Now wash your hands

The thing that makes family law worthwhile is that every time you think you’ve seen everything, a case comes along and makes you go “nope, not yet.”

This is one of those.

East Sussex v AG (Finding of Fact) 2017

http://www.bailii.org/ew/cases/EWHC/Fam/2017/536.html

This involved an infant, now aged 13 months old, but only a couple of months old when the strange things occurred. He spent time at three different hospitals, and in each of these, he was observed to have very high levels of alcohol in his system – high enough to be potentially life-threatening, and also high levels of anti-histamine.

How did the alcohol get there?

Well, the defence deployed by the parents (chiefly the mother) is that it must have happened through the application of sterilising hand-wash, which contains alcohol. He was in a hospital, parents wanted to make sure he didn’t get any germs, so hand-wash was liberally applied. It must have been that.

Mother’s case ended up being that she was rubbing hand-sanitiser into the baby’s arms thirty or forty times per day. That sounds like a hell of a lot – could a baby end up with alcohol levels like these as a result?

Here’s what the expert had to say about it:-

• Whilst considerable time was spent on the validity of Dr McKinnon’s calculations of the amount of alcohol by volume that would be required to cause the levels of alcohol that were found in AG’s system (he having undertaken such calculations in response to being requested to provide an opinion on the likely doses given to AG), the central point made by Dr McKinnon, both in his report and in his oral evidence, is that, absent any evidence to suggest that the analysis of AG’s samples was compromised (and Dr McKinnon was clear that he had no reason to believe that the tests had not been performed satisfactorily), the samples taken from AG showed that he had very high levels of alcohol in his system on three occasions and a level of antihistamine in his system on one occasion.
• Within this context Dr McKinnon was at pains to emphasise that, with respect to alcohol, the actual readings from the samples taken from AG indicated clearly that AG had been administered significant amounts of alcohol independent of the calculations that attempted to work out the precise doses of alcohol in milligrams required to cause those readings. Dr McKinnon repeatedly emphasised that the alcohol readings obtained from the samples were “extremely” high and, on occasion, the highest he had ever seen, or heard of, in an infant. Indeed, he was aware of no reported cases in which the readings had been higher. Dr McKinnon was clear that this indicated AG had ingested a large amount of alcohol.
• Dr McKinnon was pressed extensively on the mother’s contention that the explanation for the high levels of alcohol in AG’s system were the result of her alleged use of high levels of hand sanitiser on AG. Accepting that calculations can only be approximate in circumstances where the physiology of individuals varies and the physiology of adult skin is different to that of infant skin, Dr McKinnon was nonetheless very clear that even had the mother used the hand sanitiser at a higher level than she claims, this would still not have been enough to produce the levels of alcohol seen in AG, even assuming a generous level of absorption of alcohol through the skin of an infant of 10% (the level of absorption in adults being between 2.5% and 5%). Within this context, Dr McKinnon also emphasised that the mother states that she used the hand sanitiser over the course of a day and that, accordingly, any alcohol that was absorbed would have begun to be eliminated between applications, further negating the possibility of alcohol from the hand sanitiser accumulating in AG’s blood to the levels seen. Dr McKinnon further stated that for the blood alcohol levels to be caused by AG ingesting hand sanitiser he would have needed to have ingested the equivalent of 44 “squirts” of that substance to reach the highest blood alcohol concentrations seen, ruling out, in his view, accidental ingestion from hands or toys as cause of the levels seen.
• With respect to the anti-histamine, whilst conceding that anti-histamine can be passed from mother to infant in breast milk, Dr McKinnon noted that the mother had not been breast feeding for a considerable period of time prior to the antihistamine being detected in AG’s system, negating as a possibility that route of administration.

Note the ‘ingested the equivalent of 44 squirts of the hand-sanitiser above” – that’s not had it put on him, that’s ingesting it – swallowing it or such.

The Judge considered that possibility very carefully

• I am further satisfied that the alcohol and anti-histamine that I have concluded was present in AG’s system and that caused each of the then unexplained episodes was deliberately administered to AG on repeated occasions as opposed to entering his system by way of some species of accidental or inadvertent administration.

