event. I am satisfied that her evidence of the events was clear that it was only some 45 minutes between attending to two drainage bags, the second of which was full with a much lighter and much colder liquid. It was striking how the nurse described the temperature of normal gastric losses. They exit the body at body temperature and the drainage bag contents are at room temperature. She described the previous bag was in that range whereas this was much colder to the touch and she had never felt a PEG bag drainage so cold before and much colder than body temperature. In the fluids chart it reads: ‘ cold pale liquid (paler) ’, with the previous gastric loss described as a pale green colour. And in a note that was provided by the hospital after her evidence was completed it reads: ‘This liquid was much cooler to the touch than the previous drainage, but M had a cup of iced drink in the bed with her, which it may have come into contact with ’. She had given evidence that she had seen a cup of iced water lodged between M’s thighs and that the bag was on the side covered by a blanket, and not next to the drink. The concession in the note is contemporaneous, but I note that it says ‘may have’, and while it seems that her evidence has firmed up slightly since that note was made I also consider that her cross-examination took her in some careful detail through her memory of where the cup and bag were, and she clearly did not recall the bag lying between M’s legs and next to the drink. Overall she gave convincing and detailed evidence of what she had witnessed. 11.62. S.N.SP was not A’s allocated nurse at any point but assisted from time to time. On 6.12.19 she had no awareness of any safeguarding concerns. She was asked on that date by M to witness that A was suffering from dystonia. She only saw A’s legs to be low in tone. On 8.12.19 she noticed a kink/pinch in the tube following an alarm and reported it to S.N.XG to record on the sheet as A’s allocated nurse and co-signed it. M denied seeing or causing this pinch. In oral evidence she recalled seeing M fiddling under the blankets and accepted that although this was not in her statements she was certain that this was what she had seen and not as a result of talking with her colleagues. She was a calm, straightforward witness who tried to be helpful in her answers. 11.63. S.N.AH ’s evidence posed a more mixed picture. Many aspects of it were similar to the observations of her colleagues: M cuddling A stomach to stomach lying on the bed under a blanket, and observing hand movements, and draining of large gastric losses. She was vivid and detailed about seeing M’s hands bringing an item out from her clothing, fiddling under the blanket and apparent unscrewing movements - both in her e-note of 9.12.19 and in her oral evidence when added that she thought she saw M putting an object away under her clothing which might have been a syringe. She made these observations in the company of Ward Sister AS, whose evidence was far steadier and which I discuss in more detail below. S.N.AH also noted finding fizzy frothy liquid in the drainage bag which was atypical and which she documented in her e-note of 10.12.19. However, she also claimed to have seen M tearing off a plaster and tugging at a tube, but on closer examination it turned out her evidence was confused and she had not been the allocated nurse nor inspected the plaster site and was mixing her own observations with that of another nurse. It was unsatisfactory, unclear and unreliable. I place no weight on this aspect of her evidence, and treat with caution her recollections, save where they are saliently similar to observations made by her colleagues and in particular those matters she observed alongside Ward Sister AS. I see no reason to doubt her purely clinical observation that in her note of 10.12.19 at 17.41 S.N.AH included the note that A had been opening her bowels. 11.64. Ward Sister AS is an experienced and more mature nurse. She was a fair and careful witness. She described seeing M moving her hands under the blanket in a way that was busy and sporadic and unlike comforting or stroking a child. She said M seemed vigilant in the way she was looking around. When she was standing with S.N.AH and observing from the nursing station she saw M remove something from her top and then put her hand under the blanket. When Ward Sister AS went to assist and removed the blanket she saw M make rapid movements near the top of her trousers but saw no object. 11.65. She also gave some convincingly striking and specific evidence as to the qualities of the gastric aspirate drained on 9.12.19 by S.N.AA: ‘She [S.N.AA] showed me a full bag of clear aspirate … colourless … that would be an issue clinically. Most aspirates have a tinge of yellow green. To be completely clear is not what you expect to see … Would not normally expect to see any bubbles in an aspirate. I have never seen bubbles in a drainage bag before … [Q: M has seen bubbles] I have not seen bubbles … it is usually a very green bilious aspirate which is small, 10 mls, frothy. But that is quite different. It was like a fizzy drink. Small round bubbles … I was in the office at the time. [S.N.AA] came to find me. She brought it into me and we looked at it together… [Q: subjective?] yes but it was clear. I understand there are degrees. On this occasion there was no colour . Bubbles in the centre of the liquid, in the bulk of the liquid. Not congregating in a specific area … within the liquid rather than on the surface … can get frothy bit if air in stomach … [seen like video 23] … expect to see this in clinical practice … what I saw – the liquid was clear. Liquid in [video 23] is milky. Also it was more formed round bubbles. Unusual in that it was clear, small round bubbles, volume and colourless.’ 11.66. The clear and fizzy qualities of the aspirate were recorded in S.N.AA ’s e-note and the entry on the fluids chart. She observed them to be like this on the evening of 9.12.19. Similar observations made in her e-note on the afternoon of 10.12.19 do not match with the entries on the fluid chart and I ignore that reference in her e-note. I am persuaded by the clear and detailed evidence of Ward Sister AS that S.N.AA did see and show her an aspirate with these unusual qualities on 9.12.19. 11.67. S.N.MG was one of several nurses whose evidence I heard relating to 11.12.19. She gave a clear and fair account. She saw M fiddling under the blanket, brought a cup out, more fiddling under blanket. She wrote her note very shortly after incident and after told S.N.ELB who told her to write it down (c15.30) . Although she d escribed the actions as 'purposeful' in her statement, she accepted that might be speculation, otherwise she did not try to go further than what she had witnessed. It was an understandable assumption of purpose in the circumstances of seeing movements, then a cup removed, then movements resumed. She gave consistent and emphatic answers that the h and movements she saw were in front of A under the blanket and the blanket covered A's PEGJ button, and that she had definitely seen M lift a cup out from under the blanket. 11.68. I have already touched on the evidence of S.S.N.ZS . She was clearly the most obviously opinionated member of the nursing staff from whom I heard. I do not consider that her frank acknowledgement of having a negative view of M necessarily means that her evidence is unreliable. I note that many of her observations align with similar observations of her colleagues, albeit with their own particular individual timings, details and nuances. She set out her observations in a contemporaneous e-note, but also gave detailed and convincing accounts of what she had witnessed during her oral evidence. One such was of behaviour that had also been seen at the time by Ward Sister AS on 9.12.19, of witnessing M unscrewing and detaching the drainage bag: ‘At nurses desk … there is a guard but I could see over it and had a clear view … just after 2pm drainage bag emptied … within 10 mins (saw her unscrew and disconnect) … drainage bag lying on the bed. Next to child on her right … when [S.N.ELB] was away from the bed I would make sure I was within the bay and even closer view … [demonstrated how to unscrew on the equipment] M was able to do it with one hand … Then reconnected … just a few moments … [Q: any reason why a parent would do this?] no … extraordinary’. Equally, her description of the prodding/squeezing that she saw M performing and recorded in e-note, and which she showed me, was similarly immediate, detailed and vivid. 11.69. S.N.KS ’s involvement on 9.12.19 has been mentioned already in relation to discussions with Y. She also particularly noted the way M was frequently repositioning her cup – between her legs, on the side, and including under the edge of the blanket positioned close to the drainage bag that she could also spot near the cup. It was a striking and unusual description, and mentioned in her e-note. 11.70. S.N.SB ’s evidence did not add a great deal to the overall picture. She was another nurse who on 11.12.19 observed M to be ‘ looking around the ward and at staff whilst constantly moving something under the blanket. I could not hear any abnormal sounds, however this constant moving and A's mother looking around alerted me to this behaviour.’ She agreed that she did not know what M was doing, and that M was under close surveillance at this time, but she had the impression that M was ‘looking for us to see if we were looking’. Her acknowledgements appeared to be fair in the circumstances and she was pressed on it in cross-examination, but did not shift her from her overall impression of what had drawn her to notice this behaviour. 11.71. The nurse who can be seen on flushing video 1 is S.N.ELB . She was an important and impressive witness. Although young, she gave her evidence in a precise, thoughtful, respectful, intelligent and articulate way. She was on the ward on 10 and 11.12.19. She made detailed recordings in her e-notes on both dates. She was impressive in her detailed and consistent accounts in oral evidence that supported these observations. She made numerous appropriate and fair concessions. 11.72. 10.12.19 - I have set out above her comments relating to seeing A’s stomach squeezed by M on 10.12.19 at paragraph 10.83(b) and at paragraph 8.111 relating to the remarkable observations, given that they are set out in her e-note written the day before the flushing videos were filmed, where she observed M with one hand over and one hand under the blanket, screwing/unscrewing something, fiddling under the blanket, pull her hand out and appear to put something in her top, and the drainage bag was then nearly full with a clear fluid. She had not seen fluid that clear before in a drainage bag. She was surprised at the frequency with which M was checking the drainage bag. 11.73. She is criticised on M’s behalf for making twenty e-notes in eleven hours during the course of her shift as the nurse in charge of A on 11.12.19. However, it is quite clear from the content of her notes and her fair answers during her evidence that she was genuinely observing and recording. Some of the recordings refer to normal clinical matters, some to familiar concerns relating to gastric losses and M’s behaviour, some to aspects of A’s care that were unfamiliar to S.N.ELB that she simply noted (the toothbrush for the suction machine, for example). She is also criticised for providing more detail in oral evidence than her e-note itself provided in relation to the shape of an item she thought she saw was underneath M’s top: ‘I could not make out the shape’. Given how she was pressed by the questions on this topic, it was unsurprising that she did her best to give some further descriptors of what she thought she had seen, as to its approximate size etc. None of her answers attempted to define the shape itself in detail. And in the light of her numerous fair acknowledgements of matters put to her on M’s behalf, for example in relation to M’s size and clothing, to tubing getting caught, to it being reasonable for M to sit with A on her lap, I consider this was a further example of her attempts to be helpful in her evidence and not of sinister or misleading exaggeration. 11.74. It is worth considering her salient contemporaneous recordings on 11.12.19: ‘11.14 – Clinical note summary – includes: No dystonic spasms. A is passing urine. Had a big bowel movement on the night shift. 12.25 - Mum arrived to the ward at 12.20. She has got into A's bed and put her on her chest and covered her with a blanket almost straight away. Prior to mum's arrival A had drained 15ml from her PEG free drainage bag. This liquid was yellow/green. 12.56 - Mum remains in bed with A on her chest, covered by a blanket. She almost consistently has one hand under the blanket and you can see that hand fiddling with something. She also has a paper cup that she has in bed with her that she keeps switching from one side of the bed to the other and covering it with blankets. 13.53 - Written in retrospect of the events over the last hour: - PICC line dressing changed. Whilst changing the dressing mum remained sitting on the bed and I noticed what looked like a small solid object under mum's jumper. I couldn't work out the shape but could tell there was something under the jumper. Her jumper rode up once and she pulled it down quickly. - A's free drainage bag now had a lot of clear liquid in it. I drained it after I had finished the dressing change and there was 140mis of clear liquid. This clear liquid was also in the PEG extension whereas this morning it had been very yellow/green. Tested a pH of 6. Mum keen to know how much was in the drainage bag. - When there has not been someone directly at the bedspace she continues to have one hand under the blanket fiddling and I have observed her to look like she is screwing/unscrewing something. - When I went to take the bag off to drain it (mum had covered her with a blanket on her chest at this point), she handed me the drainage bag from underneath the blanket so I couldn't see under the blanket. 14.04 - Could visibly see mum with one hand under the blanket and using her other hand on top of the blanket to screw/unscrew something. 14.20 - Meds given and noticed that PEG free drainage bag had a lot of fluid in it again. Took the bag off and drained 170mls of clear fluid with a slight green tinge. pH 7. As I was reattaching the bag mum handed me the PEG port she wanted me to connect it to (there are two ports). She did this the previous time too so I asked why. She said that one port drains better than the other. 14.51 - Undertook a set of observations of A and her temperature was 37.7. I said to mum that because she's warm the blanket needs to come off so she stays cool. I left the bay to get her gabapentin, came back, and she'd put the blanket back on. I reiterated that the blanket needs to come off and I removed it again and placed it at the end of the bed. The free drainage bag has clear fluid in it again already. 15.03 - Nursing Note / Assessment / Care and Evaluation: -Since the blanket has been removed mum has leant forward in the bed with A still on her chest which obstructs our view slightly. She continues to pick up and look at the free drainage back and is constantly looking down at it. I observed her to pick up the cup of water and take a sip, she then put it to the cup back on the bedside table. 15.45 - Mum asked me to empty the free drainage bag as she was worried it would start pulling. Emptied it and there was 270mls in the bag since I last drained it. Tested pH 6. Clear fluid with a slight yellow tinge. 15.57 - Watched mum squeeze A's stomach very hard 3 times in a row as she was sat on her lap. 16.35 - Mum asked me how much A has had out of her PEG today. She said she wants to know as she is 'keeping a record to see improvement’. 16.55 - Bag emptied again as it looked full. 220mls drained. As I took the bag off, mum said the PEG port 'smelt strange' and she also said the contents of the bag was 'fizzy’. pH of content of bile bag 5.5/6. - As I went to reattach the emptied bag. the PEG port was wet. Mum said 'Oh, the cap must have come off.’ 18.12 – Written in retrospect of the past 30 minutes events… M had left at 17.30… I entered the sluice with the syringe and was followed in by the grandmother of a patient in the bedspace opposite A (Bed 30). She disclosed to me that she had been watching A's mum all day and had seen her use a syringe to give things to A. She also told me that she had recorded her doing this on her phone. She showed me her phone and has multiple videos that she has taken today. The one video she showed me showed A's mother clearly with a syringe in her hand giving something to A through her PEG. The video shows me then approaching the bedspace and A's mum hiding the syringe in her jumper.’ 11.75. When this is set against the content and analysis of the videos, the evidence of X and Y, and of F and PGM that I have considered in detail earlier in this judgment, this catalogue of carefully worded observations provides a striking insight from the perspective of a busy and conscientious nurse, which entirely chimes with the accounts given and concerns expressed. 11.76. In conclusion, considering the nursing staff’s evidence in terms of their individual contributions and with the various caveats in mind, but also looking at their evidence overall, I am extremely impressed by their commitment to care, their professionalism and their detailed individual recollections. I find their evidence persuasive and reliable. I have found no sufficient grounds to doubt their contribution, as has been suggested on M’s behalf, as riddled with examples of ‘ suspicious hypervigilance fuelled by group suspicion’, but that taken both individually and as a whole their evidence assists in adding powerfully to the overall coherent picture.

12. CLINICIANS 12.1. Dr U is A’s named consultant paediatrician. That is, she is the lead clinician in her local hospital with responsibility for A, and provides a point of contact in an attempt to marshal the overall provision for A’s various clinical needs. She impressed me with her warm and lively grasp of A’s presentation, notwithstanding its frustrations, complexities and conundrums that the clinicians have faced with her care. She provided very fair and some very striking answers in her oral evidence. She had not provided a filed statement, but was referred to her various letters and records. 12.2. I have set out some key aspects of her involvement in the history above, and notes from her assessment on 21.11.19 in paragraph 8.58 and in March 2020 in paragraph 8.143. She had extensive experience of A since A was a baby, albeit had less direct contact with her during 2019. Certain of her detailed observations will be referred to in further analysis of particular issues later in this judgment and below. I found her to be a helpful, consistent and reliable witness. And her evidence contained some particularly noteworthy elements. 12.3. In her oral evidence, remembering this November consultation, Dr U said: “ I left that consultation and walked straight to our safeguarding team and said I had never seen a child like that in 21st century Britain. I have worked in Nigeria. She looked skinny and like what I had sometimes seen in Nigeria ”. PGM remembers Dr U mentioning her shock that A was like a child ‘from a third world country’. 12.4. Again in her oral evidence on seeing A again at the March consultation, she said “ I saw her and I cried. It was just remarkable. It wasn’t just about her general well-being. Her progress with neuro-development. I was breaking down a bit in that consultation. I did not think it was even remotely possible ”. 12.5. She also stated that there was no organic cause or medical explanation for A’s lack of weight gain. She explained that they had investigated as best as they could through 2019; they did many tests, including a metabolic screen which looks at why A was not using sugars, but these came back normal; they looked at infections, genetic, autoimmune; they had screened this child for anything they could think of; she had conversations with the team at H2 and asked them to please give her their opinions of this child which led to the transfer to H2 in later November. This, she acknowledged, was probably to confirm what she already knew by then, namely that there was no medical cause for A’s failure to gain weight. 12.6. Dr U firmly disputed the suggestion made on M’s behalf in cross-examination that infections caused or significantly contributed to A’s weight loss. She stated that when a child comes into hospital with an infection, you can have mild fluctuations in weight but these are usually quickly recovered, and the hospital increases feeds and fluids – so you could lose a little weight before and after hospital admissions, but she would not expect anything significant in terms of weight loss because of chest infections. 12.7. When cross-examined on behalf of the Children's Guardian she stated that the dieticians were ‘out of their comfort zones’ in respect of the high calories prescribed to A, and that they do not commonly do that. She recollected the concern the clinical team at H1 and H2 had about A’s weight, and said that every time she spoke to the hospital dietitian she was aware that ‘ we were all maxed out about what we could do.’ 12.8. She was quite clear that although A may have had mild dystonia it was certainly not severe nor persistent. She had also seen A crying, stiff and therefore ‘posturing’, but she said that she had explained this to the family and had told them in every consultation that A had movement problems because of her cerebral palsy; they were not signs of dystonia. I note this fits with Dr F’s responses to the GP in September 2019. This approach to explaining the issues to the family, and attempting to look at the underlying features that were causing A to exhibit distress, are a feature throughout Dr U’s efforts to understand, treat and explain A’s difficulties. 12.9. The minutes of a meeting held on 2.7.19 indicate Dr U explaining that ‘A’s intermittent discomfort/distress could be caused by many factors… but dystonia is not a dominant feature and so she does not need dystonia medications.’ M then showed Dr U some video clips of A, and Dr U clarified that they are hard to label and she would preferably call them ‘ episodes ’ and were ‘ caused by movement problems from her brain injury but do not warrant treatment’ , and that ‘ unfortunately the drugs available are reserved for significant dystonia as they can cause significant problems in a child’ . She confirmed that she had never seen dystonia in A severe enough to interfere with her feeding but that she had seen it in other children. 12.10. Dr U confirmed in her oral evidence that on 21.11.19, shortly after admission to H1, she recorded in her consultation note that M had informed her that A had ‘ dystonia +++ ’, meaning severe, dystonia. She explained that M used the words ‘ very bad ’ and ‘ very severe’ . Dr U stated that M used the word dystonia and described A stiffen her legs, throwing her limbs back, her whole body stiffening in pain, and an inability to settle. She said M claimed that these episodes lasted hours and her note reads: ‘ with frequent episodes at least 3 x 1 day and for most nights lasting hours.’ Dr U said that the description M provided suggested that A had severe dystonia and was in a persistent dystonic state. This would be quite harmful and dangerous, which is why Dr U initiated the admission to H1, and had undergone an x-ray to check if her hips were displaced as a result of the mother’s descriptions of severe dystonia. 12.11. She explained that there was no possibility that A had severe dystonia in November 2019 and grew out of it. And she had never seen her with dystonic spasms sufficiently severe to interfere with feeding tube function correctly. 