This is an interesting judgment about a finding of fact where the child was in a residential assessment centre with his parents when he was admitted to hospital as a result of a torn frenulum and other injuries including fractures were later identified.
That’s a really unusual situation, and it is not a surprise that the residential assessment centre not only gave substantial evidence but also were intervenors to the proceedings.
https://www.bailii.org/ew/cases/EWFC/HCJ/2025/54.html
A, Re (Care Proceedings: Non-Accidental Injuries: Identifying the Perpetrator) [2025] EWFC 54 (14 March 2025)
It is an excellent judgment in terms of summarising and analysing all of the relevant authorities on non-accidental injuries and identifying a perpetrator as well, and would be an excellent starting point for anyone wanting to distill those authorities.
There were 4,000 pages of evidence, and the hearing lasted between 1st July 2024 and 24th July 2024. There was CCTV at the assessment centre, but viewing the tapes was inconclusive and it was established that there were blind spots in the CCTV coverage.
It appears that the baby was unwell when born (16 weeks premature) and had assisted ventilation for around 36 hours. There were concerns about his parents not visiting sufficiently in hospital. On discharge from hospital around three months later he was placed with his parents in a residential assessment centre.
Shortly afterwards, a mark was noticed on his leg and he undertook a medical examination:-
At 17.20pm on 25 November 2022 A’s parents were spoken to by staff at the Assessment Centre about the marks on A’s right leg and foot. A was taken to Hospital B where he was examined by a Paediatric Registrar. The Paediatric Registrar observed several marks on A which could be explained but also the following for which there was no explanation, namely: –
i) 1cm x 1cm x 1cm triangular red area, posterior and superior to the lateral malleolus of the right foot (the outer aspect of the right ankle).
ii) 1cm x 0.5cm red mark located on lateral surface of lower leg, superior to the lateral malleolus (above the right ankle).
iii) 1.2cm linear red mark on lateral aspect of right foot/5th toe.
iv) 0.3cm x 0.3cm red mark on left lower leg, medial aspect of the anterior tibia.
v) 1.5cm x 0.4cm red mark on left lower leg, lateral aspect of the anterior tibia.
vi) 0.3cmx0.2cm red mark on left lower leg, medial aspect of the anterior tibia.
vii) 1.6cm vertical linear red mark overlying Achilles tendon of left leg.
Each of the above marks were considered to be consistent with bruising. Father suggested that each of them could be due to tight clothing.
As a consequence of the above, A was admitted to Hospital B for observation and investigation. Those investigations did not include a skeletal survey.
A Strategy Discussion on 28 November 2022 concluded that there was no evidence of a non-accidental injury given the CCTV footage from the Assessment Centre and given a skeletal survey had not been deemed necessary. A was therefore discharged back to the Assessment Centre where he continued to be placed with his parents for residential assessment.
Then on Christmas Day :-
25 December 2022, at or about 21.36hrs M ran out of their family room with A in her arms shouting that A is bleeding from his mouth. F observed bleeding coming out from under A’s tongue. Despite this episode possibly indicating damage to the lingual frenulum, which Professor Fleming states is a marker for potential significant abuse by forceful feeding, it appears that after repeated failed attempts by staff to get through to 111, staff at the Assessment Centre gave up and no medical attention was sought for A
And then a further issue in January 2023
- 59. At approximately 16.00 pm on 12 January 2023, F was changing A when he noticed a large bruise on A’s right thigh which he drew to the attention of staff. The mark was placed on a body map and photographs were taken. At 18.30 hrs A was seen by a GP who advised attendance at Hospital B. There, A was assessed at 21.30hrs in the Paediatric Emergency department where the following was noted:-
- A had an ophthalmic review the next day which revealed no evidence of retinal haemorrhages. A had a skeletal survey whilst in hospital (see below).
- On 20 January 2023, M and F were arrested for GBH with intent. On the same day the placement at the Assessment Centre was terminated.
…However, the skeletal survey which the clinicians had ordered showed multiple rib fractures including multiple posterior rib fractures and a fracture of the left distal radius (bone in forearm). The fractures, particularly the posterior rib fractures, were considered by the clinicians to be suspicious of an inflicted injury.
That’s a lot to digest, but basically this child had either been in hospital or with his parents at a residential assessment centre, so how had these injuries occurred (and how had they not been seen at the residential assessment centre if they occurred there?)
