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You are here: BAILII >> Databases >> England and Wales Family Court Decisions (other Judges) >> North Lincolnshire Council v M & Ors [2025] EWFC 60 (B) (12 March 2025) URL: http://www.bailii.org/ew/cases/EWFC/OJ/2025/60.html Cite as: [2025] EWFC 60 (B)

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IN THE FAMILY COURT AT Great Grimsby

		Grimsby Combined Court Centre
		12 March 2025

This judgment was handed down remotely at 2 pm on 12 March 2025 by circulation to the parties or their representatives by e-mail and by release to the National Archives
HHJ Brown

Parties

1. This case is about C a girl who was born on the 15 December 2023 and is therefore now aged 15 months.
2. C's interests are represented in these public law proceedings by her guardian, Korina Bulman who instructs Mark Watterson.
3. C's mother is M, represented by Liz Shaw. M is a young, first-time mother. When she was a child, she was removed from her own mother's care and placed in foster care due to neglect and other issues. It is clear to me both from her background and her presentation in court that she is vulnerable. In the parenting assessment she described herself as being 'full of sadness to her neck and then fear at the top' and at times that is how she came across to me.
4. C's father is F, represented by Justine Cole. He too is young and a first-time parent. He has a diagnosis of ADHD and is suspected to have ASD. It is clear from the evidence that he has difficulties both with expressing himself and with emotional regulation. In his evidence he compared himself to the Anger character from the film 'Inside Out' and there are clearly large parts of his persona that would match that description.
5. The local authority which brings these proceedings is North Lincolnshire Council represented by Joanna Hawkett. The allocated social worker is Alexandra Thorpe. Unfortunately, shortly before this final hearing she became unwell. The local authority therefore made an urgent application to restore the matter before me. At a hearing on the 26 February 2025 all parties agreed that delaying these proceedings was not in C's interests and that I should hear from Ms Thorpe's practice supervisor, Amy Macdonald, with respect to welfare matters and that insofar as Ms Thorpe was a witness to any contested factual matters, her non-availability would affect the weight that I could give to her evidence. As it has turned out, I have not had to rely on any factual evidence from Ms Thorpe to reach the findings that I make in this Judgment.
6. This Judgment is being delivered on the 12 March 2025, following a final hearing which has taken place at the Great Grimsby combined court centre between the 3 and 12 March 2025. I heard evidence between the 3 and 7 March, received written bullet point submissions from the advocates on the morning of the 10 March, to which they spoke that afternoon. I took the 11 March for Judgment writing.

Background

7. The parents met at University in late 2022. The mother became pregnant and C was born on 15.12.2023. From the latter stages of the pregnancy and up until the end of January 2024, when C was around 7 weeks old, the parents lived with the paternal grandmother and step-grandfather. At the end of January 2024 they moved into their own flat.
8. On 6 February 2024 C was seen by a Health Visitor for her 6-8 week check. C's physical examination was unremarkable. Her head circumference was noted as being on the 50^th centile, which was in keeping with the trajectory noted at birth.
9. C was not seen again by a Health Visitor until 10 April 2024, owing to a change in doctor's surgeries following the parents' move of address. On that date a different Health Visitor examined C as part of her routine 16-week check and noted that the circumference of C's head had increased to above the 99.8^th centile. A referral was made to the GP due to the increase crossing two centiles. On 8 May 2024 C's head circumference continued to be above the 99.8^th centile.
10. On 25 May 2024, at 6.10 pm, M along with the paternal grandmother presented C at the Diana Princess of Wales Hospital, Grimsby, with a reported head injury. The account given by M to the advanced clinical practitioner to whom she first spoke, was that C had been seated in her bouncer chair on a kitchen work top and had fallen, hurting her head. She was seen to have a haematoma to the parieto-occipital region of her head. A CT scan revealed a left parietal skull fracture but also bilateral subdural haemorrhages of different ages which could not be explained by the reported fall from the work top.
11. C was transferred to Sheffield Children's hospital later that evening. Over the following hours and days she was subject to various tests which revealed a series of injuries summarised below. It is not necessary to list the various tests for the purposes of this Judgment because the conclusions are accepted by all parties and are not controversial. C was found to have:

a. An acute left parietal skull fracture underlying a scalp haematoma;

b. Large bilateral subdural haemorrhages of different ages;

c. Spinal subdural collection;

d. Laceration on inside of right cheek, measuring between 1.5 and 2.5 cm;

e. An acute fracture of left clavicle or collar bone.

12. Medical opinion at the time was (and remains) that whilst the reported fall from the kitchen counter might explain the skull fracture and associated haematoma, as well as the fractured clavicle, it could not explain the older bleeds or the laceration to C's mouth. For ease of reference, within this Judgment, I will refer to the reported fall from the kitchen counter as 'the bouncer incident'.
13. As a result of C's injuries, some of which were unexplained, the local authority issued proceedings on the 6 June 2024 and they are therefore in week 40.
14. Within proceedings C's paternal grandfather has been positively assessed as a carer for her. To their very great credit, and notwithstanding their aspiration – at least throughout proceedings – to have C returned, the parents did not oppose a plan that C transition to the paternal grandfather's care. The transition took longer than envisioned because C had formed strong attachments to her foster carers and the move had to be progressed at a pace sensitive to her needs. Pleasingly, the foster carers and the paternal grandfather worked well alongside each other and in conjunction with the local authority: the transition has now been successfully effected. It is still in its early days but C is said to be doing well and is now seeking out her grandfather for reassurance and comfort, when visited by professionals, as she was in the week before this final hearing.

