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	England and Wales Family Court Decisions (High Court Judges)
You are here: BAILII >> Databases >> England and Wales Family Court Decisions (High Court Judges) >> Cheshire East Borough Council v PN & Ors (Flawed Local Authority Assessments) [2017] EWFC 20 (03 March 2017) URL: http://www.bailii.org/ew/cases/EWFC/HCJ/2017/20.html Cite as: [2017] EWFC 20, [2017] 4 WLR 56, [2017] WLR(D) 173, [2017] WLR 1359

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IN THE FAMILY COURT
SITTING AT LIVERPOOL

		03/03/2017

Mr Justice MacDonald:

1. This matter was listed with a time estimate of three days, to determine by whom PN, a little girl aged 11 months old, should be cared for following findings of fact I made in December 2016 with respect to how she came to sustain serious head injuries on separate occasions earlier in 2016 and significant emotional harm. This judgment should be read with the judgment I handed down on 20 December 2016 detailing my findings of fact (see [2016] EWFC 61).
2. Neither the mother nor the father advance themselves at this hearing as a carer for PN. The local authority that brings these proceedings, Cheshire East Borough Council, has filed and served a care plan that proposes that PN is placed permanently with her paternal great aunt, NM and her husband, HM, under the auspices of a special guardianship order. That plan is supported by the father, LN, and, nominally, by the Children's Guardian but opposed by the mother, NA. The paternal great aunt and her husband have been the subject of a positive assessment.
3. In opposition to the local authority's plan, HA, who is PN's maternal aunt, seeks placement of PN with her and her partner, CS. The maternal aunt's case is supported by the mother. Whilst initially positive during the course of its completion, following certain findings I made about the maternal aunt at the fact finding hearing, the outcome of the assessment of the maternal aunt that is before the court is negative. The maternal aunt, who has appeared in person throughout these proceedings, seeks a direction for a further assessment by an independent social worker, arguing that the local authority's assessment of her is deficient.
4. Achieving a listing of this matter on these three days has required considerable work on the part of the court to identify available dates within a very busy list, has involved the considerable expense of convening the parties and their respective lawyers at court for the final hearing, has involved the expense of utilising a courtroom and associated court resources for the duration of the hearing and has involved changing the High Court itinerary, with the associated costs of moving a judge of the Division from London onto circuit specifically to hear this matter.
5. Within this context, it is a matter of very considerable dismay to the court that it has been necessary, on the second day of this final hearing and having heard the evidence presented by the local authority in support of its case, not only to grant the maternal aunt's application for a further assessment of her and her partner by an independent social worker, but to direct a further assessment of the paternal great aunt and her husband by an independent social worker, in order to remedy patent defects in the local authority's assessments caused by social work that has, at best, been lackadaisical and, at worst, is in plain contravention of the applicable statutory guidance and long established good practice.
6. In the circumstances, I consider it appropriate to record in a short, published judgment the highly regrettable failures on the part of Cheshire East Borough Council that have led to the need to adjourn this final hearing and to delay in the resolution of proceedings in respect of a very young child.
7. The extensive background to this matter is set out in my judgment of 20 December 2016 and I do not repeat it here. In summary, I found that PN had sustained head injuries on two separate occasions and that those injuries were, on the balance of probabilities, caused by the mother in April 2016 and at a point between 1 and 4 July 2016 during momentary losses of control at a time when she was abusing alcohol, was suffering from mental health difficulties, was under significant stress and struggling form a bond with, and parent PN.
8. Further, I found both parents caused significant emotional harm to PN, and exposed her to a risk of significant physical harm, on repeated occasions over an extended period of time by reason of their toxic and volatile relationship, which relationship characterised by incidents of domestic abuse on both sides fuelled by alcohol without any regard to the emotional or physical wellbeing of PN. I found that both parents failed to prioritise PN's emotional needs and failed to ensure a safe home environment.
9. The parents have each filed statements in response to these findings. The mother does not accept the court's findings in relation to the injuries sustained by PN. Indeed, she continues strenuously to dispute those findings. Whilst she goes someway to accept that she caused PN emotional harm, she places the blame for that outcome squarely on her decision to continue her relationship with the father rather than acknowledging any deficits on her own part. By contrast, the father accepts the findings of the court in their entirety.
10. With respect to the injury sustained by PN at some point in the period between 1 and 4 July 2016, I further found that the maternal aunt and / or the maternal grandmother had, contrary to their assertions to the court, allowed the mother to have contact with PN without close supervision on at least one occasion over the course of that period, at a time when the mother's alcohol use and mental health difficulties persisted, at a time she continued to be under stress from her relationship with the father and at a time she continued to struggle to bond with, and parent PN, on which occasion the mother injured PN.
11. In addition to my finding that the maternal aunt and/or the maternal grandmother had allowed the mother to have contact with PN without close supervision on at least one occasion over the course of the weekend of 1 to 4 July 2016, during which period the mother injured PN, I also made the following observations in respect of the maternal aunt:

i) The maternal aunt accepted that the mother is capable of telling lies and that she does not always tell the truth.

