A Local Authority v A Mother & Ors

Mrs Justice Arbuthnot: Introduction

1. This hearing is to decide whether allegations by the local authority (“the LA”) against the first respondent mother are made out.

2. The second respondent is the father and the third respondent is “Hannah”, the child represented via her guardian Ros Lau. Hannah was born in January 2022. She will be aged three in about two months. She is said to have suffered serious unusual physical abuse at the hands of her mother.

3. The mother has been represented by leading counsel Miss Branigan KC and her junior Anita Garrod. Both are very experienced. She has had the assistance of an intermediary and there is no doubt that her functioning combined with her past life makes her vulnerable. The mother gave evidence and was cross examined for two and a half days. I was satisfied that the questions she was asked were asked in accordance with the intermediary’s advice, the ground rules hearing and the Advocate’s Gateway. The mother was given lengthy breaks and the court sat early to ensure that she was able to give evidence when she was at her best.

4. I noted the police and the defence solicitor did not consider she needed an intermediary or an appropriate adult when the police interviewed her. The police interview was short and the questions the mother was asked did not require additional explanations whilst the substantial medical evidence heard in the family proceedings did. From what I observed the mother understood the straightforward questions she was asked and was able to answer them.

5. The father has been represented at this hearing and has observed on occasions. He struggles with anxiety and ADHD. None of the threshold allegations were made against him. He was not involved in Hannah’s life at the time, nor is it suggested he injured Hannah.

6. Ms Lau the guardian attended at key moments of the case. Miss Lee KC for the guardian made very powerful submissions on her behalf in support of the local authority’s case. Outline chronological framework

7. TIMEFRAME ONE : In 2022, when Hannah was very young, she suffered breathing difficulties and went to Hospital A, then Hospital B with a respiratory collapse and when in hospital on 29 th May 2022, suffered a bleeding ear for the first time.

8. Proceedings were started (“the first proceedings”) and Hannah went into foster care between 14 th June 2022 and 16 th February 2023, a period during which she suffered no bleeds from the ear. Leaping ahead, on 14 th July 2023, the first proceedings concluded with a Supervision Order for nine months.

9. TIMEFRAME TWO : Within five days of returning to her mother’s care, on 21 st February 2023, Hannah suffered another ear bleed. There were a number between then and 28 th September 2023. Hannah was in and out of her GP’s surgery with ear issues. She also attended Hospital C and Hospital D on 17 th May 2023.

10. TIMEFRAME THREE: . She was admitted to Hospital C for a week in July 2023. During this period she suffered an ear bleed after a fall from her high chair. The mother witnessed this.

11. TIMEFRAME FOUR : On 11 th August 2023, after an ear bleed Hannah was examined at Hospital D and a pope wick was inserted into the left ear. This was to ensure antibiotics would reach deep into the ear. On 17 th August 2023, Hannah was in London for the night before she was due in Hospital D on 18th for the possible insertion of grommets. On 17 th August she had a very heavy ear bleed. She went to Hospital D, was bandaged, went back to the hotel and then had to call 999 and get an ambulance to Hospital E as the ear was continuing to bleed.

12. On 18 th August 2023, Hannah was admitted to Hospital D. She remained there until 13 th November 2023. During the earlier period of the admission, she stayed in a private cubicle or room with an ensuite bathroom. On about 15 th October 2023, she was moved to a bay next to the nurses’ station.

13. The doctors looked for infections whether fungal or bacterial and she was put on antibiotics. She was scanned repeatedly. No explanation could be found for the heavy bleeding from the ear. She also underwent examinations under anaesthetic when biopsies were taken from the ear. Two in particular feature in the evidence, one taken on 18 th August 2023 and the other, a deeper biopsy, on 6 th September 2023.

14. By late August 2023 the doctors identified that she had suffered a catastrophic infection which had gone from the ear, to the base of the skull and then to the eye. It had caused Horners syndrome. This had led to Hannah losing the hearing in the left ear and her eyesight in the left eye. This infection and track was confirmed by the independent jointly instructed experts.

15. On 2 nd September 2023, Hannah suffered her first eye bleed. Then she had a number. A PICC line, unusually, was found to be broken in two places on 23 rd September 2023. In October 2023 on three occasions Hannah was locked into the bathroom with her mother and after coming out, 20 to 30 minutes later her temperature had spiked. A cannula, unusually, had snapped on 13 th October 2023. As a result of this and the mounting safeguarding concerns, on 14 th October 2023, Hannah was moved from a cubicle or room in a ward to a bay next to the nurses' station where she could be observed. An urgent strategy meeting was held when it was agreed that a joint police and social work investigation should take place.

16. On 17 th October 2023, now moved to the bay, Hannah seemed better, happier and she was walking in a more stable manner. A ward manager noticed a considerable improvement in Hannah’s health after she was moved to the bay and out of the cubicle. Her eating seemed to improve, she had no signs of vomiting and there was no bleeding from the eye. She was beginning to walk and talk and “her infection markers had shown signs of improvement”. This started about a week after she was moved into the bay. The nurse thought it was an unusual recovery.

17. By 20 th October 2023, Dr H found that Hannah was clinically improving and had stopped spiking high temperatures. She was active, eating, appeared happy and was speaking some words. A number of medical staff noted the difference.

18. I noted that the ear bleeds that happened in July and August 2023 and the five eye bleeds which took place in September 2023 stopped. Hannah was in the bay for just under one month before being discharged. If the previous pattern of eye bleeds had continued, there would have been possibly another four or five eye bleeds during this month but there were none.

19. TIMEFRAME FIVE : On 13 th November 2023 Hannah and her mother were discharged from hospital. They went to stay with the maternal great aunt and her husband, Mr and Mrs Elm. On 20 th November 2023 after an eye bleed, Hannah and her mother were back in Hospital C. On 5 th December 2023 during an examination under anaesthetic at Hospital C, cuts were found deep under the upper and the lower eyelids, they would have been invisible unless they were examined under anaesthetic.

20. The cuts went almost all the way around the eyeball in the whites of the eye (or conjunctiva) in the area called the fornix. Dr CP described them as nearly 360 degrees. There was a cut in the canthus or outside corner of the eye where the eyelids met. There was a red bruise leading from the outside corner of the eye going towards the ear. The consensus of the medical evidence was that at least one these were non-accidental injuries which had happened prior to Hannah’s admission to hospital on 20th November but it was not possible to say how long before.

21. Hannah was taken into care on 7th December 2023 and has not returned to the care of her mother. For the last 11 months the mother has had carefully supervised contact with Hannah. During this period of foster care, Hannah has suffered no eye or ear problems nor has she suffered any infections linked to the eyes or ears. Experts - summary

22. There were five independent experts instructed in this medically complex case. Professor Raine, a consultant oto-rhino-laryngologist and a consultant ENT Surgeon at Bradford Teaching Hospitals NHS Trust considered the ear issues. Dr Newman, a consultant paediatric ophthalmologist, considered the eye issues. Dr Kosmidis, a consultant in infectious diseases considered the ears and eyes and the biopsies. Dr Marnerides a consultant histopathologist and specialist in perinatal and paediatric pathology at St. Thomas’ Hospital considered too the biopsies. Dr Cartlidge was the paediatric specialist who gave an overview of the case.

23. The experts were provided with the updated evidence before they gave evidence to the court. Four of the experts attended a meeting on 19 th August 2024 when Dr Marnerides was unable to attend.

24. Dr Cartlidge considered the eye injuries of November/December 2023 (timeframe five) to be the key issue in the case. The other issue was whether trauma may have caused or exacerbated the ear infections. All of the experts agreed that the eye injuries of November/December were non accidental. They were not caused by infection.

25. So far as the ears were concerned, the biopsies taken on 18 th August 2023 and 6 th September 2023, were examined by Dr Marnerides and by Dr Kosmidis. The biopsy of 18 th August was not of particular significance whilst the deeper biopsy made on the 6 th September 2023 was.

26. Dr Marnerides initially did not favour either osteomyelitis or injury but in his evidence he favoured trauma. He observed what he considered to be wood in the slides from the biopsy of 6 th September 2023, although he could not exclude wool. It was a foreign body which if it was wood would suggest insertion of a foreign object through the ear canal.

27. Part of Dr Kosmidis’ evidence concerned the finding of a fungal organism Phlebia from DNA analysis conducted on the material found on the slides made during the biopsy of 6 th September. Phlebia existed in nature inhabiting wood and causing wood rot. The finding of this suggested the presence of foreign material in the ear.

28. The ear expert was Professor Raine, he made the valid point that in all the examinations conducted on Hannah there was no sign of trauma in or around the ear. This I found to be Miss Branigan’s strongest argument against trauma and non-accidental injury in the ear. As against that all of the experts, including Professor Raine, said that they had never experienced bleeding of the type seen either from the ear or the eye in the absence of underlying issues.

29. The eye expert was Dr Newman, he considered that the eye bleeding which took place in Hospital D was part of the infection process and Horners syndrome. He said he was most concerned about the bleeding that had taken place before a cut to relieve the pressure in the left eye (a canthotomy) was made in a procedure on 7 th September 2024. He had searched for signs of trauma to the eye and found none. Dr Kosmidis disagreed as he had never seen the pulsatile bleeding seen in a case of infection.

30. In these proceedings, the experts met (bar one) and agreed the two main issues were the cause of the eye injury of November/December 2023 and what may have caused, if anything did, the original ear infections which went to the eye. The parties’ positions

31. The mother had denied these allegations to the police when she was interviewed on 6 th December 2023. She has denied each allegation during these proceedings when she was subjected to thorough and methodical questioning conducted by Mr Stonor KC for the LA.

32. The LA supported by the father and guardian have contended that the injuries were inflicted by the mother. The LA said it was a classic “wide canvas” case where the court should consider all the evidence in the round. Mr Stonor KC submitted that the photographs taken by the mother were particularly significant and showed she was documenting the abuse of Hannah. He said the court’s natural sympathy for the mother who has suffered some poor life experiences should not get in the way of a forensic analysis of the evidence.

33. Miss Branigan KC relied on past reports on the mother’s borderline intellectual difficulties of a full scale IQ score of 77 and on a psychiatrist’s report of the mother’s state of having ‘mind freezes’ when stressed. The same psychiatrist in 2021 observed that the mother had a flat affect during interview. She was cut off from her own feelings and was increasingly overwhelmed by certain factors.