The issues

15. At this final hearing the local authority invites me to make findings with respect to C's injuries and approve a plan that she remains in the care of her grandfather. Given the recent nature of the transition the local authority invites me to make a care order on the understanding that the local authority will, in due course, support him to apply for a Special Guardianship Order.
16. At the outset of proceedings, the local authority's case on threshold was that all of the injuries set out above were non-accidental and were caused either by the father or mother or both. That is, they sought what is commonly referred to as a pool finding. In addition, the local authority sought findings that any non-perpetrating parent had failed to protect C; that the parents had failed to work openly and honestly with professionals; and findings with respect to both home conditions and C's reportedly unclean presentation at hospital on the 25 May 2024.
17. At the conclusion of the evidence the local authority amended its findings, seeking findings that F had caused all of the injuries to C and that M had failed to protect her from them. They sought to withdraw findings relating to home conditions and C's cleanliness. Having heard the totality of the evidence and read all the relevant written evidence I am satisfied that the application to withdraw the findings about home conditions and C's cleanliness was well founded and, accordingly, I say no more about those issues.
18. With respect to the injuries, the parents' case remains that the injuries they originally attributed to the bouncer incident, are so explained. That incident was, they say, an accident. However, they accept that the rest of the injuries are non-accidental. Unusually in my experience both parents positively invite me to make a pool finding with respect to those other injuries and to find that the pool of perpetrators is limited to the two of them. They invite me to do this notwithstanding each parent's flat denial that she or he caused the injuries or knows anything about them. This is unusual, particularly with respect to M, because even though she accepts that the injuries to her daughter could only have been caused by her or the father, and even though she absolutely denies causing them or knowing anything about them, and even though the local authority now says there is enough evidence for them to point the finger at the father, she prefers me to find that I cannot say who the perpetrator was and that there is a real possibility that it was her.
19. Both parents deny any failure to protect, and both deny that they have failed to work openly and honestly with professionals.
20. The guardian agrees with the local authority that all of the injuries, including those that the parents say were caused in the bouncer incident, were non-accidental. However, the guardian does not agree that the evidence points with sufficient clarity to F. The guardian supports a pool finding with respect to all of the injuries.
21. The parents accept that if I find that they are both in the pool of perpetrators for injuries which they accept are non-accidental (i.e. the subdural bleeds and the mouth laceration) I am not going to conclude that it is safe for C to be placed in their care either together or separately. The height of their case appears to be that if – contrary to their own position on threshold – I was to exonerate M from having caused their daughter any harm, they would separate so that she could care for her as a single parent. It is notable, in this regard, that the parents have remained together throughout proceedings notwithstanding the fact that each, by process of elimination if not directly, says that the other must have caused serious injuries to their daughter.

The law

(i) Fact-finding

22. Ms Hawkett has helpfully prepared a document entitled 'Agreed summary of the law' which, as the title indicates, is agreed by all parties. It sets out the legal framework with respect to the fact-finding exercise and the welfare decisions I have to make. I have read it and endorse it. However, in Re A (Children) (Pool of perpetrators) [2022] EWCA Civ 1348, the CoA cautioned against judges cutting and pasting agreed legal documents into Judgments. Therefore, for the sake of clarity, I will set out the key legal principles that I have applied. The following legal principles – which are well known and uncontroversial – are drawn from paragraphs 46-53 in the case of Re L and M (children) [2013] EWHC 1569 (Fam), a decision of Baker J as he then was:

a. First, the burden of proof lies at all times with the local authority.

b. Secondly, the standard of proof is the balance of probabilities.

c. Third, findings of fact in these cases must be based on evidence, including inferences that can properly be drawn from the evidence and not on suspicion or speculation.

d. Fourthly, when considering cases of suspected child abuse the court must take into account all the evidence and furthermore consider each piece of evidence in the context of all the other evidence. The court invariably surveys a wide canvas. 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.

e. Fifthly … [w]hilst appropriate attention must be paid to the opinion of medical experts, those opinions need to be considered in the context of all the other evidence. It is important to remember that the roles of the court and the expert are distinct and it is the court that is in the position to weigh up the expert evidence against its findings on the other evidence. It is the judge who makes the final decision.

f. Sixth, cases involving an allegation of non-accidental injury often involve a multidisciplinary analysis of the medical information conducted by a group of specialists, each bringing their own expertise to bear on the problem. The court must be careful to ensure that each expert keeps within the bounds of their own expertise and defers, where appropriate, to the expertise of others.

g. Seventh, the evidence of the parents and any other carers is of the utmost importance. It is essential that the court forms a clear assessment of their credibility and reliability.

h. Eighth, it is common for witnesses in these cases to tell lies in the course of the investigation and the hearing. The court must be careful to bear in mind that a witness may lie for many reasons, such as shame, misplaced loyalty, panic, fear and distress, and the fact that a witness has lied about some matters does not mean that he or she has lied about everything (see R v Lucas [1981] QB 720).

i. Ninth, as observed by Dame Elizabeth Butler-Sloss in an earlier case '[t]he judge in care proceedings must never forget that today's medical certainty may be discarded by the next generation of experts or that scientific research would throw a light into corners that are at present dark'.

23. With respect to the fifth, sixth and ninth of those principles, whilst I have set them out for the sake of completeness, in this case the medical evidence is not challenged. That said, the medical evidence is but one part of the wider canvas that I must consider.
24. I remind myself that precisely because the local authority bears the burden of proof, the parents do not have to prove any alternative explanation for C's injuries. As HHJ Clifford Bellamy said in Re FM (A Child: fractures: bone density) [2015] EWFC B26, at paragraph 122:

It is the local authority that seeks a finding that FM's injuries are non-accidental. It is for the local authority to prove its case. It is not for the mother to disprove it. In particular it is not for the mother to disprove it by proving how the injuries were in fact sustained. Neither is it for the court to determine how the injuries were sustained. The court's task is to determine whether the local authority has proved its case on the balance of probability.