On behalf of the Assessment Centre, their advocate in closing chose to answer a number of specific questions. They are as follows: –
i) Did the Assessment Centre fail to adequately supervise A’s bath time? It was submitted that when the family arrived at the Assessment Centre, they signed a “Working Agreement.” Paragraph 3 of the agreement included the parents agreeing to be observed by a staff member whilst undertaking all care tasks in relation to A. Paragraph 4 of the agreement says the parents should “report all basic care tasks with A to staff so this can be observed in person or via camera/or be recorded.” It is averred that the evidence demonstrates that the parents failed on several occasions to follow these important rules and principles. It is said that they failed on several occasions to verbally inform staff before starting to bathe A. The father told the court that the reason why he sometimes failed to wait for staff was because he just wanted to get things done quickly, because other residents might want to use the bathroom. It is submitted that he also told the court that he was always expecting someone to come up. Mr X (junior) gave evidence that when parents took A to the bathroom without informing Assessment Centre staff first, they usually went to the bathroom without adequate preparation for A’s bath. That meant that when staff arrived at the bathroom, they would have to go back to the family’s room to bring adequate items of clothing or whatever else was needed for A. This would usually result in A being left on his own with his parent or parents. One of the rooms, apart from the staff toilet, where there is no CCTV at the Assessment Centre is the bathroom.
(ii). Did the Assessment Centre fail to protect A adequately? It is submitted that it is wrong to assume that the Assessment Centre staff failed to protect A adequately. Evidence revealed there were occasions when the father was seen to be heavy handed or rough handed when handling A. Staff intervened on such occasions, advising the father to be gentler with A. It is submitted that the Assessment Centre was diligent in its observations of A and ensured any bruising, marks or injuries were evidenced by body maps and photographs, brought to the attention of the local authority, and that A was taken for medical attention at the GP, Hospital B or that medical attention was sought from 111 in relation to the mouth injury.
(iii) Did Ms H cause injuries to A on 4.1.2023? It is submitted that it is clear from the CCTV evidence of 4.1.2023 and the expert medical evidence in the proceedings that A’s injuries could not have been caused by Ms H.
(iv) Did the Assessment Centre staff cause A’s injury when they had sole care of him in the absence of his parents? It is submitted that the evidence has shown that A was looked after by the Assessment Centre staff on five occasions without his parents. On behalf of the Assessment Centre, the evidence of Ms N, Ms X (senior), Mr X (junior), Ms D, Ms S and others is relied upon. In evidence, the Assessment Centre staff have confirmed that there were always other staff members in the staff room whenever A was taken to the staff room. Hence, A was never truly alone when taken there. It is averred that evidence from Ms N revealed that the only time that A was truly alone with staff members was when he was taken to the GP for his immunisation; and this was because his parents were unable to wake up to take him to the GP for his appointment.
In terms of the evidence of the managers and senior assessors at the assessment centre, Henke J said this:-
i. Ms X (senior). Ms X (senior) is the Registered manager and company director of the Assessment Centre. She has been running the Assessment Centre for 8 years. When she gave her evidence, it was obvious that she had pride in the centre, was defensive of it and its practices. After all, the whole purpose of the centre is to safeguard, and A had been injured whilst staying there with his parents and she and the centre had much to lose. That said, I formed the view that she was ultimately a truthful witness who gave evidence upon which I could rely.
Ms X (senior) told me that she does not have any social work experience; Mr K was to provide a parenting assessment. The PAMS element of the assessment was to be conducted by Ms N. The PAMs assessment was not included in the Midway assessment. She had no direct contact with the parents.