(i) Hand Sanitiser

• By the conclusion of their oral evidence, both parents appeared to be moving towards accepting that the levels of alcohol found in AG could not have been caused by the application of hand sanitiser to his hands and arms, the father being, ultimately, perhaps more accepting of this than the mother. In any event, I am satisfied that the levels of alcohol found in AG’s system were not caused by the use of hand sanitiser containing alcohol. I have reached this conclusion for two reasons.
• First, I am not satisfied that the mother is telling the truth in respect of the levels at which she used hand sanitiser on AG whilst he was an in-patient having regard to the following matters:

i) The use of hand sanitiser assumed no significance at all in either of the police interviews of the parents conducted immediately after their arrest in May 2016. The mother claims that this was because she was not aware at the time of the interview that the hand sanitiser contained alcohol.ii) The mother’s first statement, directed by the court specifically to address the question of hand sanitiser and dated 14 August 2016, details lower rates of application than those for which the mother now contends, she stating that she first used hand sanitiser on AG on 26 April 2016, using two doses. Specifically, the mother stated “I also put 2 pumps into my hand and wiped it over both of AG’s hands and arms” (my emphasis). She states that she did the same on 28 April 2016. At the Evelina Children’s hospital the mother states that she used hand sanitiser on AG 30 to 40 times per day “at the highest”. Dr McKinnon’s report ruling out the use of hand sanitiser as the cause of the levels of alcohol found in AG is dated 4 November 2016. The mother thereafter filed a second statement dated 25 January 2017 in which she said of her first statement “what I mean is that I used two pumps on the left hand and arm and two pumps on the right hand and arm”, amounting to between 120 and 160 pumps per day. The mother denied that she inflated her account in her second statement to match the emerging medical evidence. However, given the size of the discrepancy between the two descriptions and the fact that the second statement followed the report of Dr McKinnon, I am satisfied that this is evidence of the mother having changed her account of the level of use in response to the conclusions reached by Dr McKinnon.

iii) In circumstances where the mother contends that her use of hand sanitiser on AG continued in the PICU the local authority sought confirmation as to whether members of staff saw the mother use hand sanitiser at the levels she claims whilst AG was on the PICU. By an email dated 25 August 2016, Professor Ian Murdoch, Professor of Paediatric Intensive Care at the Evelina confirmed that medical staff had not witnessed the mother use hand sanitiser on AG. Whilst that confirmation is in the form of an email rather than a statement in the proper form, it is corroborated to an extent by the evidence of the father who stated in his written and oral evidence that he saw the mother use hand sanitiser on only two occasions, stating in cross examination by Mr Bennett that he did not see the mother apply it with the frequency she claimed and did not himself see excessive use. In the circumstances, no person who came regularly into contact with the mother and AG whilst at hospital appears to have seen her using hand sanitiser on AG at the levels she claims.

iv) The clarification contained in her second statement is to the effect that the mother was using high levels of sanitiser from the outset, commencing that use on 26 April 2016. However, this appears to be at odds with a text exchange between the parents in respect of “hand gel” on 28 April 2016. On that date the father texted the mother stating “The reason I told you to use the gel stuff is cos there’s at least four kids in here with pneumonia including rose (sic) in front of us and her mum gave you a cuddle”). The mother replied “Oh ok I’ll make sure I use it a lot then”. In my judgment this exchange is inconsistent with the mother’s evidence to the effect that she was using between 120 and 160 doses a day on AG from 26 April 2016.