25. I have firmly in mind the decision of the Court of Appeal in Re A (Children) (Pool of Perpetrators) [2022] EWCA Civ 1348, where at paragraphs 17-34 King LJ considered previous caselaw guidance that trial judges should not 'strain' to identify a perpetrator in a pool of perpetrators case. Having reviewed the history of this guidance she concluded at paragraph 34:

[I]n 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.

26. In keeping with the above, if I fail to identify a perpetrator, the test is not whether a named individual should be removed from the 'list' or 'pool'; it is whether an individual should be included on the final list or in the pool, on the basis that the local authority has established that there is a 'real possibility' that they inflicted the injuries.
27. If I find that one parent has caused C's injuries it does not follow, automatically, that the other failed to protect her:

Any Court conducting a Finding of Fact Hearing should be alert to the danger of such a serious finding becoming 'a bolt on' to the central issue of perpetration or of falling into the trap of assuming too easily that, if a person was living in the same household as the perpetrator, such a finding is almost inevitable; per King LJ in L-W Children [2019] EWCA Civ 159.

28. I have borne in mind that due to the delay in reaching this fact-finding hearing I was hearing from witnesses, and in particular the parents, nearly a year after key events happened. I have therefore taken into account that their memories will have faded or, in line with the process described by Legatt J, as he then was, altered with the passage of time: Gestmin SGPS SA v Credit Suisse (UK) Ltd and Another [2013] EWHC 3560 (Comm).

(ii) Welfare

29. I can only make a Care Order for C if I am satisfied that threshold is crossed as per s31(2) of the Children Act 1989. Threshold is not in issue in this case in the sense that even on their own cases, the parents concede that it is crossed. If I am satisfied that threshold is crossed then I can go onto consider what order, if any, I make. At this stage C's welfare is my paramount consideration; the welfare checklist in s1(3) of the Children Act 1989 applies, and in line with s1(5) of that Act, I must only make any order if I consider that doing so is better for C than making no order at all.

The evidence and my analysis of it

30. There is a PDF bundle running to over 1600 pages which includes a wealth of medical, police and telephone evidence. Ultimately, as issues have narrowed in this case it has not been necessary for the parties to refer to some parts of that evidence and for that reason, some of it does not form part of this Judgment. Indeed, much of the evidence is agreed and for that reason is dealt with briefly, as and where required. In addition to the written evidence, over the course of 3 to 7 March I heard from the following witnesses:

a. Amy Macdonald, the practice supervisor who gave evidence in Ms Thorpe's stead, for reasons already set out.

b. Chloe Carr, who conducted a PAMS assessment of the father, as recommended by Dr Ian Brown in a cognitive assessment prepared early in these proceedings.

c. CS, a staff nurse at Sheffield Children's Hospital who gave brief evidence via the CVP relevant to the father's presentation at hospital.

d. Zoe Hare, a Family Intervention Worker who was allocated to the family to do parenting work with them.

e. Police Constable DT a police officer who transported the parents from Grimsby to Sheffield on the 25.5.2024 and heard accounts of the injuries from them.

f. Police Sergeant RM, a police officer who was also involved on the 25 and 26 May and conducted a visit to the family home where she observed the kitchen in which the accident was said to have occurred.

g. I heard from F. He gave evidence before the mother as she was unwell with tonsilitis during the early part of the first week, and it was agreed by all parties that taking the parents out of order would give her an extra day to recover.

h. I heard from M.

i. I heard lastly, in terms of live witnesses, from the guardian, Korina Bulman.

31. With respect to the parents, the court took regular breaks during their evidence in particular when the mother became emotional, or it was clear that either of them was losing concentration.
32. It is not necessary for me to set out the totality of the evidence that I have read and heard. Instead, I focus on those aspects of the evidence that have helped me in making findings and welfare decisions.

(i) Evidence with respect to parenting

33. The evidence from Ms Macdonald, Ms Carr and Ms Hare largely related to the basic parenting abilities of M and F and the extent to which they had been given and/or could be given training and support to make up for any perceived deficits. For my part, I do not find it necessary to set that evidence out in this Judgment. My view is that if this case was simply about basic parenting, then insofar as there are any deficits, they could be addressed in relatively short order. However, the case is not about basic parenting. It is about very serous injuries that C suffered whilst in the care of her parents and some of which, on their own cases, both parents invite me to find they are in the pool of perpetrators for.

(ii) The undisputed medical evidence

34. Within proceedings the court permitted the instruction of 4 independent medical experts:

a. Dr Fionnan Williams is a paediatric neuroradiologist who has prepared a report dated 30.7.2024 and addenda dated 1.10.2024 and 23.1.2025.

b. Dr Benedetta Pettorini is a paediatric neurosurgeon who has prepared a report dated 7.8.2024 and addenda dated 3.10.2024 and 21.1.2025.

c. Dr Oystein Olsen is a paediatric radiologist who has prepared a report dated 27.8.2024 and addenda dated 23.9.2024 and 12.11.2024.

d. Dr Kavita Chawla is a consultant paediatrician who has prepared a report dated 8.9.2024 and an addendum dated 23.10.2024.

