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You are here: BAILII >> Databases >> England and Wales Family Court Decisions (High Court Judges) >> A & B, Re [2025] EWFC 65 (27 March 2025) URL: http://www.bailii.org/ew/cases/EWFC/HCJ/2025/65.html Cite as: [2025] EWFC 65

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IN THE FAMILY COURT
SITTING IN CARDIFF

		27 March 2025

This judgment was handed down remotely at 10.30am on 27 March 2025 by circulation to the parties or their representatives by e-mail and by release to the National Archives. ............................. MR JUSTICE PEEL

 


Mr Justice Peel :


 


Introduction

1. These proceedings relate to twin children, A (a girl) and B (a boy), (randomly chosen initials) born on 15 February 2024 and now 1 year old.
2. This is a fact-finding hearing to determine the cause of a total of 20 fractures sustained by the twins; 4 fractures to A and 16 fractures to B. The hospital attendance that led to the identification of all of the injuries started on 29 March 2024 (when they were about six weeks old) due to significant concerns over A's left leg, which transpired to be a displaced spiral fracture of her left femur.

The specific findings sought

3. The fractures were:

i) To A (identified on and after 29 March 2024), 4 fractures:

a) Displaced spiral fracture to shaft of left femur, with accompanying swelling to her left thigh.

b) Fracture at the posterior arc of the left 4^th and 7^th ribs.

c) Fracture at the proximal metaphysis of the right tibia.

ii) To B (identified on and after 2 April 2024), 16 fractures:

a) Fracture at the posterior arc of the left 5^th, 6^th, 7^th, 8^th, 10^th and 11^th ribs.

b) Fracture at the posterior arc of the right 5^th rib.

c) Fracture at the anterior aspect of the right 2^nd, 3^rd, and 4^th ribs.

d) Fracture at the distal metaphysis of the right and the left femur.

e) Fracture at the proximal metaphysis of the right and left tibia.

f) Fracture at the distal metaphysis of the right and left tibia.

4. The LA alleges that all of the fractures to both twins were caused non-accidentally by their mother ("M") and/or their father ("F"), and the perpetrating parent(s) would have been aware of the harm inflicted. If one parent inflicted the injuries, the LA contends that the other parent failed to protect the children.
5. A and B were initially placed in foster care, but since October 2024 they have been in the care of their paternal grandmother and step-grandfather. They see their parents three times per week in a contact centre setting.
6. The parents accept that the twins suffered the fractures while in their care. Neither the Local Authority ("LA") nor the parents suggest that any other person could have been a possible perpetrator of inflicted injuries.
7. The parents dispute that they caused any non-accidental injuries. I have at all times borne in mind that it is not for them to disprove the LA's case; it is squarely for the LA to prove the case. The parents say they are at a loss to explain how this happened. They have raised a number of potential explanations including:

i) Babies wriggling during nappy changing;

ii) Techniques used by them to soothe winding problems;

iii) A specific possible explanation advanced by F that he leaned over A on 29 March 2024 while cradling her, and may thereby accidentally have caused the left femur fracture;

iv) Organic susceptibility to fracture, which may have caused or contributed to fractures during normal handling (including during (i) – (iii) above).

If these are not accepted, it does not follow that the parents (or either of them) must be responsible for causing significant harm. This is not a linear process of rejecting hypotheses and then seeing what is left. The court must consider the entirety of the evidence and submissions.

The Law

8. The foundation stone of any fact-finding hearing is Section 31(2) of the Children Act 1989:

(2) A court may only make a care order or supervision order if it is satisfied—(a) that the child concerned is suffering, or is likely to suffer, significant harm; and

(b) that the harm, or likelihood of harm, is attributable to—

(i) the care given to the child, or likely to be given to him if the order were not made, not being what it would be reasonable to expect a parent to give to him.

9. The burden of proving the facts pleaded rests with the LA. The parents are under no obligation to disprove a case; that would amount to reversing the burden of proof. As Mostyn J said in Lancashire County Council v R and W [2013] EWHC 3064 (Fam):

"There is no pseudo-burden or obligation cast on the respondents to come up with alternative explanations".

10. The standard of proof is the simple balance of probabilities, neither more nor less: Re B (Care Proceedings: Standard of Proof) [2008] UKHL 35.
11. Findings of fact must be based on evidence, not on suspicion or speculation: per Munby LJ at paragraph 26 of Re A [2011] EWCA Civ 12.
12. The inherent probability or improbability of an event remains a matter to be taken into account when deciding whether, on balance, the event occurred: Re B (supra). As Peter Jackson J (as he then was) said in Re BR (Proof of Facts) [2015] EWFC 41 at [7]:

(3) "The court takes account of any inherent probability or improbability of an event having occurred as part of a natural process of reasoning. But the fact that an event is a very common one does not lower the standard of probability to which it must be proved. Nor does the fact that an event is very uncommon raise the standard of proof that must be satisfied before it can be said to have occurred.

(4) Similarly, the frequency or infrequency with which an event generally occurs cannot divert attention from the question of whether it actually occurred. As Mr Rowley QC and Ms Bannon felicitously observe:

"Improbable events occur all the time. Probability itself is a weak prognosticator of occurrence in any given case. Unlikely, even highly unlikely things do happen. Somebody wins the lottery most weeks; children are struck by lightning. The individual probability of any given person enjoying or suffering either fate is extremely low."

I agree. It is exceptionally unusual for a baby to sustain so many fractures, but this baby did. The inherent improbability of a devoted parent inflicting such widespread, serious injuries is high, but then so is the inherent improbability of this being the first example of an as yet undiscovered medical condition. Clearly, in this and every case, the answer is not to be found in the inherent probabilities but in the evidence, and it is when analysing the evidence that the court takes account of the probabilities."

13. It does not follow that once all other possibilities are rejected, whatever remains must be the truth: Rhesa Shipping SA v Edmunds, The Popi M [1985] 1 WLR 948 per Lord Brandon at 955G.
14. The LA must prove not just the primary facts, but also the causal link between any facts found and the risks alleged: Re A [2016] 1 FLR 1 and Re L-W [2019] 2 FLR 278.
15. The decision on whether the facts in issue have been proved to the requisite standard must be based on all of the available evidence. The court looks at the broad canvas of the evidence before it in order to make findings on the balance of probabilities. Each piece of evidence should be considered in the context of all of the other evidence. As Dame Elizabeth Butler-Sloss P observed at para 33 of Re T [2004] 2 FLR 838:

"Evidence cannot be evaluated and assessed in separate compartments. A judge in these difficult cases must have regard to the relevance of each piece of evidence to other evidence and to exercise an overview of the totality of the evidence in order to come to the conclusion whether the case put forward by the local authority has been made out to the appropriate standard of proof."

16. Appropriate attention must be paid to the opinion of medical experts, but those opinions need to be considered in the context of all the other evidence; A County Council v KD and L [2005] 1 FLR 851. The judge is the decision maker, the expert is not. The expert evidence is part of a wider picture. The judge can make findings which are contrary to the unanimity of medical evidence: Lancashire v D and E [2008] EWHC 832 (Fam).
17. It should be borne in mind 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: Re U (Serious Injury: Standard of Proof): Re B [2004] 2 FLR 263 at paragraph 23. Scientific certainties of a past age are often proved conclusively wrong by later generations: per Mostyn J in A County Council v M and F [2012] 2 FLR 939 at paragraph 251. Today's orthodoxy may become tomorrow's outdated learning: R v Holdsworth [2008] EWCA Crim 971 at paragraph 57. Consideration has to be given as to whether the cause is unknown: Re R (Care proceedings: Causation) [2011] EWHC 1715. In this respect I was referred to first instance examples of "unknown cause" decisions.
18. A witness may say false things during an investigation and/or a hearing for many reasons, such as shame, misplaced loyalty, confusion, panic, fear, and distress: R v Lucas [1981] QB 720.
19. The evidence of the parents and carers is of utmost importance. The court should form 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; Re W and another (Non-accidental injury) [2003] FCR 346. Peter Jackson J (as he was) said in Lancashire County Council v M and F [2014] EWHC 3 (Fam) at para 9 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."