ii) The maternal aunt saw the mother intoxicated whilst having sole care of PN on 4 March 2016 but did not refer to the incident in her statement and conceded that she did not tell the social worker about it.

iii) Despite her being told by the mother that the father had on one occasion thrown PN on the bed, the maternal aunt did not relate this to the Police.

iv) The maternal aunt sought to explain why she had withheld matters from the social worker and from the Police by saying "I did not give the full story because [the mother] wouldn't let me".

v) The maternal aunt accepted that at times the mother was aggressive and challenging towards the father and that there was fault on both sides, although, she felt, more so on the father's part.

vi) There was evidence before the court that is inconsistent with the assertion by both the maternal grandmother and the maternal aunt that they did not have a great deal of contact with the mother between 27 May 2016 and 11 July 2016.

vii) The maternal aunt sought to minimise the significance of the time spent by the mother at her home over the weekend of 1 to 4 July 2016, one of the periods during which I am satisfied that PN was injured by her mother.

viii) The maternal aunt admitted in cross examination that she had, in effect, colluded with the mother to minimise concerns to social services, succumbing to a request from the mother not to raise issues concerning the father with the social worker and going along with the idea of not giving a full picture to the social worker.

ix) The maternal aunt at one point sought to blame the social worker for not responding properly to the situation, the full extent of which situation she conceded she had agreed to conceal.

x) In the series of conversations with the father recorded by the mother the mother is heard conspiring with another female to make an allegation of theft against the father, which allegation is then duly made and thereafter an offer to withdraw the allegation if the father admits he caused the injuries to PN. These recordings also record the maternal aunt offering to testify on the father's behalf regarding his conduct towards PN if he is prepared to make an admission that he harmed PN.

12. The maternal aunt has filed and served two statements responding to my judgment. Whilst she states that she accepts and respects the judgment of the court, it would appear that her position since that judgment, both in her statements and in conversations with professionals, has at times been somewhat at odds with the findings of the court and, at times, seemingly at odds with the evidence she gave to the court during the hearing in December.
13. It is important to note however that, notwithstanding the observations from my December judgment outlined above, there are also significant positives in respect of the parenting capacity of the maternal aunt. She has two children of her own who she has parented appropriately. There is no suggestion that either of her children have come to harm. During the course of her own assessment she is considered to have worked well with social care professionals. There are no concerns regarding drug or alcohol misuse. She was assessed during observations of her parenting to be a confident, patient and understanding parent of children who appear to be leading happy lives. Her children were comfortable in her presence. She has a well-established relationship with PN and has demonstrated unwavering commitment to these proceedings, in which she has represented herself during a ten-day fact finding hearing and at this hearing in a diligent, measured and considered manner. Her wish to care for PN has likewise been unwavering as has her commitment to contact with PN. Further, and importantly, as I have already related, the maternal aunt does not advance herself as a sole carer for PN but seeks to care for PN with her partner.
14. Within this context, it is also important to note that, in respect of my finding that the maternal aunt and/or the maternal grandmother had allowed the mother to have contact with PN without close supervision on at least one occasion over the course of the weekend of 1 to 4 July 2016, during which period the mother injured PN, in my judgment in December I made the following observation:

"First, as I have recounted, it is plain that the agreement that DA and HA signed was far from clear in its terms. For example, the prohibition on leaving PN "alone" with the mother does not make clear whether supervision has to be one-to-one at all times or simply involves DA and HA being in the same property as the mother. The agreement is also confused in its description of precisely who is bound by it as between DA and HA. The omission of DA and HA must be understood in this context. Second, it is important to remember the very difficult position family members are placed in when they are asked by a local authority to supervise a parents' contact with their child. For family members that task is freighted with complex feelings of love and loyalty as well as a desire to ensure the child is protected. Within this context, the task facing family members is, paradoxically, a far more difficult one than that which faces professionals trained to undertake it…Whilst the assessments of DA and HA remain to be finalised, and without in anyway seeking to suggest what the final outcome of these proceedings may be, the local authority will need to consider the conduct of HA and DA within the context of the matters I have outlined."