35. None of the court appointed experts was required to attend court for challenge. Their evidence is accepted by the parents. In those circumstances it is not necessary for me to set it out at any length, but I can confirm that I have read all the reports and accept the findings therein. Of relevance to the local authority's case on threshold the following findings are accepted by the parents and by me:

Finding 1

On 25 May 2024 C was presented to hospital and was identified to have the following injuries:

a. A linear left sided posterior skull vault fracture of the parietal bone;

b. Acute scalp haematoma over the left posterior parietal region;

c. A fracture of the left collar bone;

d. Widespread multi-focal and complex subdural haemorrhages of different ages;

e. Intraspinal subdural haemorrhage;

f. A 1.5cm-2.5cm laceration to the inside of her right cheek with surrounding petechiae.

36. I have found the following further aspects of the expert evidence helpful:

a. Dr Williams, to whom Dr Chawla deferred, opined that the skull fracture and associated haematoma occurred within 7-10 days of C's presentation at hospital. Accordingly, the bouncer incident is within the relevant time frame.

b. Dr Williams' view was that the bouncer incident could have caused the skull fracture. However, he went on to say '[The fracture] is located very posteriorly on the left. This would imply the point of impact was to the posterior left parietal and/or occipital region i.e. right at the back of the head. This would be viewed as a somewhat unusual impact location'.

c. Dr Pettorini was of the view that 'the fall from the kitchen top is compatible with causing the skull fracture and the time frame is also compatible with it'.

d. Dr Williams' opinion is that the intracranial findings are likely to reflect multiple episodes of trauma and not one occurring on 25^th May. He says, 'the appearances can be explained on the basis of either one episode of shaking following which there was rebleeding into the resultant collections or multiple episodes of shaking. I would favour the latter as this would explain the volume of collections and varying appearances including the recent spinal bleedings'.

e. Dr Williams said that with respect to at least some of the subdural collections that they 'are large and complex … they contain multiple membranes. It is accepted [that] membranes take 2-4 weeks to form in subdural collections. This means the supratentorial collections are likely to have been present for at least 2 weeks and probably more'.

f. Dr Pettorini's view is that 'the mixed appearances of the subdural collections are compatible with a shaken mechanism of injury. The time frame is up to 4 weeks for the subdural collections as there is presence of membranes … The acute blood in the posterior fossa over the tentorium and in the spine is compatible with a more recent event, with a mechanism of acceleration/deceleration and not related to the fall'. She goes on to say that 'the presence of different ages [of] blood is indicative of multiple injuries which have not occurred at the same time … [T]he presence of acute blood is indicative of another acceleration/deceleration injury which happened within up to 10 days from presentation. There is the possibility that the acute blood in the convexity is related to the fall however the acute blood within the posterior fossa and the spinal canal is not compatible with it'.

g. Dr Pettorini also says, 'in my opinion the most likely reason for the increase in head circumference before the 16 week measurement is [that it is] compatible with the development with the subdural collections at that time which were caused by an acceleration/deceleration injury'.

h. Dr Olsen's opinion with respect to the fractures to the skull and collar bone is that both fractures were recent and may have occurred on the same date and that if the court accepts the parents' account of the bouncer incident 'there is a real possibility that both fractures are explained by that event'.

i. Dr Chawla's opinion is that the laceration to the cheek is 'very likely to have occurred at a time separate from the event causing the acute skull and clavicle fracture'.

j. Dr Chawla said 'a fall from height, if accepted to have occurred, can … explain the fractures seen on balance of probabilities.'

(iii) The evidence of the parents

37. I heard first from F. His evidence was a combination of occasionally frank, with respect to his own anger, and frankly alarming, with respect to never-before related episodes that occurred whilst he was caring for C, including one in which he said she lost consciousness. He had a tendency to minimise his own responsibility for his behaviour, for example describing a video in which he had clearly lost control and repeatedly hit their pet puppy in the head, as 'smacking'. Overall, I did not conclude that he was telling me the full truth about what has happened to C. I do not accept Ms Cole's submission – which was perhaps the best that could be said in the circumstances – that his account, given for the first time under cross-examination, of the occasion when he says C stopped breathing, lost consciousness and turned purple/blue was simply an extension of accounts previously given, including to the police and the parenting assessor. Assuming his account to have been true, I don't accept that the first time it occurred to F that there was any significance to the facts that his daughter stopped breathing and lost consciousness, in the context of an enquiry into unexplained brain bleeds, was in the witness box. I reject his explanation, given more than once, that the reason he didn't previously disclose potentially relevant information to health professionals was that he had lot going on, including with University deadlines.
38. I heard next from M. She had been described by other witnesses as being the more talkative of the parents. That much was certainly true. However, I did not find her to be unnecessarily verbose nor did I find that, as described by some witnesses, she went off at a tangent in her answers. My overall impression of her is that she has an unwavering loyalty to F and that sadly she would sacrifice C's interests to this. Even though her case, throughout, has been to accept that C's injuries happened whilst in their joint care and even having heard F give the previously undisclosed account of C having lost consciousness, she refused to advance any case against him, saying that she couldn't have it on her conscience to do so. My overall impression of her as a witness is that she knows significantly more than she has been prepared to tell the court. That is consistent with some of her dealings with professionals. For example, after the laceration to C's mouth had been identified, when a treating medic asked her at the Sheffield Children's Hospital if she had noticed any bleeding, she reported a 'tiny bit of gum bleeding – once – 2 weeks ago' (as per that medic's handwritten note). Her oral evidence was that she had in fact seen blood – albeit a little speck – come from C's mouth and onto the father's cheek, on the 24^th May, the day before C's presentation at hospital. She told me that 'it wasn't obvious to mention it [to the Doctor], it probably slipped my mind'. I don't accept that in the context of a cut having been identified to C's mouth M would mention gum bleeding from 2 weeks previously, which she had apparently attributed to teething, but not an occasion within the previous 36 hours when she had seen blood coming out of C's mouth and onto the father's cheek. My impression that M is unwaveringly loyal to F and is not telling the court everything she knows is also consistent with her invitation, in the face of the local authority now seeking a finding that F caused all of the injuries, to put herself in the pool of potential perpetrators for her daughter's shaking injuries and mouth laceration.