• In the circumstances, I am satisfied that the evidence before the court suggests strongly that the mother has sought to construct, after the fact, an account of excessive use of hand sanitiser to seek to explain the high levels of alcohol found in AG’s system. This conclusion is of course also relevant to the question of whether the court can identify who administered alcohol to AG and I deal with this further later in this judgment.
• Second, and in any event, I accept the expert evidence of Dr McKinnon that even on the revised figures for dosage provided by the mother in her second statement, the level of use suggested by the mother would not result in the levels of alcohol found in AG even if administered all at once and assuming a generous figure for absorption of ten percent to account for an infant’s skin being more porous than the skin of an adult. More importantly, I note again that Dr McKinnon was clear that the manner in which the mother contends she in fact administered the hand sanitiser, namely repeatedly over the course of the day, would not have been able to result in the levels seen because AG would have begun eliminating each dose over time after it was applied, meaning it could not accumulate to the levels seen. On this basis, even assuming a greater absorption than in adults, the use of hand sanitiser at the level contended for by the mother could not result in very high concentrations of alcohol seen. Dr McKinnon was equally clear that the father’s contention that AG might have ingested alcohol by means of hand sanitiser on his (AG’s) hands and toys was not a plausible explanation for the levels of alcohol seen in AG.
• In the foregoing circumstances, I am satisfied that the high levels of alcohol in AG were not caused by the use of hand sanitiser on him

The Court found that the alcohol and anti-histamine at high levels in the baby’s test results were as a result of him having been administered those substances by one of his parents.

(ii) Human Agency

• There is no evidence before the court of any other accidental or inadvertent mechanism for the administration of alcohol to AG whilst he was an in-patient. There is no suggestion of an organic cause for the levels of alcohol found in AG. In the circumstances, and being satisfied that the levels were not the result of the use of hand sanitiser, I am satisfied that there is no explanation for the administration of alcohol to AG other than human agency.
• Whilst the father posits the possibility of negligent administration by medical staff or the use of antihistamine as part of AG’s treatment regime that medical staff subsequently failed to record, neither parent seeks to suggest that antihistamine came to be in AG’s system other than by way of the same being administered to him by somebody. On the evidence of Dr McKinnon, it is clear that fact that the mother in the past took antihistamine does not explain its presence in AG in May 2016 in circumstances where the mother had not been breast feeding for a month prior to the antihistamine being detected. There is no explanation before the court for the levels of antihistamine found in AG on 17 May 2016 beyond administration by human agency. I accept the evidence of Dr Ward that the presence of antihistamine in AG’s system indicates that someone administered that substance to him.

Perpetrator(s)

• Satisfied as I am for the reasons set out in the foregoing paragraphs that the alcohol and antihistamine found in AG’s system whilst he was in hospital was administered to him at that time by human agency, I turn now to consider the question of who administered those substances to AG. In summary, I am satisfied that the alcohol and antihistamine were deliberately and covertly administered to AG by one or other of his parents or both of them.
• There is no evidence before the court that alcohol and antihistamine were administered to AG by one of his treating doctors or nurses. As I have already observed, neither parent has sought to suggest explicitly that the alcohol and antihistamine found in AG’s system was administered by a member of medical staff. Further, in my judgment, there is evidence before the court that positively points away from a conclusion that it was one of AG’s treating doctors or nurses who was responsible. Namely, that AG suffered unexplained episodes that I am satisfied were caused by the administration of alcohol and/or antihistamine in three different medical locations that do not share common staff. In my judgment this undisputed fact militates against the possibility that a member of staff was responsible. This conclusion is in my judgment reinforced by the fact that AG’s unexplained episodes ceased immediately upon the parents being arrested notwithstanding that AG remained an in-patient in hospital for a period of time thereafter. Neither parent has sought to allege it was another family member who administered alcohol and anti-histamine to AG and there is no evidence to that effect before the court.

The Judge carefully explained to the parents that it would be in their best interests now to be honest about what had happened.

parents who fail to be frank with the court regarding how their child came to suffer harm may often believe that they thereby put themselves at an advantage. In fact, the very opposite is true. The family courts are not concerned with punishment but with the welfare of the child. An early and frank admission by a parent who has harmed their child allows the court to establish accurately what occurred, to direct a fully informed assessment of risk and, in an appropriate case, to formulate and approve a plan for the safe return of the child to the parent, if necessary with a tailored package of support to address the deficits that first led to the harm. Conversely, where a parent or parents make a conscious decision to hide the truth, the court is much more likely to be left in a position where it will be unable to conclude that the parent can safely parent the child in the future. This is especially the case where the court is compelled to conclude (as it is entitled to do) that the harm was caused by one or other or both of the parents but that it is not possible to tell which. In such a situation, additionally, the parent who did not inflict the harm is materially prejudiced by the failure to be frank of the parent who did.