12.12. At that July meeting M suggested using a sedative in order to get some sleep at night and Dr U advised against it in order to avoid problems with worsening A’s respiratory difficulties. F acknowledged that this had also been explained to them by other doctors. As a result, Dr U was very clear that she would have expected M to have sought advice before using Phenergan as an over-the-counter remedy for A on top of other medications, it being a sedative. She was quite clear that M told her during the November admission assessment that she was using 20ml regularly and not simply when A was in distress and that M had said that H3 had told her she could do so. (I note that there is no record of any H3 clinician so advising M, and that she has also claimed that her pharmacist and GP approved it.) 12.13. I also note that Dr U fairly and appropriately intervened in an email trail that was generated at a point in October 2019 when concerns had arisen among H3/Oxleas professionals that M was seeking a second opinion from H3 in relation to A’s respiratory problems (this did not involve H2). She wrote : ‘I don't think this needs to be complicated. The family have been through Court and I think we should consider the rulings thereof. I do not see that undue presumptions should be made about this child in this instance. The family have a right to seek a second opinion. [H3] has a responsibility to procure any previous correspondence prior to consulting on a complex child (as I'm sure they do with other patients with complex medical histories). I am therefore happy for you to contact my secretary if you would like copies of her clinic letter. But that is as far as I am willing to engage in this line of action/correspondence. Of course, if any additional safeguarding concerns arise, please reinstigate safeguarding proceedings and contact our Childrens Safeguarding Team for any specifics.’ I consider that in Dr U, A has had a skilful, caring, open-minded champion of her medical needs. 12.14. Dr V is a consultant gastroenterologist based at H2 who was responsible for this aspect of A’s care. He called on his experience of A and of treating such children, and made every effort to be helpful. He had clearly faced a perplexing and challenging picture. He was fair, careful, and thoughtful. He did not try to remember what he could not, and admitted points of weakness or contention. He did not over-emphasise troublesome or concerning points in his statement, and where such issues emerged during his oral evidence he dealt with them without any dogmatic affect. 12.15. I have set out some key elements of his involvement in the history, and in particular the note of his consultation with A on 28.6.19 at paragraph 8.25 above. He too had extensive experience of A. Certain of his observations will be referred to in further analysis of particular issues later in this judgment and below. His filed statement explained A’s gastroenterological treatment during the H2 November-December admission. His oral evidence was helpfully summarised into a note, for the benefit of efficiency and brevity in assisting Dr Campbell get to grips with the updating information in the case. It was not a completely agreed note, being agreed by the LA, F, PGM and the Children's Guardian, and M adding certain entries to it but without formal agreement due to lack of time. His evidence also contained some particularly noteworthy elements. 12.16. He confirmed that he was completely reliant on the patient history given by the child’s carers. He c onfirmed that he was not aware of any child protection alert on A’s H2 file, and he was unaware of any safeguarding issues being alerted to H2 by H1 on A’s transfer to H2 in late November, and I am satisfied that he approached A's case objectively and professionally. 12.17. He provided helpful explanations of the PEG-J mechanism and function. He explained that the internal tubing needs to be changed every 6 months, and the giving set is changed every week, according to the manufacturers. In his experience problems with the tube do not happen in the first month, and the immediate alarming of the tubes right after the PEG-J tubing had been replaced on the 3.12.19 suggested third-party action in respect of the occluding of the tubes as this ‘does not happen.’ ‘ I have never known a tube to kink so soon after being replaced and never known a tube to alarm so often and numerous times on a given day in 5 years of fitting children with these tubes. The tubes are resistant to accidental pressure. Babies wriggle and sleep on them and do not occlude. Tubes are not likely to get caught in a non-mobile child [as here] … Lying in bed alone chance of kink is low ,’ albeit he accepted that certain types of handling or movement might kink it. 12.18. He added that given that there was no obstruction in the tube, as confirmed by checking the patency of the tube and the tubogram, the only explanation was that there was external compression on or blocking of the tube. 12.19. He firmly disputed the suggestion made on M’s behalf that something internally in A could have squeezed her tubes and caused a blockage. He stated that the majority of children with the internal jejunal tubing that have cerebral palsy do not have this problem with the pumps occluding. ‘ All I can say is lumen of bowel that even if goes into spasm, compared to lumen of tube and consistency, it is beyond my imagination that lumen can come down on tube to squeeze. Need to have malformation of orientations of bowel itself which A does not have’ , nor did she have any obstruction in her bowel as she would be very ill if so. 12.20. He explained that as A was just under 10 kg, normally the amount of gastric drainage would be 20ml/kg and so 100-150ml would be produced in a day, and he could find no medical reason for the significant volumes of gastric losses that A was reported to have in 2019. He said he had about a hundred children on the same type of enteral feeding as A and did not see this in the other ninety-nine so that was why he was so concerned and why he wanted to admit A to hospital. 12.21. In terms of gut dysmotility he accepted that children with severe brain injury can often present with vomiting and reflux. He also accepted that chest infections can cause an increase in gastric secretions. But he was very concerned by the inexplicably high gastric losses and noted that they decreased once the family were no longer visiting her in hospital. He thought that the reported appearance of the gastric losses was not normal, although that could be subjective. He did not think that the variations in drainage would be caused by distress, physiotherapy or other therapy, the position a child lay in, or being awake or asleep. He did not think mobility could affect gastric output, although he conceded it may be ‘technically possible’. 12.22. He could not explain the figures for ongoing gastric losses in the period 12-20.12.19, but considered that they then came into balance, but he thought maybe there was something else going on there during that period. He did not address this conundrum in his statement. 12.23. In considering the hospital’s arrangements he said that it would still be possible for the mother to insert liquids into A’s PEG tubing or drainage bag even when she was being watched at hospital because there would be gaps when she was not being observed, including when nurses change shifts, dealing with other patients, their general duties. He said that even where there is supposed to be 1:1 monitoring, nurses are busy and not by the bedside 24/7 (and this certainly appears to have been borne out by the various accounts I heard, certainly before 6.12.19 and even thereafter where attempts were being made to keep close observation). He said he thought that if water was introduced to the stomach via the gastric port it would filter out of the tubing fairly instantly into the drainage bag. 12.24. He was absolutely clear that there was no medical explanation he had seen for A failing to increase weight prior to entry into hospital, and it was clear that she was not thriving. It was clear that there was not enough nutrition going in, and by mid-2019 when he saw A at his June clinic consultation he was even more concerned. The plan was to have an admission and see if A was getting the number of calories that she should be getting. He explained that while cerebral palsy children have faltered growth, when you get nutrition right they start putting on weight. He acknowledged that chest infections do not help. They would be deleterious to this process because the child’s calorific requirement would be higher, however they would still be absorbing calories. He noted she was on some 177-230% of her calculated calorific needs which he described as extremely unusual, and he could not explain why there was no growth or weight gain when A was receiving that many calories. He thought that having too few calories and very little fat could have explained her low blood sugar episodes. He pointed out that on the same level of calories (in fact on fewer – which I will discuss later in this judgment) she gained weight in hospital. 12.25. He was so concerned that he told the court that when he saw A in August 2019 that he recommended an in-patient admission in order to tease out what the problems were and that he discussed this with M and PGM at the appointment on 9.8.19, but that she was reluctant to permit to A to come into hospital and he could not make it mandatory. This is the point at which Dr V increased A’s feed to 24 hours to try to add more calories and therefore they were increased to 1150 k/cal per day from this date. 12.26. He explained that her gut dysmotility and reflux would not impinge on her calorie intake as the jejunal tube feeding bypasses that problem and so she was receiving her feeds. In terms of gastric or oral feeding, he pointed out that there was so much coming out as gastric losses that there was no point in putting something in to her mouth or stomach – it was only when negligible amounts come out through gastric drainage, could you start gastric feeding. So, while gastric losses remained high, the net effect was that this kept her on a regime of PEG-J feeding. His observation in relation to the rapid transition to gastric feeding and then on to oral feeding was as follows: ‘ the chance of the transition happening is generally months for a child with A’s disability. In the majority of cases it would not happen at all. Chances of happening is low and when it does, transition is slow ’. 12.27. Dr V was the first witness heard during this hearing, and as a result of the later development of certain aspects of the evidence, he was not asked about his decision in late July 2019 that led to the reinstatement of the drainage bag after it had been successfully removed during her H1 admission. However, he did confirm that in his view clamping the gastric output would be unrelated to the jejunal input and would therefore have nothing to do with weight gain. 12.28. While it is arguable that he made the wrong call at that point in July and A should not have had her drainage bag reattached, I can make no finding on that decision of his. This episode is referred to in the chronology at paragraphs 8.31-8.34 above, and in my consideration of the family members’ evidence earlier in this judgment. Given: the inconsistencies in M’s evidence and with the GP email and PGM’s text; the clear and widely preferable accounts of F and PGM generally and whom here neither shared M’s assertions as to A’s degree of illness or the levels of their involvement; the lack of observations of signs of aggravated gut dysmotility by other professionals who saw A that week – I conclude that A showed some distension as seen in the video clip but the accounts given now by M of extensive vomiting are not substantiated, and A’s symptoms in the days following her discharge were exaggerated by M. She agreed in her oral evidence that she had wanted the drainage bag to be put back on, and it is clear that she pursued that via the GP, A&E and the Ellenor nurse. 12.29. Dietitian DM is a community children’s dietitian, qualified in 2004 and specialises in enterally fed children. She had visited A’s home 24 times (with each visit being 1-1.5 hours), saw A with M at least 10 times in clinic, spoke to M 57 times, and attended more than 10 Child Protection or Child In Need meetings. She provided a witness statement in August 2020. Her contemporaneous notes are extremely detailed, containing references to visits, clinics, telephone conversations, emails and observations. She was an impressive witness . She was fair, familiar with A’s history, matter of fact and clearly highly experienced in her field. She gave clear, cogent and consistent answers. 12.30. I have set out some key aspects of her involvement in the history above. She had extensive experience of A. Certain of her detailed observations will be referred to in further analysis of particular issues later in this judgment and below. However, her evidence contained some particularly noteworthy elements. 12.31. She is still involved in A’s care and described her as doing amazingly well now, with all her nutrition now orally, but her gastric tube is used for fluids as she finds swallowing liquid hard but is building up her skills with SpeH2 And Language Therapy input. In describing the difference with A’s presentation in 2019 she said: ‘ The most noticeable thing was the level of interaction. When you went over to her, she was smiling and interacting. She wanted to know what was going on. There was a huge difference in her personality. She was smiling, laughing. She was bigger, had a nicer colour to her. Her personality and level of interaction was different ’. DM had never had experience of another child who went from fully jej fed to fully gastric fed in 3 days. 12.32. DM confirmed that mother took the lead in appointments and that the PGM did not. M was the primary source and if the secondary carer said something different, DM would have noted this down. DM added that most of her contact with father was at meetings, not appointments, and that he knew about her care and could raise appropriate concerns. However, she got the impression that mother was in charge of the day-to-day care of A. She had observed that mother was the one who did the ‘hands-on’ work in respect of feeding A when she saw the family. M was confident and knowledgeable regarding the feeding equipment; she had been provided with training when the pump was introduced. 12.33. She confirmed that there was no medical reason as to why A was not gaining weight: ‘the calories that were going in, she should have been gaining, so no explanation.’ She considered that there did not have to be long periods when A was not fed to get the level of weight loss seen in A. She clearly refuted the idea that diarrhoea/malabsorption was responsible for A’s weight loss. She said that if the diarrhoea is short term, it does not affect ability to gain weight but would affect hydration. If a child has malabsorption, there is long standing diarrhoea and a certain type of stool which is oily. When A had an issue with her stool it was principally constipation. When she did have diarrhoea, it was not the type associated with malabsorption. 12.34. DM disputed the suggestion that A’s chest infections caused her weight losses. She stated that with children that are ill, one sees a dip and plateau of weight, followed by rapid gain to where they were before. A did not show this. She added that A was already getting 140/145% (between late 2018 to mid-2019) of her calorie requirements and the extra 40/45% should have covered any extra calories that the chest infections would be burning off. She also explained that neither crying for hours nor being up and unsettled would significantly affect calorie usage. She also did not see A’s presentation as to her tone and movement/dystonia as of the sort that would use up more calories. There would have to be severe frequent movements to burn that extent; a high level of movement to burn that levels of calories. And she never saw any dystonic movements or seizures during all her visits or appointments with A that would explain the need for additional calorific intake. 12.35. She explained that it was very unusual for a child of A’s mobility to be on 140%, then 177%-230% of her caloric needs (from August 2019). She would have expected an obvious presentation of something requiring that level of calories, like suffering from burns. DM noted that a child with A’s limited mobility is usually on 75-80% mark; she would not normally need the full 100% that a healthy child does as not she was mobilising the same way. She should not have needed the extra percentage that she was on. She confirmed that from July 2019 the doctors had effectively taken over the feed plan and that it was outside of her clinical judgment to give A more – as Dr U said: it was beyond the dietitians’ recommendations. 12.36. She clarified the different feed types that were tried; in effect they provided the same nutrition given the content and calculations. Paediasure peptide was the equivalent to Peptamen Junior, an equivalent of a different brand. The calories, minerals, and vitamins were very similar. Paediasure peptide had slightly fewer calories than the Neocate that she was put on. Paediasure takes more digestion. Neocate is differently formulated to be easily tolerated as it was ‘ right to bare basics’ , which was prescribed because of the persistent feed tolerance problems that were being described. She added that she has many children on Neocate without problems. 12.37. It was pointed out on M’s behalf that DM’s notes made back in July 2018 did not reflect all the details set out in the accompanying family support worker’s notes, in particular there was no mention of M having raised problems with both of the pumps then assisting with A’s naso-gastric feeds. It was therefore suggested that DM may well have overlooked subsequent noting of pump concerns that M claimed she was raising through 2019. I accept DM’s oral evidence, which ties in with the evidence of F and PGM. She clearly recalled the concerns raised with her when they were particularly worried and filmed the pump not working on two occasions, and otherwise remembered the family raising issues with the feed pump but that it was not one of the biggest or most frequent problems coming up. She had never heard the feed pump alarm in her presence in the family home or during appointments. 12.38. DM did not think that the breaking down of pumps was relevant to A’s weight loss. She said pumps break down, are replaced, and work fine. Pumps would be replaced within 4-6 hours so that would be the longest A would have to go without feed. She was certain that if A went days and days not being fed constantly, the concerns would have been fed back to her, and that the issues were one-off occasions that she had been told about. 12.39. In relation to the gastric losses, she said professionals would be concerned by anything over 100ml, and explained that fluid losses were not relevant to weight gain because you lose fluid and salts, so it is more relevant to hydration. A’s losses were higher than any that she ever worked with and she could see no medical explanation for them. The danger of high gastric losses was that it indicated that something was not working properly, and that there was an underlying issue with the child. It would also result in low potassium, and other salts, and affect hydration levels. She explained that she had given adamant advice to the GP that the drainage bag should stay off in July 2019 after A was discharged from H1 because it had been successfully removed, and therefore it was possible. So there was no evidence that it was needed; the drainage bag being taken off had positive effects. 12.40. DM was very clear both in her notes and particularly her oral evidence that she understood from the mother that Dr F was considering TPN as an option for A. DM added that she did not think that A ever needed TPN as she never presented with signs of gut failure or malabsorption. She was also clear that M had also clearly cited Dr F as saying that temporary gut paralysis caused by dystonia was why she was not absorbing her calories. Not only did this not make sense in itself, but she specifically explained to M that there was no sign of malabsorption and that children with dystonia would still normally grow at this amount of feed. 12.41. There are two issues to observe at this point in my review of the clinicians’ evidence: a) One of the impacts of taking Dr V and DM through the issues in their evidence, and in particular the settling of A’s gastric losses and her subsequent progress to gastric feeding and now oral feeding, is that they each concluded during their oral evidence that A may have never required a PEG-J nor jejunal feeding. As I have already discussed earlier in this judgment, this is not a point of consideration in this judgment and I do not include this observation in my determination of the issues. b) A persistent trope of the case put by M and on her behalf, is that the doctors and professionals failed to spot or take seriously how underweight A was, whereas M was the only one who was constantly pursuing this. Having considered carefully the background history, the medical records and the evidence of the three above clinicians, this claim is wholly unfounded. To the extent that M asserted it, it has to be seen at the very least as an utterly mistaken belief, but it is more likely to be an outright and misleading lie. To the extent it is claimed on her behalf, it appears to be primarily based upon two points: firstly, that DM described A as ‘tracking’ at the meeting held on 31.5.19, and expressed some positive words to the meeting about A doing better; and secondly, Dr U being so viscerally shocked at A’s condition on 21.11.19. There is a wealth of evidence to the contrary, some examples of which are as follows: - The emphatic and persuasive oral evidence of each of the above clinicians that they were each very concerned about A’s low weight and faltering growth. - In early September 2018 DM records M’s own report of a consultation with Ms R who was ‘very concerned as to A’s low weight’ and a detailed plan as to graduated feed increases is set out. - DM records a home consultation on 19.11.18 with A weighing at 0.4 th centile: ‘ Advised will review weight in another month. Prior to problems with feed tolerance, required 800kcals to gain weight so may need further increase if still not gaining.’ - On 21.11.18, in response to an email query from Dr Q regarding weight gain, DM replies: ‘ A was 7.93kg on Monday, so she has lost the weight she previously gained. I have spoken with Mum about increasing her feed .’ - At a home consultation on 18.12.18 DM records: ‘Is the current feeding regime meeting requirements?: Current feed should be meeting requirements but still no weight gain. … Advised to give a 2 week trial on Neocate. To then review if any improvement has been seen and to look at increasing kcals .’ Over this period in late 2018 A’s prescription feeds are increased to 120% of her calculated requirements. - In an email to consultant Ms R on 9.1.19 DM wrote: ‘ Mum wanted me to raise her weight loss. This is something I am addressing, we are increasing the concentration of her feed to aim to promote weight gain. do not know why she is losing weight, she is currently on 140% of requirements, at least and will be re-weighed next week. ’ - The February 2019 hospital admission looking at all A’s presenting issues could find no reason for her failure to gain weight. - In DM’s note of a home visit on 28.3.19 she wrote: ‘ Discussed poor weight gain. Mum felt A was doing better and has had a hospital admission. Agreed to review in another 4 weeks and can amend feed then if no weight gain ? to reduce rate of Dioralyte and increase rate of feed.’ ’ - And on 18.4.19 she wrote: ‘ Has gained 200g in the last month. ? starting to track below 0.4th. Appeared slim, some loose skin on arms’, - And on 31.5.19 she wrote: ‘ Weight tracking below 0.4th centile but height static and falling across the centiles’ . - The consultation on 28.6.19 with Dr V was a referral due directly to A’s ‘faltering growth’ and it was noted that: ‘ Referred in view of faltering growth … Feeding regimen of Neocate Junior which is concentrated to 1.26 Kcals per ml for the last 7 months- 750ml per day via pump at 37ml an hour for 20 to 22 hours (that would amount to 120 Kcal/Kg per day) Plan: 1. Discuss with parents that her calorific intake looks sufficient generally for growth. However, since there is ongoing faltering growth, we would aim to Increase the calorie content of her diet further (I asked the dietitian to discuss further concentration of feeds). 