20. In respect of the pool of perpetrators jurisprudence, King LJ said this in Re A (Children) (Pool of Perpetrators) [2022] EWCA Civ 1348:

13. "In Re B (Children: Uncertain Perpetrator) [2019] EWCA Civ 575, [2019] 2 FLR 211 ("Re B: 2019"), Peter Jackson LJ clarified the proper approach in respect of uncertain perpetrator cases and the concept of a pool of perpetrators.

14. At paragraph [46], he "state[s] the obvious" by highlighting that the concept does not arise either where the allegation can be proved to the civil standard against an individual in the normal way, or where only one person could possibly be responsible.

15. Peter Jackson LJ went on at paragraph [48] to emphasise that the concept of a pool of perpetrators does not alter the general rule as to the burden of proof and that it is for the local authority to show, in respect of any potential perpetrator, that there is a real possibility that that person had inflicted the relevant harm before they are placed in the pool.

16. Having emphasised these parameters, Peter Jackson LJ at paragraph [49] ("paragraph [49]") went on to set out the proper approach to be applied in every case:

"[49]….The court should first consider whether there is a 'list' of people who had the opportunity to cause the injury. It should then consider whether it can identify the actual perpetrator on the balance of probability and should seek, but not strain, to do so: Re D (Children) [2009] EWCA Civ 472 at [12]. Only if it cannot identify the perpetrator to the civil standard of proof should it go on to ask in respect of those on the list: "Is there a likelihood or real possibility that A or B or C was the perpetrator or a perpetrator of the inflicted injuries?" Only if there is should A or B or C be placed into the 'pool'." (my italics)

And later:

33. "The evaluation of the facts which will enable a court to identify the perpetrator of an inflicted injury to a child will be determined on the simple balance of probabilities and nothing more. Having considered the matter afresh in the light of Elisabeth Laing LJ's observation, I am of the view that to go further and to add that the courts should not "strain" to make such a finding is an unnecessary and potentially unhelpful gloss which has outlived its usefulness and which was directed at a different issue as set out in paragraph [24] above.

34. I suggest, therefore, that in future cases judges should no longer direct themselves on the necessity of avoiding "straining to identify a perpetrator". The unvarnished test is clear: following a consideration of all the available evidence and applying the simple balance of probabilities, a judge either can, or cannot, identify a perpetrator. If he or she cannot do so, then, in accordance with Re B (2019), he or she should consider whether there is a real possibility that each individual on the list inflicted the injury in question."