34. Miss Branigan’s overarching submission was that the mother had done nothing to harm Hannah. There was no evidence that the mother had injured Hannah’s ear or eye. She relied on Professor Raine who said he would have expected damage to the ossicles in particular had pieces of wood including cocktail sticks been inserted. In relation to the cutting around the eyeball under the eyelids, Miss Branigan invited the court to find the injuries were undetermined.

35. Counsel for the mother contended (correctly) that there was a great deal of evidence that she was a loving mother to her daughter, that she was attentive to her and responsive to her needs. She showed Hannah appropriate emotional warmth. Miss Branigan said the social worker had noted that there appeared to be a very close and warm relationship between them. At contact, Hannah runs towards her mother and there is a good interaction and eye contact between the two of them with grins and smiles.

36. Miss Branigan said the multiple photographs the mother had taken of Hannah’s injuries and distress was a common habit of young people, there was nothing sinister about what she was doing. The mother voiced her frequent frustrations because the doctors did not know what was wrong with Hannah. She found that upsetting. She wanted to document what was happening to Hannah.

37. When Hannah was taken to Hospital C on 20 th November 2023 and Dr E at Hospital D started speaking to Hospital C, the concerns multiplied. The concerns about the ear and eye issues were being raised with the benefit of hindsight. It was not for the mother to disprove the case brought by the LA.

38. In what has been a difficult case, I am very grateful to the counsel for their meticulous approach to the evidence. Their approach alongside the use of an intermediary have enabled the mother to understand what the issues are and to give her best evidence in these difficult proceedings which I accept were clearly stressful for her. Threshold

39. The 14 allegations made by the LA are to be found in the amended threshold document of 30 th October 2024.

40. Section A to B, numbers 1 to 4, relate to injuries observed in the left eye and to eye bleeds. Allegation C, number 5 relates to bruising near the eye. Allegation D, numbers 6 and 7 relate to left ear bleeds. Allegations A to D were said to be inflicted by the mother.

41. Section E, numbers 8 and 9, relates to the catastrophic infection leading to the loss of hearing in her left ear, the loss of sight in her left eye and Horners syndrome. The severity of the infection was said to be exacerbated by trauma inflicted by the mother and/or the deliberate or reckless introduction of infective material into Hannah’s ear by the mother.

42. Section F, numbers 10 and 12, alleges tampering by the mother with Hannah’s PICC line and cutting the cannula leaving part of it in Hannah’s foot. The PICC line port was detached and cut under the bandage on Hannah’s skin on 23 rd September 2023. The cannula was cut on 13 th October 2023. Allegation 11 is that on three occasions between 10 th and 13 th October 2023, the mother introduced infective material into Hannah’s cannula.

43. Section G, numbers 13 and 14, alleges the consequences to Hannah of the abusive conduct alleged. As at 7 th December 2023 when protective measures were taken, Hannah was said to have suffered life-changing injuries, emotional harm, pain and distress and had been subjected to unnecessary medical investigations and procedures. As a result Hannah had suffered and was likely to suffer significant harm. Evidence

44. The evidence has come from a number of treating nurses and doctors at Hospital D and Hospital C. There also has been expert evidence from the five jointly instructed experts. Their names and details are set out above. I heard from the social worker, the mother, as well as the maternal aunt and uncle, Mr and Mrs Elm.

45. In his meticulous cross examination of the mother, Mr Stonor KC drew together the medical evidence, as well as the texts and records of phone calls made by her at the relevant times. The numerous photographs taken of Hannah by her mother became particularly significant as the timing of the photographs led Mr Stonor to suggest that the mother was documenting the abuse of her daughter.

46. There were a great number of witnesses. Some I do not refer to at all and some are mentioned in brief. I have taken all of their evidence into account.

47. I have also attempted not to use medical language where it can be avoided. I have tried to make this judgment as accessible to the mother as possible. General observations and some law

48. The treating doctors and the nurses who gave evidence had often provided statements recently including in September and October 2024 but relied on copious, contemporaneous medical notes which had been provided to the parties. Some of the medical specialists had no independent recollection of the events of about one year ago.

49. Generally there was no suspicion of inflicted injury during Hannah’s numerous attendances at the GP and in the hospitals with ear issues until late September/early October 2023 at Hospital D.

50. Although non accidental injury had been suspected in 2022 when Hannah was a small baby (see TIMEFRAME ONE above), this had been ruled out after an independent expert, not an ENT specialist, had given her opinion and the proceedings had ended with a supervision order agreed in 2023.

51. The medical staff at Hospital C and Hospital D never considered that the 2023 ear and eye issues were other than an infection which had tracked from the ear to the base of the skull before going into the eye. They were mystified by the bleeding. Hannah was given any number of antibiotics and was examined often under anaesthetic by the ear and then eye specialists. Although suspicions were mounting, perplexing illness was raised formally at Hospital D on about 14th October 2023, after the cannula incident.

52. After the left eye injury in mid-November to early December was observed on 5 th December 2023, the past month’s ear and eye issues became a focus of concern to the medical staff. It was obvious that if a person was capable of causing such an unusual and serious injury, what else might they have done to Hannah. I say unusual, because none of the treating doctors or independent experts had ever come across such an injury before. It made the professionals reevaluate what had been observed on earlier occasions.

53. It is the local authority that has made these allegations and it is for the LA to prove them on the balance of probabilities on all the evidence. Speculation is not evidence but inferences can be drawn from an overview of the evidence as a whole. I bear in mind that it is not for this young woman with challenges to prove she did not cause any of the alleged injuries. The burden does not rest on her.

54. I have given myself a Lucas direction about lies. The mother admitted that three sentences in her statement were untrue. She said she had written that she had not been alone with Hannah when staying at the Elms’ between 13 th and 20 th November 2023 (TIMEFRAME FIVE). This was untrue because there were at least three occasions when she was alone with her.

55. She also admitted in evidence that when she had said in her statement that Mr and Mrs Elm had waited outside Pizza Hut whilst she went there with Hannah, a friend and her child, that that was not true and that her friend had come to fetch her to drive her to Pizza Hut. She said she had lied essentially because she did not want the authorities to think she had an opportunity to injure her daughter (this is my interpretation of what she said, not her precise words). This was a lie for an innocent purpose. It was a silly lie because of course it was obvious that she had had the opportunity to injure Hannah.

56. The mother told another lie (or lies) to the police when she was interviewed by them on 6 th December 2023. The mother told them she did not know and had not been told what type of injury Hannah had. In fact Dr HA had told her about the cuts they had found. The mother in her evidence said to Mr Stonor that it was because she had been arrested on suspicion of grievous bodily harm. She said she had not been told what the injury was. I noted that she could have chosen not to reply to any of the police questions. On the whole I could understand why she told that lie. I have not held her lies against her in my consideration of the case.

57. I have relied very little on the mother’s demeanour as she gave evidence although I do rely on some of the answers she gave or did not give. It was clear to me that she found the process gruelling. There were silences in response to some of the questions she was asked. Miss Branigan reminded me in her submissions of the report of a psychiatrist in 2021 who said the mother had a “flat effect” in interview. That could have been the description of the mother’s demeanour in evidence. This is the way she reacts in a formal setting. I also considered that the mother found talking about her feelings or her motivation for doing certain things (like taking the photographs of Hannah’s distress) difficult.

58. I also bear in mind that in 2023 and still today the mother suffers from bleeding from her bowel. This must have been and must be incapacitating. It is only on 24 th August 2024 that the mother had to go into hospital for blood transfusions and intravenous iron before being discharged on 27 th August 2024. She is currently waiting an urgent colonoscopy and endoscopy.

59. The approach I have taken is not chronological but I start with what I consider to be the strongest and by far the most serious allegation, that of the injury to the eye in November/December 2023 (TIMEFRAME FIVE). At all times I bear in mind that the burden of proving this allegation remains on the local authority and that the mother does not have to prove that she was not responsible for or caused the injury found in the eye. TIMEFRAME FIVE – Allegation A (1 and 2) Left eye – November-December 2023

60. The mother presented at Hospital C on 20 th November, via the GP, with Hannah having an eye bleed. Although it was disputed by the mother, the evidence from medical notes at A & E was that Hannah was drowsy. The term used was “knocked off”. Dr OD, a paediatric consultant told the court he understood that to mean she had a reduced level of consciousness.

61. Dr E an ENT specialist at Hospital D was contacted that day by Hospital C, she had treated Hannah and knew her well. When she heard that Hannah had not resisted a cannula being put in place at Hospital C she asked A & E to carry out a toxicology test. For some reason this did not happen.

62. Dr HA, a locum paediatric consultant at Hospital C said he and Dr BM saw Hannah on 22nd November 2023 and noted a mark at the canthus. It was extending laterally towards the ear. Dr HA described it as “very prominent”.

63. Dr CP was the consultant paediatric ophthalmologist at Hospital C who saw Hannah first on 21 st November 2023. He was the author of many of the entries in the medical notes and records. He found the eye to be incredibly swollen, there was active bleeding, the cause for these was a mystery as there was no clear evidence of infection, of inflammation or trauma.

64. On 27 th November 2023 he saw Hannah again. She had bruised eyelids and skin but the swelling had decreased. There was still come oozing of blood.

65. On 5 th December 2023, Dr CP examined the eye under anaesthetic. The eye was still actively bleeding but not as much as it had been on 21 st November 2023. At first he could not see where the blood was coming from. The eyelids were pulled back with instruments which were rounded and would not have damaged the eye.

66. Dr CP found an abrasion on the surface of the eye (the cornea) and a scarred lacrimal gland. There was also a cut where the lateral canthotomy (an operation to relieve pressure in the eyeball when the place where the eyelids meet is cut) had been made on 7 th September 2023, he said that might have reopened. They would have healed by then but “relatively minor trauma could easily cause that area to potentially break down”. He found a curved “linear” cut following the shape of the eyeball which went through the fornices of the eye deep under the upper and lower eyelids (“laceration of the superior and inferior fornix almost 360 degrees right up in the fornix deep with communication to anterior orbit”).

67. The way the doctor put it was that they were able to pass their instruments far too far back to the orbit where they should not have been able to gain access. He described that as the “stand out unusual feature”.

68. The team took photographs and they have been exhibited. In cross examination Dr CP described it as cuts sweeping under nearly all of the upper and lower eyelid. They were deep cuts and neither a finger or fingernail would reach them. He said the photographs did not show the whole cut or gap. He said that the blood was coming from the cuts and there were no others in the area. The surfaces of the lids were not damaged. The cuts would only be visible when Hannah was under anaesthetic. The other doctor and he agreed that it was mechanical. A colleague sewed up the cut under the lower eyelid.