2. Reassured parents that the symptoms are not suggestive of any calorific loss (no vomiting or diarrhoea) …7. May need an inpatient admission in view of the faltering growth…I have discussed with her mum that given that she continues to falter growth, we have increased the calorific intake and that we can do this by increasing the rate of feeding or by increasing the concentration and hence l have asked the dietitian to have a chat with mum’. - On 1.7.19 The H2 dietitian emails DM: ‘A was seen by Dr V today in clinic. He would like her calories to be increased and asked me to talk to mum. He wants to see her again in 1 month with some weight gain… chatted to mum and she explained how you have been working hard to increase rate and calories. ’. - DM replied that she is worried about her gastric losses and that she is ‘already on 145% of her requirements and that's without allowing for her low mobility’. - I have already referred above to the 9.8.19 consultation that Dr V had with M and A where he recommended an in-patient admission to address these issues, and increased her feed to 24 hours and 177-230% of requirements at 1150 kcals per day. - Dr U’s vivid comment that she was well aware that they had ‘maxed out’ their options in terms of A’s feeding regime. 12.42. So while it is true that M was raising the issue of A’s weight, alongside her many other problems, it is inconceivable that she was unaware of the professionals’ concerns and plans in this respect, and to attempt to characterise it otherwise is wrong and misleading. 12.43. Dr F . I now turn to Dr F. He is a leading consultant in paediatric neuro-disability, head of paediatric neurosciences and sleep at H2, an advisor to NHS England and contributing consultant for NICE guidelines within his speciality. His witness statement is dated 13.10.20. He had far fewer interactions with A and M, seeing her on three occasions between August 2018 and September 2019. He conducted a video appointment in August 2020. I have summarised them in the history set out above. 12.44. There were two particularly striking features of Dr F’s evidence. Firstly, he is clearly an extremely sincere, conscientious, knowledgeable, earnest, thorough professional, with an unfortunate tendency towards verbosity. Secondly, with regard to M’s numerous assertions that she had made about Dr F’s involvement and her apparent reliance on his position on various issues, he manifestly disagreed with her. This was all the more telling given his championing of and respect for carers of disabled children, which shone out from his evidence. 12.45. He also emphasised the reliance of paediatricians on the history given by carers: ‘ … with any consultation, it is dependent on the history given by the parent …’, and ‘You [as a doctor] are so reliant on the history … [in the majority of clinics] 95% is history, 4% is observation, 1% is examination … You believe what you are told ... [Q: is that a fundamental tenet of being a paediatrician?] A: Yes. The parents are the world expert on that child. [Q: As long as they are giving an accurate history?] A: Yes ’. 12.46. Examples he gave included that both the prescription for drooling and for Buscopan were based entirely on the history given by M. 12.47. M and PGM attended his lectures on the topic of dystonia. In his August 2018 consultation he concluded there was a ‘developing degree of dystonia’, and suggested in his oral evidence that he observed some dystonic symptoms during that examination, but was otherwise reliant on the history given to him. There was a similar picture at a January 2019 consultation, where he observed A’s right arm tightness and from the history diagnosed a ‘ mixed motor abnormality with fluctuating tone – dystonia’. He explained that if there is constant high muscle tone then you would see it all the time and it would be evident during clinical examination, but if it is a fluctuating problem then it can be triggered by a number of sensory or emotional stimuli and you may not see it during a consultation but would be reliant on the history given. He stressed how screaming/distress was multi-factoral (as per the list of issues he referred to in his responses to the GP in September 2019), and not due to dystonia. 12.48. At the referral consultation on 4.9.19 which took place due to A’s distress which was attributed to dystonia, he was given descriptions by M of A’s extreme discomfort, distress and difficulty sleeping. He also observed some degree of tightness in the legs/hip. However, the history given was so extreme in his view that he immediately booked A in, ahead of a long waiting list, to have botox treatment 8 days later. The injections were given to her leg and hip muscles and their effects would have lasted some 3-6 months. 12.49. He stated that A’s dystonia was reported to him by M as severe but it never came across as severe, except on one occasion when he saw her agitated. But he emphasised that to get a proper idea, you need to have a prolonged look, which is why Dr K admitted A to hospital. He stated that all the other multi-disciplinary clinical analyses and records, and in particular the physiotherapy and OT assessments should be relied on when looking at dystonia. He concluded, in that context and on reconsidering the whole picture that at most, A only ever had mild to moderate dystonia, and then modified his answer further to mild dystonia. He confirmed that this was very different from the picture painted by M in September 2019. He also concluded that it may well have been unnecessary to have administered the botox treatment. 12.50. He clarified that the suggestion that dystonia could prevent feed flowing through a jejunal tube was beyond what he would expect in his experience, and it was unlikely that dystonia would cause blocking of A’s feed. He pointed out that it would be better to ask a gastroenterologist about this. He added that it would be unlikely to cause the necessary pressure, particularly where there is a free drainage tube from the child’s stomach as that is, in effect, a release valve. He observed that crying can raise the pressure inside the body. 12.51. He deferred to the dietitian’s expertise and agreed with her analysis in terms of feeding issues. He confirmed that at his recent video consultation in August 2020 he saw no obvious dystonic challenge, nor were there any gut dysmotility nor respiratory issues reported. 12.52. He was reluctant to comment on A’s marked developmental progress to date, but did note that a comment he could confidently make is that the challenges described to him were not seen to that extent during her November-December admission. When pressed on M’s behalf, he stated that the changes in A appeared to be at the most extreme end of possible thinking on this topic. While he agreed that there were many variables and that you might extraordinarily see children crossing different functional levels, it was greater than he would expect in A based simply upon good nutrition and fewer medications. 12.53. He said that it was very rare for gut dysmotility to get better as it normally gets worse over time in brain damaged children, and equally that an unsafe swallow usually deteriorates over time and improvement is not usual. Whereas there can be positive development regarding a drooling problem due to the maturation of the oromotor system. 12.54. He was absolutely clear on the following further points that had been asserted by M: - That he would never have made any recommendation for A to be given Gabapentin as he is reported to have done by M in her consultation with Dr K (set out in Dr K’s letter dated 23.5.19). He considers it to be a medication of absolutely last resort due to its side effects. His aversion was striking and he went so far as to say: ‘ I cannot see any time I would recommend [its] use’ . He accepted he may have referred to it for completeness, although he thought that was highly unlikely, but not for any recommendation. - That he would not have said that the gut gets temporarily paralysed due to dystonia and that is why it is not absorbing calories. - That it was exceptionally unlikely that he would have raised TPN, as he would not have considered it except in the most extreme of situations due to its risks and A was not such a profoundly disordered child. He said that in 22 years of practice he had never brought this up. - That he never said he had felt ‘coerced’ into withdrawing from involvement in A’s case and that it was a consensual decision as he had always understood that the local team should be in charge in order to avoid the possible proliferation of different recommendations, and this kept things simple and logical. He described himself as ‘ old enough and experienced enough not to be coerced in any of my clinical practice’ . He added that a more telling point is that he himself felt that A’s care should be led locally by Dr K rather than himself at H2. 12.55. It is puzzling and concerning that M appeared to have misunderstood and/or misrepresented Dr F’s input in so many significant ways. I have no hesitation in accepting his version and recollection. He was evidently deeply concerned to be exact, accurate and honest, while also sympathetic and supportive to family members. I do not speculate here as to the psychology or motivation behind M’s position, but I gained the distinct impression from her case and her evidence that there was at the least a disappointed expectation in Dr F as some sort of alternative resource to set against the local clinicians. 12.56. I have specifically reminded myself of the guidance on the considerations to be given to the evidence of treating clinicians, and in particular the helpful observations of Ryder J (as he then was) in #96-100 of Oldham Metropolitan Borough Council v GW & Ors [2007] EWHC 136 (Fam) , the case cited in Re H-L [2013] (supra). 12.57. I have carefully considered the extent to which their ‘inevitable partiality’ towards child protection in their roles as A’s clinicians may have affected the cogency, reliability and objectivity of their contributions. I found each of them willing to consider and listen, and where appropriate reconsider issues thoughtfully. I have heard reasoned explanations based upon their respective expertise and experience. I have found their contributions to an understanding of the medical issues to be extremely helpful, and I have found each of these professionals to be careful and reliable witnesses of fact as to their interactions with M and involvement with A. I unhesitatingly prefer their evidence where it differs from that of M.

13. EXPERT EVIDENCE 13.1. PAEDIATRIC OVERVIEW 13.2. Dr Knight-Jones provided a report dated 20.8.20. It was hampered by the unwieldy medical records disclosure at the time, and the absence of a properly arranged searchable bundle as Caselines was only available thereafter. In addition, she did not have access to the nursing e-note records that were only disclosed by H2 at the start of this hearing. Her report was intended to be an important and necessary part of the proceedings, in particular informing the court as to any issues arising from A’s medical records, and thereby assisting the LA in its forensic exercise of considering which allegations could properly be considered to be included in their case. 13.3. Dr Knight-Jones is a consultant paediatrician of many years’ experience. She specialised towards the end of her training in child development and disability. She was lead consultant at Nottingham's Child Development Centre for 20 years, retiring from full time NHS work in 2002, where her work was to assess and diagnose children referred with the following problems: developmental delay/learning disability; cerebral palsy; autistic spectrum disorder; speech and language delay; attention deficit disorder; developmental co-ordination disorder/dyspraxia; and other neurodevelopmental problems. Thereafter she acted as a locum consultant community paediatrician until 2012. A substantial part of her work was the follow-up from age 1-4 years of babies from two Neonatal Units who were either very premature or who had suffered from conditions with a risk of impairment and disability, dealing with any general paediatric problems or illnesses, and if inpatient admission was required, those children remained under her care. She has provided medico-legal reports since 2000. 13.4. She identified at the outset that she was not familiar with the details of jejunostomy fed children, and of principal assistance in this case was her early recommendation that a gastroenterologist should be instructed, which led to the joint instruction of Dr Campbell. 13.5. She also flagged up in her conclusions, as an outstanding feature of the case, A’s lack of weight gain over the year 2019: - ‘ the major harm done to A was the under feeding at home which resulted in reducing her to a state of severe malnutrition. A child with cerebral palsy in a state of chronic malnutrition is very vulnerable to infection’. - In my opinion the most striking aspect of this case is the vastly improved weight gain, on which I have commented above. I have commented on her developmental progress in paragraphs 821-828. Her weight gain is striking. So is the absence of the respiratory symptoms which resulted in many prescriptions for antibiotics and frequent hospital admissions. Another aspect is that A is stated to be considerably happier in foster care, whereas in the care of her mother, particularly in 2019, she presented as very unhappy child. Her modest developmental progress in foster care is also significant.’ 13.6. Overall however, her conclusions in certain respects were variable in terms of the impression gained of her analysis of the case. 13.7. Her above conclusions in relation to weight fell more confidently into her fields of experience and expertise, with her analysis of this aspect of the case largely standing up to rigorous cross-examination, and also sitting squarely alongside the evidence of Dr Campbell and the relevant clinicians from whom I heard evidence on this issue. 13.8. Another example is that she very fairly acknowledged that most presentations to the GP, from the records that she did have access to at the time of writing her report, were likely to have been justified particularly in relation to respiratory concerns. And she noted the GP’s identification of symptoms such as wheeze and chest sounds. 13.9. Additionally, she fairly pointed out that the surgical intervention to change A’s PEG-J on 3.12.19 would have been required only two weeks later in any event when the unit was due to be updated. 13.10. However, she also concluded that the hypoglycaemic episodes ‘may have been induced’ and ‘may possibly have been the result of substances administered by the mother’, when there was no clear evidence upon which to base that conclusion. And she also failed to include in her conclusions the other potentially applicable possibilities that she mentioned in the body of her report, including the effects of malnutrition and ‘dumping syndrome’, where an increase in carbohydrate into the jejunum can induce a sudden increase in the production of insulin. Similarly, she asserted that the repeated chest infections were likely to have been due to M inappropriately giving A oral feed or drink, again when this was speculative and there was no clear basis set out for that conclusion. 13.11. She expressed opinions in her report about what she considered had likely been going on in relation to the nurses’ observations of M’s behaviour, when these were properly matters of fact for the court and not for a paediatric overview. When questioned about this, she found it hard to absorb or acknowledge the implications of other aspects of the contested evidence that were posed to her, for example the suggestion that the pump alarm may have sounded when M was not present. I note that of course she did not have the more complete picture that the court and advocates had benefitted from, having heard evidence from nurses as to the records kept, their observations, and their demonstrations and explanations of the pump’s functioning; nor was it within her proper domain of paediatric medicine, and demonstrated certain weaknesses in her approach. 13.12. She was obliged to correct her conclusion that the issue of dystonia was ‘fabricated’, and amend it to ‘exaggerated’, when she was taken to some of the treating clinician’s observations. However, she very fairly stated that while Dr F’s treatment of A’s dystonia by injecting Botox appeared to have been based on M’s history related to him, she noted that it may have been justified by clinical findings. She also concluded that in retrospect it appears that his prescription for Baclofen was unnecessary. Having heard Dr F’s evidence, it seems that her analysis in this respect was in fact largely in tune with Dr F’s own conclusions. 13.13. In her oral evidence there was again a mixed picture with an uneven set of responses. She did not give the impression of being on top of or comfortable with the relevant information in the medical records and made errors or demonstrated an occasional misunderstanding of the relevant history. 13.14. On a particularly disappointing occasion she declined to agree that what could be seen in a photograph of A’s face taken during a contact visit in early 2020 was some saliva on her face to one side of her mouth. She first claimed that it could be some left-over breakfast, when A was not eating orally, then she said that it could be some sort of gel. Both were unnecessarily defensive and unhelpful answers. By the end of the series of questions relating to drooling Dr Knight-Jones had moved on to concede that there had been a history of drooling and that it had been reasonable to treat her while younger, albeit she appeared to have grown out of it more recently. That, at least, showed an ability to reflect on the material being posed to her and to adapt her position and analysis logically and appropriately. 13.15. Dr Knight-Jones also engaged in some surprising correspondence. In an email to the solicitor for the Local Authority dated 10 th November 2020, by implication she queried the weight to be given to the analysis by Mr Hutchinson and Ms G as to M’s vulnerabilities, by commenting upon M’s intelligence and school qualifications. She communicated directly with clinicians by letters dated 18 th August (Dr U) and 23 rd October 2020 (Dr U again and Dr Q) to enquire about the existence of samples that could be sent for testing in relation the hypoglycaemic episodes. This was beyond her remit. She also had to be reminded as to the nature of an expert’s role in relation to the types of questions that she proposed should be put to the gastroenterologist, and that assumptions or expressions of opinion should not be made by experts as to findings of fact. Dr Knight-Jones was heavily criticised by M’s counsel in the light of these and related matters. 13.16. However, I also note that she very fairly acknowledged that a parent would be worried about the mortal risk of aspiration pneumonia in a child with A’s combination of difficulties, and would watch every move and try to interpret it when a child was unwell or distressed. She also agreed that this might be particularly the case in a child with cerebral palsy, and accepted that where a parent suffers from anxiety that this needs to be factored into the picture. She also agreed that A’s improvement was likely to be multi-factorial. 13.17. I note that it is not said on behalf of the M that Dr Knight-Jones’ evidence should be disregarded. On the one hand it is asserted that she was skewed and prejudiced in her approach, but on the other hand I am urged to consider and accept those points that Dr Knight-Jones conceded that assist M’s position. 13.18. The LA expressed disappointment at the overall contribution of Dr Knight-Jones and did not seek to ask the court to rely on her evidence to reach its conclusions. The LA pointed out that the evidence of Dr Campbell, an instruction appropriately suggested and deferred to by Dr Knight-Jones, properly covered the key issues via his specialist expertise. On behalf of the Children's Guardian and the F, it was submitted that the court should not ignore all of Dr Knight-Jones’ evidence, but could safely rely on those areas that were securely within her expertise and where there was important conjunction of opinion between the experts. 13.19. Overall, the court was disappointed by the lack of help and to some extent the added confusion that Dr Knight-Jones’ evidence provided. The court in these cases almost always looks to the paediatric expertise for help and analysis, set out in a comprehensive and readable report, accompanied by fair, knowledgeable and thoughtful oral evidence. This was only partially provided in this case, and on occasions I gained the impression that Dr Knight-Jones was comfortable in some areas more familiar to her and in other areas was operating out of her depth and with a lack of a full grasp on the issues. It is also clear that although she gave some unbalanced answers, she also was willing and able to concede other matters fairly or explain her reasoning underpinning her opinions. In the circumstances, although it is a mixed and critical picture, I consider it is safe and appropriate to give some weight to elements of her opinion and analysis that are confined to her general paediatric and developmental expertise, and in particular where those matters chime with the conclusions or opinions of Dr Campbell and the clinicians. 13.20. GASTROENTEROLOGIST 13.21. Dr Campbell is a highly experienced Consultant Paediatric Gastroenterologist and General Paediatrician. His qualifications are in Paediatric Gastroenterology from the University of London in 2001, a medical degree from St Bartholomew's Hospital in 1991, a council member of the British Society of Paediatric Gastroenterology, Hepatology and Nutrition, a Fellow of the Royal College of Paediatric and Child Health, and has published 31 peer reviewed journal articles on paediatric medicine. He has a permanent consultant position at Sheffield Children's Hospital in paediatric gastroenterology and general paediatrics. 13.22. His initial report of August 2020 was concise, however this meant that a number of matters of varying complexity had to be explored in further written questions and in his oral evidence as it was necessary to understand them in more detail. 13.23. He provided an addendum report dated 2.10.20, primarily addressing issues relating to high volumes of gastric drainage, and his opinions on the reasons for the low blood sugars and low weight, again extremely concisely. 13.24. When it became apparent at the outset of the hearing that the date error had been made by Dr Campbell as to when M had been excluded from the ward which had evident implications for the conundrum of ongoing gastric losses in the subsequent ten days, he was sent further questions and provided a further addendum report dated 2.11.20. This step had been resisted on M’s behalf. The submission was that they wished to draw this error to Dr Campbell’s attention in the witness box, rather than in advance, and argued that I should gauge his reaction (in terms of his analysis and handling of the medical evidence) to this challenge as part of my appraisal of his expertise. The other parties firmly opposed this submission, pointing out that this would be likely to cause delay by preventing him from being able to consider the correct data, thus raising the need for an adjournment to permit Dr Campbell to review the relevant material in order to assist the court properly. It was further pointed out that ambushing an expert does not assist with the appraisal of their opinion in terms of its logic and analysis; he was not a witness of fact and his response to being notified of an error was not a necessary part of the court’s analysis of his evidence. In applying the overriding objective, it was clear to me that the fairest, most efficient and proportionate outcome that would ensure that the court would benefit most from obtaining the best evidence from Dr Campbell, was by ensuring he had the opportunity to understand the data error and consider its implications by answering written questions on the points, and thereby providing notice to all parties of his analysis and also thereby avoiding delay and the risk of adjournment. 13.25. Following his oral evidence he was also asked to set out in writing his observations that had been in response to questions about A’s urinary output, and he provided a further brief addendum report dated 7.12.20. 