CONCLUSION

• In conclusion, I make the findings set out in the Schedule appended to this judgment. I will allow a short period for the parents to consider the findings made by the court and to respond by way of a further statement to those findings. I will then give directions for the welfare stage of this hearing.
• Finally, for the reasons I have set out, I am satisfied that neither of the parents has been entirely frank with the court. I am satisfied that they have each made a conscious choice to withhold certain matters rather than giving an account of all that they know about the circumstances in which AG came to have extremely high levels of alcohol and levels of antihistamine in his system. Within this context I have had to try and divine what happened to AG in circumstances where his parents have chosen not to assist the court fully with that task. This judgment represents my considered attempt to discharge the duty of the court in those circumstances on the evidence available to me at this hearing. In so far as the mother and the father consider that this judgment does not represent the full picture of what befell AG, the responsibility for that lies solely at their respective doors.
• There now comes a very important decision for the parents. To adopt the words of Lord Nicholls of Birkenhead in Lancashire CC v B at 588, in the present case AG is proved to have sustained significant harm at the hands of one or other or both of his parents. Within this context, the parents have a choice. They can consider the findings of the court and choose now to provide the information that I am satisfied that they have thus far withheld from the court to ensure that the local authority assessment that will follow this hearing constitutes a fully informed assessment of risk and allows the court the best possible opportunity to determine whether AG can be safely returned to their care. Conversely, they can continue to withhold information from the court and from professionals and increase thereby the risk of the court of having ultimately to conclude that AG cannot be safely returned to their care.
• That is my judgment.

SCHEDULE OF FINDINGS 

• Whilst an in-patient at the local hospital and the Evelina Children’s Hospital in London, AG experienced repeated unexplained episodes of unusual limb movements, apnoea, unconsciousness and coma, some of which incidents were life threatening and required intubation and ventilation.
• No medical explanation for AG’s episodes was found despite extensive testing being undertaken.
• Specialist blood tests undertaken on 17 May 2016 identified high levels of alcohol in samples of AG’s blood taken on 27 April 2016, 10 May 2016 and 17 May 2016.
• Specialist urine analysis undertaken on 17 May 2016 identified high levels of alcohol and levels of antihistamine in AG’s urine.
• Analysis of a sample of AG’s gastric aspirate taken on 17 May 2016 identified high levels of alcohol and levels of antihistamine in his gastric aspirate on that date.
• The levels of alcohol found in the samples taken from AG were extremely high and would have caused serious toxicity and could have been potentially fatal to him but for the emergency treatment he received as an in-patient.
• Each of the unexplained episodes experienced by AG at the local hospital and the Evelina Children’s Hospital in London were caused by AG being administered alcohol and / or antihistamine, including those episodes in respect of which blood and urine testing was not undertaken.
• Each of the unexplained episodes was caused by the mother or the father or both of them deliberately and covertly administering alcohol and /or antihistamine to AG.
• In deliberately and covertly administering alcohol and /or antihistamine to AG, the mother or the father or both of them caused AG to be subjected to extensive, unnecessary, uncomfortable and painful invasive tests to try and ascertain the cause of the episodes (including but not limited to MRI imaging, electrophysiology, two lumbar punctures, genetic and metabolic testing and video telemetry) and extensive, unnecessary uncomfortable and painful treatments (including, but not limited to, extensive blood testing, catheterisation, intravenous and arterial cannulation, intubation, mechanical ventilation and the administration of antibiotic, anticonvulsant and anti-reflux medication).

Extraordinary case – I’ve never come across anything like it.  Luckily, when it comes to matters of hand-washing within a hospital setting, we have the Marx Brothers to give us a visual demonstration.   (In this scene, Groucho has been pretending to be a physician, Dr Hackenbush. He is about to be unmasked by a real doctor, Dr Steinberg. What follows is a masterclass in stalling for time)