69. It was such an unusual occurrence that four consultants in the same field who were working at Hospital C that day came in to observe what he had seen. They agreed with Dr CP’s observations. He said there was no tumour, there were no autoimmune problems and they would not have caused the line or incision which had to be a form of “mechanical disruption with a linear edge”.

70. What he saw had such an effect on him that it led him to step away, he described it as an “overwhelming experience”. He then rang Dr IG at Hospital D because she had biopsied the eye to find out what procedure she had carried out on Hannah when she had biopsied the eye.

71. Miss Branigan explored with the specialist whether the cuts could have been made longer by what he and his colleagues did. It was a reasonable question to ask. Dr CP replied in two ways, first pointing out that they were trained to be gentle and second saying that the extent of the cut was obvious from the beginning. He said that the fornix cuts would not have been obvious on an examination by just pulling down and up the eyelids, they had to use instruments to get a view of that part of the eye.

72. As to the timing of the eye injury, the doctor said at least one of the cuts must have predated when the mother brought Hannah to Hospital C because it was oozing then and something had to have caused that. The cuts caused the bleeding.

73. Dr CP, an experienced specialist had never seen an injury to the fornix before.

74. Dr IG the paediatric ophthalmologist at Hospital D explained in evidence that Dr CP had contacted her on 5 th December 2023 during the examination under anaesthetic of Hannah’s left eye. She had told Dr CP that she did not go anywhere near the white of the eye in the fornix area. Her colleague had performed a canthotomy on 7 th September 2023 whilst Hannah was under an anaesthetic. This would not have led to the injury seen.

75. Dr IG explained that she had performed a biopsy on 6 th October 2023 and a canthotomy and had repaired the canthotomy wound with dissolving stitches. By 2 nd November 2023 the canthotomy had healed. If there had been lacerations in the fornix on 6 th October 2023 or on 2 nd November 2023 they would have been noted and repaired.

76. Dr IG had marked up the wounds which were not present before with dots on the photographs of the eye taken at Hospital C on 5 th December 2023 and said the wounds looked fresh and clean. In cross examination she said it was a clean cut like a paper cut. She described it as linear. There was not a lot of bruising.

77. Overall Dr IG said in their investigations of the left eye in September, October and November they did not find any cause for the swelling, blood etc. They could not explain how the infection process that originated in the ear had led to bleeding from the front of the eye. She said in cross examination that if there had been previous cuts to the fornices which had healed she would not necessarily see the scarring.

78. Dr Newman was the independent eye expert. He considered the photographs and reports provided of the examination of 5 th December 2023. He said the V-shape cut (to the side of the eye nearest the ear) should not be there neither should the cuts to the conjunctiva right up under the upper and lower eyelids (the fornices). The latter were “abnormal”. Dr Newman said the cuts were not a complication of the earlier infection. The canthus could be more vulnerable because of the earlier canthotomy conducted at Hospital D but on balance he thought it was more likely to be a fresh cut.

79. In relation to the red mark seen in the photographs running from the side of the eye towards the ear, he said it was possibly a bruise. Overall he said on the balance of probabilities there would have been three separate lacerations caused. It would have been painful but just for a few minutes. The fact that Hannah could not see out of her eye and that she had had a number of issues with it may have lessened the pain. He accepted Miss Branigan’s point that it would be difficult to produce the injuries in a conscious child.

80. Dr Cartlidge the expert paediatrician had looked at various photographs including ones taken by the mother on 20 th November 2023, which showed bloody tracks down Hannah’s face and a grossly swollen eye with what appeared to be bruising. This included photographs of the red mark running from the left eye where the eyelids meet (the canthus) to the ear. He agreed with Dr Newman and said it was a bruise. Having given it some more thought, he said the red mark was more likely to be a non-accidental injury and inflicted because of where it was situated. TIMEFRAME 5 The mother’s evidence

81. The mother described how she went home from Hospital D late on 13 th November 2023. There had been no safety plan put in place as suggested by the social worker with supervision of the mother by the Elms. The mother’s account was confirmed by Mr and Mrs Elm. I heard from the social worker who said there was a safety plan but found she was vague. There was no signed document that she could exhibit nor any note that it had been discussed. I found that neither the mother nor the Mr and Mrs Elm had been given a safety plan nor had it been discussed during this period.

82. In her evidence, the mother set out what she had done between leaving Hospital D late on 13 th November 2023 and attending Hospital C on 20 th . On 15 th November 2023, she had gone to Hospital D for a check-up. The eye was not bleeding then. On about 17 th November 2023 the mother had noticed that Hannah had been rubbing her eye so she put on an eye guard.

83. On the Saturday 18 th November 2023 she became worried about Hannah rubbing her eye more frequently than the day before and the evidence of her telephone calls showed she rang Hospital D at about 10.30am. That evening the mother took Hannah to Pizza Hut with a friend for a birthday meal. The mother thought this happened on the Friday but the texts showed it was Saturday 18 th 2023 that she went there between about 5.30pm returning about 9pm or 9.30pm.

84. On Sunday 19 th November 2023, the mother said she and Hannah had a lie in as the Mr and Mrs Elm went to church between 9.30am and about 12.30pm or so. The mother’s texting starts just before 10am. The mother noted that Hannah was rubbing her left eye and had a blue stitch in the corner.

85. On 20 th November 2023, the mother went to the GP and obtained eye drops which she said caused Hannah’s eye to bleed. She was alone with Hannah when it happened. The mother rushed her to Hospital C and was driven there by the Elms. Hannah was drowsy and off her food. Her eye was swollen with yellowish fluid and blood was oozing from the eye. The mother was told there was swelling on the site of the lateral canthotomy “which was oozing blood”. The swelling increased over the day. Hannah remained in Hospital C until she went into foster care on 7 th December 2023.

86. On 21 st November 2023, there was blood from the eye on Hannah’s bed and pillow and again the eye was bleeding on 23 rd and 24 th November 2023.

87. In her evidence the mother explained how frightened she was over the following days. She was frightened they would take Hannah away again.

88. On 3 rd December 2023, Hannah woke up in Hospital C and was bleeding from her left eye again. There was a new swelling with oozing and a discharge on 4 th December. The examination under anaesthetic of the left eye was on 5 th December 2023.

89. On 6th December 2023, the witness Dr HA and others spoke to the mother about the findings from the day before. She was told that there was a concerning cut inside the eyes The mother said Hannah had been scratching her eye. She questioned whether there was a stitch in the eye from the earlier procedure. She asked about whether it might have been caused by intra-ocular pressure but was told it was “very low”. They told her that scratching had not caused it but that it was “significant and concerning”. The mother said the cut had not been there before and that she had been with her all the time.

90. Dr HA told Miss Branigan that when the issues were discussed with the mother on 6th December 2023, she “certainly had seemed surprised”. She was fairly calm, she did not seem “over surprised”. He said “she took it in her stride”.

91. The mother in her evidence denied injuring the left eye. The mother said that she had not caused nor did she know how the injuries to the fornices had been caused. She had been supervised at the Hospital C.

92. Mr and Mrs Elm gave evidence about the week between 13 th and 20 th November. They contradicted themselves about whether they were in the room when the eye started bleeding on 20 th November when the mother said she put in the eye drops. In the end, I considered Mrs Elm was probably more reliable than Mr Elm, and that it was likely that they were outside the room (although close by) when that happened. TIMEFRAME ONE Discussion and conclusion

93. The medical evidence from experts and treating doctors all leads me in one direction. The left eye was cut in the lead up to the mother’s presentation at Hospital C on 20 th November 2023. The first cut was likely to have happened between 15 th (after the mother’s visit to Hospital D) and 20 th of November 2023. When the eye was examined by Dr CP on 5 th December 2023, the bleeding was coming from the cuts in the fornix. That was the only cause of the bleeding.

94. Bleeding from the left eye happened on three other occasions in the hospital. It may have been that a further two cuts were made which formed part of the three cuts observed by Dr CP.

95. There is no evidence that the eye injury was caused by any doctor or medical examination. When Dr CP was examining under the eyelid it was the first thing he noticed. His instruments did not cause this injury. Hospital D examinations under anaesthetic were not recent enough nor close enough to the cuts in the fornices to cause the fresh bleeding. This was confirmed by Dr IG.

96. The specialists and experts said the injuries could not be accidental. Hannah could not reach and put a finger in that area. It could not have been her. They must have been inflicted.

97. In terms of who did it, it could only be the mother or her aunt and uncle. The mother does not suggest it is them. They gave evidence and I do not find that they were likely to be responsible for these injuries. I noted they had 19 grandchildren and there has been no suggestion of any safeguarding issues. The eye had bled before when Hannah and her mother were not living with them. The eye bled after Hannah had gone into Hospital C on 20 th November 2023.

98. Bearing in mind the blood came from the cuts and the blood was particularly noticeable on 20 th November, it seemed to me that the eye was probably cut from about 19 th or 20 th November 2023. I cannot say whether the cuts were done at one time or spread over the following days in hospital.

99. I noted that the Elms left Hannah and her mother alone for at least three hours when they went to church on Sunday 19 th between 9.30am and 12.30pm. The mother had an opportunity to cause at least one injury then. When Mr and Mrs Elm returned from church the mother told them that Hannah was rubbing her eye. I accept the Elms looked at her eye but decided that it was not an emergency then. I accepted their evidence that they could see redness or swelling at that point. The following day the eye poured blood.

100. On 20 th November 2023 at Hospital C Hannah was thought to have been a bit floppy. A toxicologist test was suggested by Hospital D to Hospital C but nothing was done until 23 rd November 2023 when the mother refused to allow a test. It seems to me more likely than not that Hannah had been sedated somehow, possibly with Calpol, when the injuries occurred.

101. I find there was at least one episode of non-accidental cutting of the upper and lower eyelids and the canthus. There was a linked bruise probably caused at the same time at least one of the cuts was being administered. The cuts would have been done by a sharp instrument which could have been scissors. The cuts were linear and were such that they could have been caused in surgery, but they were not. The Elms were not responsible and it was not accidental. The mother has denied causing these injuries to Hannah but I find on the balance of probabilities that she is the only person who could have cut Hannah in this way.

102. Having found that the mother was responsible for these very unusual injuries and of using some form of sharp instrument to do so that inevitably has an impact on my approach to other parts of the evidence.