13.26. He gave oral evidence on two occasions. The first occasion was unfortunately shortened due to the failure by the LA to ensure he had been notified of updates to the electronic bundle, and so he helpfully made himself available for a second occasion to answer further questions relating particularly to the gastric losses measured on the day of M’s contact on 20.12.19 and to the impact of certain medications. 13.27. He is clearly extremely experienced both as an expert with relevant expertise and in clinical practice. He stated that the care of young children with intestinal dysmotility and gastrointestinal tract problems related to neuro-disability is “… a core part of my day to day practice. I have met children with these problems several times a day every day for more than two decades.’ 13.28. Like Dr F, he too evidenced great respect for the role of carers, but also what has to be considered when difficulties arise: ‘ As a first principle, it is very important to trust implicitly what is said by the parents. But then when there are repeated episodes of features that do not match or what I see is not what I hear or what I am being told is not credible, then you have to think about the problem being what I am told rather than a medical problem with the child’ . 13.29. I also take into consideration the following: - He was a thoughtful and respectful witness who attempted to be as helpful as possible in terms of exploring points, and was open to the reconsideration of certain issues in terms of being asked to look afresh at data sources or addressing errors or corrections; - His opinion was not challenged on the basis of contrary published research or alternative expert opinion; - Where there was overlap, his opinions accorded with that of Dr Knight-Jones, and with the observations of the relevant clinicians; - His discipline did permit him, particularly when interpreting biochemical data concerning A, to provide certain definitive opinions. - Notwithstanding A’s complex presentation, I found his opinions in relation to all the matters that he addressed were straightforward to grasp from his explanations, save for one particularly complex area which is that of certain aspects relating to A’s gastric losses. - He made several errors in his initial report as follows: a) Page 6 – There were 3 date errors that required correction; none appeared to be of significance to his overall analysis save that it suggested some inaccurate attention to or transmission of the data to his report, b) Page 6 – A reference to zero gastric loss on a particular date, to reflect the wide range of amounts lost, was incorrect; the least amount measured at H2 was 2ml on 23.12.19 and was corrected in his second addendum in the attached chart showing gastric losses. c) Page 8 – He wrongly thought that M had been excluded from the hospital on 18.12.19 and not from 12.12.19, and made an assertion as to her responsibility for dilution of the gastric losses from the later date and so did not properly consider the amount of losses from 12.12.19 in his initial analysis. 13.30. PUMP, TUBES & OCCLUSIONS – Dr Campbell provided explanations of the PEG-J, pump, connectors etc. He confirmed he was familiar with the equipment, and described the tubing as tough but soft so that it could become occluded in an active child and if it was folded a kink would show. In his report he wrote: ‘Simple kinking of the tubing running from the feed pump will cause recurrent alarming of the pump due to occlusion pressures being exceeded. The tubing may show signs of kinking (page 1121 of H2 nursing records, more than 9 episodes within minutes are documented). Though the tubing is resistant to fracture, it can easily be occluded if the tube is kinked. Recurrent kinking, of the level observed in the nursing notes above, is not common in a child simply being active. Often a child lying on the tubing will not occlude the pump, the pump simply raises the infusion pressure (within the preset limits) to compensate .’ 13.31. Dr Campbell explained that fluid could be introduced into the drainage bag either by injecting it through gastrostomy into the stomach or directly into the bag. He stated that it was easy to unclamp the bag, put fluid in by either means and reconnect, especially for someone who has been trained to use these devices. 13.32. He was clear that dystonia would require severe visible spasms in the child to be responsible for blocking the jej tube (which was not the case here), and he did not accept that dystonia/spasms could occur that would do so without any outward sign of spasms or pain. 13.33. In relation to that last suggestion he said it was ‘ not a main stream view’ that bowel dystonia would be a reason for a pump to block, and added ‘Dystonia of the whole body is and could be. But we are talking the type of dystonia which is so severe and so distressing, that a child’s hip could be dislocated. We are not observing that level of dystonia on any occasion [in A]’. He also said that this type of ‘ dystonia strong enough to cause occlusions are very very painful. And so would be associated with crying .’ That was not the picture in hospital. 13.34. He said that distress and other presentations such as coughing that could raise internal abdominal pressure could momentarily lead to pressures that might prevent the inward flow into the jej tube. He also explained the two incidents of blockage when the nurses were giving a bolus of feed to A on the afternoons of 29 and 30.11.19. The descriptions of the incidents are set out above at paragraphs 8.66 and 8.67. In both cases feeds ran before and after satisfactorily, but then the pump began alarming with no apparent cause and so a bolus feed directly by syringe into the jejunum via the jej tube was authorised, and in both cases the nurses felt some sort of resistance to the feed being delivered and described A as showing distress. Dr Campbell explained that this type of bolus feeding can cause a dumping syndrome. The huge surge in insulin can cause cramping and pain similar to the sudden onset of a hangover. He thought the rate of 30ml in five minutes recorded in the notes would almost certainly cause this syndrome, and it would be this distress that would have caused the occlusion. It was not a sign of dysmotility or dystonia. 13.35. His opinions on this aspect of the case fitted entirely with those of the relevant clinicians. The demonstrations and explanations of the equipment, and the nature of its components that I have been able to observe, also accord with his analysis of its properties. I found his explanation of the impact of a bolus of feed on the jejunum to be a persuasive explanation of those two incidents. 13.36. LOW WEIGHT & WEIGHT GAIN – In his first addendum report he clearly opined that A’s weight loss in the period from May to November 2019 was due to inadequate nutritional intake rather than any underlying gut problem that interfered with nutrient absorption. He confirmed that there were no clinical signs or medical explanations for lack of weight gain, such as malabsorption. 13.37. He remained firm in his oral evidence on the absence of medical explanations for her malnutrition and then her subsequent weight gain, stating that there was ‘almost certainly inadequate delivery of the feed volume’, and that the period in foster carer shows that ‘simple nutrition leads to good weight gain’. He relied on the evidence that when she was fed she showed good growth, and that she made rapid progress through the centile charts once in foster care. He thought that it was almost certainly due to inadequate delivery of feed volume, particularly where A was on more than 150% of her calorie requirement. He did not consider that the modest amounts left over that were witnessed by F (of about 50-100ml) would be significant in this respect (and particularly where the family’s evidence was that an extra amount of about 50ml was included in any event). 13.38. He considered that while infections or anti-biotics might affect how much feed she could tolerate, it would not affect her ability to absorb the calories. I note that while this may be particularly true of children who feed normally/orally and whose appetites are affected, A was fed jejunally and therefore should have been receiving the full amount in any event. 13.39. He explained that A’s reflux and gut dysmotility are not adequate explanations for lack of weight gain; neither clamping the gastric tube nor gastric losses would prevent weight gain; dystonia, unless so extreme as to interfere with the overall ability to deliver feed (which was not the case here), does not prevent weight gain; and he explained that none of the medications administered in the November/December admission would explain a subsequent ability to gain weight; nor would different feed, changes in medications, nor any vicious cycle associated with low blood sugar episodes prevent weight gain; there was no sign of malabsorption nor any genetic factors or other disorders. There were no factors individually or multiply that he accepted could explain A’s lack of weight gain and subsequent significant improvement. 13.40. He thought that her low blood sugars might also be due to a vicious cycle triggered where feeds are increased to add calories, this stimulates insulin by another type of dumping syndrome and it overshoots leading to hypoglycaemia. 13.41. He confirmed that A’s malnourishment would leave her at greater risk of infection and dystonia, and to a certain degree she would be more susceptible to aspiration problems. 13.42. Again, his opinions and rationale accorded with the analyses of Dr Knight-Jones and the clinicians in relation to failure to gain weight and subsequent weight gain, and I found them to be sound and persuasive. 13.43. GUT DYSMOTILITY – In his initial report he set out his opinion that the mother exaggerated A’s intestinal dysmotility: ‘ A long history of apparent feed intolerance due to gastroparesis and or foregut dysmotility appeared to be fabricated as well, as all the evidence of gastric hypersecretion disappeared and A tolerated gastric feeds with the exclusion of the mother from A’s bedside’. He confirmed in his evidence in chief that the degree of certainty with which he held this view was 90%. 13.44. However, during his oral evidence, he shifted his position and accepted that there were other features than simply gastric losses and gastric feeding to consider, and he acknowledged that A had some signs of foregut dysmotility, albeit not severe. She had diagnosable signs of reflux in 2018, family members described her vomiting and gagging, she had distension and wind, and the gastric losses did show some bile staining in the form of greenish colours (indicative of some passage of jejunal fluids through the pyloric sphincter into the stomach). I recall in this context the video clips of her distended stomach taken in July 2019, and another taken in August 2019 during the pH study, in which A is lying on a hospital bed and is showing distress, passes an audibly large amount of wind and then vomits gastric fluids. 13.45. He remained clear and reasoned that this did not explain A’s difficulties with benefitting from jejunal feeding, which again accorded with the views expressed by the relevant clinicians. 13.46. He noted the successful clamping of her gastric tube and removal of the drainage bag during the July admission which did not produce difficult dysmotility symptoms as predicted by M, which would have been associated with more severe gut dysmotility, and noted that A had settled, tolerated her jejunal feeds, put on some weight and appeared brighter and happier to PGM over that admission. He also noted the rapid transition to gastric feeding from jejunal feeding in early January 2020. He explained that, unlike here, maturation normally made gut dysmotility problems worsen rather than improve. However, in the light of the overall picture put to him he accepted that various features of A’s presentation in 2018 and 2019 leading up to her admission were consistent with some gut dysmotility. 13.47. He clarified that TPN would never have been an appropriate option for A. It is a very serious intervention for very sick children that requires another operation and bears real risks of septicaemia and liver damage. 13.48. He was taken carefully through all the possible medications that A was prescribed and ruled out each of them in terms of worsening her gut dysmotility by considering each of their likely effects. It was put to him in particular that M considered that the Alimemazine would have affected A in terms of gut dysmotility. He disagreed, pointing out that although it can have a variety of effects, its main use is a form of sedation and anti-sickness, but has no or negligible effects on the motility of the stomach or secretions, but it may have an effect on ‘feelings’ or sensations from the stomach. 13.49. Although Dr Campbell too, like the clinicians discussed above, considered that jejunal feeding and a PEG-J may not have been necessary, again I do not take this observation into consideration in my determination of the issues. 13.50. This shift to accepting there was likely to have been a degree of gut dysmotility was an appropriate shift of his position in the circumstances of the evidence he was referred to, much of which has been discussed earlier in this judgment, and showed a willingness to adapt his thinking to an exploration of the relevant issues and an absence of a dogmatic approach, albeit it undermined the certainty with which he had expressed his initial view given the availability of much (although not all, such as the family videos) of this material previously. This shift also had implications for the next and most difficult topic. 13.51. GASTRIC LOSSES – GENERALLY – In his initial report he considered that there was no evidence of gut dysmotility, and set out his opinions in relation to gastric losses in that context. His subsequent agreement that A suffered to some mild degree meant that he also agreed that a degree of gastric secretions would be expected. 13.52. This led to a shift away from the assertion that M had fabricated a history of apparent feed intolerance as set out in his initial report, to the assertion that M had diluted and added to A’s gastric secretions produced due to her gut dysmotility. 13.53. He confirmed that A presented with none of the medical reasons that might explain such high or irregularly high gastric losses. M’s and F’s evidence was that on some days there might be little or nothing and on other days hundreds of millilitres. At the consultation in June 2019 with Dr V she was reporting an average of 800ml/day, when a normal amount would be 100-120ml/day. In her April statement M stated: ‘ The drainage would vary considerably on a day to day basis, this could go from being at 1000 ml or more for a period of say three days, and then without reason decrease to a 100 ml or less. Following prescribing Domperidone the average was approximately 600 ml, but this was an average and it could still change quite rapidly.’ 13.54. Dr Campbell’s clear evidence was that the amounts reported prior to the November admission were pathologically high, at a level where you would expect to see significant underlying disease. He is criticised on this point on behalf of M in that no other clinician treating her described A’s gastric losses in these terms through 2019. However, it is quite clear that they were all deeply concerned by it and were trying to address it in terms of immediate fluid replacement therapy, and two admissions in February and June 2019 where attempts were made to clamp the gastric tube and to remove the drainage bag. It is also clear that A was not showing the signs of significant underlying disease that might be associated with such high losses, such as various types of anatomical problems, obstructions or gastropathies, as set out in his August report. This therefore posed a perplexing picture to the doctors, who were trying to work their way through the thick of it. Dr Campbell has had the advantage of providing the overview with the benefit of the knowledge gained from having an oversight into a wide range of information and not being caught up in events with an incomplete picture, and even bearing in mind the reflex responses that I explain below, this led him to firmly conclude that the pattern of losses reported was not one seen in nature and could not be explained by any credible medical issue. 13.55. He explained that gut dysmotility which prompts excess gastric secretions is of an intermittent but frequent nature, so that the amounts drained in 24 hour periods would be largely similar and would not have shown the massive differences being reported by M. Importantly, he also explained that gastric secretions can also be increased by respiratory or viral infections, or by diarrhoea. 13.56. In terms of the timescale for losses to move from the stomach to the drainage bag he accepted that the speed might depend on the position of the child and the possible movement of some fluid into the small intestine. Initially he gave a range of ‘a few seconds or minutes up to about an hour or two’ . However, when he was pressed to explain more closely the puzzling presentation on 20.12.19 (to which I will refer in more detail below), he expanded his timescale to up to 4 hours. For reasons referred to below, I found this later expansion of the timescale to be an unsatisfactory and unpersuasive element to his evidence, and consider his initial and unpressured assessment of timescales to be more reliable. 13.57. He also explained that the high pH measurements taken by the nursing staff were likely due to A’s treatment with omeprazole/esomeprazole due to its gastric acid suppressant effects. Accordingly, those measurements which were fairly consistently in the neutral or alkaline range are of no clinical significance here. I note that the nurses nonetheless took the measurements, and may have been unaware of the impact of this medication. In the circumstances of such large gastric losses, taking those measurements was unsurprising. 13.58. GASTRIC LOSSES – REFLEX RESPONSES – Due to the impact on the body of losing excess fluid and electrolytes in such gastric losses, these were then replaced by a prescription for Dioralyte from late November 2018. This treatment, other than on two notable occasions, remained in place until late December 2019. 13.59. Dr Campbell provided an important insight into the implications of this treatment. Whatever the cause of the gastric losses, the treatment itself (namely providing an input of extra liquid) can cause the body to react by producing further gastric fluid. Additionally, the draining of gastric fluid also causes the stomach to react by replacing it with further production of gastric fluid. These ‘reflex’ responses can be seen to be iatrogenic contributors to the issue of gastric losses. It becomes a vicious circle. 13.60. The rationale underpinning and the implications of these phenomena appear to be borne out by the reaction when A’s Dioralyte replacement therapy was reduced and gastric tube was clamped on those two occasions: the February and July 2019 admissions. On both those occasions losses dropped significantly when her gastric tube was clamped and Dioralyte replacement fluids were reduced. 13.61. The discharge letter from the February admission reads as follows: ‘ Initially, PEG drainage volumes were approximately 750mls over a 24 hour period. This was reported as typical for A. The gastroenterology team, led by Dr V, initially suggested replacing gastric losses ml per ml with Dioralyte via the JEJ. This was reduced to replacing losses above 30mis/kg/day, which significantly reduced gastric losses to approximately 150mls over 24 hours. However, following a further review Dr V suggested going back to ml for ml replacement of gastric losses. On the day of discharge, the gastric losses had increased to approximately 1000ml…We started clamping the PEG for 2 hours for every 5 hours of free drainage. A tolerated this well. ’ 13.62. I note at this point that it is not possible to arrive at any firm findings in relation to the February 2019 admission in terms of the question of the large gastric losses that were drained at the beginning and end of that admission and whether or not they are indicative of an interference by M or simply due to A’s conditions. I simply do not have sufficient evidence to do so. For example, I have not heard from witnesses that could assist as to the detail and types and timings of arrangements and treatments that took place. I do consider, however, in the light of Dr Campbell’s analysis and explanation of the reflex responses, that it is right and possible to glean a useful element of information from the clamping exercise and reduction in Dioralyte replacement therapy undertaken during that admission which led to a significant decrease in gastric losses. 13.63. Taking this forward logically, this explains the gastric losses seen even when M was not on the ward in November and December 2019. A was a child who clearly was producing gastric losses whether due to the vicious cycle of the reflex responses to drainage and replacement fluids alone or in combination with an element of foregut dysmotility. 13.64. Additionally, if that replacement therapy was further increased to reflect artificially increased amounts drained due to insertion of fluid into the system by M, then there would also have been a consequent further increased reflex response and thus even more gastric fluid would have been produced 13.65. This would therefore explain those figures set out in the fluid balance charts, where gastric losses were drained either during or at the end of the night or in the morning when only PGM was present and M had not been present on ward for some or many hours. Principal examples are: 2.12.19 – 24.00-171ml 3.12.19 – 09.00-100ml 4.12.19 – 06.00-84ml 5.12.19 – 23.00-87ml 6.12.19 – 10.00-94ml 7.12.19 – 20.00-103ml Although it is unclear when M left the ward it is likely she was not present by then as the only date she stayed late into the evening was 3.12.19. 8.12.19 – 09.00-80ml 9.12.19 – 20.00-82ml 10.12.19 – 06.00-72ml and 18.00-81ml. Even so, these figures are significantly less than the amounts drained during the periods when M was on the ward. 13.66. It is also the case that these reflex responses, in combination with A’s gut dysmotility, would have been in play prior to her admission and while at home. This may explain the larger losses seen by the family members and at earlier hospital admissions. It does not appear to explain the irregularity of the larger losses as reported by M. It is not possible for me to firmly infer, from the findings in the rest of this judgment, that M was diluting or adding to those losses or whether she was reporting them in exaggerated terms. I note that findings are not sought in relation to gastric losses measured prior to the H2 admission. 13.67. GASTRIC LOSSES – DILUTION – There were a number of factors which led Dr Campbell to confidently conclude that M must have been diluting the gastric losses by some means. 13.68. He explained that the following factors were important in looking at gastric losses: appearance; volume; timing; chemistry. 13.69. In terms of appearance, he explained that naturally produced gastric losses would be cloudy and not clear but could be colourless. There would be some colour, although that could range from pale yellowish through to deep dark green. The deeper the colour the more bile had entered the stomach from the jejunum. He also confirmed that he would not expect a gastric aspirate to appear fizzy, and A was not receiving any effervescent medication. Gastric aspirate would not be cold. Normal body temperature is 37-38C, and he added ‘there is nothing cold in hospital’. 