(iv) The unexplained subdural bleeds and the laceration to the mouth

39. F has previously suggested a range of possible explanations for injuries to C's head. The medics, in particular Drs Williams and Pettorini, have discounted these and in fairness to F he no longer suggests that any of the proffered mechanisms could have caused the unexplained subdural bleeds. For the avoidance of doubt, I have discounted as plausible mechanisms for any of C's injuries, the following:

a. An occasion in January 2024 when F says he was changing C on a work top and bumped her head on a spice rack accidentally. His account is that she 'did not hit her head with any force and she did not cry'.

b. An occasion in February 2024 when F says he was laid on his bed watching TikTok videos on his mobile telephone; he says that C was laid on his chest and he dropped the telephone which hit her on the head. He says, 'she cried very briefly but settled and my 'phone did not fall very far'.

c. An occasion in March 2024 when C was sat in her baby-swing and pushed back: 'her head hit the back of the baby swing, but it did not cause her any distress'.

d. A separate occasion on which he is said to have accidentally dropped his X Box controller on C's head whilst celebrating victory in a game.

40. The unchallenged medical evidence is that the subdural bleeds were caused by shaking or acceleration/deceleration.
41. The parents have not sought to intervene any third parties as potential perpetrators of C's injuries. This was confirmed at the IRH when the parents accepted that the list of potential perpetrators was limited to just them. F had previously said in his written response to threshold that the maternal grandfather and his partner who the parents say cared for C between 1 and 3 of February 2024 had an opportunity to cause the injuries. Even then he said, 'I have no reason to believe that they would have harmed C'. He did, in his oral evidence, seek to resurrect the possibility that they could have caused at least some of C's injuries. For my part I am satisfied that there is no real possibility that the maternal grandfather or his partner injured C; they cared for her around 4 months prior to her presentation at hospital. Shortly after they cared for her, on 6 February 2024, C's head circumference was measured at the 50^th centile; it was then a further 2 months later that her head circumference was noted to have risen to the 99.8^th centile. Dr Pettorini's evidence is that some of the subdural bleeding was fresh and had occurred within the 10 days prior to presentation; even if the maternal grandfather and partner had opportunity to cause some of the injuries, they did not have opportunity to cause those later injuries and I discount as inherently improbable any suggestion that C had 2 separate groups of relatives who were causing her shaking injuries. Finally, and in any event, in closing submissions both parents accepted that the pool of potential perpetrators for the unexplained injuries was limited to the 2 of them.
42. The local authority point to a number of factors that, they say, allow me to identify F as the perpetrator of all of C's injuries (including the injuries attributed to the 'bouncer incident', which are considered separately below). The factors that they say point towards the father being the perpetrator are as follows:

a. The family routine. The parents both say, and no one challenges this, that they effectively worked a shift pattern in caring for C, with the mother doing the night-time routine (after C was in bed) and the father doing the early morning routine until lunchtime/early afternoon whilst the mother remained in bed. However, they also both agree that C generally slept well at night, which meant that in practice the father was doing the significant majority of the practical care. The local authority say that the father had far greater waking opportunity to cause injuries and also, in combination with his propensity to emotional dysregulation, more occasions on which he was likely to have become impatient with C and caused her injuries whilst the mother slept.

b. The father accepts a number of incidents of poor/careless handling including bumps to C's head. This is correct. However, the medical experts have discounted these as mechanisms for C's injuries, as have I. In that context, in my judgment they don't assist me in deciding whether F has caused subdural bleeds by shaking C which would go significantly beyond poor or careless handling. Even the mouth laceration, which could be caused by poor or careless handling, is different in character to the incidents that the father has accepted. Moreover, neither parent reports any accident or example of careless handling which could explain that injury.

c. The father has a clear and accepted propensity towards anger and emotional dysregulation. The father's propensity towards angry outbursts is well documented and was accepted by him in oral evidence. He told Dr Brown, 'I never show emotions, unless they've built up too much and then I lash out'. He said during the parenting assessment that 'my anger takes over and I could have caused it [the injuries] and not realised'. He accepts a number of incidents of lashing out including the one where he repeatedly hit the family dog. In his oral evidence he accepted that when he becomes really angry, he 'almost loses consciousness'.