103. Whilst I must take care that I am not considering the evidence of what happened in the past with the benefit of hindsight, I also must consider that I have found that the mother has the propensity and ability to cause these very unusual and serious injuries which were hidden beneath the eyelids. I bear in mind that the mother has self-harmed in the past with the blade from a pencil sharpener. Whilst there is no evidence which might lead me to find she used that to harm her daughter, the experiences of cutting herself may have taught her how to handle blades or even how to cut skin to a particular depth.

104. I turn to the damaged PICC line and cannula which I consider together. TIMEFRAME FOUR Tampering with lines and Hannah’s temperature spikes, razor The PICC line 23 rd September

105. The PICC line was broken in two places on 23rd September 2023 when Hannah was at Hospital D. Nurse Q gave evidence. Although another nurse had found the break, she was called to repair it. She saw that the PICC line was broken by the single lumen (the injectable port furthest away from the skin). The lumen had disconnected away from the line.

106. She then looked at the whole line and inspected it and saw that it had snapped under the clear dressing. Part of her job was to repair them. She had been in nursing for 20 years and had never seen such breaks before although she had seen tears in the line. She had not seen before either a PICC line detached from the lumen before or a clean break under a dressing

107. Dr HA of Hospital C provided a sample PICC line for a child of Hannah’s age. He said that they last for between six to eight months if properly cared for. He said it was a fairly robust tube. It was very flexible. It needed to be flexible because it needed to track all the way to the shoulder and stop before the heart. With child PICC lines there was a lot of bending and pushing and the tubing was fairly robust. He had never seen a PICC line snap.

108. Dr HA told Miss Lee for Hannah that he had seen before a longitudinal split in the line but it could not be snapped like a drumstick. Even a longitudinal split in the line attached to the lumens end (the furthest away from the skin) was “incredibly incredibly rare”. He had seen it more in lines into babies where the lines are “super fine”.

109. The mother said that she had gone to the toilet and Hannah was walking in the room when she came out. The PICC line had become tangled and Hannah had stretched it and it had broken, she said it had “pinged” off. In cross examination she said she had been at the other side of the room to the IV stand when it happened. Having considered the explanation, it did not seem to fit a double break as described. If it was tangled and stretched, it may I suppose, have pinged off the lumens end but not have been broken in two places. Temperature spikes after visits to the ensuite with her mother

110. On three occasions between 10 th and 13 th October 2023, the mother took Hannah into the bathroom for an extended period of time. On at least one occasion Hannah was heard to be distressed. When Hannah was checked by a nurse 20 or so minutes later, her temperature would spike (in other words climb). The local authority’s case was that infective material of an unknown type was being introduced into the cannula.

111. The mother’s account was that she could not leave Hannah on her own when she went to the lavatory as in October she was clingy. Hospital D was short staffed and she had asked for a nurse to come and watch Hannah but “in the end” she took Hannah into the lavatory with her. The first time the mother remembered this happening was on 11 th October 2023. On the first occasion Hannah had been sick on her so they went in to clean up. On the second occasion that day, Hospital D was aware that the mother had issues with her bowels and that it could take up to 30 minutes for her to go to the lavatory. Hannah was crying because they had been in there so long. The mother denied doing anything to harm Hannah in the ensuite lavatory.

112. I found these three events to be suspicious: this type of behaviour, that of the mother taking Hannah into the bathroom with her, was new; on one of the occasions the mother had asked a nurse repeatedly to take Hannah’s temperature which then spiked; the spiking stopped once Hannah was moved to a bay close to the nurses’ station and the nurses denied the mother’s account that she had told them that she had bowel problems. Against that there is no evidence that infective material was in fact introduced. In a lavatory there is material that could have been introduced into the cannula but with nurses checking the cannula regularly I cannot find on balance that that happened. Cannula – 13 th October 2023

113. On 13 th October 2023, Nurse Z was on duty for the night shift. She was going to flush the cannula and it was at about 10pm that she found the bandage around Hannah’s right foot was “partially unravelled and the dressing had peeled off with the canula still attached to it”. The bandage was loose and easy to unravel. She said the dressing and canula were off the skin when she removed the bandage.

114. The nurse realised that part of the cannula (the straw) was still in Hannah’s foot. An ultrasound confirmed that. The nurse took photographs. She said in evidence that it appeared cut. The nurse then submitted a Datix report which is for broken equipment. She was concerned about Hannah because the cannula had appeared cut and the dressing had been unravelled.

115. In her oral evidence she said she had not seen one of Hannah’s bandages unravel before but in general that could happen. She provided photographs of the broken cannula which showed a part missing which had been left in the foot. She said she had never known a canula snap before.

116. In cross examination she told Miss Branigan that initially she said it had snapped. It was after the medical staff had reviewed it and there had been a discussion that they had decided it had been cut rather than had snapped.

117. Dr GR who was a senior house officer at Hospital D working out of hours at the time, was called to examine the foot. She told the mother that part of the cannula had been left in the foot and the mother told the doctor that it was going to travel to her heart. As the doctor said in evidence, when the mother said that she thought it was a valid concern and noted that the mother was thinking further ahead than she was. She said the mother was upset.

118. On Saturday 14 th October 2023, the general paediatric consultant Dr H was on call. She reviewed Hannah at about 1030am with Nurse PI and other members of staff. They found that Hannah had the plastic sheath from a cannula retained and lodged in the top and side of the right foot. Neither the mother nor the staff had an explanation for the “very unusual event”. Hannah had to have the part of the cannula left in her right foot removed under a general anaesthetic. She was left with scarring.

119. Dr H said she had not inspected the broken cannula as there was a good image of it in the notes and she did not want to contaminate it. She said in cross examination that she had been a paediatrician for 24 years and had not seen a broken cannula ever before. She told Miss Lee she had never seen a cannula retained in the patient. Cannulas are used a lot, on a daily basis. She said it was “highly unusual”.

120. In cross examination Dr H said that she was one of the Hospital D team who had significant concerns about Hannah and her mother. The safeguarding concerns were alongside the medical care. There were parallel discussions going on.

121. It was Dr H after the cannula incident who recommended that Hannah be moved from a cubicle to an open bay close to the staff. After she had spoken to Nurse Q about the PICC breaks, Dr H escalated her concerns on 16 th October 2023.

122. On 17 th October 2023, now moved to the bay, Hannah was better and happier and walking in a more stable manner. An urgent strategy meeting was held when it was agreed that a joint police and social work investigation should take place.

123. The mother’s account of the cannula breakage was that on 13 th October 2023 a nurse found that Hannah’s cannula was not working, the bandage was wet and that on removing the dressing it seemed to be broken.

124. In her first statement the mother said she did not know how it broke or how it was cut when there was no equipment in the room to do that, “the cannula was still dressed and bandaged, the same as it was when the nurses or doctor had inserted it”. I noted this contradicted the nurse’s account.

125. In her second statement the mother said she did not remember the bandage having unravelled in any way. The nurse had to use a special wipe to remove the dressing from the cannula. The mother accepted that it seemed to have snapped. The mother said it was not her who did this. The cannula was on the part of Hannah’s foot where there was lots of movement. In her evidence in court she repeated that she did not know how it had broken. She pointed out that she did not know how to insert a PICC line or a cannula.

126. The mother’s recollection that scissors, syringes and gauze etc had been removed just before the cannula incident. She was told by a doctor that this was best for Hannah and herself. On 14 th October 2023, the mother was told they were going to be moved to a bay in the ward and away from the cubicle. The bed was moved from the cubicle into the bay.

127. The mother felt she was being watched in the bay even when she changed a nappy (she was) and that it was being suggested she had done something to her daughter. She felt judged all the time. The mother felt it was history repeating itself as that was what had happened the year before. She felt angry and fed up.

128. The mother accepted that Hannah made a “dramatic improvement” after a few days in the bay. She said she had had a blood transfusion and a change of medication and that had worked. PICC and Cannula - conclusions

129. For both these pieces of medical equipment, there was similar evidence that none of the doctors and nurses who were asked about the breakages had ever seen or heard of this happening before. When DATIX was consulted about the broken PICC line, there was no other report, it was not part of a faulty run of equipment. Both these pieces of equipment had broken under the dressing close to the skin.

130. The mother was alone in the cubicle or room, away from the gaze of the nurses and medical staff and would have had the opportunity to cut this equipment. There is no other explanation that makes sense. It is completely improbable to think that both pieces of robust equipment would break in a similar way. I do not accept that the mother was telling the truth when she told the court she was not responsible for the breakages. On the balance of probabilities, I find that the mother was responsible for cutting the PICC line in two places and the cannula in one.

131. From the findings I have made above, the mother was using sharp implements to interfere with her daughter’s care on 23 rd September 2023 and on 13 th October 2023. She had also used a sharp implement to cause the injuries to Hannah’s left eye between 20 th November and 5 th December 2023. Razor

132. At one point it was being suggested that the mother’s uncapped eyebrow razor blade had been found in Hannah’s puzzle on 14 th October 2023. It turned out it was capped and not just a blade but the whole razor. The mother could not explain how it got into the puzzle from a zipped washbag. In any event, there was no expert evidence about what implement might have been used to cut the cannula at around the same time. It could have been done by any number of implements that the mother had with her or that were around her in the ward. In the circumstances, I draw no inferences from the finding of the razor in the puzzle. Ear evidence

133. The LA’s case was that Hannah had left ear bleeds which were caused or exacerbated by inflicted injury on various dates. The mother had used blunt force trauma and/or the poking of a pointed object into the ear canal to cause the ear bleeds.

134. The complicating factor when I come to consider the allegations made by the local authority against the mother is that there were undoubtedly a number of ear infections and one of those infections had started with the ear and then tracked through parts of the base of the skull to the eye causing Horners syndrome. That combined with the lack of evidence of trauma from any doctor or specialist who had examined Hannah at the time, makes the decision process anything but straightforward.

135. The expert evidence in this case from Professor Raine does not favour trauma although he admitted that the ear bleeding of the type documented in Hannah’s case was something he had not come across before except once in much earlier times.

136. The allegations start with the ear bleed which occurred in Hospital B on 29 th May 2022. There is then the bleed which occurred on 21 st February 2023, less than a week after Hannah returned into her mother’s care after eight months in foster care. Following that, there is a gap until 16 th July 2023, when the mother said Hannah fell out of a high chair and then there were at least three more ear bleeds on 11 th August, 17 th August and 28 th September 2023. Some of these are documented by the mother in photographs.

137. The local authority relied on the pattern of bleeding, which did not occur when Hannah was in foster care or was being supervised more closely at Hospital D and the fact that the bleeds happened only when the mother was alone with Hannah. Dr Cartlidge said that those facts “lessens the chances of a natural disease process and increases the chances of inflicted injury”.