The background

21. M is 27 years old and F 26. M has, since leaving school, worked in a children's nursery, initially as an apprentice, and then progressing through to her current role as manager. She is accustomed to dealing with young children, including infants. F similarly started as an apprentice and is currently in full time employment as a machine operator. They started a relationship in September 2019. In October 2022, F moved in with M and her mother. In October 2023, they acquired their own rental accommodation, by when M was pregnant. The pregnancy was unplanned, but both knew it was a possibility as they had stopped using contraception. In the parenting assessment of F, he told of some early ambivalence about the pregnancy, including whether they wanted to keep the twins. I am confident that this was his attitude rather more than M's, but I have no reason to doubt that from the time of the first scan onwards, he abandoned any such reservations and both were committed to the births.
22. M's mother and F's mother, to whom both parents are close and with whom they have spent a great deal of time, gave me a clear picture of the relationship between M and F. They described them to me as a caring, loving, hard-working couple who are patient and have a very close relationship; they have never heard F or M say a cross word to each other.
23. There is no background history for either parent of criminality, domestic abuse, mental health issues or misuse of drugs/alcohol. They both have extensive support networks with family and friends nearby. Home conditions were clean and tidy. M is, and was both before and after birth, organised and well prepared.
24. Both parents were fully engaged throughout the pregnancy.  There were some concerns as to the health of both babies in utero: the obstetric notes detail episodes of diminished foetal movement and slow growth.  M generally appeared well although she suffered with heartburn, for which she was prescribed Omeprazole.  She also took Rennies and Gaviscon, which she purchased over the counter.
25. The babies were always due to be delivered by elective C-section. However the booking date for the C-Section was advanced due to concerns for A's growth. They were born on 15 February 2024 at 36 weeks + 4 days, weighing 5lb 8 oz (B) and 4lb 3 oz (A). There were no problems of note during the birth itself. M and the children were discharged home on 19 February 2024. F is named on the birth certificates and has parental responsibility.
26. F took two weeks paternity leave and two weeks holiday, so that he went back to work on 14 March 2024. M was on maternity leave throughout the relevant period described in this judgment.
27. From the point of discharge home, the evidence is that both parents were involved in caring responsibilities, such as changing and feeding the twins. My impression is that M was primarily responsible for the children, particularly after F went back to work. But F was a hands on father. He helped M (for example they did the night feeds together) and, on the evidence I heard, on occasions was solely responsible for the children while M was doing household chores, walking the dog, having a bath or the like. This was a small house and little would go unnoticed. M told me that F described himself to her as a bit more heavy handed than her, but she saw nothing untoward in the way he handled the children other than on one occasion on 11 March 2024 to which I will return.
28. Their rental property proved to be damp, mouldy, and too small for the family. They decided to rent a different property, with the move due to take place on Good Friday, 29 March 2024; the same day, as it transpired, as the occurrence of the femoral fracture in A.
29. These parents faced the same stressors faced by new parents up and down the land every day. M told me that being a parent is hard, but she expected it to be so. They had premature twins who needed round the clock care. Their house was damp, and they were worried about the impact on the children's health. Phone messages at the time referred to the children "kicking off" on occasions, F expressing concerns about finances (although M, in my judgment, was not particularly concerned), some difficulty feeding, and the babies causing sleep deprivation. None of this is exceptional. The question, however, is not whether these stressors were unusual, but whether they had an impact on one or both of the parents.
30. A number of witnesses (friends and family), in written and oral evidence described both parents as loving, caring and attentive to the twins. The maternal and paternal grandmothers were regularly on hand (both live very nearby) to provide a significant level of support. They told me that the parents were patient, gentle and safe in their handling of the children. There were no outward signs in the children's presentation, or the parents' behaviour, to cause them any concerns.
31. After birth, routine checks (including by clinicians, GP, health visitor and midwife) did not identify any concerns in respect of the twins' development. There was no bruising or signs of pain. There were a number of post-natal issues, which needed addressing but which were not out of the ordinary given their prematurity and low birth weight: they needed monitoring for blood sugar levels, there was a presentation of jaundice which needed light therapy, they were prescribed medication for reflux (Gaviscon and Omeprazole), both children were on oxygen for a while after difficulties breathing, they were diagnosed with bronchiolitis and for a short time were fed by NGT. There is no criticism by any of the hospital clinicians, or other professionals, as to the parental engagement with them.
32. The parents were not under scrutiny in the sense of being monitored because of concerns. But the timeline shows that between birth and 29 March 2024 there was at least one other person present with them and the children for some time every day other than on five days, whether that be a friend, relative, or health professional.
33. Both children were, according to the parents, gassy and presented with trapped wind, reflux, and colic. To alleviate these wind symptoms, F and M did bicycle movements with the children's legs, which they found online by a user called "Enchanted nanny," and a technique of creating movement in the child's belly with a circular motion while the child was supported upright sitting on the parents' knees.
34. On 1 March 2024, M phoned 111, saying that A had cold like symptoms, was congested, lethargic and a bit irritable. She said that B was similar, but not so bad. Both children were taken to hospital to be on the safe side, where they were diagnosed with bronchiolitis. They were discharged on 4 March 2024.
35. Both parents told me that on 11 March 2024 F held A on his lap, bobbing along to "dancing fruits" on the TV. M was worried about A's head flopping, and said to F to be careful. She mentioned shaken babies. F then searched on the internet: "why do babies wave their arms and legs" and "what happens if you shake a baby".
36. On 12 March 2024, M did an internet search about "ribs retracting when breathing baby", "what should babies ribs look like when breathing" and "mottled skin". Later that day, she phoned 111, saying that A's ribs were "retracting like she is sucking in when she is breathing" but otherwise seemed fine. She took A to the out of hours doctor.
37. On 24 March 2024, M searched various terms concerning pallid breath-holding.
38. On 25 March 2024, the twins had routine hip screening at about 9am which reported as normal. The paternal grandmother accompanied M and the children. F was at work. The grandmother remained with the family during the morning and saw nothing untoward. There were exchanges of text messages between M and F from 11.38 until 13.29 in which M mentioned that the children seemed congested and unsettled, "sucking in"; she told me they had had a bit of a sniffle overnight. F asked if M planned to call the doctor and she said, "I don't know…". F said, "Better to call and be safe". At 13.29 M messaged F that "They've calmed down now". It was not clear exactly how long the grandmother was present, but I do not detect any undue concern in this period. F returned home at or shortly after 15.30, and was with the family the rest of the day.
39. Later that evening, at 20.21 M searched "is it normal for babies to go pale after strong crying". Shortly afterwards, she phoned 111 on two occasions (and joined a further call between 111 and the hospital), reporting that both children's breathing had become laboured, they were "really pale and short of breath". The first call was at 20.38. She described A as being a bit worse. They were taken by ambulance to hospital for assessment. Observations were normal and they were discharged home.
40. On 27 March 2024, F asked his mother to come over to listen to A's chest. She looked at her breathing and said they should take her to hospital to be checked. A attended hospital where the parents reported her as being chesty and short of breath. After assessment, she was discharged home.
41. On 28 March 2024, the twins attended the health visitor's clinic. No concerns were noted.
42. On 29 March 2024, when the children were 6 weeks old, F, with a friend, set about doing the house move. F left the old home between 09.00 and 10.00. He went back and forth between the two homes three or four times. M took the twins to her mother's house for an hour or so. She then took them to the house of a friend, N, at about 12 noon. Another friend, R, was also there. None of these witnesses noticed anything untoward, and A was seen to be moving her legs normally.
43. M and the children left N's home at about 15.30 to go to their new house, arriving at about 16.00 where they were met outside by another friend, AM, who had been waiting for them. M, AM, and the children went into the house. F was not there at the time. F returned at about 16.30 and went upstairs to put their bed together while M stayed downstairs with AM and the twins. AM held the children on occasions and noticed nothing unusual. AM then left shortly before 17.30. The precise time cannot be definitively established but in my judgment it was probably no later than 17.20. Just before leaving, AM saw M hand A, who was asleep, to F, who then went into the kitchen with A to see to the barking dog. M was holding B and showed AM out. AM told me (and I accept) that when she left it was a perfectly normal, happy scene, with nothing to cause any concern.
44. According to the parental accounts, after AM left, F went to sit near the corner of a L shaped sofa with A in the crook of his arm, her legs across his waist. M, having seen AM out, put B on the double cushion on the other side of the join of the L shaped sofa, diagonally across from F and A and on their right hand side. M went to the kitchen for about five minutes to make up a bottle feed.
45. F says that during that time B spat out his dummy. He leaned forward diagonally to put the dummy back in B's mouth, using his free arm and hand to do so. He then placed A in the crook of his other arm, legs across his waist. B spat it out again; he could not remember whether she was first in his right arm, and then in his left arm, or vice versa. F says he leaned forward diagonally again to put it back in. When he sat back up, according to him A started crying and he noticed that her left leg was hanging down, almost floppy. He told me that he knew almost instantaneously that something had happened, and that he was the cause of it in some way; "I realised at once it was something I had done". He told me that he did not feel, or sense, the fracture, but he thinks he did cause it in that moment.
46. M heard A crying; she described it as unusually loud. F called out to M to say that A's left leg was in an unusual position. She came back into the sitting room. A was still in F's arms. M undressed A's bottom half to look at the leg and they both agreed it did not look right. She tried to soothe A with a bottle. She asked F what had happened, to which he replied, "I don't know". He did not say to her at any time that day, or in the immediate aftermath, that the injury occurred when (on his case) he leaned over her for the second time and she immediately cried. He did not tell M of this event (which I shall term the "leaning over" episode) until June 2024.
47. At 17.26 and 17.27 F did two internet searches "why is my babys leg floppy" and "why is my babys leg floppy all of a sudden". He did not tell M that he was doing the searches. She was not aware of them until May/June 2024, two months after their phones were removed from them.
48. At 17.32, M phoned 999 for an ambulance, and was told the wait time was three hours. I have listened to the recording of the call and there is obvious background noise of A crying loudly, and clearly distressed. At 17.40 and 17.41, F phoned his mother; during one of the calls, F said to her that he noticed something wrong with the leg "straight away" when M passed A to him.
49. The parents decided to take her to hospital in their car and at 17.54 rang 999 to cancel the ambulance. They took A to A and E in their vehicle, dropping off B at the paternal grandmother's house on the way. It took 50 minutes to reach hospital at 18.36. A cried all the way. On admission, A was still crying, with her left leg held at an angle and swollen. A pelvis and left femur X-ray conducted at 19.13 showed a displaced fracture to the mid-shaft of the left femur. She was seen by the trauma orthopaedic doctor at 19.45. The safeguarding process was then instigated. At 20.00, A was referred to social services.
50. At 21.57 M searched on her phone what makes a child's bone break easily.
51. On 30 March 2024, at 01.49 F searched on his phone "why is my baby's leg floppy all of a sudden". At 09.00, M searched brittle bone disease.
52. On 2 April 2024, F did further searches about fractured bones in babies.
53. The twins remained in hospital until discharge on 23 April 2024. They were immediately placed with foster carers, and, after a contested hearing on 10 September 2024, with the paternal grandmother and step-grandfather from October 2024 onwards. Since then, B has had check-ups at hospital on two occasions, and has seen the GP twice, because of a wheeze in his chest for which he has been given a nebuliser. A has been seen once at hospital, but not by a GP. The paternal grandmother told me that the children are now in a walker and more mobile; they are thriving in her care and show no signs of anything to cause her concern. She has not seen any incidents similar to the ones for which M called 111, when the children presented as pale and with laboured breathing. I formed the clear sense that she has not been treating the children unduly gently and cautiously; rather, she has provided excellent care, with normal handling.
54. I asked whether any X Rays had been conducted after the children went into foster care and then grandparental care. I was told that X Rays would not have been conducted unless there was a medical reason to do so. There is no evidence of any fractures since removal from the parents.
55. In respect of the court proceedings, it is of note that on 30 May 2024, in his initial response to threshold, F stated he "may have accidentally caused A's leg fracture as per the account given by him to Dr A", although he did not explain to what he was referring in that document. F told me in evidence that he was referring to the "leaning over" event.
56. In June 2024 (the precise date was unclear), F told M of the "leaning over" event. He subsequently placed it before the parties and the court for the first time in his witness statement dated 25 June 2024.