43. In addition to the above, there is the occasion already summarised in this Judgment but never disclosed prior to the father's oral evidence, when he now says C lost consciousness and stopped breathing. The father was clear that he told the mother about this occasion, in summarised form, after she had woken up. The mother was clear that she had not been informed about it. In my Judgment, it is highly relevant, when I consider the wider canvas, that even where the mother claims to have learnt about a previously undisclosed serious incident for the first time in the witness box, she continues to invite me to find that she is in the pool of perpetrators for the unexplained injuries. I have considered whether that is explicable solely by her loyalty to her partner. Having set that against her undoubted love for C I have concluded that it is not. Rather, the conclusion I have drawn is that the mother's insistence that she remains in the pool of perpetrators is explicable only by the fact that the parents truly are 'in this together'; that is, they both know what has happened to C and/or are both involved in what has happened. As Mr Watterson put it in his closing submissions on behalf the guardian, the parents are 'co-dependent [and] protective of each other'. In my judgment they have deliberately withheld the truth about their daughter's experiences in an effort to protect themselves; this has meant that notwithstanding the local authority's carefully crafted submissions, I have been unable to conclude that the most likely explanation for C's unexplained subdural bleeds is that F caused them all.
44. Considering the evidence of Dr Williams and Dr Pettorini, in particular the evidence with respect to the formation of membranes, which take at least 2 weeks, and Dr Pettorini's evidence with respect to acute blood within the posterior fossa and the spinal canal which would have between within 10 days of presentation, I have come to the clear conclusion that C has suffered at least 2 separate shaking or acceleration/deceleration injuries as well as a separate, inflicted injury to her mouth. I am unable to say whether those shaking injuries were caused by one parent or both. I am however satisfied that the local authority has proved (which the parents in any event accept) that there is a real possibility that F and/or M caused these injuries. They are both on the 'list' and that list is limited to them.

(v) The bouncer incident

45. The parents written responses to threshold accepted that all of C's injuries were non-accidental. When I raised this with the parent's advocates during closing submissions, they conceded that it was on oversight on each of their parts and that the parents had never intended to make any admission with respect to injuries that they have always attributed to the bouncer incident. In truth, I too had overlooked this aspect of the way that the parents' responses to threshold were pleaded and did not raise it prior to the point of submissions. For the avoidance of doubt, I have treated the parents' evidence as being that the skull fracture, associated haematoma and collar bone fracture were caused by the bouncer incident and have not placed any weight on the apparent concessions in their formal threshold responses. I set this out in in case anyone subsequently reading the papers should query this aspect of the written documentation.
46. The parents have consistently claimed that the injuries that led to C being presented at hospital on the 25 May 2024 were caused by a fall from the kitchen worktop that afternoon/early evening. They both say that the mother was preparing spaghetti Bolognese and that to avoid their newly acquired pet dog licking C she had been placed in her bouncer on a kitchen work surface. They both say that the mother was concerned that the freezer felt warm and had asked the father to look at this. Whilst he was doing so, and with the freezer being at the opposite end of the kitchen from C, she fell from the work surface and hit her head on the kitchen floor.
47. Whilst their accounts have generally been consistent both internally and with each other, the local authority and guardian point to a number of inconsistencies and other potential evidential issues with their account.

a. It was the opinion evidence of Sergeant RM that the bouncer would not have fit on the section of work surface reported by the parents. There is a photograph, taken by the police, of that work surface and it is small. In the face of that opinion evidence, I permitted the mother to adduce a manufacturer's diagrammatic of the bouncer as well as photographs of the work surface with a tape measure for reference. The footprint of the bouncer, according to the manufacturer, is 58 cm (front to back) by 66 cm (side to side). The photographs of the work surface indicate a depth of exactly 58 cm albeit with the end of the tape measure seemingly pushed into the silicon sealant. The width of that same work surface is between 56 and 57 cm. The photographs taken by the police show that there was additional work surface area available 'width-wise' in front of the microwave oven. The parents' case is that the bouncer was placed with the head end against the window-sill/wall and with C facing out into the kitchen (photograph H169 for reference). The father's evidence was that it fit securely and that he checked all of the rubberised feet were securely on the surface. In my judgment, it would, at best, have been a precarious fit. However, one of the following propositions must be true:

i. Either the bouncer fit securely, as per the parents' case, in which case it would have needed some application of force in order to cause it to fall off;

ii. Or the bouncer did not fit securely, as per Sergeant RM's opinion, in which case there would be no obvious reason for the father to leave it insecure (and in which case the father has also lied to me about at least that aspect of his evidence).

b. In the mother's final statement to the court she claims that they had never placed the bouncer on a work surface previously. In oral evidence both parents said this. The mother says that she had put C onto the work surface in a 'sit me up' cushion previously, but never in her bouncer. This is inconsistent with what she told Sergeant RM at Grimsby Hospital on the evening of 25 May 2024 when she said that the bouncer fit exactly on the worktop and 'we've never had any problem'. It is also inconsistent with what she told the police in her interview under caution the following day, when she said 'obviously got her bouncer and put it on the kitchen side … we've never had a problem with it before' with the officer asking by way of confirmation 'Okay, so previously you've sat her in the bouncer on that side' and the mother replying 'Yeah'.

c. M has repeated to a number of professionals on a number of occasions that she saw C trying to sit up and that this is what caused the bouncer to fall. She said this to Dr A at Grimsby Hospital, to Sergeant RM, to nurse AB and Dr Cat Sheffield children's hospital. To both Dr P at Sheffield children's hospital and in her police interview she specified that this was the first time that C had sat up. In her police interview she said that C sat up 'fully'. In her oral evidence, and for the first time, M said that in fact she had not seen C sit up. Rather, she told me, when she turned round C was already falling through the air, which made her look like she was in a seated position. She told me, contrary to previous accounts, that she had 'guessed' that C sat up as this would explain how the bouncer came to dislodge itself from the work surface. In my judgment that is a significant change of account given the frequency with which M has previously described seeing her daughter sit up. M's other evidence was that C was not yet developmentally at the point of being able to sit independently; she said that if C was in a seated position already (for example on her lap and leant against her chest) she could lean forward a few inches and support herself momentarily before falling back. This is different, in my view, from having the core strength to sit upright from a reclining bouncer chair to the point that it falls from a work surface.

d. Dr Williams' unchallenged opinion is that the fracture being right at the back of C's head, is a 'somewhat unusual impact location'.

e. In the above regard, M told the police that when C fell, she hit the right side of her head. In oral evidence she told me that she was not very good with left and right and that C had been facing the radiator (which would make it the left side of her head). Whilst it is possible that M confused left and right, what is harder to envisage, in my judgment, is how a child falling face forwards (which is both parents' account) even turning their head to the side comes to fracture the back left part of their skull, which is the point made by Dr Williams.