15. There are, likewise, positives in respect of the assessment of the parenting capacity of the paternal great aunt and her partner and the overall outcome of that assessment is positive. In addition, however, it is also apparent from the evidence heard by the court yesterday that there are significant issues of concern, including the assertion that, from some point following the court's judgment in the finding of fact hearing and up until Thursday of last week, the paternal great aunt and her husband allowed the father to stay with them because he had nowhere else to go and a decision by the paternal great aunt's husband not to disclose in the context of the assessment a, albeit very old, conviction for a violence.
16. Within the context of the foregoing account of the background it is plain, and must have been plain to the local authority, that one of the key issues (if not the key issue) to be addressed when assessing the viability of a placement with the maternal aunt and her partner and the viability of placement with the paternal great aunt and her husband was the ability of each of those adults to protect PN against the identified risk of harm presented by the mother (in light of the court's findings that she injured PN and subjected PN to emotional harm and risk of physical harm by reason of her relationship with the father) and the father (consequent upon the court's finding that he subjected PN to emotional harm and risk of physical harm by reason of his relationship with the mother).
17. In support of its case, the local authority has placed before the court assessments of the mother, the maternal aunt and her partner and the paternal great aunt and her husband. The assessment of the maternal aunt and her partner (who is at times incorrectly named in the assessment as 'CN') was completed by a social worker from the fostering team, Ms Anne Fallows in January 2017. The precise date on which final conclusions were reached by Ms Fallows in respect of this assessment was entirely unclear on the evidence I heard prior to the local authority conceding the assessment was deficient. There is at least some evidence that a negative conclusion was arrived at before Ms Fallows had discussed the finding of fact judgment with the maternal aunt and ascertained her views in respect of the same.
18. The assessment of the paternal great aunt and her husband was completed by another social worker from the fostering team, Mr Chris Twigger. The initial assessment is dated November 2016. An updated, but undated assessment, was completed following the finding of fact hearing and has been included in the bundle. I pause to note that Mr Haggis informed the court that the structure of the process at Cheshire East Borough Council appears to be that 'kinship' assessments are undertaken by assessing social workers from the fostering team, which assessments are then considered by child's allocated social worker, in this case Mr Richard Bolt, and a care plan arrived at based on a consideration of the outcome of those assessments and the other relevant assessments and information.
19. The assessment conducted by Ms Fallows makes it plain that the assessment was intended to be of both the maternal aunt and her partner, CS (at times incorrectly referred, as I have already noted, to as 'CN' in the assessment). Notwithstanding this, Ms Fallows was forced to concede in cross-examination that, apart from a very brief conversation with him on the telephone whilst he was at work, she had not spoken to CS as part of her assessment. It would appear that whilst Ms Fallows had planned to speak to CS (and indeed had cancelled a number of appointments with him) she changed her mind after becoming aware of the outcome of the finding of fact hearing, apparently concluding without discussing the findings with CS (and possibly before she had discussed the findings with the maternal aunt) that the findings made by the court were simply fatal to any proposed placement of PN with the maternal aunt and CS.
20. Having listened to the evidence of Ms Fallows, I was left entirely unclear why she considered she was justified in drawing such a definitive conclusion without first speaking to CS to establish the extent to which he constituted a protective factor and, accordingly, the extent to which his presence in the household mitigated any concerns Ms Fallows had regarding the maternal aunt's capacity to protect PN from the identified risk of harm presented by the mother and the father. Whilst it might be the case that CS does not constitute a protective factor, it might also be the case that he does. The point is that Ms Fallows made no professional effort whatsoever to assess the position before reaching her conclusion that the assessment of the maternal aunt and her partner was negative.
21. In particular, Ms Fallows took no time to explore with CS his understanding of the findings made by the court, his acceptance of those findings, his attitude towards those findings and, in light of the information provided by him, the nature and extent of his ability to protect PN from the identified risk of harm consequent upon the findings of the court, including those in respect of the maternal aunt. This despite the fact that Ms Fallows' task was to assess the capacity of the maternal aunt and CS to protect PN from harm, including from any person who presents a risk of harm to her. In the circumstances, Ms Fallows assessment of the maternal aunt and her partner contains a patent lacuna and is fundamentally flawed.
22. The assessment of the paternal great aunt and her partner by Mr Twigger gives the court even more cause for concern and is of extremely poor quality. It comprises little more than a collection of bare statements of fact with virtually no evaluation or analysis, leading to conclusions that are so simplistic and anodyne as to be little more than a statement that the paternal great aunt and her husband have successfully raised children before and would be able to promote PN's identity.
23. However, of most concern is the manner in which the purported assessment deals with the key issue when assessing the viability of the placement, namely the ability of the paternal great aunt and her partner to protect PN against the identified risk of harm presented by the mother and the father. In this respect, the relevant part of the initial assessment in November 2016 and the same part of the updated assessment completed following the finding of fact hearing read in the following identical terms:

"Ensuring safety (Describe the applicant's capacity to protect the child from harm and danger, including any person who presents a risk to them.)

[NM] and [HM] would wish to ensure that PN is taught age appropriate life and safety skills as she grows older and matures in their care. From an early age this would include issues such as safety around the home and they would of course ensure that they had the necessary safety equipment in place once PN became mobile. This would incorporate such items as stair gates and plug guards etc. As PN grows older she would be taught basic road safety and personal safety e.g. not talking to strangers and always telling someone where she is going which is what the couple have taught their own children and then grandchildren.

The couple have a dog that is a Jack Russell dog. As stated elsewhere in this report [NM] and [HM] have stated that they are aware that PN becomes alarmed by sudden noises and for this reason if their application were to be successful they have suggested that they would be willing to re-home the dog to their nephew who also has a Jack Russell"

24. Despite the Form C prompting the need to include harm and danger from any person who presents a risk to them, there is no reference at all in the updated assessment to the plainly identified risk of harm presented by the parents or to any engagement with the paternal great aunt and her husband regarding their response to that identified risk of harm and the manner in which they would propose to ensure PN is protected from such risk. Indeed, the courts detailed findings of fact do not appear to be set out anywhere within the body of the updated assessment.
25. Of further concern is that the relevant part of the initial assessment in November 2016 and the same part of the updated assessment completed following the finding of fact hearing are in identical terms. Indeed, it is plain that the latter has simply been 'cut and pasted' from the former. Within this context, the concern engendered by Mr Twigger's assessment is heightened still further by Mr Bolt confirming during his oral evidence that the paternal aunt and her husband have not been shown the finding of fact judgment of this court, are not aware of the precise terms of the court's findings against the mother and the father and that the same have not been discussed with them by the local authority.
26. In the circumstances, Mr Twigger's assessment of the paternal great aunt and her husband is wholly inadequate and fundamentally flawed. Whilst Mr Twigger deals with road safety, stairgates and a loud Jack Russell, there is no assessment or evaluation whatsoever of the central question of the ability of the paternal great aunt and her husband to protect PN against the clearly identified risk of harm presented by the mother and the father, nor does any attempt at all appear to have been made to undertake such an assessment. The inevitable result is that there is no assessment of this cardinal issue before the court in relation to those proposed carers.
27. Finally, there were also very real difficulties with the evidence of Mr Bolt when it came to the question of the capacity of the paternal great aunt and her husband to protect PN against the identified risk of harm presented by the mother and the father.
28. Despite the fact that he claimed to have considered the assessments of both Ms Fallows and Mr Twigger when arriving at his final care plan, Mr Bolt demonstrated a marked inability to recall even basic elements of the contents of those assessments relevant to the question of capacity to protect. In particular, he had apparently not identified the patent and obvious deficiencies in each of those assessments that I have outlined above. Further, he was not able to assist the court with even the most basic information concerning other matters highly relevant to the question of the capacity of the paternal aunt and her husband to protect PN from harm. For example, having revealed that the father had, between his release from a recent custodial sentence and until last Thursday, been permitted by the paternal great aunt and her husband to sleep at their property because the paternal great aunt was not prepared to see the father sleep on the streets, and that the father had not disclosed this information, Mr Bolt was unable to assist the court with answers to the very obvious questions that flowed from that information and which the court would have expected an allocated social worker to investigate.
29. In particular, Mr Bolt was entirely unable to assist the court with how long the father had stayed with the paternal great aunt and her husband for, whether the paternal great aunt and her husband had volunteered the information that the father had been staying with them or had been discovered allowing him to do so and whether the paternal great aunt and her husband considered it appropriate to allow the father to reside with them when they were putting themselves forward as carers for PN. Mr Bolt's evidence reached a remarkable nadir when he claimed, in answer to questions put by the maternal aunt regarding number of contacts the paternal great aunt had had with PN (in the context of the paternal great aunt having only recently commenced contact with PN and her husband having had only one contact with PN despite the fact he is retired and does not have work commitments), that it was "not necessary" for him to know the details of how many times the paternal great aunt had had contact with PN since the very recent commencement of that contact.
30. Accepted good practice in respect of assessments is plainly established by statutory guidance and longstanding good practice. The statutory guidance Working Together to Safeguard Children (HM Government March 2015) sets out at [35] the principles and parameters of good assessment.