Clinical examinations

57. A child protection medical in respect of A took place at hospital on 29 March 2024, and on 31 March 2024 in respect of B. Thereafter:

i) A had a CT head scan on 3 April 2024, radiographic skeletal surveys on 3 April 2024 and 16 April 2024, and a left tibia and fibula X-ray on 22 April 2024.

ii) B had a CT head scan on 2 April 2024, and radiographic skeletal surveys on 2 April 2024 and 16 April 2024.

58. Dr S, the supervising consultant paediatrician, who saw A on 30 March 2024 and B on 3 April 2024, says in the child protection medical reports for both children:

i) The CT head scans were normal and there was no sign of bruising or abrasions, or other suspicious markings.

ii) The skeletal survey on 2 April 2024 in respect of B suggested multiple fractures, some of which had callus present which indicated that the fractures may have occurred at different times.

iii) The skeletal survey of A on 3 April 2024 confirmed the left femoral spiral fracture, and identified a possible fracture of the left seventh rib and possible metaphyseal fractures of the left and right tibia.

iv) Subsequent skeletal surveys on the children showed fractures at different stages of healing.

v) The orthopaedic consultant had reported that the X ray findings were consistent with non-accidental injury. The radiologist had stated that the bone health was normal. There were no signs of osteogenesis imperfecta. There was no evidence of injury during birth.

vi) Unexplained fractures in a non-mobile child are highly associated with abuse. Femoral and rib fractures are highly specific for abuse, often occurring on the same location on adjacent ribs, and typically affecting ribs 4 to 12. The most likely explanation for both children's fractures is non-accidental injury. Any fracture requires significant force and the perpetrator would know the mechanism of the injury.

59. She told me orally that M gave her an accurate record at hospital of the children's medical history (it being a holiday weekend, medical records were not readily accessible). She said that both parents cooperated fully with the child protection medicals and were shocked when they were told of the multiple fractures.
60. I also heard from Dr A, a paediatric registrar, who was part of the child protection medicals. Questions of her were directed at the accuracy of her notes recording contemporaneously the parents' accounts of what happened on 29 March 2024. She was somewhat unclear, and her notes contained some obvious errors (for example they referred to F calling the ambulance, whereas it was M) which reflected either inaccurate recording on her part, or confused parents who were in a state of shock. Most significantly, her notes say that "Immediately" on M passing A to F, F noticed the leg was floppy whereas orally she told me that he noticed the floppy leg after the handover, at a time when M was making the bottle. Then during re-examination, she said she was not sure about the exact timing and sequence.

The expert evidence

Dr Olsen

61. Dr Olsen, the paediatric radiologist Single Joint Expert, told me in written and oral evidence:

i) It is highly unlikely that any of the injuries date back to birth. All radiologically occurred after birth.

ii) The matrix of fractures occurred on at least two separate dates after birth for each child.

iii) There is no radiological sign of underlying bone fragility, but he acknowledged that it cannot be completely excluded. Certain conditions such as a relevant connective tissue disorder and bone demineralisation would not show up on the imaging. He agreed that an underlying condition could affect both spontaneity of occurrence of fractures, and level of force required to generate fractures. It was suggested to him, and he agreed, that a number of features can be indicative of bone fragility: reduced foetal movement in utero, prescription of Gaviscon and Omeprazole, jaundice, NGT feeding, hypoglycaemia and prematurity.

iv) He reiterated that he saw no reason to change his overall view that gentle, normal handling would not have caused any of the fractures. On the assumption that these were normal bones, the level of force used was far beyond normal handling.

v) If there was an underlying, or organic cause, there would need to have been a very significant degree of bone fragility in A's femur for the fracture to have occurred.

vi) The metaphyseal fractures (one to A, four to B) are most likely explained by unnatural, severe, forceful bending, pulling or rotation to relevant parts of the limb, and/or possibly shaking. He felt that shaking could not be excluded as a possibility, although there were no other markers of shaking which are commonly found such as cranial or ocular injury. If shaking, was the cause, they could have happened on one occasion for each child. The force required to cause the metaphyseal fractures was less than that required for the left femur fracture.

vii) Rib fractures require significant force. Most of the rib fractures were towards the back, and most likely caused by squeezing forces to the babies' chests, with or without simultaneous shaking.

viii) Three rib fractures to B were at the front, most likely caused by direct application of pressure (the equivalent of CPR in force).

ix) Dr Olsen describes B's rib fractures as a "very severe chest injury".

x) A's left thigh bone spiral fracture was complete and very significantly displaced, most likely caused by a clearly traumatic twisting force to the left leg relative to the pelvis or torso. The force required for this fracture was likely to be higher than for the other fractures in either child. He said that the twisting would need to be in excess of the rotation allowed by the hip bone, which is up to about 90 degrees. He thought that a significant twisting force caused the fracture.

xi) There is no credible explanation in the parents' evidence for the injuries. He was taken through the bicycle movement, pivotal winding techniques, nappy changing, holding children by the ankles who then wriggle, and F's leaning over explanation for A's femoral fracture, but told me that, absent underlying bone fragility, none of these would explain the fractures.

xii) In respect of the femoral fracture, it was put to him that if, on F leaning over, A was caught in a vice or clamp in her hip area, the force could have generated a fracture. Dr Olsen replied that as the fracture was high up the thigh bone, clamping the hip would in fact have prevented the fracture, whereas if it had been the other end (round the knee) that might have been a possibility.

xiii) Fundamentally, fractures do not occur spontaneously and in preambulatory children are not self-inflicted. They do not have the strength to injure themselves by wriggling, kicking or otherwise. It follows that they were inflicted by external agency after birth.

xiv) In terms of timings, A's fractures can be dated as follows:

a) The femoral fracture is likely to have been perpetrated up to two weeks before her skeletal survey on 3 April 2024, i.e no earlier than 20 March 2024. It could have occurred on 29 March 2024.

b) A's two rib fractures are similar in healing so may have occurred on a single date, most likely up to two weeks before 3 April 2024, i.e no earlier than 20 March 2024.

c) The metaphyseal fractures occurred up to 5 weeks before 3 April 2024, i.e no earlier than 27 February 2024.

d) It is possible that all the injuries occurred on one occasion (albeit with separate applications of force). He also said it is possible they occurred on up to four separate occasions.

xv) As for B:

a) The rib fractures cannot have occurred at the same time because of marked differences in healing; the left showed signs of healing, the right none.

b) The right rib fractures are likely to have occurred up to two weeks before the skeletal survey on 2 April 2024, i.e no earlier than 19 March 2024.

c) The left rib fractures probably were at least two weeks old, but no more than a month old, which puts the date of the injury at between 2 March 2024 and 19 March 2024.

d) The metaphyseal fractures were probably 1-5 weeks old on 2 April 2024, i.e caused between 27 February 2024 and 26 March 2024.

e) It is likely that the fractures occurred on at least two separate dates.