13.70. In terms of volume and timing, he expanded on his general observations when asked to consider particular drainage losses noted at H2. When considering particular examples, he explained that they would have been physiologically impossible, and producing so much fluid loss per kilogram of body weight A would have presented as a very unwell child due to the rapid and drastic loss of fluid from the body. One such example was the aggregated losses of about 800ml over a 4 hour period on 11.12.19, which would represent more than 100ml per kg. 13.71. Another such example was on 7.12.19, where aspirates were being checked each hour, and produced three small volumes at 3am/40ml, 7am/35ml and 11am/ml, and zero aspirates at 12 noon and 1pm. M arrived soon after noon. S.N.ST then noted that at 2pm she measured a gastric loss of 310ml, then recorded that at 2.10pm she aspirated the PEG-J gastric port (that is to say, she used the suction from a syringe to withdraw any stomach contents) and obtained only 2mls of fluid – the significance of this being that in doing so the nurse evacuated the contents of A’s stomach. About ten minutes later at 2.20pm, after she had returned from drawing up medications in the drug room, the bag contained a fresh gastric loss of 365ml The loss of 365ml is set out at 3pm in the fluids chart where there are pre-printed hours in the ‘time’ column, but is recorded as being taken at 2.20pm in S.N.ST’s hand-writing next to the entry and in the e-note which was logged on the electronic filing system at 14.44. I accept that S.N.ST’s timing of 2.20pm is accurately recorded. . This represented an aggregated total between about 1pm and 2.20pm of 675ml, and Dr Campbell stated that it was not possible for A to produce a loss of 365ml in about 20 minutes, nor a loss of 675ml over 1.5-2 hours. He explained that it represented so much water donated from her bloodstream in such a short period of time that it would become a biochemical issue and would lead to shock and unconsciousness and a cardiac arrest situation. He considered that the most likely explanation was someone adding fluid to the bag in some way so that it was being measured as gastric drainage. 13.72. In terms of chemistry, there were two sets of samples tested that provided Dr Campbell with powerful arguments to support his analysis: firstly, urinary sodium levels, and secondly, gastric fluid biochemistry. 13.73. Urinary Sodium – In his report he wrote: ‘I note the urinary sodium is 133 on 17" (sic) [4 th ] December 2019. This shows that the body’s sodium balance is high. The urine output is documented to always be high (7th December 2019) i.e. 6mls per kg per hour. The blood urea remained low . Poor nutrition can lead the blood urea to be low, but taken together with high urine output and high urinary sodium levels, suggests excess fluid administration. If the gastric fluid replacement volumes are in fact not from the stomach, but have fluid added to the drainage bag, then this is the pattern of biochemistry that I would expect. If the gastric fluid volumes, replaced as Dioralyte in to the jejunal tube or IV saline, were truly drained from the stomach, those losses would be high in sodium [but were not] and not lead to a urinary sodium of 133 (more likely to be in the region of 40-60mmols/1). If the fluid volumes were not all gastric, but the fluid were replaced as if the losses were all gastric, then the urinary sodium would rise to these levels, as excess sodium is being inadvertently given. … the results available in the [H2] files are strongly suggestive that A was given excess water containing sodium because gastric volume replacements were over estimated. ’ 13.74. Despite rigorous cross-examination on this point, Dr Campbell’s analysis remained consistent and well-reasoned. He was challenged on a range of issues including whether or not he had included the impact of the IV saline, glucose and Dioralyte treatments that A had been receiving in the period up to 4.12.19, as they were part of her replacement fluids regime of which he was aware. He also considered and discounted the impact of her operation and high urinary volume. He was able to confirm his awareness and inclusion of the relevant issues, and indeed although concise they are touched on in the paragraph quoted above. 13.75. In his oral evidence he confirmed it as follows: ‘the glucose, Dioralyte and sodium provided through the saline drip at both H1 and H2 did not cause the problems seen in respect of urinary sodium. He explained that the chosen rate of installation of Dioralyte and IV sodium was dependent on amount of fluid measured from gastric losses. If we postulate that the losses from PEG were all due to a dysmotile gut, then the sodium losses would approximate to the amount of fluid distilled into the child. Therefore, the urinary sodium levels would be within normal levels. But they were high. So if they were high, the only possibility is that some of that volume was added to the bag and had not gone through child’s system, so the true losses from the child’s gut were over-estimated and were then replaced with a sodium-rich replacement fluid. This caused urinary sodium levels to rise, as A’s body struggled to get rid of sodium and urine. The urine output was high as well, suggesting fluid measured was probably higher than was a true gastric loss. In other words, high urinary sodium and high urine output rates are indicative of the child getting more fluid and more sodium rich fluid than the child was losing.’ 13.76. He also noted, in his final addendum report, that urinary output up to 11.12.19 was high at a range of 3.7-6.0 ml/kg/day, that it then fell in the ten days following and from 22.12.19 had an average of 2.75 ml/kg/day. This led him to conclude: ‘There is evidence of high urine output, but on analysis this is a normal response to high fluid intake, above what was required, due to over estimation of fluid losses due to PEG drainage. From 22nd December onwards, urine output is normal for a tube fed child.’ This factor also supports his above analysis. 13.77. Gastric Fluid Biochemistry – He analysed the biochemical test results of three samples of gastric aspirate taken from the drainage bag on: - 9.12.19 at 1pm (Time Point 1) - and at 4.30pm (Time Point 2) - 10.12.19 at 8.30am (Time Point 3). Time Points 1 and 2 are when M was alone on the ward with A (M leaving at 5.30pm), and Time Point 3 is first thing the following morning after PGM had spent the night with A and before M returned to the ward. 13.78. He wrote: ‘ There are normal ranges published … The 3 time points when samples were sent for analysis of the 3 major electrolytes (sodium, potassium and chloride). … Time point I shows chloride in the lower limit of normal, but sodium and potassium abnormally low. Time point 2 shows all electrolytes to be low. Time point 3 is a normal chloride and sodium with potassium just below the lower limit of normal. Time points I and 2 are strongly suggestive of dilution with water. Time point 3 is probably normal. Dilution of gastric fluid with small intestinal fluid would be detected with high, not low potassium, as well as bile being present in the fluid. Time point 1 and 2 are unlikely to be due to another biological fluid contaminating the PEG drainage bag.’ 13.79. Again he was carefully questioned and maintained a reasoned and firm analysis. He confirmed that A had no kidney problems that could lead to these results, and nor could the Dioralyte or other medications that were detected in the gastric fluid. 13.80. He confirmed that if water was introduced into the stomach, because of the PEG-J and the free drainage via the gastric tube, the vast majority of it would drain into the bag and would not therefore enter into A’s system (save for a very small amount, he estimated about 20ml). 13.81. He therefore concluded, and I consider he did so on a soundly reasoned scientific basis: ‘Taking all these findings together [urinary sodium and gastric aspirate biochemistry] , there is a very high likelihood that the intermittently high gastric fluid losses, are due to the intermittent, external administration of water to the gastrostomy drainage bag.’ 13.82. When he was asked to consider the overall picture: the chemistry, the volumes, the pattern set out in the fluid charts - where there was a consistent picture of very much smaller volumes of gastric losses drained during all periods when only PGM was there, compared to significantly larger amounts beginning shortly after M arrived on the ward in the afternoons - he considered that the picture appeared consistent with fluid being added and not generated by A. This appraisal was well-supported by his well-reasoned analysis. 13.83. GASTRIC LOSSES – CONUNDRUM PERIOD & 20.12.19 – Following M’s exclusion from the ward after the events of 11.12.19, a conundrum appears to be posed by ongoing gastric losses until 22.12.19, and in particular the allegation sought by the LA in relation to the loss of 153ml on the afternoon of 20.12.19 following M’s contact. 13.84. I reproduce here the figures from the table attached to Dr Campbell’s second addendum report (with added figures for the dates 2-5.12.19 for completeness): 2.12.19 – 801ml 3.12.19 – 655 4.12.19 – 953 5.12.19 – 1039 6.12.19 - 791 7.12.19 - 948 8.12.19 - 693 9.12.19 - 690 10.12.19 - 565 11.12.19 - 839 (M’s last day on the ward) 12.12.19 - 30 13.12.19 - 100 14.12.19 - 368 15.12.19 - 330 16.12.19 - 363 (Start of reduction in fluid replacement with Dioralyte?) 17.12.19 - 279 (M had supervised contact) 18.12.19 - 219 (Clamping began) 19.12.19 - 239 20.12.19 - 404 (M had supervised contact) 21.12.19 - 48 22.12.19 - 3 23.12.19 - 2 24.12.19 - 9. 13.85. I note briefly here that in an e-note dated 16.12.19, there is a figure of 423ml given for the previous day 15.12.19. On the fluids chart it shows the figure of 330ml. It is unknown where the figure of 423ml comes from, and I consider that the fluids chart, as it is completed at the time by the nurse measuring and recording the amounts, is more likely to be accurate than another nurse in a separate note the next day where she is more likely to have made an error or mistyped. 13.86. Dr Campbell’s initial analysis based on an erroneous understanding of the date when M was last on the ward was as follows (and in his report where he was not acknowledging the presence of gut dysmotility): ‘ The observation that the high gastric fluid volumes settled after mum was excluded on 18 th (sic) December 2019 suggests the mother was at least involved with diluting the gastric fluids. ’ In getting the date wrong he only addressed the two to three subsequent days of higher gastric loss levels in his assessment and as a result failed to consider the figures in the conundrum period from 12.12.19. 13.87. His subsequent approach, in his second addendum report where he had the opportunity to revisit his opinion with the correct date was as follows: ‘ The daily average PEG fluid loss from 6th December to 11" December was 754.3mls. The daily average over the subsequent 3 days fell to 166mls per day. The fall was abrupt and did not taper. It should be noted that from 14th December the volumes of PEG losses did seem to rise from the daily average of 166mls to around 300mls, but fell consistently day by day since that time. It is common knowledge that after a prolonged period of gastric drainage, the stomach needs some time to recover its normal peristaltic capacity over a number of days (a week or sometimes more). It is not a surprise that the gastric losses rose from 3ml to 100mis to 368 mis on 130, 14" and 15th December respectively. It would be expected in the absence of an underlying motility or obstructive problem, for the volume of PEG fluid drained to fall across several days. That is what in fact happened. Occasional days of increased losses can be recorded in the normal situations. I am concerned that the trend of day on day reduction of PEG fluid drained reversed on 20" December and the following day showed a ten-fold reduction. This is not the normal pattern of variance where I would accept a single day of one off 20% increased fluid increase, and a steady decrease thereafter. This of course happened between 18 and 19th December (more like a 10% increase rather than a 28% increase). On the one hand a daily variance rising to 28% on the previous day could be overlooked as innocent, given the trend is so strongly down ward I would be concerned that the trend was strongly reversed on the day when the mother visited would suggest that possible interference with gastric drainage may have occurred. No such trend was observed on 17" December when a similar supervised contact occurred. I would want to consider any further factors that come to light and change my opinion in the light of those factors, but on balance I am concerned that supervised contact with the mother on 20th (but not 17th) December led to a change in the volume of fluid lost via the PEG . ’ Importantly, he acknowledged that there would be a degree of variance, but (because at that point he still held the position that there was no gut dysmotility) he had not built in the impact of gut dysmotility nor the reflex responses. 13.88. When he was taken through the chart of figures from 12.12.19 on his first day of evidence, he stated that he thought the progressive reduction with day-by-day variations as A’s system recovered, plus the underlying dysmotility could account for the larger losses during that period. When specifically asked about the loss of 404ml on 20.12.19 he agreed that these factors might explain it although it is unusual; he said it might be possible; he was not too confident and would not want to say he was completely convinced; he would not want to say it could be only due to M adding fluid to the bag. Later in his evidence he shifted from this position to firmly assert that it looked as if M had added fluid on 20.12.19. 13.89. While his overall analysis of the genesis and provocation of gastric losses that I have discussed in earlier paragraphs, and their subsequent settling in general, is sound and would rationally explain the features discussed earlier and during this conundrum period as set out above, I found some of his reasoning to become increasingly confused and strained in relation to reaching for an explanation as to the figures seen on 20.12.19. 13.90. From the fluids chart for 20.12.19 it is apparent that gastric losses were measured at the following times and the following details emerge: 02.00 – 18ml 06.00 – 13ml 10.00 – 55ml 12.00 – 62ml – gastric tube is clamped and bag removed for next 2 hours (12.00-14.00 – M’s contact takes place) 14.00 – gastric tube is unclamped 18.00 – 153ml – dark green aspirate 23.00 – 103ml Total – 404ml 13.91. From this it is clear that there is (a) a period of six hours between the last measurement/draining of losses, and (b) a period of four hours between the end of M’s supervised contact, and the next measurement at 6pm when 153ml is drained from the gastric bag. Moreover, in the two hour period between 10am and 12 noon before M attended there is a loss of 62ml, and the total losses for the first twelve hours of the day until 12 noon totalled 148ml. M could not be said to be responsible for this loss which represented a marked increase by comparison with similar periods on previous days since 12.12.19. Dr Campbell refused to consider the possible relevance of these losses prior to M’s arrival and in particular the rapid rate of increase between 10am and 12noon. He emphasised that it was statistically misleading to look at only a few hours instead of the overall 24 hour period. While that might be true of broader analyses, it becomes forensically highly relevant when there are significant losses taking place on that day but prior to (or well after) M’s arrival. 13.92. In terms of rate of gastric losses per hour the period 10am to 12 noon demonstrated a significant increase to a rate of 31ml/hr, and Dr Campbell told me that the rate leading up to 6pm was 38ml/hr and therefore supported his concerns about the loss of 153ml measured at 6pm. However, this was an erroneous calculation based on a four hour period. In fact, given that no gastric aspirate was drained for six hours between 12 noon and 6pm, the correct rate was only 25.5ml/hr (153ml/6hours = 25.5ml/hr). This represents a reduction in the rate during this period compared to the rate between 10am and 12 noon, and therefore does not support Dr Campbell’s argument. 13.93. There was a further 103ml drained at 11pm. This period of 6-11pm was also a time period in which M could not have tampered with the drainage. Again 103ml was a significant amount in itself, the relevance of which Dr Campbell declined or failed to include in his analysis of this day. This period equates to a rate of 20.6ml/hr. There appears to be a picture therefore of a rapid increase in gastric losses peaking at its highest rate per hour prior to M’s arrival for contact, and then gradually and steadily reducing over the next 12 hour period. 13.94. Additionally, Dr Campbell was asked to consider this period of four hours that went by between 2pm when M left and 6pm when the loss of 153ml was drained. It was when faced with this timing that Dr Campbell changed his opinion on how long it would take gastric losses to drain from the stomach. On his first day of evidence he had three times explained that it would take a maximum of up to about 2 hours for fluid to drain from the stomach into the gastric bag. On the last of those occasions it was specifically brought to his attention that there was a four hour period after M left at the end of the visit, and he repeated: ‘ I said up to 2 hours – that’s probably right but there’s a bit of uncertainty about it’ . He did not change his evidence to stretch it all the way to a 4 hour period for the stomach to drain until he was recalled for a second day of evidence and was asked to address this point, albeit he couched it as 2-4 hours and when ‘not well’ it could be up to 4 hours. This was markedly different and had been wholly missing from his earlier comments. This was an unedifying and unconvincing stretch, and I find that his repeated answer given in the first part of his oral evidence was indeed evidence he meant and intended to give at that time. It would have been based on his experience and I consider it is the appropriately applicable time period to apply. 13.95. I add into the picture the fact that A was experiencing some form of gastro-enteritic illness on 20.12.19 - she was noted to have loose stools. Dr Campbell’s initial evidence on this point was that this would be likely to add to her gastric secretions and he mentioned this twice on his first day of evidence, however when he was recalled and gave further evidence he changed his position entirely to resile from this point and asserted that any contribution to the amount of her gastric fluid from her gastro-enteritis should be ignored as it would normally have had an effect over several days and not just on 20.12.19 and where the loss the next day was only 48ml. This was despite the change to green colour noted in the 12 noon aspirate, and the noted dark green bile colour of the loss taken at 6pm, which he had previously acknowledged meant that there was an extra degree of gut disturbance from illness. And the following day the gastric loss was still noted to be green. He now did not want to include the relevance of this colour, despite that it appeared, on his own earlier analysis, that there was likely to have been an impact from illness to produce gut disturbance, and that the dark colour would be indicative of less or no dilution. It was at this point that he attempted to dilute his own earlier evidence by suggesting that ‘ a little bile can go a long way’. 13.96. I note that full drainage was still in place until 18.12.19 when a plan of two hourly clamping twice per shift was in place (therefore four such periods in each 24 hour period), and there is some suggestion in the nursing notes that Dioralyte fluid replacement therapy may have been reduced to replace only those losses over 200ml/day from 16.12.19, although there is also subsequent reference to ml/ml replacement. In response to cross-examination during his first period of evidence, on this point of clamping possibly ‘kicking into action’ a more normal stomach, he was prepared to accept that this could be correct, although he found it hard to recognise the pattern from a higher loss on 20.12.19 to a very low loss on 21.12.19. 13.97. Therefore the iatrogenic components identified by Dr Campbell were only beginning to be removed from the picture from 18.12.19 when some limited clamping began. In view of that, the ongoing picture of losses 12-18.12.19 shows the levels occurring with those factors still in play (in accordance with the implications of his evidence on the relevant factors), and Dr Campbell did not appear to take this into account. And the levels from 18.12.19 could well be said to fall within his explanation of day-to-day variants following the period when gastric drainage and replacement fluids are beginning to be curtailed. 13.98. It is telling that Dr Campbell’s initial error/argument coincided with the date when A’s treatments that prompt reflex responses began to be removed, namely from 18.12.19. It was in correcting that error, and then perhaps over-compensating for it, that I consider that Dr Campbell was tempted into less sound arguments and to ignore certain important factors. 13.99. Although at one point he said he was certain ‘this is not how biology works’ and that ‘this is my job, this is what I do, this unusual’, I also note that later in his evidence he accepted that he had a degree of uncertainty over this issue and he emphasised that it would be for the court to build in the various other pieces of information available. Plus given the alterations in answers he gave to various issues, I have to consider that his expression of certainty may also have a variable quality, as it did in his shift to accepting the presence of gut dysmotility. 13.100. He was reluctant to acknowledge the combined impact of these factors when I invited him to do so: (the reflex responses to treatment and recovery therefrom, the gastro-enteritic illness, the underlying gut dysmotility, the timing issues). This was disappointing given the variations in his answers and his own identification of this important component of the reflex responses. I consider that under the pressure of court questioning he simply failed to apply his own logic to the data, dates and circumstances and became caught up in working backwards from an opinion rather than forwards from the data and analyses. It is therefore strongly arguable that the gastric loss figures following 18.12.19 are entirely consonant with this being the period when the stomach was only beginning to correct itself in response to some limited clamping and thereby reduce its response to the treatment of both drainage and fluid replacement, in addition to the illness component, and the other variables and issues identified, and therefore it is not possible on the balance of probabilities to ascribe so great a significance to the gastric loss of 153ml taken at 6pm on 20.12.19 that it can be properly asserted that it included an element of dilution by M. 13.101. I found there were various aspects of his assertions on this particular point where he was reliant upon withdrawing or changing some of his earlier opinions, and failed to draw in and include other aspects of the picture. I have considered all the submissions made in relation to his evidence while working through all of the issues upon which he gave his expert opinion. While there were a number of unsatisfactory elements on this last topic and I found his reasoning to be flawed in the narrow respects examined above, his rationales and explanations for the other elements of his expert opinions on the issues in this case were soundly reasoned, reliable, and well supported by the other medical evidence.