31. These principles and parameters include the need for such assessments to be rooted in child development and informed by evidence, to involve children and families, to adopt an integrated approach, to be a continuing process and not an event and to be transparent and open to challenge. It is self-evident that the need for the assessment to involve children and families and to be informed by evidence will require information to be gathered from all of those adults in the child's household or in the household it is proposed the child should live.
32. The three domains of the assessment specified at paragraph [36] of the guidance should be the child's developmental needs, the parents' or carers' capacity to respond to those needs and the impact and influence of wider family, community and environmental circumstances. Once again, it must be self-evident that an assessment of the carers capacity to respond to the child's needs (including their capacity to respond to the child's need for protection against an identified risk of harm) must involve contact and communication with each of the carers who are, or it is proposed will be, responsible for meeting the child's needs.
33. At [37] the guidance makes clear that the interaction of these domains requires careful investigation during the assessment and that it is important that (a) information is gathered and recorded systematically, (b) information is checked and discussed with the child and their parents/carers where appropriate, (c) differences in views about information are recorded and (d) the impact of what is happening to the child is clearly identified. With respect to the assessment and management of risk, at [47] the guidance further provides that in order to manage risks, social workers and other professionals should make decisions with the best interests of the child in mind, informed by the evidence available and underpinned by knowledge of child development. Overall, Working Together makes clear that the aim of an assessment is to use all the information to identify difficulties and risk factors as well as developing a picture of strengths and protective factors.
34. Within this context, when undertaking an assessment concerned with establishing capacity to protect against an established risk of harm, in addition to ensuring that an assessment of the carers capacity to respond to the child's need for protection against an identified risk of harm involves discussions with each of the carers who are, or it is proposed will be, involved in meeting the child's needs, it is also surely self-evident that the assessment must include a process that ensures that those who are the subject of the assessment of their capacity to protect from risk of harm are aware of what the precise nature of the risk of harm is. Further, it must likewise be self-evident that having been made aware of the precise nature of the risk of harm, each of those being assessed must be the subject of a comprehensive evaluation of their understanding of and attitude towards that risk in order to establish the extent to which they have, or do not have, that capacity.
35. Having regard to the summary of the deficiencies set out above in respect of each of the assessments, and to the summary of the applicable statutory guidance also set out above, I am entirely satisfied that the assessments completed by Ms Fallows and by Mr Twigger are inadequate and fundamentally flawed. I am further satisfied that, in the circumstances, the assessments do not permit the court to reach a properly informed or fair decision at this final hearing as to which of the placement options before the court best meets PN's identified welfare needs or, indeed, whether either is capable of doing do. The patent deficiencies in the assessments are such that, the court having heard Ms Fallows and Mr Bolt give evidence and be cross-examined, Mr Haggis on behalf of the local authority has been compelled to concede that the assessments were each insufficient to allow the court to reach a properly informed and fair decision. Notwithstanding the concession made by the local authority I make clear that this is my conclusion in any event having read the assessments and heard the oral evidence to which I have referred.
36. With respect to the assessment of the paternal aunt and her partner it is plain that the local authority simply decided, unilaterally, that the finding of fact judgment justified it terminating the assessment notwithstanding that that assessment of the couple was plainly incomplete and failed properly to address the key issue with which the court would be concerned at the final hearing. With respect to the assessment of the paternal great aunt and her husband, the assessment is entirely cursory and fails to engage in any meaningful way with the key issue that the court is required to resolve in determining whether the placement can meet PN's identified welfare needs. It is apparent that, following the outcome of the fact finding hearing, the local authority felt that it could simply take a short cut by terminating prematurely the assessment of the maternal aunt and her partner and by undertaking the most cursory of updating assessments of the paternal great aunt and her partner. That is an entirely impermissible approach in circumstances where the process of assessment must not only constitute a comprehensive assessment of the child's identified welfare needs and how those needs are best met in accordance with the statutory guidance, but also must be fair and be seen to be fair.