Dr Cartlidge

62. Dr Cartlidge, the SJE retired consultant paediatrician reported in writing that:

i) All the fractures to A were caused non accidentally, probably on at least two separate occasions.

ii) All the fractures to B were caused non accidentally, probably on at least two separate occasions.

iii) There is no evidence of an organic explanation for the injuries, including osteogenesis imperfecta, genetic predisposition, rickets, copper deficiency, or vitamin C deficiency. Omeprazole therapy received by M in pregnancy would not have caused bone fragility. The prematurity of the twins at birth was minor and not a risk factor for bone disease.

iv) Given the twins' ages and immobility, self-inflicted trauma can be ruled out.

v) There is no evidence that they were left with an irresponsible person who might have inflicted the injuries.

vi) The "leaning over" explanation provided by F does not explain the twisting mechanism and force required to cause the femoral fracture in A. Other potential explanations (e.g. changing a nappy, winding techniques) might have caused injury only if excessive, unnatural, and abusive force was applied. There is no plausible explanation advanced by the parents.

vii) It is notable that there have been no fractures since April 2024 (when the twins were removed from parental care), yet sustained multiple fractures in the first 43 days of life

viii) A's left femur was probably fractured on 29 March 2024. Her rib fractures may have occurred on or about 25 March 2024, when she became very pale and had laboured breathing. The date of the metaphyseal fractures cannot be more precisely ascertained than being up to 5 weeks old.

ix) B's right rib fractures may have occurred on or about 25 March 2024 when he was reported as very pale with laboured breathing. The left rib fractures occurred (per Dr Olsen) between 2 and 19 March 2024, and the metaphyseal fractures cannot be more precisely ascertained than being up to 5 weeks old.

x) The fractures were inflicted on at least two separate occasions to each child.

xi) Anyone present during the causal events would have known that the child had been hurt. A person not present would have subsequently noticed A unsettled and not moving her left leg, but would probably not have noticed any outward signs of the rib or metaphyseal fractures in either child, or known that the child had been injured.

xii) A's left femur fracture would have been initially very painful, and obviously so for 10-15 minutes. She would have ceased moving her left hip and knee. A saw the health visitor on 28 March 2024 who observed no concerns, which suggests the fracture post-dated that appointment, so somewhere between 28 and 29 March 2024, and possibly just before the ambulance was called. That is supported by the evidence of AM who left about 10 minutes before, with no indication of a broken leg then. The 999 call at 17.32 shows A crying, and in extreme discomfort, which is indicative of the injury having just occurred. The likely force was a twisting mechanism.

xiii) A's two rib fractures would have been initially painful for 10 minutes. Thereafter deep breaths, crying and handling around the chest would have exacerbated discomfort. That would not have been obvious to someone unaware of the trauma, because babies cry frequently without an obvious reason, and diagnosing a rib fracture by physical examination alone is difficult. It is likely that because she was pale and had laboured breathing on 25 March 2024, that was caused by recently fractured ribs.

xiv) The metaphyseal fracture to A's right tibia would have been initially painful for 5 minutes. Again, this would have been easily overlooked by someone not aware of the trauma. The mechanism was likely to be a yanking, twisting, or bending force to the right knee.

xv) B's rib fractures were likely caused by compressive force. As with A, someone not aware of the inflicted injury would not recognise any symptoms thereafter as caused by trauma.

xvi) B's metaphyseal fractures were probably caused by yanking, twisting or bending force applied to each knee and ankle, and would not have been obvious to someone not aware of the inflicted injury.

63. He was impressive in his oral evidence. He confirmed/reconfirmed his general conclusions as follows:

i) X Rays do not show bone fragility below about 20%-40%.

ii) There is no material evidence of any bone fragility (whether mild or severe) or hypermobility. There is no sign of osteogenesis imperfecta or osteopenia. Even if there was mild fragility, or mild hypermobility, the fractures would not have occurred with normal handling; the bones would have needed to be "remarkably fragile", and, if that were the case, the bones would have continued to fracture which they have not. A significant precipitating force would be required.

iii) He was taken through a constellation of factors which it was suggested, when looked at in the round, are indicative of at the very least the potential for susceptibility to fracture. He rejected them individually and globally:

a) He did not accept that prematurity (which was relatively short), or the fact of twins being born, or some in utero difficulties, was relevant to bone fragility. For that to be a feature, a baby would need to be very ill with multiple other medical issues.

b) M was prescribed Omeprazole and Gaviscon while pregnant. However, the calcium and phosphate of the children was shown to have been undisturbed so this was not material. M had an asthma nebuliser, but that would have had no impact on the children's bones unless taken in more than the prescribed amounts. If there had been deficiencies, the bones would have gone into overdrive to compensate but the alkaline phosphatase was normal.

c) A was prescribed Omeprazole on 20 March 2024, but that would not have had any bearing on possible fracturing between then and 29 March 2024 given the short timescale, and in any event is of very marginal effect. Further, B was not prescribed Omeprazole but nevertheless sustained fractures.

d) The fact that there was a short period of gastric feeding was irrelevant. So too the jaundice, which might be relevant in older patients where jaundice is conjugated, but not in infants. Similarly, bronchiolitis is irrelevant.

iv) He considers it notable that they had multiple fractures in the first 6 weeks or so of life, but none since then while with different carers. He agreed that the current carers might be gentler because of previous events, but on the other hand the children are older, likely to be sitting and crawling.

v) There is no evidence of a genetic mutation causing or contributing to bone fragility. He said dEDS is mainly associated with the skin, not bone fragility.

vi) Pain would have been noticeable to a perpetrator of the episode unless, potentially, the episode took place at a time when the baby was already crying.

vii) The femur fracture would have been caused by a significant twisting force. The perpetrator would have likely "sensed" the fracture. He rejected F's explanation, saying he did not see how that could have generated the twisting force required. The rib fractures were caused by a compressive, squeezing force, and the lower limb metaphyseal fractures by twisting or pulling. He did not consider shaking to have been the mechanism.

viii) He rejected the winding mechanism of pivotal rotation as being a cause of the rib fractures unless undue force was applied (akin to CPR). He adopted the same view in respect of nappy changing and the bicycle movement causing the metaphyseal fractures.

ix) For each child there are likely to have been at least two episodes of abnormal force.

a) A's femur fracture took place on 29 March 2024 and he agreed that on the available written evidence, it occurred in F's care.

b) On or about 25 March 2024, based on her presentation with a pallid complexion, crying and laboured breathing, A had probably sustained her rib fractures.

c) On or about the same date, and based on his similar presentation, B's right side rib fractures were probably sustained. His left side rib fractures probably occurred on a different date in line with Dr Olsen's report.

d) The metaphyseal fractures may, or may not, have occurred on the same dates as the rib fractures.

Professor Saggar

64. Professor Saggar, the Single Joint Expert in clinical genetics, wrote in his first report dated 15 September 2024:

i) Initial gene testing did not identify any clear mutation in the genes of the children associated with bone fragility.

ii) There was no evidence of osteogenesis imperfecta ("OI") or other bone fragility in the twins. The possibility of a rare or undefined fragility syndrome is less than 1%.

iii) There was no evidence of hypermobile spectrum disorder, as the children did not present with joint hypermobility; their Beighton score is zero.

iv) He noted that M has a very mild form of connective tissue disorder ("CTD"), within normal limits of human variation. She has a history of cleft palate and clicky joints, but not joint laxity. Even if the CTD has been inherited by the children, it would not lead to increased susceptibility to fracture in normal handling.

v) B has mild dysmorphic features; widely spaced eyes, folds round the eyelids and a slightly unusually shaped mouth, all of which might suggest some form of CTD.

vi) He identified two gene mutations in B. One, a mutation of ROR2, is associated with Robinow syndrome, a malformation in fingers presenting with complete absence of fingernails.

vii) The other is a mutation in ADAMTSL2 which likely represents carrier status for geleophysic dysplasia (characterised by short stature, short hands and feet). The mutation may also be associated with Dermatosparaxis Ehlers-Danlos Syndrome ("dEDS"), a rare and mild subtype of EDS. He said that the children did not have an obvious diagnosis of dEDS (also known as EDS7), and there was no family history of unexplained fractures. There is no significant joint laxity. Thus, the mutation in any event would not explain fracture susceptibility in normal handling.

viii) He recommended further testing on both parents and A to see if the gene mutation was segregating in a dominant pattern to suggest it was causing a mild form of dEDS, although he said that even should that be the case it was highly unlikely to result in significant susceptibility to fracture.

ix) Abnormal force was required to cause the fractures. There was no genetic explanation.