14. DISCUSSION & ALLEGATIONS 14.1. In coming to my conclusions, I have stood back and taken careful account of all of the evidence before me, all the submissions made, and I have applied the law which I have summarised above. I have already set out various conclusions and discussion earlier in this judgment, in order to provide appropriate determinations at points in the structure that is relevant to the topic or witness being discussed. Any findings or conclusions, whether here or earlier, are made or reached with full awareness of and regard to all the material and all the other findings or conclusions set out elsewhere. This judgment is not a linear function, but an aggregate of all the considerations I have applied, and each part has been written with an awareness of the content of the other parts. 14.2. I have particularly borne in mind M’s vulnerabilities and all the positives and caveats that I have referred to and that have additionally been drawn to my attention on her behalf. 14.3. It is a particular feature of this case that many of the allegations can be established entirely without any expert evidence (although the expert evidence is clearly corroborative). It is also a feature of this case that many of the issues concerning A’s health overlap. Another is that there has been a vast amount of material to digest, sift, understand and cross-reference. I have tried to group my discussion of the findings sought by reference to the allegations set out in the Schedule. As pointed out in paragraph 5.1 above, it is not possible nor proportionate to include each and every factor, item or contention in relation to each issue. 14.4. ALLEGATIONS 1 & 3 – M failed to provide A with sufficient food or calorific intake at home, and A’s lack of developmental progress was caused by her extreme malnutrition. 14.5. The experts and the clinicians all coincided in their unanimous views that there was no medical cause for A’s failure to gain weight, save that Dr F deferred to the dietitian as to A’s feeding issues. Dr U’s evidence was particularly striking and Dr Campbell’s very clear. I also note Dr Q’s concern expressed in his letter of September 2019 that A had made no developmental progress in well over a year. All considered that her subsequent progress was significant to understanding this picture. I have set out my analysis of and conclusions arising from the medical evidence earlier in this judgment. 14.6. It is pointed out on behalf of the Children's Guardian that A began putting on weight in hospital while receiving fewer calories than she had been at home. From August 2019 A should have been getting 1150 kcal/day. This was the amount calculated to be 177-230% of her requirements. This should have continued until her admission. On admission the amount was reduced and on 9.12.19 it is recorded that she was getting 888 kcal/day and her weight was 8.1kg, about 200g heavier than on admission. By 16.12.19 this had been increased to 960 kcal/day and her weight was 8.75kg. By 20.12.19 A was getting 1104 kcal/day – still lower than her feed at home. She remained on that level of feed and was discharged a month later on 21.1.20 at 10.2kg. 14.7. On M’s behalf it is submitted that because of the pump issues it is likely that A was not getting her full feeds and therefore was not getting sufficient calories to grow. I note that all the family agreed that extra amounts of 50ml were added to each feed to carry it over if necessary, and that both F and PGM only recall insignificant amounts left at the end of feeds. These were not measured as they were not significant, and the extra had been added. Dr Campbell did not consider this would be significant enough to diminish the feeds materially. 14.8. M’s account of feeds was inconsistent and concerning. M’s description of the pump alarms began as significantly higher than F’s. She initially asserted it was up to 30 times per day, but clarified that to about 5 occasions made up of a number of a beeps going off in clusters until the issue was corrected. M agreed that there would be short breaks in the feed while alarms were sorted out. PGM said this would normally be a few minutes. M’s evidence started out as being that A might miss 2 hours of feed due to pump problems – this had never before been stated. Once it was put to M that A was anyway getting more than she needed due to the excess amount, M then changed this figure to 4-5 hours of time lost to the pump problems. M claimed to have mentioned the feeding problems to her GP but there are no GP notes of this throughout the period June to November 2019. 14.9. Of particular concern, was that she asserted that a full 1-2 feeds per week were completely undelivered by the pump. I have referred to the F and PGM’s frank shock at this claim. I prefer their evidence that neither of them accept or recall that full feeds or significant amounts were not delivered by the pump, save for the only two occasions which were so shocking that they filmed the pump on each occasion, in January and June 2020, and informed the dietitian DM. They were quite clear that M never shared this critically important information with them. I have no hesitation in accepting this evidence as I have discussed earlier in this judgment. It was also concerning that when pressed on the point, M admitted that she had not told the Dietitian DM about these missing feeds each week. This does not make sense given M’s alleged concerns about A’s weight and about faulty pump delivery. I am obliged to conclude that M’s accounts of these issues are inherently unreliable and untrue. 14.10. Why would M want to tell these untruths unless she considered these issues worth lying about? I have reminded myself of the guidance in relation to lying, and of M’s circumstances, and thought carefully about what reasons she might have. Given the nature of the inconsistencies, however, it appears unavoidable to conclude that M is trying to exaggerate the role of the pump problem in terms of the failed delivery of A’s feed. The only plausible reason why she would do that is to obscure some other cause, relating to A’s feeding, of which she is aware. 14.11. I have taken into account the submissions made on M’s behalf as to the practical difficulties in interfering with A’s feed: the nature of the pump, home life, the shared routine. I note that although F and PGM were heavily involved in the weekly routine, this was a very busy household. They made up many but not all of the feeds, they were often not there to see them through, and on four nights per week since July 2019 M was alone overnight with the children. Prior to July the PGM had slept downstairs on those nights. I also note that other than one night per week PGM made up the midnight feed and set it running but admitted that she never actually checked the figures on the screen to check the amount that had gone through as she had no suspicions and assumed it would have. 14.12. I recall the issue that I have covered earlier in this judgment, that M has attempted to mislead the court that the clinicians were unconcerned about A’s weight. This represents a very serious effort to deflect the attention they were in fact paying to this issue. 14.13. I also note that M told the Ellenor nurse that she was unhappy about the fact that A’s admission to hospital would be examining her weight and feeding issues. Initially she denied having said this, and only when pressed admitted she had said this but said she meant she was frustrated not unhappy. 14.14. I also noted with concern that M twice mentioned in her oral evidence that ‘ A did not show hunger symptoms. She appeared to be in pain and not hungry’ . This was a strange and remarkable thing to say. If you believe your child does not show hunger, there is a risk that you do not understand or acknowledge that they may be hungry. If you describe your child as being in pain (as M claimed for the few weeks leading up to the November admission) rather than feeling hunger, you may seek to treat something painful rather than provide them with adequate food. But I am also forced to ask: how did M know this? A was a disabled non-verbal two year old. In what way other than distress would A express either her hunger or her pain? If she was chronically malnourished and hungry, it is hardly surprising that in the few weeks before her admission she is described by M and PGM as sometimes inconsolable. 14.15. Another submission made on M’s behalf is that we are not comparing like with like: a) A was having multiple chest infections prior to her admission. Chest infections improved, it is said possibly due to less drooling and maturation. It is certainly the case that there were fewer respiratory infections, however I note that A had a respiratory infection in late December and still continued to thrive. The doctors’ evidence was that there might be some slight impact on weight when unwell, but that it would not be significant and would be quickly made up. b) There were medications that were started in hospital (Alimemazine, Esomeprazole and Gabapentin) which M believed benefitted A. Dr Campbell’s evidence was clear that these medications would not affect the ability to gain weight. Esomeprazole is an isomer of the drug it replaced (Omeprazole) and therefore performed the same chemical function. Both Alimemazine and Gabapentin were stopped in December 2019 as they were not indicated, and A continued to thrive. And again Dr Campbell discounted their contribution to A’s ability to gain weight. c) Natural stomach function and gut motility was restored and replacement fluids were stopped, thus relieving the body of this strain and the risk of reflux. Dr Campbell pointed out that even very disabled children with cerebral palsy and multiple associated comorbidities including gut motility issues and enteral feeding manage to grow and gain weight once their feed arrangements are in place. 14.16. In the circumstances, I am satisfied that the LA has established this allegation and I accept the medical evidence. I also conclude that M has tried to lie and mislead on this issue. I have borne in mind her difficulties, and tried to consider any other reasons she may have had for choosing to present these matters as she has. But I am driven to the conclusion that it must be to try to deflect onto other causes and away from matters that she knows would not reflect well on her. Her comments to the Ellenor nurse and in relation to A’s hunger are revealing, and form part of a worrying picture. 14.17. I find that by her actions or omissions in terms of making provision for A’s adequate nutrition, M has been responsible for A’s inadequate weight gain and state of malnourishment by the date of her hospital admission in November 2019. It is clear from the medical evidence that her poor development in 2019 and striking progress since shows that her development was held back by her malnutrition. 14.18. ALLEGATION 4 – I do not consider that the LA has satisfied the burden and standard of proof in relation to the allegation that M exaggerated A’s difficulties regarding copious secretions, wheeze, and recurrent respiratory infections. 14.19. All the family members vividly recalled copious drooling from time to time. Dr U confirmed she had seen it. Dr F described the mechanism of pooling of saliva and inefficient management of the structures of the mouth and jaw. He explained it could be intermittent and could improve over time as the muscles of the mouth, jaw and throat develop. There is some evidence of it persisting mildly. 14.20. Wheeze is clearly an element of respiratory distress and could arise in relation to respiratory infections. The chronology clearly sets out numerous respiratory infections and symptoms, for which A was often seen by the GP or at hospital. Dr Knight-Jones acknowledged that the GPs had picked up symptoms associated with chest infections and confirmed that the records and observations showed a repeated history of chest problems. The emergency admission for respiratory distress at H3 in October 2019, following a vomit on her way to a separate appointment there, led to a diagnosis of aspiration pneumonia, and the doctor assessing A on admission to DCH on 20.11.19 noted chest sounds ‘creps’. 14.21. I take into account that A’s inhaler and suction were not required in hospital, and her prophylactic antibiotic, and saliva reducing medications were ceased by late/end December 2019. I also note that excessive secretions or recurrent respiratory issues were not observed in hospital, although she was on her antibiotic until 23.12.19 and was treated prophylactically with antiviral Tamiflu for a week due to flu exposure risk. Equally, A was in a warm, nursed environment where she was receiving feed and IV fluids. She then began putting on weight. All of these factors would have been likely to prevent her from developing as many chest problems while in hospital and subsequently, compared to previously. 14.22. Accordingly, there is insufficient evidence for the LA to have satisfactorily established this allegation. 14.23. ALLEGATIONS 5 & 6 – Manipulation by M of the feeding tubing and drainage, resulting in occlusions and increased gastric losses. 14.24. OCCLUSIONS – The tubogram and various patency flushes were all able to establish that A’s PEG-J and jej tube was functioning correctly, without an invisible internal blockage. To be absolutely sure, the scheduled replacement of the PEG-J was brought forward. 14.25. It is clear from the nurses, Dr V’s and Dr Campbell’s evidence that pump occlusion alarms might occur from time to time for various reasons. Their combined evidence, which I accept, is that such alarms went off rarely, and certainly not as frequently as here, nor in the sort of pattern that emerged. I also accept their evidence that children with little mobility would rarely cause an occlusion by entangling the tubing by their minimal movements, albeit this might occur by some chance kinking or pressure on the tubing; and that due to the nature of the tubing and the system even more mobile children rarely prompted this problem to arise. 14.26. I am rightly directed to the manufacturer’s material which identifies possible causes: poor flushing techniques; failure to flush after measurement of gastric residuals; inappropriate administration of medication; pill fragments; viscous medications; thick formulas, such as concentrated or enriched formulas that are generally thicker and more likely to obstruct the tubes; formula contamination that leads to coagulation; and reflux of gastric or intestinal contents up the tube. I have also listed some additional issues earlier in this judgment, such as air entering, a feed ending or a particular movement. An example of the latter was recorded by Ms O on one occasion when M lifted A during a supervised contact. 14.27. While at home, it is clear that the pump alarmed from time to time. M claimed it was about 5 times per day, and that there might be clusters of alarms on each occasion. I note that the pumps used at home were similar but not the same as the hospital system that I have been shown, and have not been examined or demonstrated at this hearing. Neocate was a particularly difficult milk to mix without problematic lumps or sediment and was used from late 2018 until A’s November admission. I have not been informed in any detail as to the texture of particular medications that A was being administered, save that F recalled one particular medication which required care because it was thick. It is clear that occlusions occurred sometimes when A was moved, or the car jolted. I note that they also occurred when A was calm or sleeping, therefore excluding the possibility of the ‘inner dystonia’ theory that I have addressed elsewhere in this judgment. It is clear from the family’s evidence that these occlusions did not all occur with M nearby. 14.28. What is notable, however, is that once A was observable in hospital, a distinct and striking pattern emerged: multiple alarms when M was on the ward, and almost none when she was not. Firstly, while PGM was present overnight alarms were not noted, and I accept PGM’s evidence that she was never woken by an alarm. There were a very few alarms at times in the mornings or evenings when only PGM was present, and they appear to be explicable by the variety of reasons normally seen when an alarm might sound. I have explored this in more depth earlier in this judgment. It is suggested on M’s behalf that there were numerous repeated examples of alarms at such times, but there is not the evidence to support that assertion and I am satisfied on the evidence that there were not. Secondly, as I have considered in detail earlier in this judgment, the nurses recorded numerous alarms sounding when M was present, particularly when she was there alone without PGM. While it is not a perfect document, I am satisfied that the Feeding Pump Alarm Chart ties in with the observations of the nurses in their e-notes and their oral evidence that I have discussed earlier in this judgment, and reliably represents a log demonstrating the pattern discussed above. 14.29. While I note M’s evidence that she did more with A during the day than PGM did, and that this might have contributed, most of the evidence I have heard (including from M) that describes the periods of these repeated occlusions, is of M cuddling A closely and somewhat passively, while lying or seated on A’s bed, often stomach to stomach, and with a blanket over A and her tubing. On two occasions, M is described as sitting next to A, for example once the OT had visited and placed A in her blue seat. 14.30. Given the nature of the tubing and the pump mechanism, I am satisfied that pressing, pinching, or squeezing the soft tubing sufficiently tightly is likely to cause the milk to stop flowing through and trigger the pump to register an occlusion. This would evidently also occur if a clamp was closed. Once this pressure is released, there would be no evident visible cause of the occlusion, as was repeatedly the case here. It might lead, as I have seen demonstrated on the tubing, to some slight indentation or kink mark. This was observed on occasions by members of the nursing staff. 14.31. In considering the numerous accounts of M being seen to be fiddling under the blanket, I have taken into account that she is anxious and fidgety, and particularly so in hospital. However, I note that: the fiddling was almost always noted to be under the blanket rather than over it; in the region of A’s abdomen or side, hence near the tubing; the association on pertinent occasions with fiddling being seen and then the alarm sounding; a nurse hearing a click like a clamp on approaching on the occasion of an alarm; M occasionally stopping fiddling when a nurse stood up from the desk; there were no alarms during the two periods when a nurse was sat very nearby, and in the case of S.S.N.IBE it was a period in which she could clearly see M’s hands. 14.32. It is clear that various nurses requested that M should leave the tubing, and on occasion A, uncovered. Five nurses referred to this type of request (S.N.ST, S.N.PMDC, S.N.XG, S.N.SP and S.N.ELB), and all found that their requests were only partially complied with and then only for short periods. I note and accept that M, given her vulnerabilities, may not have heard their polite requests as firm instructions and may have considered her own preferences for A’s comfort or the safety of the tubes took priority. However, where M professed her own apparent anxiety to get to the bottom of the problem, it is bizarre that she should not have facilitated this by ensuring that the lines stayed visible. 14.33. The feed used in hospital (save for a 12 hour period on 8.12.19) was a liquid feed unassociated with the problems of thicker feed like Neocate. I note that no cause related to that feed such as sediment or lumps were found in the feeding system on that date to explain the numerous alarms. The nurses’ evidence was that they checked the tubing through for any blockages and never found sediment or lumps. In particular, I found wholly unconvincing M’s evidence to explain away what S.N.ST witnessed when she told me she saw M pinching the tubing together with her hand down by her leg. M explained she had been smoothing sediment away, but when she demonstrated it to me she (and PGM) did so using two hands in front of her as I have described earlier. S.N.ST clearly described a quite different one-handed pinch hold. 14.34. M claimed that it was the effects of the Gabapentin that was prescribed on 4.12.19 that brought the alarms to a halt, due to its action on A’s dystonic spasming which she claimed was the cause of the occlusions. I have considered and accepted the medical evidence that rules out dystonia operating in this way as A simply did not have severe enough dystonia, nor visible stomach or body spasms. I also note that this goes no way towards describing the absence of alarms prior to the arrival of M on the ward around lunchtimes and from the point of her departure and overnight. There is no feasible suggestion that Gabapentin was able to work from the outset at all times of day save for the afternoons. It adds to the implausibility of the M’s evidence on this issue. 14.35. I bear in mind M’s vulnerabilities, but I have to consider her evidence to be unsatisfactory and implausible in response to the catalogue of material relating to the pattern of occlusion alarms in hospital. For the reasons discussed earlier and above, I accept the observations of the nurses in relation to the occlusion alarms as reliable and persuasive. Accordingly, I find that M purposefully and repeatedly interfered with the tubing with her hands, which included pinching and folding the tubing and also clamping the tubing, primarily while her hands were hidden under the blanket to do so, in such a way as to block the flow of feed and trigger alarms on numerous occasions as recorded from 2-8.12.19. Accordingly, she was aware that her comments made to the nursing and medical staff that it was due to dystonia were false. 14.36. GASTRIC LOSSES – I do not repeat here my analyses set out earlier in my judgment of the primary evidence of the family members, X and Y, the videos, the nurses and the clinicians. 14.37. In relation to the videos and X and Y’s evidence, for all the reasons explored in section 10 above, I prefer their accounts. I am wholly persuaded by the genuine astonishment of F and PGM, their own evidence on the related issues from their own experience, and their hard questions posed of M’s explanations in her evidence. I find the accounts given by M to be wholly implausible, inconsistent and unreliable. 14.38. In relation to the nurses’ evidence, for the reasons discussed in section 11 above, I found their recordings to be reliable both in their charts and e-notes relating to gastric losses, and their statements and oral evidence of profound assistance as I have described earlier. 14.39. The clinicians’ evidence, as I have also set out earlier, consistently supports the analysis of Dr Campbell in terms of their clinical observations and experiences of A and their own work in the relevant fields. In terms of their own primary evidence, I have concluded that they were reliable and important witnesses of fact. 14.40. In terms of the primary evidence, I am therefore driven to conclude that M was seen repeatedly and frequently inserting water into the PEG-J tubing through the afternoon of 11.12.19 as witnessed and recorded by X and Y. She was interspersing this with squeezes to A’s stomach that were not to ease wind but were with the intention of encouraging the flow of fluid from A’s stomach into the drainage bag. She was looking at the bag from time to time to check the level of drainage achieved. 14.41. M was not inserting water in order to flush or hydrate. The insertions of water were too frequent. M did not check whether A required hydration. She was not constipated or dehydrated. There was no clamping afterwards to ensure some water would be absorbed before it drained out again. 14.42. The reasons why her behaviour and explanations do not make sense to F and PGM are because they are not actions which flow from genuine flushes/hydration. M was hiding her syringe in her clothing, risking contamination of her own clothes and of A’s tubing and stomach. The water she was using was not even clean tap water but was water she said she drank from, let alone sterile or boiled water. She was not using a tissue to catch waste, but she was using the blanket to hide her actions. If her actions were genuinely what she described, she would not have needed to behave in this way but could have openly and cleanly conducted these activities, as F and PGM recalled she would have done at home. 14.43. M told neither PGM nor the nurses. This did not make sense given the need for fellow carers to understand what fluids had been administered to A. Given this, plus her awareness of the relevance of flushes to the sum of gastric losses revealed in her police interview, it must mean that she wanted to conceal her own actions as they would not be justifiable if their nature and extent were known. It is likely that her intention was thus for the gastric losses to appear to be genuine bodily losses. She did not take obvious opportunities to explain to S.N.ELB what she was doing, for the same reasons. 