138. The mother denied being responsible for any of the ear bleeds. Miss Branigan’s understandable argument was that in the earlier proceedings and also in 2023, there was no evidence that there was a traumatic cause for Hannah’s bleeding ear. It was examined repeatedly by medical staff from her GP to specialists. The evidence which pointed to a non-accidental trauma having occurred was the amount of blood which came pouring from her ear at various points. This bleeding had never been seen by any of the experts unless there had been some form of trauma or there was some predisposition to bleeding, which was not the case with Hannah. TIMEFRAME ONE - Allegation D 6 (1)

139. The 29 th May 2022 when Hannah was in Hospital B was the first time that her left ear had bled. The bleeding was followed by an infection. This was a time when Hannah was flagged as a child for whom there were safeguarding concerns. Hannah was there as there were concerns about pauses in her breathing that were reported by the mother. There were three pauses reported by the mother between 28 th and 31 st May 2022.

140. On 29 th May 2022, the mother told a nurse that Hannah’s ear looked sore. An hour later there was some dried blood around the ear. When the ear was examined by a specialist registrar there was dried blood in the ear canal and the ear drum (tympanic membrane) could not be seen. Later on the same day, the mother called the nurse and there was fresh blood coming out of Hannah’s ear. Photographs were taken which showed a blood filled ear and dripping blood.

141. In the medical report written by Dr AA who was a locum paediatric respiratory consultant at Hospital B, it was said that when the blood was found on 29 th May 2022 there was no infection or perforated ear drum. This was checked repeatedly. It was only on 6 th June 2022, when the ears were examined under anaesthetic, that the ear drum was found to be perforated and a middle ear infection was found. The infection that had been found did not fully explain the blood in the ear.

142. In the safeguarding meeting, Dr AA from ENT at Hospital B said that whilst they had found a ruptured ear drum and evidence of infection, “this was an unusual presentation for amount of blood observed… without history of trauma”. Hannah was prescribed ear drops for the infection and then went into foster care where there was no ear bleeding.

143. The ear expert was Professor Raine. In his original report of May 2024 he had not seen the photographs of the ear bleeding in Hospital B in 2022. He agreed in evidence when he saw that it was concerning and very unusual. Significantly in evidence he said that it might be indicative of trauma in the absence of any diagnosed infection. Professor Raine did not know the date of the examination when the ear drum was found perforated (it was 6 th June although there was some discharge beforehand) and said that if the ear drum was truly intact, the blood would be a concern. It was intact when the ear bled.

144. Between 14 th June 2022 and 16 th February 2023, when Hannah remained in foster care, there was one visit to the GP on 2 nd November 2022 when Hannah was diagnosed with middle ear infection (otitis media) with both of her ear drums bulging (bilateral bulging tympanic membranes). A visit to the GP on 16 th November 2022 took place when Hannah’s right ear was red. On 7 th February 2023 her left ear canal contained white discharge and the doctor diagnosed outer ear infection (otitis externa) but by 10 th February 2023 the ears were back to normal. Although there were infections there were no perforations or ear bleeds during this eight month period whilst Hannah remained in foster care. TIMEFRAME TWO – Allegation D 6 (2)

145. The next bleed was the one on 21 st February 2023 just after Hannah had returned to the care of the mother. The mother told the GP that she noted the blood after Hannah woke screaming in pain. There was a bit of blood tricking from her nostril. The doctor said he conducted only a limited examination as there was blood in the external ear canal. It was thought that Hannah had a middle ear infection and the left ear drum was perforated secondary to the infection.

146. One week later on 28 th February 2023, Hannah was back at the GP’s for a follow-up visit and again Hannah was said to be having a bloody discharge from the left ear but when he examined her the GP could not see the ear drum because there was clotted blood in the external ear canal. There were no signs of infection present.

147. Hannah was seen the same day at Hospital C. Examination of the ear was difficult but the diagnosis was acute middle ear infection with a perforation of the ear drum.

148. On 11 th March 2023, Hannah was seen by ENT at Hospital C. On examination there was some wax obscuring the view and the doctor could not find the perforation in the ear drum. She was diagnosed with recurrent ear infections.

149. In the following two months, Hannah was taken to hospital with discharges from her ear. There was a diagnosis of middle ear infection.

150. Hannah had been referred to Hospital D and was seen on 17 th May 2023 by the witness Dr PH a consultant Paediatric Otorhinolaryngologist at Hospital D. The right ear had an intact ear drum but signs of middle ear infection whilst the left ear was full of a bloody discharge. He was unable to see the left ear drum. Hannah was to return for an examination under anaesthetic. The LA does not suggest what Dr PH saw was as a result of trauma.

151. In June and early July 2023, the ear issues continued, including the right ear which was extremely inflamed. Hannah had bilateral ear infections and an ear drum perforation in the left ear. Mostly it was the left ear discharging fluid that was sometimes blood stained. Again these discharges are not said to be trauma related. TIMEFRAME THREE - Allegation D 6 (3)

152. In mid-July 2023, Hannah was admitted to Hospital C where a fresh perforation in the ear drum was found. There were various bleeds from the left ear and antibiotics were given.

153. The mother said on 16 th July 2023 that there was a fall off a high chair which caused some bleeding from the left ear. The LA alleges that the mother had caused this bleeding in some way. In her cross examination she was asked by Mr Stonor how it was that Hannah fell off the high chair. She said she was in the chair next to Hannah a few feet away. Hannah was trying to get up and her legs wobbled and “it tipped”. She was too late to stop it from happening but tried to, and may have been on her phone.

154. On 17 th July 2023, Hannah and the mother returned home to live with Mr and Mrs Elm. Later in July and in early August 2023 the GP saw Hannah three times. There was blood in Hannah’s left ear with a small perforation in the ear drum and at the second visit there was a moderate bloody discharge to the ear with no signs of infection. On the third occasion, the left ear was oozing and there was blood in the ear canal. There was a central perforation in the ear drum. These do not form part of the allegations made against the mother. TIMEFRAME FOUR - Allegation D 6 (4))

155. The mother had come down to London on 10 th August 2023. She had taken photographs of Hannah on the way down. There were photographs of her left ear at 9.29am where the ear looked as if it had a little dried blood in it. Hannah looked generally content. By 0657 on 11 th August 2023, a photograph shows blood dripping from her ear onto a stripey top Hannah is wearing. At 0906am the ear had fresh blood in it.

156. When asked, the mother explained that she took many photographs of Hannah’s left ear to keep a log of what was happening. On 11 th August 2023, there was at least one photograph of Hannah looking distressed. She said she did not know why she had taken it. She said she did not find the sight of Hannah’s blood or her distress thrilling or exciting.

157. Dr PH at Hospital D saw Hannah on 11 th August 2023 when he had examined Hannah under anaesthetic. He said the left ear was difficult to see due to swelling and granulations. It was filled with blood. He inserted a pope wick (a sort of sponge for the ear which can deliver antibiotics deeper into the ear). He booked Hannah in for the following week for the removal of the dressing. Hannah and the mother returned home.

158. The following day, in the evening the mother took Hannah to Hospital C with bleeding but she was discharged home shortly afterwards. On 15 th August the mother contacted Hospital D about ear bleeding and she was told to go to her GP or ENT at Hospital C. TIMEFRAME FOUR - Allegation D 6 (5)

159. On 17 th August 2023, there had been the severe bleeding which had taken Hannah to A&E at Hospital E as an emergency the day before she was due at Hospital D.

160. Dr PH examined her under anaesthetic again on 18 th August 2023, to remove the pope wick and for imaging and a biopsy. He could not recollect whether the pope wick was still there on 18 th but said it would be difficult for it to be removed and reinserted.

161. Dr PH described Hannah as a bit drowsy so on 18 th August they decided to get a CT/MRI. These were conducted with the MRA first then the CT scan followed by his procedure. Dr PH said the left ear canal lining was “grossly abnormal”. Generally although there was more blood around there was the same swelling as there had been the week before. He told Mr Dugdale that they thought a big blood vessel was causing the bleed but they could not find one that was the cause.

162. They took biopsies from the canal between the opening in the head and the ear drum for histology and microbiology. Because of the bleeding, these were less deep than ones taken later on 6 th September 2023, when the biopsies were taken from beyond the drum and into the middle of the ear. The imaging on 18 th August 2023 did not show trauma or injury but Dr PH said that the working hypothesis was infection.

163. Dr PH said that in terms of the biopsy any bony debris found could be part of the biopsy process when spicules (particles) of bone come away with the skin taken for the biopsy. He said the later finding of fungus usually relating to wood was not expected. They thought the bleed must have been caused by a big vessel but did not find the site on 18 th August 2023.

164. Dr PH commented to “get anything that deep in the ear on an awake child would be hard”. He told Miss Branigan that he had met with Hannah and the mother on various occasions but did not have any safeguarding concerns. TIMEFRAME FOUR - Allegation D 6 (6)

165. There was less evidence about this ear bleed which had occurred on 28 th September 2023. There was a photograph of Hannah’s bloodied ear in the Hospital D medical notes and a comment that the mother had reported an ear bleed. The mother had taken four photographs in seven seconds of Hannah’s bloodied ear. The ear had reddening around it as well as the blood. The evidence from the biopsies taken on 18 th August and 6 th September 2023

166. The biopsies of 18th August 2023 and of 6th September 2023, were examined by experts Dr Marnerides, the expert histopathologist and Dr Kosmidis the expert in infectious diseases. The findings made from the biopsy of 6th September 2023, have led the local authority to allege that wood had been found in Hannah’s ear which had been deliberately or recklessly introduced by her mother. The local authority contends this may have led to the infection which went from the ear to the base of the skull and then to the eye.

167. On the day Dr Marnerides gave evidence he had been provided with the most recent report of Dr Kosmidis.

168. In terms of 18 th August 2023 biopsy, Dr Marnerides agreed that fragments of tissue taken from the ear on 18 th August 2023 included non-viable bone fragments with a few inflammatory cells. It would appear from the evidence that when a biopsy is taken from an ear the skin taken away can contain some bone fragments.

169. In relation to the biopsy of 6 th September 2023, Dr Marnerides was asked to consider whether he was able to identify a ‘foreign body’ and ‘giant cells’ found in the left ear. Of relevance, he observed bone fragments and tissue, a foreign body which appeared to be vegetable matter “refractile material” and an inflammatory response to that material. In his statement he said he could not say whether it was fibres of wool or wood. Wool could be accounted for by medical intervention in the ear.