65. Professor Saggar prepared an addendum report dated 17 December 2024, having conducted the further testing referred to. He said that:

i) Both children have inherited the very rare genetic mutation from M known as ADAMTSL2.

ii) The children do not meet the diagnostic criteria for dEDS.

iii) He cannot exclude the possibility that the mutation may cause some very mild features of dEDS. For example, it may be an explanation for the mild dysmorphic features in B. However, the mutation is highly unlikely to result in any clinically significant susceptibility to fracture.

iv) It is much more probable that both M and the children are carriers of a recessive geleophysic dysplasia; as it is recessive, the children are not affected.

v) The degree of CTD observed would not lead to unexplained fractures.

vi) He remains of the view that an abnormal force is required to explain the fractures.

66. He told me orally that:

i) He agreed that it is not possible to exclude completely the possibility of an underlying bone fragility. However, neither twin shows signs of a primary bone disorder (such as osteogenesis imperfecta), and the residual possibility of bone fragility is very low. Neither of them would meet the diagnostic criteria for EDS3, a CTD which causes joint hypermobility and, although not free from controversy, may reduce bone fragility. In particular, they are 0/9 on the Beighton score, i.e they have no joint hypermobility or joint laxity. To make a link with bone fragility, there must be clear evidence of a CTD which is not the case here. Further, their mother shows some signs of CTD, but only in mild form and within normal bounds. If either child had inherited this non-specific CTD, it would not lead to increased susceptibility to fracture.

ii) The children do not have an obvious diagnosis of dEDS. If it is present at all, it is in hypomorphic (mild) form which would not explain fractures for normal handling in children this young.

iii) CTD and susceptibility to fracture must be looked at together. In his clinical experience he has not seen fractures in children under six months old (a time scale which I asked him about) with EDS unless there is a history of precipitate force, i.e beyond normal handling. He does not consider any of the explanations advanced by the parents to be viable.

67. Having heard the experts, I accept their evidence. In my judgment, little headway was made in cross examination or closing submissions to undermine, or cast doubt on, their essential conclusions.

Non-parental lay witnesses

68. I heard from AM, M's mother, and F's mother, all of whom confirmed what they had said in statements and seemed to me to be giving honest accounts.

The parents' evidence

69. Both parents deny causing any injury, or seeing the other cause any injury. Both, in their oral evidence, were composed and courteous, as they were throughout the proceedings.
70. M, I felt, was doing her best to help me. She is devastated by what has taken place. On the whole, I accept her evidence. There were a handful of (in my judgment) relatively minor inconsistencies about the events of 29 March 2024 which did not detract from her overall presentation, and were the product of extreme confusion and distress on that day.
71. F, by contrast, I found at times to be evasive and/or unable to explain inconsistencies and peculiarities in his account, particularly in respect of the events on 29 March 2024.
72. Turning to M first, during the 999 call, she said that her friend (AM) had passed A to M quite awkwardly. She did not subsequently mention the awkward handover to clinicians at hospital, nor to anyone thereafter. AM herself said she felt it was not awkward, and in oral evidence, M told me that it was no more than AM being a bit tense when she handed A over. I find nothing particularly suspicious about this exchange. M in the same emergency call said that they noticed the leg when A woke up from her bottle, which M accepted was not a fully accurate history, but again, in my judgment, was a result of confusion and understandable, particularly as she had been making a bottle. She told her mother later that evening the injury might have happened when A was passed to F, which does not appear to have been the case, not least because AM saw nothing untoward. I am inclined to accept that M was distressed and looking for explanations in the moment. Moreover, the timing of the fracture (within at most a few minutes after A was handed to F) is not wholly inconsistent with what M said; a reasonable interpretation is that injury happened "after" passing A, with "after" being synonymous with "when". Finally, M told Dr P at 20.00 that they noticed the leg "after mum changed the nappy". M was clear, and I accept, that she noticed it before then, but became sure after half undressing A. In accepting that these accounts by M were not suspicious, or an attempt at a cover up, but instead the product of confusion and casting around for possible explanations in the heat of the moment, I bear in mind that M, unlike F, was not in fact present when (as in my judgment is now clear) the fracture took place while he was on the sofa with A. I also bear in mind that M's distress was, understandably, intense; her mother described M as hyperventilating when they spoke on the phone.
73. At hospital, as the notes show, M said to a clinician (Dr S) that it was after she handed A to F, and made up a bottle, that A was unsettled and inconsolable, and F noticed that the left leg was floppy. There was momentary confusion in Dr S's evidence when she appeared to say that M's account at hospital was of the leg being noticeably floppy immediately upon handover by her to F, but I am satisfied that the contemporaneous notes reflect M's account given at the time that she only became aware of the floppy leg later, when called from the kitchen by F.
74. The phone records in respect of M do not strike me as particularly consequential. It is not surprising that after the events of 29 March 2024 she did internet searches of possible organic causes, given that on her case neither she nor F caused any injury. Such searches are just as capable of innocent explanation as malign explanation. In my judgment, they were natural attempts to try and work out what had happened, made by someone who had no idea what may have caused the injuries.
75. By contrast, I cannot accept F's explanation (or lack thereof) of a number of matters:

i) He told me that he realised at once that he had caused A injury on 29 March 2024, during the second part of the "leaning over" event, when she started crying very loudly. He accepted that, even though he did not (on his case) know exactly what had happened or how it had happened, he knew that he had done something, and that it was obvious something was seriously wrong. He accepted in cross examination that he knew the "exact moment" when the injury occurred.

ii) Despite that knowledge, when M, emerging from the kitchen, asked him what had happened, he replied that he did not know rather than tell her about leaning over. He was sufficiently alarmed to do internet searches before the 999 call about "why is my babys leg floppy" but not to tell M that he had done the search, nor to give her an account of the potentially relevant "leaning over" movement. He did not in fact tell M of the "leaning over" event until June 2024. He was unable to give any explanation as to why not. It seems to me to be surprising that he did not recount what had happened to enable M to explain it in the 999 call. Nor did he tell her in the 50 minute drive to hospital.

iii) He did not tell the clinicians at the hospital that evening or in the next few days of the "leaning over" event, although he must have realised how important it was to doctors who were trying to work out what had happened, particularly as he swiftly learned that a femoral fracture had occurred. He had time to gather his thoughts. He could easily have explained the "leaning over" event to a clinician but did not do so. Nor did he tell non-clinical professionals, family members, the court or indeed anybody, of what he said had taken place while he was holding A until he narrated it to M in June 2024, over two months later. He could not explain why not.

iv) Just before midnight on 29 March 2024, the parents met Dr A. I have referred above to some confusion in Dr A's evidence, and I am inclined not to attach much weight to her note suggesting that F told her he noticed the leg was wrong "straight away" when M handed A to him, not least because both parents told me (and I accept) that they tried to correct her, albeit unsuccessfully. However, far more significantly in my view, F (who by then was aware of the spiral leg fracture), did not tell Dr A what had (on his case) happened; he made no mention of the "leaning over" event.

v) Significantly, as noted above, on 30 May 2024, in his initial response to threshold, F stated he "may have accidentally caused A's leg fracture as per the account given by him to Dr A" (emphasis added). Yet F did not give the "leaning over" account to Dr A. When F told me in evidence that in trying to correct Dr A about the "straight away" record, he was working his way towards explaining the "leaning over" event, I did not think he was credible as (i) he did not in fact tell any other clinician, or indeed any other person, of that vital sequence of events until June 2024 and it seems unlikely to me that he intended to do so just to Dr A on this one occasion, and (ii) the first time he suggested he was trying to get to it with Dr A (but did not manage to do so) was in his oral evidence, never having previously referred to it in writing.