37. Before the court takes a final decision as to the welfare of a child it must be astute to ensure that the case has been fully and properly investigated and that all the relevant evidence necessary for the decision is in place, both to ensure that the court makes a fully informed decision as to the child's welfare and to ensure that the proceedings are fair, the former being an aspect of the latter. Having regard to the matters set out above, I am wholly satisfied that the court is not in a position to conclude that the central question of respective capacities of the maternal aunt and her partner and of the paternal great aunt and her husband to protect PN from the identified risk of harm from the mother and father has been full and properly investigated and that all relevant evidence necessary to determine that issue is in place before the court.
38. Within this context, and with much regret, I am entirely satisfied that it is not possible to conclude the final hearing fairly without further assessment of the maternal aunt and her partner and the paternal great aunt and her husband, in particular as to the central question of their respective capacities to protect PN from the identified risk of harm from the mother and father. In the circumstances I have set out above, those additional assessments are plainly necessary for the court to deal with this case justly. I am further satisfied that the additional assessments should be conducted by an Independent Social Worker and should be funded by the local authority. In light of the patent omissions in the assessments of the local authority as identified above, those who are to again be assessed cannot reasonably be expected to have any confidence in a further local authority assessment. Further, in circumstances where the further assessments are required solely by reason of the local authority having comprehensively failed to discharge its duties I am entirely satisfied that it should pay for the additional assessments that are require in consequence of that default.
39. I of course bear very carefully in mind that an adjournment will result in further delay for PN in circumstances where these proceedings were issued in July 2016 and that PN has been in foster care since her discharge from hospital in late July 2016. Plainly, this is a factor that must weigh very heavily indeed in the court's decision whether to adjourn the final hearing and I have born this factor very carefully in mind having regard to PN's very young age and the urgent need for her to move to her permanent placement. However, against this very weighty consideration, I am satisfied that to proceed in the absence of the assessments that I am satisfied need to be undertaken as a result of the local authority's default would be to proceed in a manner that is both unfair and antithetic to the aim of arriving at a fully informed decision as to the placement that best meets PN's identified welfare needs, including her need to be protected from harm.
40. Within this context, it is important for the local authority to recognise that its failure in this case to discharge its duties has consequences. The failure results not only in unnecessary and harmful delay but also has a human cost in terms of unnecessary upset, stress, confusion and, often, the further entrenchment of already entrenched positions. Further, by reason of the need to adjourn this hearing, it will no longer be possible in this case to maintain fidelity to the principle of judicial continuity. Due to the demands on my list, I am not now able to accommodate a further final hearing until the end of November 2017. That is simply too long for PN to wait for a final decision. In circumstances where the Designated Family Judge for Liverpool is able to accommodate a final hearing at the end of May 2017, which will allow for the completion of the further assessments that I am satisfied are necessary, I shall re-allocate this case to Her Honour Judge De Haas QC for a further IRH and final hearing.
41. In conclusion, I adjourn the final hearing and grant the maternal aunts application for a further assessment of her and her partner by an independent social worker. I direct of my own motion that a further assessment of the paternal great aunt and her husband by be undertaken by an independent social worker. I direct that the local authority fund both of those assessments. I re-allocate this case to the Designated Family Judge for Liverpool and will give directions timetabling the matter towards an IRH before Her Honour Judge De Haas QC in mid May 2017 and a final hearing at the end of May 2017.
42. Finally, the serious mistakes made by East Cheshire Borough Council in this case are of very real concern and must not be repeated. In the circumstances, as I stated at the beginning of this judgment, I am satisfied that it is appropriate to publish an anonymised version of this judgment on Bailii. I am further satisfied that it is appropriate to direct the Head of Service for Children's Social Care at Cheshire East Borough Council, Mr Nigel Moorhouse, to file and serve a statement explaining to the court precisely how the highly regrettable mistakes that I have recounted in this judgment came to be made and the steps that the local authority intends to take to ensure that they are not repeated in the future.
43. I hope that those responsible at the local authority for the unfortunate omissions I have had to deal with in this judgment will reflect on the consequences for PN and her family of their failure to comply with their professional obligations and their obligations to this court, and on the need for them to do better in the future for a child whose welfare they are charged with safeguarding and promoting.
44. That is my judgment.