170. Dr Marnerides concluded that the histology findings in the absence of an alternative plausible medical explanation (such as natural disease), which might account for the bone fragments in the fragments of tissue taken from Hannah’s ear on 18 th August 2023 as well as bone fragments with foreign body inflammatory response to the bone fragments found on 6 th September 2023 was “best explicable on the basis of trauma to the left ear region”.

171. Dr Marnerides said that the non-viable bone fragments could be due to underlying osteomyelitis but could also be due to injury to the left ear region. If it was osteomyelitis either acute or chronic he would have expected different histological results. In his supplementary report he was unable to favour either osteomyelitis or injury.

172. He said that in the slides of 6 th September 2023, he saw no evidence of fungal infection and the vegetable/refractile matter was not fungal spores or hyphae. Fragments of wood or a wood like object, would “to my eyes” correlate to the matter he had seen and should it be the case then “their identification would in my opinion suggest insertion of a foreign object through the ear canal”. He said he could not exclude that it was fibrous cotton wool. He said he could not quantify the vegetable matter nor could he think of any tests which would identify that matter.

173. In his oral evidence after he had seen Dr Kosmidis report Dr Marnerides said that in his experience in his eyes, it was most likely to be wood. That was his first thought when he saw it. He said he had not seen it in the ear canal before but it reminded him of wood he had seen it in muscle after a death of a man who fell off a cliff and landed in trees. He said that although it looked like wood there was no histological signature which could identify it as wood rather than wool.

174. He said what he could say for sure was that the vegetable matter there was not a “bystander”, in other words, there was an inflammatory response to it. He concluded in his oral evidence that the history of Hannah’s ear issues had extremely rare complications and would be a case of multiple rare things happening in sequence to account for the findings if it were not trauma. Trauma would account for what he had seen in the biopsy of 6th September 2023. He favoured that as an explanation. There was nothing he had seen which was inconsistent with an injury. He could not say whether there had been one trauma or more than one.

175. When cross examined by Miss Branigan, Dr Marnerides said that from reviewing the histology there was evidence that there was more likely than not that there had been injury through the region of the ear canal caused by wood. When cross examined by Mr Dugdale, he said that if there had been an insertion or poking it would have caused some damage to the ear. He said the inflammatory response to the foreign material showed that it had been there for longer than a few minutes but he could not say for how long, whether days or months.

176. In his report Dr Kosmidis said Hannah had several conditions that “could be manifestations of an infectious process”. As to what originated in her left ear, he said she had otitis externa, otitis media, mastoiditis, spread of the infection in the carotid artery causing a blood clot and spread of infection in the brain through blood clots travelling via the carotid artery to the brain. He could not say whether otitis externa or media occurred first. In terms of specific bacterial or fungal causes he explained that otitis externa was caused by bacteria.

177. He reported on the biopsies of 18 th August and 6th September. He said various bacteria were isolated from culture. In the biopsy of 6th September 2023, the fungus Phlebia was found from DNA analysis. The bacteria did not help determine what the cause of the infection was. The only bacteria identified, Streptococcus agalactiae, was the only one associated with serious infections. It could have contributed to the infective process. Histological examination had shown refractile material in the ear and Dr Kosmidis said this “may explain the inflammation and/or infection”.

178. In answer to questions Dr Kosmidis said he could find no evidence that Hannah had a fungal infection. Phlebia was a fungal organism which had been identified by DNA analysis of the ear sample. Dr Kosmidis said Phlebia existed in nature inhabiting wood and causing wood rot. He said Phlebia was a “very rare occurrence in clinical samples” and was difficult to interpret.

179. He was asked whether all or any of the symptoms exhibited by Hannah could be attributable to an aggressive infectious process. He said “the otitis media, mastoiditis, carotid artery involvement and septic emboli to the brain are attributed to an aggressive infectious process”. He described the “more likely” bacteria as being staphylococcal or streptococcal and was unlikely to be fungal. The biopsy of 6th September 2023, showed a histological picture of a foreign body reaction. He explained this suggested the presence of foreign material in the ear canal.

180. In his view the pulsatile bleeding from the ear, as it was described, was not a “common manifestation either of otis externa or otitis media and is more likely to suggest either a bleeding tendency, a foreign body or injury”. He would defer to an ENT expert.

181. Dr Kosmidis considered a second mechanism suggested by Dr Marnerides, that there had been “at least one episode of insertion of a foreign object through the ear canal, likely preceded and/or accompanied and/or followed by episode(s) of blunt force trauma to the region of the left ear/left temporal bone, and complicated by infection(s)”. He said that the injuries suggested by Dr Marnerides would be complicated by infection and that Hannah’s ear, brain and skull infection was “particularly severe”. He said that following injuries as described by Dr Marnerides, the most common infections would be the common bacteria introduced via the injuries. These infections were more likely to be serious “because of the accompanying destruction of tissue and the direct introduction of bacteria into the tissue”.

182. In cross examination Dr Kosmidis ruled out an infection causing the bleeding seen in Hannah’s case. Infection results in inflammation of tissues, fever and not the sort of bleeding seen here unless there was an underlying bleeding tendency. From the extensive investigations carried out with Hannah, no such tendency had been identified. He had seen aggressive infection before but only in the setting of a pre-existing medical condition such as cancer or diabetes, a person with a weakened immune system. He had never seen pulsatile bleeding from the ear caused by an infection alone.

183. He also agreed with evidence Dr E gave that the bruising of the left eye was atypical of infection. He said it was “not common” to see bruising from an infection only. Usually the eyelids would become swollen and the eye redder.

184. He agreed that if the vegetable matter described by Dr Marnerides was wood it would fit with his finding of Phlebia as it was an organism known to be present in wood. Very little was known about Phlebia as it was not a cause of disease and so had not been studied.

185. Dr Kosmidis put the finding of Phlebia in context when cross examined by Miss Branigan. There had been two tests and only the first one had shown the presence of Phlebia. The second one had not confirmed it. The expert said that the negative test may indicate that there was very little DNA of the fungus, that the second test did not pick up the DNA or it could be a false positive. It was a low certainty. If the foreign material in Dr Marnerides test was wood then the DNA test finding of Phlebia was compatible with wood but it was not a high degree of certainty. Professor Raine’s evidence

186. Professor Raine the ear expert, was asked about the repeated ear infections and what had led to the loss of hearing and vision on Hannah’s left hand side. He said that her problems were caused by an aggressive infection that went into the base of the skull and then into her eye. He admitted that he had encountered it only once before in a child in 40 years of practice. That had been 20 years before when the treatment would not have been as thorough.

187. I have set out above what he said in relation to the Hospital B bleeding ear incident when there was no infection or perforated ear drum. He had not been shown that photograph.

188. He had not seen the photographs either of the copious bleeding from Hannah’s ear on the 17 th August 2023. When he saw them he said “oh wow”. He said that would be very unusual. He also added that without an incision he had not seen that degree of bleeding in an ear which had not been touched. He added later in his evidence that he had not seen that amount of bleeding in the absence of a cut or incision or the involvement of an artery.

189. Mr Stonor asked Professor Raine whether it looked like trauma to him and he replied that it was “high on the cards for a differential diagnosis, yes”.

190. Professor Raine did not consider that something could have been introduced into Hannah’s ear without leaving damage. He pointed out that the chain of little bones beneath the ear drum (the ossicular chain) was intact. He said that a child’s ear was very narrow and inserting something into the ear would have caused damage yet from the scans of the ear taken on 18th August 2023 there was none. The ear was a curved tube and it would have been difficult to bend something hard around the corner. It was not possible to put something straight in there.

191. The inner ear sits in an area called the temporal bone which Professor Raine described as the hardest bone in the body although he accepted that repeated infections as in Hannah’s case might have reduced its hardness. He maintained that it would need a lot of force to cause any bony disruption. The bony fragments seen in the biopsy might have osteomyelitis.

192. Professor Raine’s evidence was that although Dr Marenides had spoken of trauma, his view was that it was a primary inflammatory process which had caused erosion of bone and cochlea. Professor Raine said it had been “smouldering on for some time”.

193. Professor Raine had agreed with Dr Kosmidis’ point that infections following injuries are more likely to be serious because of the accompanying destruction of tissue and the direct introduction of bacteria into the tissue. The mother’s evidence about the ear

194. The mother in her evidence set out a chronology of ear problems that Hannah had. It started on 6 th June 2022 when Hannah had her left ear examined at Hospital B Hospital. The mother took Hannah to the GP or to Hospital C frequently with her left ear issues. She had a perforated ear drum on a number of occasions and infections. The mother had written in her statements and said in evidence how much she loved Hannah and how horrified she was by what had happened to her.

195. The mother pointed out that on 7 th February 2023, Hannah had been taken to the GP by the foster carer with oozing from her left ear and had been diagnosed with an ear infection. The implication was that this happened even when Hannah was not in her mother’s care. I did not accept that, as it was clear there was no bleeding from the ear when Hannah was in foster care.

196. The mother said that on 21 st February 2023, the morning of her second overnight with her mother, Hannah had woken up screaming in pain. The mother took Hannah to the GP. She had been tugging at her left ear and had a bit of blood from her left ear but also from her nostril. The GP diagnosed a likely left ear drum perforation following an ear infection. This discharge of blood from the ear continued off and on and led to Hannah being seen at Hospital C and Hospital D.

197. On 11 th August 2023 Hospital D inserted a pope wick into Hannah’s left ear which was blood filled. Hannah went home with ear drops. A repeat appointment was to take place on 18 th August for the removal of the pope wick and a CT scan. The ear went on bleeding. When the mother took her to Hospital C it confirmed she had a middle ear infection.

198. Hannah was due to have grommets inserted at Hospital D. The mother said that they had travelled down the day before and stayed in a hotel organised by the hospital. Hannah’s ear was still bleeding. The mother took her to the ward where a pressure bandage was applied to Hannah that evening and they were to return as planned on 18 th August.

199. Within less than half an hour Hannah had a heavy bleed at the hotel and an ambulance was called which took her and the mother to Hospital E. Hospital D had given instructions about how Hannah should be treated. She was kept in for the rest of the night and then admitted into Hospital D the following morning.

200. During August the mother said that Hannah’s ear was often packed with sterile gauze or cotton wool by nurses.

201. The mother described the difficult time she had at Hospital D. She had no money and was sleeping in a reclining chair next to Hannah. The mother described the difficulties she had putting eyedrops into Hannah’s eyes. She had to swaddle her which made Hannah even more distressed when she could not push the mother away. After a while, the mother refused to hold her for the eye drops and the nurses had to do it. She always resisted the drops.