48. The local authority also identify other apparent inconsistencies in the parents' accounts for example with respect to the time that C woke up on the morning of the 25 May and which parent then gave her the morning bottle. I am not assisted one way or the other by those inconsistencies because it seems to me, they are at least as likely to be explained by the passage of time and fading memory as by any attempt to deceive the court.
49. Nor have I accorded any weight to a reported argument between the parents on the morning of the 25 May as put to F by the police in his interview. This was on the basis of a hearsay report from a neighbour that they had overheard shouting. There is no direct evidence of that and so I am not assisted by it one way or the other.
50. I accept the submissions made on behalf of the parents that there are some details of their account which are incidental and, to that extent, improbable inventions: the fact that the mother was making spaghetti Bolognese, with the police photographs providing some evidence of this; the detail about the freezer feeling warm and the father checking this. However, given the accepted timing of the injury I have also weighed in the balance that these could equally be (true) incidental aspects of the context in which a non-accidental injury occurred.
51. I weigh in the balance that the expert opinion, with the caveat noted by Dr Williams about the location of the skull fracture, is that the bouncer incident is a plausible mechanism for these injuries.
52. I have also considered and weighed in the balance the fact that the parents accept that one or both of them, in the weeks prior to C's presentation at hospital, had caused injuries to her head. Indeed, I have now found that she was caused at least two shaking injuries. I have weighed up the inherent probabilities of a child suffering at least 2 inflicted head injuries and then shortly after an accidental injury also to her head.
53. In her oral evidence M described her reactions in the aftermath of C's injuries as being 'just angry' and 'scared'. She said she remembered crying in the car on the way to hospital and asking the paternal grandmother if she was 'doing the right thing' in taking her to hospital. When Ms Hawkett explored that with her, she agreed that she was asking if she was doing the right thing because she was worried that C would be removed from her care. She did add that she was also worried that C 'might not make it'. Whilst that fear (of C not making it) is understandable it is not reconcilable with her questioning the paternal grandmother as to whether she was doing the right thing in taking her clearly injured daughter to hospital: if she was worried about her daughter dying, she was clearly doing the right thing in taking her to hospital. In his evidence, F described the mother as having an 'emotional breakdown knowing what was going to happen'.
54. The parents' joint evidence of the mother's reaction in the aftermath of the injury is, in my judgment, highly revealing. It is not consistent with a simple, albeit serious, accident. It is consistent with knowing that something wrong has happened and that there is the potential for the parents to suffer adverse consequences as a result. I have specifically considered the mother's explanation that in part her reaction was due to her own childhood experience, telling me that 'my brother had an accident the night we were taken'. I don't accept that explanation; the mother, who I remind myself was studying at University, will know that she was not removed from her mother's care due to an accident. M's reactions are consistent with knowing that she and/or the father had done something wrong and blameworthy and being worried about the consequences for them both.
55. Lastly, I have specifically reminded myself that just because I have concluded, as I have, that the parents have not told the truth about C's other injuries, this does not mean they are lying about this incident.
56. When I have considered all the pieces of the evidence separately and in context with each other and when I have stood back and considered the wide canvas, as I must, I am satisfied to the requisite standard that the local authority has proved that the fractures to C's skull, associated haematoma and fractured clavicle were inflicted injuries. I cannot say how they were inflicted, but that is not my job, unless the evidence takes me to that point. Nor am I able to say which of the parents inflicted these injuries, but I am satisfied that they are the only ones who could have caused them and there is a 'real possibility' that either of them did so. That is to say, they are both on the list.
57. The pieces of the evidence that have the most weight, in my judgment are these (though for the avoidance of doubt, the order I have set them out in is not indicative of relative weight as against each other):

a. The fact that C had previously suffered at least 2 non-accidental traumas to her head as well as another non-accidental injury, whilst in the exclusive care of her parents.

b. The fact that the parents have, in my judgment, been prepared to lie about and otherwise conceal the truth about the other serious injuries that their daughter has suffered.

c. The fact that if the bouncer fit securely on the work surface, as per the parent's case, there would be no obvious mechanism by which it fell; and if it didn't fit securely, as per Sergeant RM's opinion evidence, there would be no obvious reason for the father to have left it there, insecure as it would have been.

d. The fact that the mother has changed a key detail of her account from claiming to have seen C sit up, which developmentally the mother's case was she was not yet at the stage of doing (and which neither parent claims she had previously done); to not having seen this and simply guessed that this is what must have happened.

e. The fact that the fracture was, as per Dr Williams, 'right at the back' of C's head which, given the parents' description of the fall would be 'a somewhat unusual impact location'.

f. The mother's reactions of anger and fear that C would be removed from their care, as well as questioning whether she was doing the right thing in taking her to hospital are not consistent, in my judgment, with an accident, even allowing for M's own childhood experiences.

58. Accordingly, the further findings I make (to be read in conjunction with Finding 1, set out above) are these:

Finding 2

All of the above injuries were caused non-accidentally. C experienced significant pain as a result of each of them. The pool of perpetrators for causing the injuries is M and F.