14.44. M was particularly watchful and alert, switching her head alertly from side to side while carrying out key steps in the actions undertaken, and without looking down at her hands. The overwhelming impression given is of keeping an eye out for who may have been paying attention to her actions, and I find that is what she was doing. If PGM was there, her temporary absences were taken advantage of to continue with this behaviour, and M made requests of PGM in order to generate such absences. In considering these issues, I have borne in mind the submissions made as to M’s size and obvious presence on the ward, that when filmed she is sitting up facing outwards into the ward, and her exchange of chat with nurses. It is suggested that she is therefore not hiding, but simply carrying out these normal flushes openly. Notwithstanding these submissions, it is clear that M nonetheless managed to obscure her actions from the nurses, and most certainly did not explain them openly as I have referred to above. The position and use of the blanket, the rapid movements, the actions inconsistent with such actions at home, and the repeated returning of the syringe into her clothing are other significant markers of concealment. 14.45. The squeezing actions were never used at home nor demonstrated to M at any time by any medical professional. They were simply designed to facilitate the drainage process following the insertion of water. The squeezing involved multiple compressions of A’s stomach in that single video clip. Other observations of squeezing by the various nurses are corroborated by this video clip and I find that they were witnessing similar such activities. 14.46. I note the similar pattern as with the occlusions with significant losses being drained in periods when M is on the ward. Given these findings, I am also satisfied that the nurses’ evidence in relation to this pattern of gastric losses that recorded particularly large volumes, over unusually short time periods, or with unusual appearances in the period 2-11.12.19 are credible and represent further interferences by M with the PEG-J system. I am satisfied that the nurses’ evidence as to fiddling with the blanket, the tubes, a cup, the drainage bag, and screwing/unscrewing movements were all observations of parts of the actions set out above. 14.47. Turning to the expert evidence, I have set out at length my analysis of Dr Campbell’s evidence in section 13. For all the reasons discussed there, I accept his evidence in relation to A’s gut dysmotility and gastric losses, save for some of the issues relating to the conundrum period and in particular the losses recorded on 20.12.19. 14.48. As A was suffering from a degree of gut dysmotility and the reflex responses he described, A would have been generating considerable amounts of gastric fluids. Due to the inserted amounts being counted towards the total losses, she was also receiving further excess replacement Dioralyte which would add further to this reflex response cycle. As can be seen from the gastric losses from 12-18.12.19, when A was still on full drainage and replacement fluids, those figures could reach as high as 368ml per day. Given that the fluids added by M would also have been counted towards her need for replacement fluids in the period leading up to 11.12.19, the reflex responses in that period would have been likely to have generated even more than in the period from 12.12.19. Thus M was adding to considerable amounts of genuinely generated gastric fluids. 14.49. I have considered the submissions on her behalf pointing out how much would have had to have been added to produce some of the total losses per day. But it is clear that not only was A producing some genuine gastric losses, but drainage was being checked and measured regularly so that it is incorrect to calculate these amounts in that way based on totals per day. Smaller amounts could be added over shorter periods. I also note that while M says she was using a 10ml syringe to carry out her flushes, 20ml and 60ml syringes were also available. The length of a 10ml syringe is about the width of an adult’s hand, and that of a 60ml syringe is about the length of a hand. The latter is also broader than the smaller syringes. The nature of the tubing, ports, connectors and bags would also permit a variety of methods for introducing fluid into the system. Given the 40 second speed with which she introduced two syringe-fulls in Video 1, and given that there was almost a 20 second gap between the end of the first insertion and the beginning of the next, it is clear that a great deal of fluid could be inserted in a very short period of time. I conclude that M was therefore able to introduce sufficient amounts of fluid to dilute and increase the gastric losses in the pattern seen in the charts. 14.50. I therefore also conclude that M deliberately manipulated the tubing and PEG-J by introducing fluid and squeezing A’s stomach to increase the apparent gastric losses. These were physically abusive acts, and frustrated A’s treatment, obscured her health, prolonged her hospital stay and led her to be subject to unnecessary and harmful investigations and procedures. 14.51. ALLEGATION 7 – I do not consider it is necessary or appropriate to determine this allegation, namely that the manipulation of the apparent gastric losses was intended to support the history given by M. There may be a wide number of reasons or combination of reasons why M interfered with A’s PEG-J to introduce water to increase the gastric drainage. It may, for example, also have been to mimic certain symptoms, to confuse or exaggerate the clinical picture, or to simply perpetrate the act as a satisfaction or drive in itself. I am not asked, nor am I in a position, to determine what may have been passing through M’s mind when she did so. 14.52. ALLEGATION 8 - M sought Total Parenteral Nutrition (TPN) for A which was unnecessary and would have been harmful. 14.53. Drs V, F and Campbell all concurred that A would not have been a candidate for TPN. 14.54. Tellingly, Dr F was emphatic that he would never have recommended it and had not done so in 22 years of practice, and I have set out his evidence above, but M told Dietitian DM that he had recommended it. M continued to insist that Dr F had mentioned TPN, and accepted that she had raised this with DM. She bizarrely claimed that Dr F had forgotten this when he gave his evidence. 14.55. Dietitian DM stressed that she was not in favour of it for A and her notes clearly show that she told M that if it were to be used she ‘ would only recommend it for a few weeks for gut rest ’ but emphasised that it was for Dr V to determine. M also accepted that DM had said it should be a last resort. 14.56. Dr U confirmed that she never advised M that TPN should be tried. She explained that the conversation came up repeatedly and that she explained there needed to be a reason for it and she saw no reason why A should have it. Dr U’s note of her consultation with M on 27.11.19 reads: ‘ M would like everything else tried before using PEG [as M had expressed her concerns at the pattern of gastric feeding leading to aspiration problems] and wondering if can continue as it is [i.e. PEG-J] including IV supplementation [partial TPN]. M prefers IV supplementation. Explained TPN would need close monitoring which isn’t available’ , then later at the end of the same note: ‘ M revisited TPN option – explained will leave this with gastro team to decide’ . M has insisted that Dr U had recommended ‘partial TPN’. 14.57. On 3.12.19 Dietitian DM was contacted by the H2 dietitian and in her note of that call the H2 dietitian reported that M was claiming ‘ her community team’ /DM had said A should have TPN for gut rest. I appreciate that this is a note by DM of a report by the H2 dietitian of what M is said to have claimed. However, I note how closely it fits with the pattern of claiming that different professionals had all recommended TPN when they had not: Dr F, Dr U, and ‘the community team’/DM. 14.58. In a note prepared by the Ellenor nurse there is an entry which, although it is set out under the heading 12.12.19 must post-date the replacement PEG-J operation on 3.12.19 and may have been received earlier than 12th, clearly records M telling the Ellenor nurse that ‘the plan is if the issues of feeding continue to possible to start TPN (sic)’. 14.59. At a ward round on the morning of 4.12.19 the following is recorded: ‘M asked about the TPN again, saying that she doesn't want A to start it but if she doesn’t gain weight she would need it. We explained that it is still early to discuss TPN as we are not sure what the main problem is. M understands.’ 14.60. On 7.12.19 M is recorded by S.N.ST in her e-note as follows: ‘ mum has been asking lots of questions around TPN and saying how she thinks that’s the best option for A’. At the ward round that evening, the following is recorded: ‘mum mentioned about TPN having been suggested by a nurse on Mountain ward, and wondered if this might be an option to help A. ’ There is no such recommendation noted anywhere. 14.61. I take into account that M has a persistent style of repeated questioning to understand something better, and that there is evidence to show that she explored many avenues for A, for example asking Dr F back in 2018 whether blended feeding was possible. 14.62. I also take into account that PGM’s evidence is that she and M had discussed TPN having heard advice about how serious and risky it was and said that they had concluded that ‘ it did not sound very nice’ and it was a last resort that they did not want. 14.63. However, of particular concern is that M’s repeated comments in relation to TPN contrast inconsistently with her evidence that having heard about the risks of TPN and discussed it with PGM she had decided against it because it was so serious, and nor do they fit simply with M wishing to explore the issue. 14.64. I am unfortunately driven to conclude that M misrepresented the comments of three different clinicians to make it seem as if TPN was being recommended. I find that even though she was clearly aware of its risks given her discussions with the dietitian DM and PGM, she more than once expressed a preference or positive opinion for it. This was an intervention which she had been made clearly aware would be very serious for A, risky, was currently unwarranted and a last resort, but which she pursued nonetheless. And she did so in the context of apparent but manipulated difficulties with A’s PEG-J feeding system, as I have concluded above. 14.65. ALLEGATIONS 9 & 10 – Gross exaggeration of the extent of dystonia suffered by A, including attempts to persuade the medical team that the pump alarms were due to dystonia. 14.66. I accept that some mild signs of dystonia may have been seen in hospital, for example by S.N.NK who described the stiff in-turned position of A’s foot. This fitted with the photographs and clips I have seen of A’s feet which were taken by M to show dystonic symptoms. Dr F described A’s clenched right arm as showing high tone in his earlier consultations, and I accept that there is evidence of some slight tightness in A’s hamstrings. 14.67. It is suggested on M’s behalf that the two occasions on 29 and 30.11.19 when A was fed a bolus of feed directly by syringe, and the nurses experienced some feeling of resistance, are further evidence of dystonia. I note the explanation provided by Dr Campbell as to the impact of receiving feed by bolus, which is likely to prompt considerable distress due to the unpleasant impact associated with the dumping syndrome he described. That distress in turn raises the pressure in the abdomen and would cause this presentation. I combine with that the evidence given by Drs V, F and Campbell, that in order for dystonia to cause any disruption to the passage of feed via the jej tube there would have to be extremely violent and highly visible spasming of A’s body. This clearly was not seen, although A was recorded as showing some distress, which is more in accordance with the explanation of Dr Campbell. 14.68. I entirely accept that it is hard to grasp the different diagnoses, definitions and variations of dystonia, movement disorder, spasticity, that can occur in cerebral palsy. I heard from more than one nurse that they too felt uncertain about it and were not confident that they understood it. Dr F was clear how hard it was for non-specialists to understand the different issues, presentations and mechanisms involved. 14.69. I consider the vaguer references to dystonia in the nursing notes are highly likely to fall into this category, for example: S.N.PM on 3.12.19 ‘ stomach cramps – dystonia causing PEJ to occlude’ , particularly as this does not fit with the descriptions given by the doctors of what degree of dystonia would be necessary to cause occlusion. By contrast, S.N.SP describes what she actually observed rather than making a diagnostic leap. When asked by M to observe that the pump was alarming because A was dystonic and it was making her tense, she recorded in her e-note that A’s legs were showing ‘ low tone and did not appear to be dystonic’. 14.70. It is submitted that I should accept that M and the family may well have therefore misunderstood, and mistaken A’s agitation and distress for dystonia. Having heard the evidence given by F and PGM on this point I consider that it is highly likely that they suffered from some of that confusion. 14.71. It is clearly accepted by Dr U and Dr F that there were some physical visible signs of dystonia. However, it is quite clear that the description of dangerously severe dystonia (‘ +++ ’) lasting for hours at a time that M gave to Dr U was simply never borne out by any subsequent presentation. I have set out her evidence in more detail in paragraphs 12.8-11 above. 14.72. Equally, Dr F concluded, notwithstanding some observable degree of muscle tightness, that the drastic description given to him which prompted him to treat A so swiftly with botox a few days later could not have been accurate given the subsequent presentation of A. I have set out his evidence in more detail at paragraphs 12.47-48 above. 14.73. Those descriptions by these two clinicians are significantly different to a confusion or misunderstanding. Their evidence to me was that in the circumstances these must have been exaggerated descriptions. 14.74. I must also bear in mind the other findings that I make, with reference to this allegation. I conclude, as I set out in more detail above, that M was certainly tampering and interfering with the tubing to trigger occlusion alarms. She was then repeatedly blaming A’s ‘inner dystonia’ or ‘dystonic stomach spasms’ for the jej tube occlusions. Given my finding, M must have known that her promotion of dystonia to explain the repeated occlusions was a false explanation for what she was herself doing, and a significant exaggeration from the reality. She specifically raised this ongoing dystonia with the neurological team on 4.12.19 which led to the prescription for Gabapentin. 14.75. Accordingly, I am satisfied that M exaggerated the extent of the dystonia suffered by A, both during the consultation with Dr F, and at the start of and during her hospital admission, each of which resulted in the misleading of medical professionals and the administration of unnecessary medications. 14.76. ALLEGATIONS 11 & 12 – I do not consider that the LA has met the burden and standard of proof in relation to the allegations that M tampered with A’s tubing during supervised contact visits on 20.12.19 and 13.1.20. 14.77. I do not repeat here the analysis I set out and conclusions I have drawn in relation to this aspect of Dr Campbell’s evidence, but it is clear from those conclusions that I do not consider that there is sufficient evidence to hold that the 153ml drained at 6pm on 20.12.19 can be attributed to an interference by M. 14.78. In addition, I was impressed by the evidence of Ms O, the contact supervisor. She took notes, was aware she was supervising for safeguarding reasons (but without specific knowledge of the background concerns), and firmly confirmed that she did not see M use a syringe during contact on 20.12.19. She described M pointing out a syringe lying on the floor of the room under the bed just as they were entering. A nurse removed it and the contact session began. It would be astounding to imagine M drawing the supervisor’s attention to a syringe when she would be planning to go on and use one herself. 14.79. S.N.SM recorded that the drainage bag was off and the gastric tube clamped, but at the end of contact the cap was off. I note that Ms O recalled events that are not set out in the nursing notes. There was an attempt at a bath, with the nurse supervising A being undressed and preparing a baby bath. M helped with this task, but it did not in fact take place due to A’s distress. She was simply weighed and redressed. Ms O was present throughout. Ms O recalls that M played games with A and the OT attended to try A in her new seat. It was after this process that the port cap was found open. The caps have a slightly rubbery quality and a small flap on one side to assist with opening them. In the circumstances of the multiple activities which may have rubbed up or tugged against the port cap, and the oversight of a contact supervisor, I do not consider that the evidence meets the necessary standard to be probative of any tampering activity on M’s part. 14.80. The allegation relating to the contact on 13.1.20 also fails. Ms O also provided supervision. It is quite clear that again it was M who drew her attention to an issue, on this occasion a leak of milk through A’s clothes, and again Ms O did not witness any tampering. About half an hour into the visit M had asked if she might take A out of her chair and so S.S.N.IBE attended the room to check and assist, and said she was sure she had checked A’s tube was clamped after taking A out of the chair. Within three minutes M had alerted Ms O and they had rung the bell to summon a nurse as the leak had been noticed. S.N.AA attended the room and found the tube was unclamped and was leaking milk. Given the tiny passage of time, that M alerted Ms O to the problem, and that M was playing ‘toss up’ with A, I do not consider that this picture can prove tampering. 14.81. FII – Finally, I am requested by the LA to make a formal finding that the findings I have made fall within the category of ‘true FII’ as set out in the terminology of the guidance provided by the Royal College of Paediatrics And Child Health. I have made the above findings. The RCPCH guidance has a set of categories, and the findings here are grave and can be seen to sit within category 3. It appears otiose to seek a finding in this respect. A risk assessment is likely to follow this hearing, and the analysis of M’s actions in terms of her response and risk will be what goes on to assist the court in its determination of any outcome relating to the children’s welfare. HHJ LAZARUS 4.2.21 ANNEXE 1 Previous Agreed Threshold In Respect of B Order 23 May 2019, Annexe 1 It is accepted that none of the incidents set out below can be described as FII behaviour. M’s behaviour fell within the band of overly anxious behaviour and had it not ceased, with the implementation of the Safety Plan dated 22 May 2017, it would have exposed B to a likelihood of suffering significant harm and the likelihood of harm was attributable to the care being given to her, or likely to be given to her, not being what it was reasonable to expect a parent to give. There was a likelihood or risk of significant harm in the period leading up to the implementation of the Safety Plan. It is accepted by M that there was no diagnosis of speech and language delay in respect of B. Whereas some professionals (including the nursery) and the family have noticed some unusual behaviours by B, no professional has considered it necessary for them to be assessed and a referral to SALT was rejected by two highly specialist speech and language therapists (DC and RL) in February 2019 on the basis that her speech, language and communication development (reported on referral form from B’s nursery) was age appropriate, and that there were no social communication or language needs identified. The family have outstanding queries and the question of what (if any) behaviours exhibited by B warrant assessment will be openly discussed and kept under review during these proceedings. NO ALLEGATION MOTHER FATHER Seizures 1 M gave varying accounts of seizures or convulsions in relation to B. They were often made after the event, without accessing urgent medical attention. M’s threshold for seeking medical attention was very low but she failed to seek immediate attention for potentially very serious conditions. M’s reports about seizures/convulsions are more likely than not to have been unreliable and based on exaggerations through anxiety. 15.5.19: This is accepted. Based on exaggeration through anxiety M would accept that her threshold for seeking medical attention was variable depending on how she managed her anxiety about it and how much support and advice she had available. Please see paragraph 4 of the Second statement of F. F has in the past seen odd movements in B. He did not say they were seizures but that they looked to him like seizures. When they saw this they took medical advice. 9 There is nothing in the medical records to suggest that B had febrile convulsions either in the first year of her life or more recently. No evidence B has had a seizure disorder. Dr Ward: File 3, D.377-378 15.5.19: M accepts this. M accepts there is no evidence B has had a seizure disorder. She accepts that there is no medical record of B having had febrile convulsions. She was concerned by B’s abnormal movements in the aftermath of a viral URTI on 29.04.17. M acknowledges, as she did not take B to the doctor at the time, there is no way of knowing now whether what she observed was/was not a febrile convulsion. This allegation is for M to respond. Insofar as this pertains to F the LA is put to strict proof. 3 M sought and obtained a prescription for Nutriprem for B in circumstances where it had not been recommended or advised or prescribed by any medical professional and she continued to obtain Nutriprem on the basis that it was required for B. 15.5.19: M accepts this. She says that anxiety drove her determination to obtain Nutriprem. She accepts that she cannot identify any professional who recommended Nutriprem. This allegation is for M to respond. 4 B’s GOR and milk intolerance symptoms and treatment (which are normally self-limiting) were perpetuated by a lack of acceptance of professional advice and ongoing parental anxiety and inconsistent in terms of management. TE (Dietician; 9.5.17): File MD, 99 and File 6, C.223-225 Barium Swallow test (17.12.17): File MD, 527 DC (SALT; 4.8.17): File 2, C.134-135, File MD, 190 Dr Ward: File 3, D.373 and D.380 15.5.19: M accepts this. She accepts that she could have moved B on more quickly had she been single minded about it and more detached from B’s reactions to certain foods, but M says that B did have problems with gagging, vomiting and a heightened gag reflex, and infections would set her back. M says that B would revert to resistant eating behaviours. M says that proceeding at B’s pace was the advice that she was given and took. M says that life was a struggle as she was focussed on A who was and remains extremely unwell. M says that professionals viewed M with suspicion, for example in relation to soya milk recommendation and this added to the delay in implementing plans and advice. M says that delay meant that behavioural elements crept into B’s response to food and M was sensitive to that. M says that communication between professionals and advice to M was, however, not that great or easy to understand and little was put in writing at that time. This allegation is for M to respond. In so far as it pertains to F he puts the LA to proof on this point. 5 The pattern of M’s reports of feeding difficulties and failure to follow professional advice negatively affected B’s ability to feed. Dr Ward: File 3, D.380 15.5.19: M accepts this. See above under previous entry. This allegation is for M to respond. 6 16.1.17: M requested at a TAC meeting that she wanted further tests such as a camera in B’s mouth and throat to see if there was a physical problem. This was not supported or advised by any of the professionals. TAC Meeting (16.01.17): File MD, 42-44. 15.5.19: M accepts this. She suggested further investigation as she wanted to establish if there was a physical reason for feeding and gagging problems that she perceived B to have. She asked for this in context of the awaited result of the ENT referral. She accepts this was not recommended by the professionals. This allegation is for M to respond. 