202. Throughout Hannah’s life her mother, like many young people her age, had captured every moment, from pregnancy with the father, to walks in the park and then Hannah’s ear and eye issues. The photographs were exhibited in the bundle. They included many photographs of Hannah bleeding. She was asked why she did that and explained that it was to keep a record of what Hannah was going through.

203. Mr Stonor asked the mother about some of the photographs that she had taken.

204. On 10 th August 2023, Hannah and her mother were in Hospital D provided accommodation the night before the insertion of what was thought to be grommets. In fact a pope wick was inserted (a sponge to ensure antibiotics can reach deeper into the ear).

205. The photographs for 10 th August showed Hannah with dried blood in the ear at 09.29 hours. At 2308 hours the mother was cradling Hannah in her arms. At 0657 hours on 11 th August 2023, there was a little of what appeared to be fresh blood coming from Hannah’s ear which was still obvious at 0906am. It went from dried blood to fresh bleeding.

206. The mother agreed she had taken at least one photograph at this time, when Hannah was distressed but could not say why she had taken it. She said she was taking the photographs of the bleeding ear to keep a log of what was happening. She denied hitting the ear or poking it at around this time and said she had comforted her daughter.

207. During this period many of the photographs showed the product of the mother’s bleeding in her bowel. The photographs were mainly of blood which led to Mr Stonor’s question about whether she got a thrill from the blood and distress. The mother denied it.

208. The next allegations concerned the 17 th August 2023 when the mother came down to Hospital D with Hannah by car for the examination on 18 th . Again she took many photographs including at a hotel where Hospital D was accommodating them. The photographs showed no ear problems as Hannah and her mother explored London a little and ate at the hotel. The last photograph out and about was timed at 2036 hours. The next one at 2100 hours showed a very big bleed in the ear running down the side of Hannah’s face on to her neck. The mother took three photographs in seven seconds and six photographs in two minutes 17 seconds of the pouring blood and also of the blood on a cloth.

209. The mother said that she had taken Hannah out to rock her to sleep. She got her back and to sleep and at about 9pm she woke up crying with her ear bleeding. At 2232 hours it was still bleeding when there were two more photographs of Hannah’s ear as she sat in her pushchair. I noted Hannah had not been cleaned up in an hour.

210. The mother said she had contacted Hospital D. She got there at 2250 hours. Hannah was seen to be lethargic and dripping blood. A pressure bandage was applied and a head bandage was put in place. She was sent back to the hotel.

211. The mother took photographs of Hannah with a bandage wrapped all around her head. It covered her left ear completely. It looked as if it was tight and secure. The last of this run of photographs was at 11.30pm.

212. In evidence the mother had said that she had come out of the elevator on the third floor when it started bleeding again. It was as she got to the door of their bedroom. She called an ambulance and got in the lift and went back down.

213. At about one hour later, at 0037 hours on 18 th August 2023, the mother is in an ambulance on her way to Hospital E taking photographs of Hannah with a sopping bandage around her left ear.

214. In evidence the mother denied lifting the bandage and said Hannah had been rubbing her head against her. The implication was that Hannah had dislodged the bandage. Discussions and conclusions - ears

215. In terms of the ears, the difficulty was coming to a conclusion about whether the bloody discharge from the ear at various times was an inflicted injury or as a result of a continuing and worsening infective process. Miss Branigan’s strongest argument was that there was no sign of external trauma or internal trauma. Professor Raine was concerned about that and was of the view that other than the bleeding there was a continuing infective process.

216. Professor Raine made the point that there was no damage inside the ear or signs of trauma to the outside which he would have expected in the case of an inflicted injury or trauma. The other witnesses whilst not ear experts (although Mr Kosmidis was an expert in infections) were of the view that it was more likely to be trauma. None of the witnesses had ever come across bleeding of the sort seen which had been caused by infection in the ear. It was inexplicable as far as they were concerned. Professor Raine’s memorable spontaneous response when he saw the photographs of 17 th August for the first time as he gave evidence was: “oh wow”.

217. The other issue was the weight to be given to the foreign material found in the ear. I gave it some weight as the evidence came from two different directions. Mr Marnerides’ first thought on seeing vegetable matter on the slide from the biopsy of 6 th September 2023 was that it was wood. He had preferred that material to wool. He knew it was foreign matter because there was an inflammatory response to it.

218. Wool might have been a more obvious substance to have been found in the ear when one considers the amount of gauze etc that had been put into or over Hannah’s ear in this period but confirmation of wood came from the admittedly weak conclusion of Dr Kosimidis. He had found the DNA of the fungus Phlebia which is found in rotting wood. It was weak because only one test of the two showed the presence of Phlebia. Putting those two experts together, it seems that on 6 th September 2023, there was presence of undoubtedly minuscule fragments of wood in the deeper ear canal. It was not a bystander as the doctors described it because it caused an inflammatory reaction.

219. The first proceedings in which there was an ear bleed in 2022, had expert paediatric evidence which looked at whether an ear injury had been caused by the mother. Dr AJ considered it was not caused by an inflicted injury although accepted that an ENT expert could be instructed. The evidence above was that Dr AA who examined Hannah and saw the blood said it was an unusual presentation for the infection that she found. Significantly the bleeding happened a few days before the infection was found. A strong point made by Miss Branigan was that there were safeguarding concerns about Hannah in 2022 and she would have been examined very carefully. She is right.

220. There are arguments going both ways when it comes to considering the bleeding of 2022. One of the weaknesses of the local authority case is that it cannot say how it happened. As agreed by the experts and the treating doctor at the time however, this was a very unusual occurrence. It was also a precursor of a pattern of ear bleeds. On balance stepping back and looking at the evidence as a whole, I find the mother caused the ear bleed on 29 th May 2022. I do not consider there is sufficient evidence to say the mother caused the ear infection which followed the injury.

221. The most probative element of the next bleeding alleged to be caused by the mother is the date. It took place on 21 st February 2023 a mere five days after Hannah had returned to her full time care and after eight months when there had been no bleeding. It was not such a serious bleed that the GP considered Hannah should go to hospital. There was a middle ear infection and the GP felt there may have been a perforation in the ear drum.

222. A week later the mother was in the hospital and what was found was a serious discharge which was bloodstained and the middle ear infection.

223. This also started when Hannah was alone with the mother. That and the date inform the decision I make. Added to that is the subsequent pattern of bleeds when the mother is alone with Hannah and the lack of bleeds when Hannah is either not in her care or the mother is being supervised. The February ear bleed is part of the pattern of injury. I find it proved.

224. The next allegation relates to the fall from the high chair on 16 th July 2023 which according to the mother caused an ear bleed. The mother’s explanation was unconvincing. She said she knew that Hannah sits in high chairs with her legs drawn up. If she had been on her telephone this was poor parenting behaviour but I did not accept that this young woman sitting so close to her daughter would have missed her daughter’s fall. It is difficult for a toddler to get to their feet in a high chair, it takes time for them to get up. The staff in the hospital heard Hannah scream. Part of my consideration is that this injury to the left ear happened when Hannah was alone with her mother. On balance I find this proved.

225. I consider next 11 th August 2023 allegation. The night before there is no blood in the ear. On 11 th in the morning there are five photographs taken in 14 seconds. The local authority alleges that the injury was caused at around 0657 hours when the photographs were being taken. Later the same morning, there is new blood in the ear at around 0906 hours. This is shown in three photographs taken in seven seconds.

226. The evidence I found striking were the photographs taken by the mother of Hannah as she bled on 12 th . The photographs started at 1837 hours when she was at home. Between then and 1954 hours, the mother had not wiped away the blood trickling down Hannah’s neck. For one hour and a quarter she took photographs of her child, but she did not clean or mop up the blood. I found this evidence concerning, it made me question whether the mother was indeed getting some pleasure from what she was witnessing. This picture added to the pattern of the ear bleeds.

227. I found the allegation of 11 th August 2023 proved.

228. The next allegation was 17 th August 2023 when Hannah had been brought down the night before she was going to be examined at Hospital D. There was a bleed, a bandaged ear at Hospital D, another bleed and an ambulance ride where the bandage was seen not to be covering the ear. The mother had denied uncovering the ear between the hospital visits.

229. I noted three matters about the evidence concerning this date. The first were the differences in account the mother gave. In evidence she said the bleed happened as she got back to the hotel from Hospital D and had reached their bedroom door. When the mother got to UCH, she told the A & E doctor that the bleed had started when she had returned back to the hotel from Hospital D and “placed Hannah down to sleep”. There was then a “torrential, pulsatile bleed from the left ear”. Mr Stonor asked the mother about this difference in her accounts and there was silence. When pressed she said she did not go inside the bedroom.

230. The second matter was that the bandage over the ear had been lifted between Hannah leaving Hospital D and her being taken to Hospital E by ambulance. The photographs are clear, the bandage no longer covered the bleeding ear. The mother denied moving the bandage. I cannot see why the paramedics would have done so and the mother did not suggest they had. Hospital D had put the bandage on carefully and tightly. It was secured by plaster on the side. It did not appear to have unravelled.

231. I did not accept the mother was telling the truth when she said that Hannah was rubbing her head on her. The inference she wanted me to draw was that Hannah had moved the bandage herself. Apart from anything else the ear must have been painful and I doubt she would have wanted to rub it. Furthermore from the look of the bandage, to move it upwards, Hannah aged 20 months, would have had to insert her hand under it, exerting force to lift it. It did not seem to me that this was likely. A much more likely explanation was that the mother had lifted it to do something to the ear and was not telling the truth.

232. A final comment about the run of photographs taken by the mother. The mother was taking selfies of herself with Hannah in the ambulance on the way to Hospital E over a five second period. The mother accepted Hannah was distressed. The mother seemed unconcerned by the ear which had never bled quite this much before. The photographs show that it must have been a shocking sight. I do not give much weight to this, but I would describe the mother as looking smug. I considered whether this could be the “flat effect” noted in interview by the psychiatrist but I consider it is something more concerning.

233. I find this allegation proved.

234. The final allegation is a bleed reported by the mother on 28 th September 2023, who then took four photographs of Hannah’s ear in seven seconds. It is similar to many of the other allegations made. I find that proved.

235. The overall picture painted by the evidence that the mother cut Hannah’s eyes and also cut the PICC line and the cannula is added to by the evidence that the ear bleeds (and eye bleeds) only occurred when Hannah was alone and in the care of her mother and not when she was in foster care.