vi) F in written evidence said that A's head was in the crook of his arm, and her legs were in his hand. But in oral evidence he told me that her bottom was in his hand, but her legs were hanging over. The significance of this was the mechanism described by the experts as having been necessary to cause the fracture, which would have involved holding her tightly round the knee area (akin to a vice) and twisting the pelvic/torso area. I did not think F dealt with this inconsistency satisfactorily.

vii) At 17.40 and 17.41, minutes after the 999 call, F spoke to his mother on two occasions. He said to her that that M had passed A to him, and he noticed something wrong with her leg "straight away". As I have indicated above, I do not attach much significance to this as it seems to me "straight away" could be interpreted as "almost immediately afterwards" given that it happened so quickly. More significantly, in my view, he did not tell his mother (to whom he is very close) of the "leaning over" event.

viii) Although I have concluded that M's internet searches after the fracture were innocent, I am less convinced about F's searches after the event. He knew he had caused the injury, but had hidden that from everyone he spoke to. He was told soon after admission to hospital that it was a spiral fracture. He did not give an account of the "leaning over" event to anyone. In my judgment, he did searches on 2 April 2024 in the knowledge that he had caused the injuries, but, probably, looking for alternative explanations which might deflect attention from him.

ix) In similar vein, his account of the shaken baby internet search which he undertook on 11 March 2024 did not seem plausible to me. He did not tell M about it at the time. If, as he says, it was just a bit of curiosity, it is surprising that among the thousands of pages in the bundle about phone messages and searches, he was able to recall that particular one and mention it to M about two months after their phones were removed. It is more likely that the search stuck in his mind because he was aware of his less than careful handling of the children.

Conclusions

76. Before, during and after birth, there was nothing suggestive that these parents might represent a risk to the children. They were a settled couple, together for over four years. They both held responsible jobs, in M's case in a children's nursery. They had no particular money worries and they had secure accommodation, albeit they wanted to move house. There is no history of mental health problems, alcohol or drugs misuse, or domestic violence. They each come from stable families. They had a strong support network of friends and family. The evidence of friends and members of their families is that they were both loving, caring parents. The text messages refer to some strain in bringing up twins, but not, in my judgment, unexpectedly so; for anybody, to bring up twins in the early weeks would be challenging and it is not surprising that the parents on occasions expressed some frustration. Nothing untoward was observed by clinical staff at the hospital until 29 March 2024, or by midwife and health visitor services. There is no suggestion that the parents cut themselves off from professional support; on the contrary, they engaged normally with clinicians and support services. They were not obstructive before, during or after the awful events of 29 March 2024. These were, on the face of it, exemplary parents. There is nothing to suggest, outwardly at least, a propensity to anger or violence. I accept that on the face of it, and absent any contra-indicators, for either of the parents to have acted in the way alleged by the LA is improbable.
77. However, I regret to say that in my judgment the injuries to both children were perpetrated in non-accidental manner by F. M was not a perpetrator, nor was she aware of F's actions. In reaching these conclusions, I have had regard to all the evidence, non-medical and medical. I will set out first my approach to the non-medical evidence, and then to the medical evidence. The nature of a judgment is that it is necessarily linear in that it is sequential. But I emphasise that when I consider the different strands of evidence, I do so in the light of all the other evidence.
78. I am satisfied that A's left femoral fracture occurred on 29 March 2024 during a window of about 10 minutes when she was in F's sole care in the living room while M was in the kitchen. AM had been with M and the children for over an hour (and held the children in that time) and seen nothing unusual; the children were settled and happy. That was also the evidence of others who had been with them earlier in the day, and the health visitor was unconcerned the previous day. AM saw M hand A over to F at about, in my judgment, 17.20 and at that time all was well. There is no evidence that A was returned to M by F in the next few minutes; she remained with F while M was in the kitchen. The 999 call was at 17.32, by when A was screaming and in obvious pain. I am satisfied that the fracture occurred in those ten or so minutes, when A was in F's care.
79. I have set out above in some detail my conclusions on the parental accounts of what happened. I accept that M first knew that something was wrong when she heard A crying, F called her, and she saw the leg in an unnatural position. I have concluded that she gave me an honest account of what she saw and heard that day. Her minor inconsistencies given in the 999 call, to her mother and at hospital were the product of chaos and confusion, and in my judgment do not bear a suspicious characterisation.
80. By contrast, I found F's non-explanation of the "leaning over" events at best baffling and at worst highly suspicious; sadly, in my judgment, the latter applies. If the "leaning over" did happen as F said, it is almost incomprehensible that F would not explain it to those trying to establish the events so as to better care for A. I have considered (per the Lucas direction) whether there is an innocent explanation for his failure to recount the "leaning over" events sooner, and have concluded that there is not. Nor did F offer an explanation to me. The reality is that he caused an injury, and knew he had done so. Quite how he caused the injury I cannot say for sure. Either there was some sort of leaning over, but not carried out in the way he said (perhaps, for example, he gripped the knee and then leaned across), or something else took place. Either way, this was the perpetration of an abnormal twisting motion by F. Dr Cartlidge told me that the perpetrator would have sensed the fracture. F denied he had, but accepted that he knew at once that something was seriously wrong. I am confident that he so knew because of a combination of A crying, sensing the break, and the limp leg presentation.
81. Although the general tenor of the evidence was that both parents were, on the face of it, gentle in their handling of the children, it was clear that M was sufficiently concerned about the "dancing fruits" moment on 11 March 2024 to tell F to stop. I accept this was one incident, and the only one remarked upon by any witness, but although a small part of the whole picture, it is not inconsequential when seen in the light of the balance of the evidence. It is also, I think, indicative of M's protective attitude towards the children.
82. The internet searches by F about shaken babies/babies waving their arms and legs on 11 March 2024, at the time of the "dancing fruits" moment are also relevant when seen in the context of the other matters to which I refer in this judgment. It was a surprising search to do if he had no concerns about how he had handled the children. It is also surprising that if it was, as he says, casual curiosity, he was able to remember it so well over two months later when he told M it might appear on the phone search.
83. As I have indicated, I further take the view that his searches after 29 March 2024 are likely to have been made in the knowledge that he had caused the injury and with a view to finding explanations to deflect attention.
84. M's internet searches before 29 March 2024 (on 12, 24 and 25 March 2024), by contrast, were to my mind innocent, understandable and readily explicable. They related to the presentation of the children, including mottled skin, breathing and general pallor. For example, looking up "is it normal for babies to go pale after strong crying" on 25 March 2024 was a normal reaction to observing those symptoms, and led to the 111 call later that day.
85. M's searches at hospital on 29 March 2024 and subsequently were similarly, in my judgment, a normal reaction on being told of a displaced spiral fracture for which (from her perspective) there was no explanation, not least because F had not told her about the "leaning over" event.
86. Having concluded that F was responsible for the femoral fracture, that in itself is suggestive of propensity for the other fractures, although obviously of itself not conclusive. It would be surprising, albeit not impossible, if there were two abusive parents in the household. There is no evidence that B sustained injuries at the time of A's leg fracture. Although Dr Olsen told me that radiologically A's rib and metaphyseal fractures might have occurred at the same time as the femoral fracture, there is no evidence before me to justify a conclusion to that effect.
87. Having seen and heard the evidence, I am satisfied that F perpetrated the other injuries on, in A's case, at least one occasion and, in B's case, at least two occasions; thus, he caused the injuries (including the femoral fracture) on a total of at least four occasions in all. Some of A's and B's fractures may have been caused by F on about 24/25 March 2024 when they both (more so A) were seen to be pallid and experiencing laboured breathing, although I do not think I can make a specific finding to this effect.
88. I have borne in mind that F was infrequently alone with the children. However, (i) on the evidence, there were occasions when he had them in his sole care and (ii) the femoral fracture shows that he acted abusively at a time when M was in the kitchen, a matter of only a few yards away, which indicates that the other fractures were not necessarily caused when M was out of the house.
89. In coming to these conclusions, I have in mind not just the parental accounts, and the factual history, but the unanimous clinical and expert evidence (which I accept) that the fractures were not caused accidentally, and were perpetrated by the application of abnormal force. There are number of features which combine to generate a clear picture, from a medical standpoint, of the likely mechanisms and degree of force involved:

i) There were multiple fractures in both children, totalling twenty in all, across 6 weeks, occurring during a total of not less than four episodes. Some of the fractures are particular markers of abusive acts; the complete displacement of As' left femur, the siting of the rib fractures and the metaphyseal fractures.