Finding 3

The injuries were caused to C on more than one occasion and included at least two incidents of her being shaken.

(vi) Failure to protect/dishonesty

59. The local authority originally sought a finding that if one parent did not cause the injuries then they had failed to protect C from them. In submissions and in light of their case with respect to perpetration, they amended this to a finding that M failed to protect C.
60. Separately, the local authority seek a finding that the parents have failed to work openly and honestly with professionals as to the circumstances in which C came to suffer her injuries and in respect of the status of their relationship with each other.
61. I can deal with these findings shortly.
62. There is, in fact, no real evidence in my judgment of the parents failing to work openly and honestly as to the status of their relationship. What appears clear is that at some point last summer the mother contemplated ending her relationship with the father and may have done so for a very short period of time before quickly resuming it. Apart from that, which was known at the time, the parents have been, if anything, disarmingly frank that notwithstanding the fact that each must, by inference, say that the other caused their daughter's injuries, they are remaining together as a couple.
63. On the other hand, it is an inevitable consequence of the findings that I have made above that the parents have failed to work openly and honestly with respect to the circumstances in which C came to be injured. I have given specific examples of that in each case (the mother's failure to tell treating medics at Sheffield about seeing blood coming from C's mouth the day prior to her admission; the father's failure to tell any professional about an occasion on which his daughter lost consciousness). But it is also a general conclusion drawn from my overall assessment that these parents know more about C's injuries than they have told professionals or the court and, in particular in this regard, the fact that they were both awake and jointly caring for C at the point when they say she received her fracture injuries, which I have found to be inflicted. Therefore, the finding I make is as follows:

Finding 4

The parents have failed to work openly and honesty with professionals as to the circumstances in which C came to suffer her injuries.

64. For the avoidance of doubt, in light of the findings I have made, a separate failure to protect finding would, in my judgment, be otiose.
65. I find that threshold is crossed on the basis of the findings set out above. On the basis of those findings C has suffered significant physical and emotional harm and was likely to suffer further such harm if no interim orders were made.

Welfare decision

66. The parents accepted as part of their closing submissions that even if I only made the pool findings with respect to the shaking injuries and mouth laceration, those by themselves would be enough to lead to the inevitable conclusion that C could not be safely cared for by either of them. I have made those findings and others. The parents are right that the conclusion following from those findings is inevitable.
67. I have had all aspects of the welfare checklist firmly in mind.

a. C has suffered significant physical and emotional harm at the hands of her parents.

b. She needs a home where she can grow up free from those harms.

c. The parents are incapable of providing such care to her. At least one of them has caused her real harm; they have neither of them been honest about that fact and she would be at real risk of ongoing physical and emotional harm in the care of either parent or both together.

d. The paternal grandfather has been assessed as being able to provide C with the care she needs. He has recently proved his ability in that regard.

68. I find that C's welfare, which is my paramount consideration, requires that I approve a plan of permanence in the care of her grandfather. I endorse the local authority's care plan, which is supported by her guardian who I am satisfied has robustly and independently considered that plan. That plan is for C to be subject to a care order, with her paternal grandfather being an approve kinship foster carer. That position will be reviewed in 3 months' time with a view to supporting him to apply for a Special Guardianship Order. This is in light of the fact that C has currently only been in her grandfather's care for around 2 weeks.
69. The local authority has, within the course of the final hearing, filed and served an amended care plan in light of evidence given by local authority witnesses as to ongoing work that will be offered to the parents and the local authority's acknowledgment that there needed to be a phased (rather than sudden) reduction in supervised contact from its current level of 3 times per week to the proposed level of once a fortnight. I have read that amended care plan. I am satisfied that the contact proposals, containing as they do, regular reviews of whether contact is meeting C's needs, are appropriate and I endorse them. I echo the thanks offered to the practice supervisor Amy Macdonald on behalf of the parents in their closing submissions for the unusual degree of sensitivity, thought and detail that has gone into proposals for ongoing support to the parents under the care plan, in circumstances where they will not be caring for C.

My orders

70. I therefore place C into the care of North Lincolnshire Council.
71. Having invited submissions from all parties in light of my Findings I make the following further orders:

a. There is permission for the local authority to share a copy of this Judgment and a separately prepared schedule of my Findings with the LADO. The LADO has permission to share those Findings (only) with:

i. The parents' university;

ii. Any future employer or trainer with which the parents are engaged and through which they may have contact with children;

iii. The DBS.

b. The local authority (whether through the LADO or otherwise) has permission to share the Findings with any other local authorities involved with the children of extended family members of these parents.

c. The local authority (whether through the LADO or otherwise) has permission to share the Findings with any extended adult family members who hold parental responsibility for children who are (i) not involved with a local authority; and (ii) known or believed to be likely to have contact with either parent.

d. The local authority has permission to share this Judgment and the Findings with the paternal grandfather on the understanding that the confidential nature of the documents is emphasised to him.

e. The local authority's existing permission to share this Judgment with the police and/or CPS as set out in the Family Procedure Rules 2010 PD12G is confirmed; the local authority also has permission to share a copy of the index from these proceedings with the same agencies.

f. A&N Care solicitors and/or Counsel Miss Shaw have permission to share the Judgment and the Findings made with M's PA.

g. The father has retrospective permission to share a copy of Dr Brown's reports, prepared within these proceedings, with the Police.

72. I will circulate an anonymised version of this Judgment before the end of the week and invite any comment as to further anonymisation within 7 days. At that point, I will place a copy of the Judgment on the National Archive.
73. I make the usual order with respect to costs.
74. That is my Judgment.