7 15.12.17: Barium swallow test. MM records that M said to her on 16.08.16 that she (M) had been told not to give B solids for two weeks, that B might have a narrow oesophagus and may need surgery. There is no record of M ever having been told this. M’s anxiety and focus on feeding had the potential to misdirect professionals to unnecessary enquiries to B’s dis-benefit. M pursued the barium swallow to investigate oesophageal causes of concern which were not of concern to various professionals (SALT and dietitians who advised there was nothing wrong with B’s swallow) and given the observed improvements in B’s feeding. Mr F would not have chased for the barium swallow test had he been made aware of the discharge letter from SALT. Dr Ward: File 3, D.370 DC (SALT; 16.1.17 TAC): File 2, C.134-135, File MD, 44 (4.8.17), 189, and 578-579 16.5.19: This is accepted by M. M has had longstanding concerns about B’s swallow and oesophagus. This allegation is for M to respond. 8 The use of emergency services rather than the GP and the absence of effective communication between the agencies and M (two-way) created a risk that B would be prescribed anti-biotics in circumstances where she did not need them. Dr Ward: File 3, D.374 15.5.19: This is accepted by M. This allegation is for M to respond. In so far as this pertains to F the LA are put to strict proof. 17 MAY 2019 SIGNED: M F Social Worker ANNEXE 2 Previous Agreed Threshold In Respect of A Order 23 May 2019, Annexe 2 Having heard the very clear and considered evidence of Dr Ward, M and F now accept A’s collapse was the result of an accidental upper airway obstruction to be seen in the context of her specific vulnerabilities due to her age, gastro oesophageal reflux, laryngomalacia, stridor and co-sleeping. M cannot recall whether she placed A prone or supine on the parents’ bed. Both parents agree that as she left the bedroom, M told F that A was in the bed. F was aware that A was there but he was barely awake. The parents accept that this situation placed A at risk of significant harm and she suffered significant harm as a consequence. Neither parent knows at what point A went into hypoxic decline and saw no symptoms until M returned to the room later. The evidence of Dr Ward was that the airway obstruction could have been partial (one nostril only), caused by the fold of a sheet, or a rumpled base sheet or by a dip in a mattress and did not require any adult contribution to occur. Dr Ward’s evidence was that there may not have been any sign that A’s breathing had been compromised or any other symptoms. Dr Ward agreed that M’s intervention on discovery of A's collapse which secured emergency medical assistance and the exemplary treatment she received prevented her death and that Dr Ward, had seen many such accidents in her clinical practice. The parents have to live with the consequences of this tragic accident on a daily basis and the professionals agree that they provide exemplary care to A. 23 MAY 2019 SIGNED: M F Social Worker _______________________________________________________________________ ANNEXE 3 ORIGINAL SCHEDULE OF ALLEGATIONS [Filed on behalf of the Local Authority] _______________________________________________________________________ The local authority contends that, by reason of the matters set out below, A, B and C were suffering and likely to suffer significant physical and emotional harm at the relevant date. In relation to A, the local authority relies on each paragraph herein. In relation to her siblings, the local authority relies on paragraphs 1-12 inclusive on the basis that they witnessed the significant harm caused to A and/or were likely, consequent upon paragraphs 1-13, to suffer significant harm from their mother’s parenting. Allegations against the mother Allegation 1: M failed to provide A with sufficient food or calorific intake at home [824/E552] [2(c)/E586] and/or inflicted such a regime on A, thereby causing her significant harm by reason of: (i) her failure to gain weight between September 2018 and November 2019 [8/C165, DM]; (ii) her severe state of starvation and gross malnourishment [829/E553] [1(c)/E583] [2(a)/E585] [E267]; (iii) her long history of apparent but fabricated feed intolerance [Dr Campbell: E269]; (iv) a vulnerability to infection [2(e)/E588]. PARTICULARS a. A was prescribed jejunostomy feeds, significantly in excess of her calorific needs, by pump from the end of 2018 and yet, by the time of her admission to H2 in November 2019, she was grossly malnourished [788/E542]; b. The cause of her lack of weight gain was inadequate nutrition [E267]; c. The provision of a percutaneous jejunostomy (PEG-J) in place of the nasogastric tube in September 2018 should have resulted in an improved rate of weight gain yet her weight remained around 7-8Kg throughout the following year [818/E551], at <0.4 th per centile; [8/C165, DM] d. Following admission to H2 in February 2019, no cause for inadequate weight gain was found [789/E542]; e. During this admission, A gained weight though she was admitted for only one week [818/E551]; f. During her admission to H1 in July 2019, A gained weight on her usual prescribed tube feed, 1.05kg in 7 days [791/E542]; [9/C165, DM] g. In August 2019, after returning home, A was receiving 1150cals (177-230% of her estimate requirements), but still did not gain any weight [9/C165, DM] h. By October 2019, when admitted to H3, A was described as cachexic so that she appeared to be physically wasting with loss of weight and muscle mass [818/E551]; i. A began to rapidly gain weight once the mother was permitted to visit her only under supervision [794/E543]; j. It was possible to move her feeding regime from jejunostomy to gastrostomy without provoking vomiting [794/E543]; k. In contrast to the above, from the end of November 2019 to January 2020, whilst in H2, A’s weight increased from far below the normal range to the normal range and remained in the normal range since she has been in foster care until she became overweight in April 2020 when calorie feeds by gastrostomy were discontinued and by July 2020, she weighed 16Kg [821/E552] Dr V [30/C143][J548][J558-9]; Dr I [E243]; l. The mother grossly exaggerated A’s intestinal dysmotility by presenting her to specialists as suffering significantly from it when she did not [Dr Campbell: E269]. Allegation 2: Not pursed Allegation 3: A’s lack of developmental progress was caused by the extreme malnutrition of A by the mother [859/E561]. Allegation 4: The mother exaggerated the extent of A’s daily difficulties in relation to: (i) copious secretions (for which she was prescribed a suction machine); (ii) wheeze (for which she was prescribed Clenil inhaler), and (iii) recurrent respiratory infections (for which she was prescribed azithromycin) all of which were ceased [J549-551] [804-5/E547] [J1432-3]. PARTICULARS a. A was not observed to have (a) excessive secretions, or (b) recurrent breathing difficulties during her admission to H2 between December 2019 and January 2020. Further, the cessation of asthma inhaler and nebulised saline medication did not lead to subsequent secretions of chest problems. b. Consequently, the mother’s exaggeration of A’s symptoms led to the following unnecessary medications/interventions which were ceased prior to her discharge from hospital [J547-551: Drs V and H]: (i) use of a suction machine; and/or (ii) an asthma inhaler and nebulised saline [805/E547]; [1(e)/E577]; and/or (iii) unnecessary saliva reducing drugs, Glycopyrronium and Buscupan causing A to suffer unnecessarily by way of dryness to her mouth and tachycardia. [806/E547-8] and/or (iv) the prescription of unnecessary azithromycin [J549]. Allegation 5: The mother deliberately manipulated the feeding tubing utilised by A in both the H1 and H2s routinely and over a significant period of time with the following harmful consequences: a. Her admission to hospital was prolonged; b. Her treatment and medical care was frustrated; c. Her true state of health was obscured; and d. She was subject to unnecessary and harmful investigations and medical procedures. [Dr V C137-146] [Dr P C193-196] PARTICULARS “H1” a. In November 2019, following admission to H1 on 20.11.19, A’s pump alarm regularly sounded, indicating a blockage, yet, on admission to H2, the tube was open and functioning (but was replaced) [Dr V: C138-9] [793/E543]. The mother was responsible for causing the alarm to sound on each occasion. b. The mother advised H1 that “the feed occludes” at home “so A is often not getting full feeds” [476/E442] [J1676] when this was untrue because (a) the feeding tube had no mH2anical or other fault and/or (b) the lack of full feeds was due to the mother’s failure to feed her properly. c. On 28.11.19, A, in her mother’s care on the ward, sustained gastric losses of 360mls and JEG was found to be no longer free-flowing as earlier and following the mother’s departure, Dioralyte was administered through the JEG freely [503-504/E449] [J1705]. The mother was responsible for causing the significant gastric losses and the obstruction of free-flow through the tube. d. Further, on 28.11.19, between 1450 and 1710, in her paternal grandmother’s care on the ward, A was gravity fed Dioralyte and Pediasure without difficulty, yet on the mother’s return, free-flow of the Dioralyte ceased and had to be given with the assistance of a plunger [505/E449][J1706] as a consequence of the mother’s actions. e. Gastric losses were 540mls in the mother’s presence but in more than 4 hours after she left, such losses were just 70mls [J1706] and gastric losses of the order of 540mls were significantly in excess of those otherwise observed in H1 [516-521/E451-2] and were caused by the mother. f. Following the mother’s subsequent departure from hospital, A enjoyed free-flowing gravity feeds with no problems and minimal aspirate that night [J1706] [506-7/E450]. g. A was required to undergo an unnecessary x-ray in order to check the patency of the tube thereby exposing her to radiation [2(e)/E587-8]. h. But for the concern for an occluded PEG-J, A would not have been transferred to H2 [462/E437][J157]. H2 (admitted 29.11.19 [J258]) a. Objective assessment by the treating medical team demonstrated that there was no fault with the feeding and drainage equipment utilised by A at the start of her admission to the H2: (i) On admission, the specialist nurse was twice able to demonstrate that the tube worked without obstruction; leak or consequential aspiration [526-7/E455-6] [J258/J261]; [8/C139, Dr V]; (ii) On 1.12.19 at 0919, nurses reported no difficulty with feeding and the tube [529/E457] [J274]; (iii) On 1.12.19, the surgical team reported no mH2anical issue with the feeding tube [11/C139, Dr V]; (iv) By 1728, nurses were concerned about occluding tubing but a tubogram demonstrated no mH2anical issues [Dr V: 11/C139][531/E457] [J278]; (v) On 2.12.19, Mrs R, consultant, was able to flush tube with ease and without a pump [534/E459] [J289]; (vi) The old tube appeared normal on examination [J302]. b. Further, recurrent kinking of the level observed in this case is uncommon and unlikely to be linked to a child’s activity and/or occlusion will not be caused by a child lying on tubing [9(b)(ii)/E267]. c. From 2.12.19 until A’s tube replacement surgery on 3.12.19, the mother manipulated A’s feeding and drainage tubes: PARTICULARS (i) On 2.12.19, the feeding pump of the jejunostomy bag was observed to constantly alarm whilst the mother’s hands were over A but hidden under a blanket [S.N.FA: 7/C232]; (ii) On 2.12.19, a concerned parent reported the mother as acting suspiciously with her hands under the blanket looking to see if anyone was watching her; to have been holding a syringe and a pool of water was seen by A [S.N.FA: 9-10/C232]; (iii) On 2.12.19, the mother was observed removing a syringe from under her shirt and injecting something into the tubing [S.N.FA: 9-10/C232]; [J312][J567]; (iv) On 2.12.19, the mother created a kink in the tubing which was observed by the nurse and reported to be indicative of manipulation [S.N.FA: 15/C232]; [J312] and she claimed that the blockage was due to muscle spasm associated with dystonia [J567]; (v) On 2.12.19, the mother expressed distress when told that A should be sitting on the bed on her own and not on her lap all the time, as this would make it more difficult to manipulate the tubing and inject substances into it [J312]. d. On 3.12.19, the feed pump was occluded from 11am until A went for surgery when a PICC line inserted and replacement of the jejunal tube [537/E461] [J299]. Notwithstanding the surgery, the alarm continued to sound for 2-3 hours that evening whilst the mother was present [SN.PM: C231] [623/E499] [J568]. The nurse reported no visible dystonia [17/C140, Dr V]. The alarm was caused by the mother’s manipulation of the equipment. e. On 4.12.19, the PEJ pump alarm sounded throughout the day but did not begin until the mother was present on the ward (at 11am) [616/E495] [S.N.NK: C226-7] [J569]. f. During the mother’s absence from 1730 on 4.12.19 until 11.30 on 5.12.19, no alarms sounded and there were no signs that the tubing was occluded [616/E495] [J568]. g. Immediately after the mother attended the ward on 5.12.19, the pump first occluded and this occurred on a number of occasions [J569] which were caused by the mother’s manipulation of the equipment. h. On 6.12.19, the feed pump occluded when the mother weas present on the ward and the tube had to be straightened by a nurse [617/E495] and thereafter it occluded on a further 19 occasions and on each occasion the mother was present and the tube had to be straightened [617/E496] [J570-2] [S.N.NK: C234] and after the mother left the ward there were no further occlusions that night [J572]. Each occlusion was caused by the mother’s manipulation of the equipment, by way of putting a kink in the tubing or otherwise causing a need for the tubing to be straightened. i. On 7.12.19, following the mother’s attendance at 12.15, the tube occluded at 12.55 (when the feed set was coiled and kinked) and then on a further 16 occasions when the mother was present with and without the maternal grandmother [618/E497] [J572-5]; [7-9/C219, S.S.N.IB] [6-10/C205-206, S.N.ST] [8-9/C223, S.S.N.EDC]. The mother caused each occlusion. j. On 7.12.2019, the mother deliberately obscured A’s tubing with a blanket to allow her to interfere with it unseen [8-12/C223, S.S.N.EDC]. k. On 7.12.19, the mother held the tube line down behind the bedside rail and, when she moved her hand, a visible kink was apparent in the line where she had been holding it [S.N.ST: 15/C206] [619/E498] [J574]. The mother had deliberately put a kink in the tubing. l. In the mother’s absence on the evening of 7.12.19 until her return on 8.12.19, there were no occlusions [622/E499] [J575]. m. On 8.12.19, in the mother’s sole presence on the ward with A, occlusions started 6 minutes after her arrival and on 11 occasions thereafter [624/E499] [J576]. Each occlusion was caused by the mother, but, in particular: (i) On 8.12.19, the mother pulled the tube under the blanket and pinched the line so that a pinch mark was visible at 13.16 and on 4 subsequent occasions, the mother fiddled with the tube under the blankets before the tube occluded [624/E500] [J576-7]; [12/C169, S.N.SP]; (ii) On 8.12.19, the mother filled the drainage bag with, most likely, water and enquired about the extent of fluid loss [6/C171, S.N.XG] [625/E500] [J577]; (iii) There were no occlusions following the mother’s departure from the ward at 1530 on 8.12.19 until her arrival on 9.12.19 at 11am. [626/E500] [J578]. n. On 9.12.19, the mother attempted to manipulate the equipment used for A’s feeding and drainage: (i) At 1300, the mother removed the PEG drainage bag and thereafter a large volume of gastric losses was noted [626/E500] [J579]; [8/C179, Ward Sister AS]; (ii) At approximately 4pm, the mother removed something from her jumper and began moving her hands under the blanket; shortly afterwards A produced a full bag of clear and bubbly aspirate, which caused concerns to the medical professionals [7-8/C179, Ward Sister AS]; (iii) At 1700, the mother removed A’s PEG drainage bag; fiddled under the blanket and A cried, following which the mother asserted that the gastric fluids had turned back to yellow (from a clear, slightly colourless appearance) [627/E501] [J580] [4-5/C191, S.N.AH] [6-8/C179, Ward Sister AS]; (iv) The mother was seen to move her hands around under a blanket over A and to squeeze A’s stomach [SN.KS: 7-8/C198]. o. By 9.12.19, nurses noted that the pump alarm sounded frequently only when the mother was present on the ward [555/E470] [J332 and J338]. p. On 9.12.19, A had a large aspirate from her gastrostomy bag of clear frothy liquid [558/E471] [J340] when the mother was present [559/E472] [J342]; [9/C176, S.N.AA] [8/C179, Ward Sister AS]. q. On 10.12.19, the mother caused (a) the alarm to sound as a consequence of using an implement(s) which she hid in her leggings and /or top with A positioned between her legs and (b) caused the aspiration to turn dark brown as a consequence of using something she had hidden in her leggings and/or top, a subsequent aspiration being clear 7 minutes later [628/E472] [J581-2]; [11/C177, S.N.AA]. r. On 10.12.19, the mother squeezed A’s abdomen hard and looked to the drainage bag [629/E502] [J582]; [13/C184, S.N.ELB]. s. On 10.12.19, the mother inserted a volume of liquid in to A’s drainage bag so that it became nearly full with clear liquid [629/E502] [J582]; [15/C184, S.N.ELB]. t. On 10.12.19, the mother tried to interfere with A’s medical care and to frustrate that care, whether by unscrewing something under cover of the blanket or otherwise, either seeking to tamper with the feeding of A or the drainage of her fluid or the drainage liquid and caused the bag to be filled with green, frothy/fizzy content [629/E502-3] [J582] [14-15/C184, S.N.ELB] [6-7/C191, S.N.AH]; [11/C177, S.N.AA]. u. On 11.12.19, at 1256 and 1353, the mother tried to interfere with A’s medical care and to frustrate that care, whether by utilising a cup of liquid or a hard object under cover of the blanket or otherwise, either seeking to tamper with the feeding of A or the drainage of her fluid or the drainage liquid [630/E503] [J583-4] [5-8/C202, S.N.ZS]; [6-7/C200, S.N.SB]; [14-15, 18/C184, 19/, 23 and 24/C185, S.N.ELB] [8/C215, S.N.MG]. v. On 11.12.19, at 1435 the mother tried to interfere with A’s medical care and to frustrate that care, by unscrewing, disconnecting and then, reconnecting the drainage bag; prodding A to her abdomen 4-5 times and using a cup of water under the blanket [631/E504] [J584-5] [5-8/C202, S.S.N.ZS] [18/C184; 29/C186, S.N.ELB]. w. On 11.12.19, the mother tried to interfere with A’s medical care and to frustrate that care, by: (i) Holding A with both hands and squeezing her stomach and then looking at the drainage bag to inspect the contents [27/C186, S.N.ELB]; [G207- statement of third party]; (ii) Aspirating a liquid from a cup into a syringe and injecting the liquid in to A’s gastrostomy tube [567/E476] [J362] [631/E497] [J585] [18-19/C184-85, S.N.ELB] [8/C215, S.N.MG][G127- lay witness X]; [G207- statement of third party] [I2- Video 1] [I3- Video 2]. x. On 11.12.19, nurses reported the mother acting suspiciously by doing something under a blanket whilst hugging A [562/E473] [J349] [18-19/C184, S.N.ELB] and by constantly moving something over A but under a blanket whilst looking around her [S.N.SB 7/C200]. Allegation 6: By reason of the mother’s said deliberate manipulation of the feeding and drainage equipment, by the intermittent, external administration of water to A’s gastrostomy bag and/or increasing abdominal pressure by pressing on A’s abdomen, the mother caused the following significant gastric losses to be identified [9/C194] Dr V [C137-146] [5/E265] [9(b)(i)/E267]: PARTICULARS (i) On 2.12.19, A sustained significant gastric losses (783ml) [536/E460] [J295]; (ii) On 4.12.19, the alarm sounded every 30 seconds between 2pm and 6pm and total gastric losses were 955ml [543/E463] [J309] [8/C227, S.N.NK] (iii) On 5.12.19, gastric losses were 1039ml [544/E464] [J312]; (iv) On 7.12.19, gastric losses were 785 mls [552/E468] [J326] (v) On 7.12.19, minimal losses in the morning were 675mls and 310mls in close succession following the mother’s arrival on the ward [S.N.ST: 12/C206] (vi) On 8.12.19, gastric losses were 675ml in 24 hours [J326] [553/E469]; (vii) By 9.12.19, nurses noted that gastric losses increased when the mother was on the ward [555/E470] [J332 and J338]; [7/C176, S.N.AA] [9/C183, S.N.ELB]; (viii) On 11.12.19, gastric losses between 2pm and 7pm were 839ml [565/E474] [357]. Allegation 7: The manipulation of the apparent gastric losses was intended to support the mother’s history. Allegation 8: The mother sought total parenteral nutrition [“TPN”] for A which was unnecessary and would, consequently have been harmful to her had it been applied as it would have impeded her development, particularly her ability to feed orally and/or by less intrusive means: a. By making repeated requests for TPN when A did not require it and the mother knew she did not require it as she was so advised by treating medics [DM: J113] [Dr P J325] [892-3/E573]; b. By manipulating A’s tubing, in particular, by causing the tubing to be occluded in the circumstances described above and, at the point of apparent occlusion, requesting TPN [895/E574]. PARTICULARS (i) On 4.12.19, in the morning, the mother sought total parenteral nutrition [“TPN”: feeding via fluid to the vein] [J302]; (ii) On 7.12.19, the mother suggested that A needed TPN at 1558 when a nurse attended to address the 12 th apparent occlusion since the mother’s arrival on the ward [619/E498] [S.N.ST J574]; (iii) On 7.12.19, the mother falsely alleged that TPN [J325] had been suggested by a nurse on M. Ward [J325]. Allegation 9: The mother grossly exaggerated the fact or extent of dystonia she claimed to be suffered by A: a. At no time was there visible dystonia [539/E461] [J301]; [9/C168, S.N.SP]; b. The mother’s videos of A were not, contrary to her assertion, demonstrations of dystonia [E557]; c. In consultation with Dr F, the mother reported that A was suffering lower limb pain associated with muscle spasm and, as a consequence of this exaggeration/fabrication he prescribed Baclofen and administered Botox injections to the hamstring muscles [844/E557] which were not necessary [845/E557][1(e)/E584]; d. Further, as a consequence of the history provided by the mother, H2 prescribed medication for A which was unnecessary, namely Gabapentin and Alimemazine [845/E551]; [36/C144, Dr V]. Allegation 10: As part of the mother’s manipulation of A’s feeding and drainage equipment she attempted to persuade the treating medical team that the intermittent alarming of the pump was due to A suffering dystonic episodes when (a) she knew this was untrue; (b) this led to confusion and delay in the provision of adequate medical care for A: a. On 1.12.19 the mother related to doctors the intermittent alarming and occlusion of the tubing with dystonic episodes [Dr V: 11/C139] [J278/J286]; b. On 2.12.19 she reported and several episodes a day, worsening over the prior 6 weeks, but no dystonia was witnessed by the treating team [Dr V 13/C140] [J287] [533/E459]; c. On 2.12.19, she reported that the feed pump alarm sounded due to a blockage caused by muscle spasm due to dystonic reaction [J567]; d. On 4.12.19, she reported that there are periods when dystonia is more marked and there are blockages of her JEJ tube [J304] said also to be witnessed by the maternal grandmother [616/E495]; e. On 4.12.19, mother reported that whilst starting Alimemezine had reduced the periods of spasms and vomiting, there were still periods where dystonia was more marked and there was blocking of A’s jejunel tube [18/C140, Dr V]; f. On 6.12.19, she reported to S.N.SP that she thought pump was alarming because A was dystonic and pointed to A’s legs, saying “look, she’s dystonic.” A’s legs had low tone and did not appear dystonic at that time [9/168, S.N.SP]; Allegation 11: On 20 December 2019, the mother interfered with the gastric losses during supervised contact so that the gradual day on day reduction in gastric losses following her exclusion was strongly reversed [Dr Campbell: E795-6]. Allegation 12: On 13 January 2020, the mother attempted to interfere with A’s feeding by unclamping the PEG tube and causing milk to leak [Oral evidence of S.N.AA]. Mark Twomey QC Bianca Jackson Counsel for the Local Authority 7 th December 2020 ANNEXE 4 Diagram of PEG-J provided by Dr Campbell Annexe to Dr Campbell’s Report dated 4 August 2020