ii) It is of note that since the children have been taken into the care of foster carers and then paternal grandparents, there have been no similar episodes. True, no X Rays have been done, but nor has there been anything to suggest an X Ray should be conducted. Importantly, in my judgment, the current carers have not witnessed a combination of laboured breathing and pallid colour which were observed while in the care of the parents, and which Dr Cartlidge said were likely to be associated with rib fractures. In other words, there is no evidence of either (i) fractures or (ii) presentation which might be associated with fractures after the children were removed from the parents' care, whereas while in their care, (i) fractures occurred on at least four separate occasions and (ii) on occasions they presented with pale colour and laboured breathing. Having heard the paternal grandmother, I did not detect that she has been handling the twins with greater than usual care.

iii) The medical evidence is that each episode required a substantial degree of force beyond normal handling, of which the femur probably required the greatest application of force.

iv) The parental explanations are not consistent with the fractures, unless carried out in a deliberately, or recklessly, abusive way with a degree of force significantly in excess of normal.

90. I have paid careful attention to the evidence about the possibility of an underlying condition which could have predisposed the children to fractures. I am alive to the submission that, even if such a condition cannot be identified, this may be one of those rare cases were the cause of the fractures is not known, but in my judgment that is not the case here.
91. The expert evidence which I have heard is that there is no evidence of any underlying, or organic, condition which would innocently explain the fractures. Multiple tests have been carried out, but none have provided an alternative medical explanation. Any such explanation cannot, as Professor Saggar said, be completely ruled out, but it was clear that none of the experts considered this to be a realistic possibility. I judge that it falls into the realm of speculation.
92. It was suggested by counsel that a number of features present in this case can be indicative of bone fragility: reduced foetal movement in utero, prescription of Gaviscon and Omeprazole, jaundice, NGT feeding, hypoglycaemia, and prematurity. However, the evidence of the experts was that none of these, singly or jointly, amount to a recognised condition or diagnosis indicating underlying fragility. Nor do they present as features which, albeit falling short of a formal diagnosis, are suggestive of bone fragility.
93. M has a very mild form of CTD, within normal limits of human variation. She has a history of cleft palate and clicky joints, but not joint laxity. Even if the CTD has been inherited by the children, it would not lead to increased susceptibility to fracture in normal handling. The ADAMTSL2 mutation may be an explanation for the mild dysmorphic features in B but it is highly unlikely to cause any significant susceptibility to fracture. Professor Saggar cannot exclude the possibility that the mutation may cause some very mild features of dEDS. However, the degree of it is highly unlikely to result in any clinically significant susceptibility to fracture. The children did not have an obvious diagnosis of dEDS, no significant joint laxity (they are zero on the Beighton scale) and no family history of EDS. It is much more probable that both M and the children are carriers of a recessive geleophysic dysplasia. Thus, the mutation in any event would not explain fracture susceptibility in normal handling.
94. For this number of fractures, and in particular the completely displaced femoral fracture, there would need to be a significantly high level of underlying propensity to bone fragility to explain the fractures by reference to normal handling. On the evidence I have heard, at its highest there is at most a possible mild form of (albeit undiagnosed) dEDS, and no features of significant CTD. Given that there are no other markers of bone fragility, and no medical explanation for the fractures, it is, in my judgment, highly improbable that these injuries were the result of an underlying, organic cause.
95. Moreover, the medical evidence cannot be viewed in isolation, just as the factual evidence cannot be viewed in isolation. All the evidence interlocks to create an overall picture. Each component of evidence bears on the other components. Thus, the very remote possibility of an organic, innocent explanation must be seen against the background of the parental accounts, and in particular F's evasive and unsatisfactory evidence.
96. Looking at the evidence in the round I have come to the clear conclusion, on the balance of probabilities, that the children sustained all the fractures in a non-accidental way, and that F was the perpetrator during at least four episodes of application of excessive force. The various injuries were caused by mechanisms described by the experts (twisting, yanking, pulling, compression); I am confident that shaking was not the cause of any of the injuries, not least because of the absence of head injury.
97. I am satisfied that M did not perpetrate any of the injuries, either by herself or jointly with F. As I have articulated above, she has demonstrated herself to be an exemplary parent. I accepted her evidence. There is no material evidence on which to base a finding that she participated in causing any injury, and I am confident that she did not.
98. On balance, I have come to the conclusion that the perpetration of excessive force was probably reckless rather than deliberate. I doubt that F set out to cause fractures, or serious injury, but in my judgment, he took actions which he must have known represented a grave risk to the children, were highly irresponsible and were taken without regard to the potential negative consequences. It is probable (as Dr Cartlidge said) that he knew he had caused pain to the children during the episodes, even if he was unaware at the time that his actions had caused occult rib and metaphyseal fractures. I think it likely that the outward manifestations of pain dissipated, as Dr Cartlidge told me, after about ten minutes, although they might have been exacerbated by subsequent crying or deep breathing, and F may have assumed the episode inflicted by him had passed. In respect of the femoral fracture, he knew instantly that the leg injury was obviously serious, not least, I suspect, because it was visible with A's leg hanging limply.
99. I cannot say why F acted in the way he did. His outward presentation to professionals, family and friends was uniformly positive. The stresses on him (finances, damp house, sleep deprivation) were not particularly unusual, but they were there. He may have been frustrated at children who (as M told me) cried a lot. He may have been, when alone and not under scrutiny, blithely careless of his actions and the consequences. I cannot say precisely what led him to act the way he did. However, he caused significant harm to both children.
100. I have already expressed myself satisfied that M did not cause any injuries herself. I am also satisfied that she was not aware that F had caused injuries. I find she was not present during any of the episodes of application of force to the children by F, and in my judgment (as Dr Cartlidge told me) there was no reason for a non-witness to think that an abusive episode had taken place because babies cry for multiple reasons, their presentation would have been normal after about ten minutes, and moreover there was no clinical or other reason to suspect non accidental injury until the terrible events of 29 March 2024. Further, M acted promptly when seeing the limp leg, and on earlier occasions telephoned 111 when concerned about the pallid colour and laboured breathing of the children, and she gave clear and accurate medical histories to professionals. I conclude that the episodes took place with M not present, and she was not aware of the actions of F. I acquit her of any failure to protect the children.
101. Finally, I am satisfied that there was no conspiracy between F and M. There is no evidence to support such a finding. M was unaware of F's actions. She did not witness the perpetration of injuries. There is nothing to suggest that F told her what he had done, and that she covered up in order to protect him. In the thousands of pages of phone records, there is nothing to point to that conclusion and I am confident, having heard both parents, that there was no such complicity between them.
102. The threshold is met. My findings are as set out above. I invite the parties to consider the way forward and send in a draft order which (i) reflects the findings and (ii) timetables welfare directions.