In terms of observation in the placement, she told the court that the CCTV covered all areas except the bathroom. She accepted that there were blind spots in the parents’ room, namely behind the door and from the chest up by the room’s window. The CCTV did not have audio but there was a baby monitor. A member of staff should be present when all care tasks are carried out and parents are expected to notify staff if they intend to carry out such tasks. She had not reviewed the CCTV footage relevant to A’s stay at the placement because the police had taken it. At the time staff had seen the father rough handle A and had intervened. That was recorded in the logs which they had reviewed after A was found to have been injured. She had not asked any member of staff if they had caused injuries as staff had reported their safeguarding concerns. Staff had taken A into the office but there was always at least one other member of staff there. She could not countenance any member of staff having caused the injury. They had a safe recruitment policy
ii. Mr X (junior). Mr X (junior) gave evidence before me twice. He is Ms X’s (senior) son. He was the key worker who worked with the family. He had concerns about the tit-for-tat between the parents; about them not getting up early enough etc. The mother was overall gentle and caring but had to be encouraged to do tasks. The father could be gentle with A but he was also heavy handed when patting his back and touching him. You could hear the father on the monitor patting A’s back. He was mortified that A was injured on the Unit. Mr X (junior) actually broke down in tears when giving evidence and was clearly devastated at what had happened but also, I considered during his first time in the witness box, defensive of the Unit and worried about reputational damage. When he gave evidence for the first time he had not seen the CCTV footage of the time A was at the Unit because it had been in the possession of the police. When he returned to the witness box for the second time, he had had the opportunity to view selected parts of the CCTV. Having done so he had to accept that there were two occasions when A had been in the bathroom with his father without supervision in January 2023. Mr X (junior) accepted in cross-examination on behalf of the mother, that the father had a habit of not reporting that he was going to carry out a care task before he did it. However, in cross-examination by the father, he had to accept that on 4 January 2023 the father had said over the monitor that he was taking A for a bath. I got the impression from listening to what the witness said and the way he said it, he had informally relaxed supervision of the father with A because he did not consider A would come to harm in his care and that he could leave him to bath his son. I have asked myself why then did his log entries not reflect that conclusion or the lack of supervision on two occasions. I have decided that there is only one answer to that question – that is that he knew the tasks should be supervised and that was what the local authority expected of the Unit. What had happened was not consistent with the 24/7 monitoring and supervision the local authority had requested of the placement. I consider that Mr X (junior) was a defensive witness. When he gave evidence on the second occasion, he did not appear to me to understand the import of two occasions when there was no supervision or of his log not being accurate on those occasions.
[I pause here to say that residential assessment centres are a scarce resource – demand for them is greater than supply, and that they are a very expensive resource – that’s not to contend that they are not value for money, but just that in cost terms they are many tens of thousands of pounds. If there are such failings about lack of supervision and inaccurate record-keeping, there’s at least a question as to whether they should have been identified here so that Courts, parents and Local Authorities considering their future use do so on an informed basis… There is some later information about an Ofsted report which could be used as a sifting mechanism, and it may be that there’s a judgment to follow about the decision to anonymise]
The findings :-
I find that there was an agreement between the local authority (who were paying for and who required the assessment) that the Assessment Centre would monitor A 24/7 within the placement. However, in February 2023 Ofsted issued a compliance notice because serious shortfalls were found in the monitoring of two families at the centre that undermined safeguarding practice. Since those incidents a revised CCTV policy has been introduced at the centre and arrangements for monitoring the parents at the centre were strengthened.
At the time A and his parents were at the Assessment Centre, there was no CCTV rota in place. The staff were responsible for monitoring the CCTV at all times, but I find, as Ms X (senior) set out in her written evidence, there may have been times when the office was left empty briefly. In the bedroom A shared with his parents there was a blind spot behind the bedroom door when it was opened and another in the right-hand corner of the window in the bedroom. There is no CCTV in the bathroom. It is accepted on behalf of the mother and the father that in early January 2023 two bath times were wholly unsupervised. The father having heard Mr X (junior) give evidence on the first occasion brought them to the attention of the court. That is to F’s credit. Mr X (junior) had to be recalled to give evidence to explain why the logs did not accurately record what had or had not taken place. In particular, the log of 4 January 2023 gave a misleading picture. It is written as if Mr X (junior) had directly observed the bath time when it is now known he did not. On the CCTV the father can be heard clearly calling that he is about to bath A and no one comes to supervise. On 7 January 2023 the father alerted the staff that he has just bathed A who he then took to the office. These are two clear breaches of the Assessment Centre’s agreement with the local authority. I find that the Assessment Centre did fail to monitor A at all times. I find that towards the end of the family’s placement at the Assessment Centre, it is likely that, as M told me in evidence, towards the end there was less supervision. I find that Mr X (junior) was aware of this. I find that his logs for the two known occasions do not reflect what actually happened because he knew that A was meant to be supervised constantly and he knew that he was not.
I find on the basis of all the evidence before me that whilst at the Assessment Centre, A suffered multiple fractures. He sustained 23 fractures to his ribs which fall into four groups:
i) 6 fractures to the posterior right side
ii) 5 rib fractures to the anterior right side
iii) 8 rib fractures to the anterior left side
iv) 4 rib fractures post laterally on the left side.
In addition, I find that whilst at the Assessment Centre, A sustained a fracture to his left wrist. He also suffered a tear to his lingual frenulum.
I find that the tear to A’s lingual frenulum is likely to have occurred close to the moment when blood was noticed coming from his mouth on 25 December 2022. I accept the radiological evidence which provides a broad timeframe in which the factures are likely to have occurred. The rib fractures are likely to have occurred between 3-8 weeks prior to the skeletal survey on 19 January 2023. The wrist fracture is likely to have occurred 2-5 weeks before the skeletal survey.
…I have read and heard the evidence of many of the staff who worked at the Assessment Centre. They were day and night time family support workers. Whilst the parents did not directly accuse any one of them in the hearing before me of harming A, some were on the list of people who had the opportunity to cause harm. They were understandably anxious when giving evidence and sometimes fearful. However they each gave their evidence calmly and with compassion. I have already made my assessment of the relevant independent witnesses. I find that they did not cause A’s injuries. Specifically I find that Ms H did not cause any injury. She was an impressive witness. She was clearly truthful. The occasion when she nearly dropped A was caught on CCTV and viewed by Professor Fleming. I accept his evidence that nothing he witnessed on the relevant clip is evidence of Ms H causing A to sustain fractures.
…I find that it is likely that F was stressed when feeding A on 25 December 2022. I find that it is likely that he became frustrated when feeding him as he had previously on 3 December 2022. I find that on 25 December 2022 and shortly before 21.45hrs, F had given A his bottle without taking the care that a reasonable parent should have given to him. He did not ensure that the teat was not under A’s tongue, and he placed the bottle in A’s mouth with inappropriate force, sufficient to cause the lingual frenulum to tear. I find that M’s reaction was almost immediate at the sight of the blood. She might not have seen F cause the injury but she saw the aftermath. M did not tell the court the truth when she said she didn’t know what caused A’s mouth to bleed. I find that she knew that A had been fed by his father shortly before blood came from A’s mouth and that she knows in her heart of hearts that F caused that injury. However, I find that she simply could not bring herself in evidence to say he did it.
…On behalf of M, it is submitted in closing that as F caused the lingual frenulum injury, it is inherently improbable that there are two perpetrators and that I should factor that in when considering the fractures and who caused them. However, I balance against that that the mechanism to cause the fractures would have been different.- However, standing back and considering all the evidence as a whole, I find that it is likely that F caused the rib fractures and the wrist fracture. He did so within the radiological time frame which I have already accepted above. I cannot on the evidence pinpoint an event or events and say that is exactly when the fractures occurred. However, F has accepted that on occasion he was too rough when handling A, he was too rushed when carrying out care tasks for his son and he took risks with A. F would not take advice about how to handle his son and thought he knew better. Given the number of fractures and their sites, I find that there is likely to have been more than one occasion when F used more force than a reasonable care giver would give to A and caused his rib fractures and his wrist fractures. I have already accepted Professor Fleming’s evidence that the person causing the injury will have known that they have done something inappropriate even if they do not know that they have caused fractures. I find that F does know that he has harmed A by being too rough with him and using too much force when playing with him and carrying out care tasks. I find that he has chosen not to tell the court what has happened for fear of being thought to have deliberately harmed his son. I find that F did not set out to harm his son but he was over confident in his own ability; too rough when handling A and took risks. He used inappropriate force when handling his son and caused the fractures.
- In relation to M’s alleged failure to protect, I take into account that the Assessment Centre themselves did not consider that F would have caused A injury. Thus, whilst they recorded risk taking behaviours and rough handling, they did not intervene to remove A or to stop F carrying out caring tasks. Indeed they bought into his self-confidence and, as I have already found, towards the end of the placement did not supervise him as thoroughly when caring for A as they ought. Having heard the evidence I find that M bought into that confidence, just as the Assessment Centre did. I find that, as she told me in evidence, she did not perceive his handling to be too rough and, although he did things she would not have contemplated doing, she did not perceive him to be a risk (see paragraph 106 above).
A very sad and difficult case.
suesspiciousminds 