236. I am satisfied on balance that one probable explanation for the bleeding ear was that the mother has been introducing something made of wood into Hannah’s ear. I accept that Professor Raine (and other witnesses) pointed out how difficult it would be for that to be done. Professor Raine said in reply to a suggestion that a cocktail stick might have damaged the ear that it would be like poking a tank with a feather. I accept too that other than the very frequent perforations in the ear drum, there was no other sign of damage beyond that included to the ossicles. I find nevertheless based on the evidence looked at as a whole that the mother was poking or causing trauma to the ear and this caused the bleeds as set out above. Eye bleeds – Hospital D 3 rd September 2023 to 27 th September 2023

237. The local authority alleged that Hannah had left eye bleeds which were caused or exacerbated by inflicted injury on various dates. They alleged the mother inflicted direct trauma on Hannah. Just as was the case with the ear bleeds, the eye bleeds occurred when Hannah’s infection was moving from the ear, via the base of the skull into the eye.

238. Miss Branigan’s case was that the eye bleeding was associated with the development of Horners syndrome from 26 th August 2023. She said the mother’s denials that she had inflicted or caused injuries were supported by the evidence of the eye expert Dr Newman. The mother admitted to taking the photographs of the left eye in the way that I have set out below and also of Hannah’s distress. She said she had taken the photographs to keep a log of what was happening or because she just takes photographs. On occasions when asked she said she did not know why she did but that she takes them all the time.

239. In terms of the eye bleeds, I heard evidence from Dr E who was the Senior Clinical Fellow at Hospital D at the time. She had become involved in Hannah’s care on 18 th August 2023. Having observed atypical bleeding from the ear, she arranged an emergency MRI as well as a CT temporal bones under general anaesthetic. The findings were in keeping with a left skull base infection. The inflammation was extensive and involved the “great vessels” supplying the head and neck on the left. She had arranged the biopsy on 18 th August.

240. By 28 th August 2023, Dr E noticed that Hannah had unequal pupils on the ward round. A neurological review was arranged and the working diagnosis was Horner’s syndrome related to inflammation around the carotid sheath.

241. On 29 th August Hannah had worsening eye redness. The mother said that Hannah had been given a warm bath and this had caused her to scream and for her eye to become swollen. On 2 nd September Hannah developed bleeding from the left eye. It was shut by 5 th September 2023. From then onwards there were a number of eye bleeds. They never started when the nurses or doctors were present, it was always the mother who reported them.

242. On 7 th September Hannah underwent a canthotomy which was a cut at the outer corner of the eye which would allow the pressure in the eye to reduce.

243. Dr Newman said that the eye problems started in September 2023. The clinical findings were consistent with an inflammatory process even if no cause had been found for it. In his 40 years he had never seen the combination of base of skull neck vessels and orbital disease. He said that had there been trauma he would have expected to see outwards signs such as subconjunctival haemorrhaging or much more severe injuries. He had checked the scans and there was nothing to suggest organic or metallic matter and there was no air in the orbit either. He accepted he was not a radiologist but he had found no clinical observation that something had been introduced into the orbit via the conjunctiva or eyelids.

244. In terms of pure blood coming out of the eye, he said it was really unusual without a defect or point of bleeding. In Hannah’s case it was the bleeding before the 7 th September 2023 canthotomy which concerned him the most because there was no cause for the bleeding identified. Most children with orbital syndrome did not have bleeding unless there had been surgery or an obvious bleeding point. He agreed that the eye had issues such as unequal pupils, venous congestion of the left eye and Horners syndrome but it had been relatively healthy as at 26 th August 2023.

245. Dr Newman said the eye becoming engorged in the bath because of the heat on 29 th August 2023 was also a sign of Horners syndrome although he said it could possibly be trauma. In the photographs of 2 nd September and 3 rd September, he said the bruised and swollen eye could be consistent with infection and trauma if there had been an impact injury.

246. Mr Stonor took him through the following days when Hannah’s left eye was swollen and red. He was pressed repeatedly to find trauma rather than infection. He resisted the questioning and said if there had been trauma he would have expected to see other injuries in the eye depending what the trauma was.

247. He explained that after the surgical intervention on 7 th September 2023, the tissue would have been friable and may well have been oozing blood from pouches under the eyelid which can occur. This causes lots of swelling and then episodic bleeding. He also explained that Hannah was on aspirin and that would extend the bleeding time although it does not reduce the threshold for bleeding.

248. The healing processes for the procedures which were undertaken on 7 th September would be between two and six weeks with the majority of the healing having taken place by the earlier date. Dr Newman’s evidence was that the bleeding which had taken place before 7 th September 2023, concerned him the most.

249. He was also taken through the later swelling of the eye and explained that orbital disease can get better then worse.

250. In cross examination he also made it clear that the Hospital D left eye was explicable by the inflammatory process and the only part which was inexplicable was the bleeding prior to the first intervention.

251. In view of Dr Newman’s evidence, I concentrate therefore on the first bleeds which were reported by the mother. The first two which were alleged took place on 3 rd and 6 th September 2023.

252. The strongest piece of evidence when I came to consider the bleeds from the eye were the photographs taken by the mother on 3 rd September 2023. She took a number on the day of Hannah’s eye bleed. These were taken between 2157hrs and 36 seconds and 2200 and 50 seconds. In a three minute 14 second period, 15 photographs were taken.

253. In these photographs Hannah first appears to be asleep on a lightly blood stained pillow which the mother agreed was from the ear. Then at 2157 and 58 seconds and 2158 and 1 second, she is sitting up distressed and crying. Her left eye is swollen and there may be some blood on the bandage over the ear.

254. At 2158 and 34 seconds and at 36 seconds, the photographs show a hand gripping a distressed Hannah. The mother in evidence admitted it was her hand. At 2158 and 56 seconds and 2159 and three seconds, Hannah is sitting up distressed holding her bunny. Eight seconds later at 2159 and 11 seconds, at 2159 and 15 seconds and then at 17 seconds the bunny is no longer in Hannah’s arms but has been put just to one side of her hanging on the side of the box bed, she continues to be distressed.

255. 29 seconds later at 2159 and 46 seconds, Hannah has her hand to her face and the bunny is still next to her hanging from side of the box bed, she seems distressed. At 2159 and 51 seconds (five seconds later) blood can be seen along the line of the eyelashes to the left eye but the bunny and another soft toy have been returned to Hannah. 28 seconds later (at 2200 and 21 seconds) she is holding the teddies to her face cuddling them. Seven seconds later, at 2200 and 28 seconds, what appears to be watery blood is running from her eye. 22 seconds later (at 22.00 and 50 seconds) the blood has been wiped away. She is still distressed.

256. There is just under three minute gap and there is a photograph of blood on the sheet at 2203 and 43 seconds. Three seconds later is a photograph of Hannah clutching soft toys to her face. At 2203 and 50 seconds, she appears to be still sitting and half asleep clutching her bunny. At 2204 and 26 seconds, she is lying down in her cot and appears to be asleep.

257. It was suggested to the mother by Mr Stonor that this was a photographic record of her abusing her daughter. The mother denied this. She was also asked whether at any point she had comforted Hannah and said in reply that she had pushed the call button. For about three minutes Hannah had been very distressed, the mother had taken away her cuddly bunny and had taken numerous photographs of the child’s distress and bleeding eye.

258. Having considered those photographs in detail, I cannot see why the mother woke Hannah up in the first place. She was asleep. It was about 10pm. I do not see why the mother sat Hannah up. It was nighttime. I do not understand why she then held her in what seemed to me, anyway, to be in a firm way before sitting her up 20 seconds later. Further I did not understand why the mother had removed Hannah’s bunny which she was clinging on to. The mother accepted that she had removed Hannah’s bunny and when asked why, she said it was so that she could take a photograph of her.

259. Hannah had an eye bleed. It was her first, but what then followed shortly afterwards was the mother leaving to have a cigarette with another mother at the hospital.

260. I found that what the photographs showed were not the actions of a loving or concerned parent who wanted to comfort their child. I noted that the door to the cubicle remained closed during this time as was shown by the photographs and the mother was in a private space at night where she could wake her toddler up and treat her in the way I have set out above.

261. I had no doubt that during the period the photographs were taken, that Hannah’s left eye was injured in some way.

262. The next allegation is that on 6 th September 2023, that the mother caused an eye bleed. Again this is supported by the mother’s photographs, this time six photographs in about seven minutes, with a number just a few seconds apart. As before they show Hannah distressed and then blood coming from her eye. This is similar to the 3 rd September 2023 allegation.

263. On balance, I make findings B 3 (1) and B 3 (2). In view of Dr Newman’s evidence whilst accepting as I do that allegation B 3 (4) (the box bed fall) is very suspicious, I make no further findings in relation to the Hospital D eye.

264. I have made findings that Hannah has been caused trauma and injury by her mother. In the Hospital D ears and eyes findings I have not been able to find out exactly how Hannah was injured.

265. I have set out above my views that the photographs may show that the mother has an interest in blood, the mother’s own blood and Hannah’s. I was struck that even taking into account that the mother was not articulate, she was not able to explain why she wanted to take so many similar photographs of a bleeding eye or ear. I suppose one photograph to show the doctors might have been acceptable but to take numerous ones was odd. The other photographs I found disturbing were ones where she took numerous shots of her distressed daughter. In the end I was driven to agree with Mr Stonor for the local authority that by taking photographs of the blood and distress the mother was documenting her abuse of Hannah.

266. A whole series of photographs showing Hannah’s ear bleeding were taken on 12 th August starting at 1837 hours. This was not one of the the LA’s allegations against the mother. She was at home and at some point went to Hospital C. I noted that between 1837 hours and 1954 hours, one hour and 17 minutes, the mother had not wiped away the blood which was trickling down Hannah’s neck. It was coming onto or very close to what she was wearing.. The mother said when that bleeding started she had been possibly in a different room to her aunt and uncle.

267. On 14 th August 2023, she had taken photographs of a small but what looked like a fresh ear bleed at about 2253 hours, the day before she was going to Hospital D.

268. On 15 th August 2023, there was a lot of blood from the ear as shown in photographs taken at about 1601 hours before what appeared to be even more fresh blood in photographs taken at about 2100 hours. On this occasion the mother mopped up the blood. The mother said she was taking all these photographs as the bleeding was happening so often.

269. I am not going to speculate but there was evidence that the mother kept souvenirs such as an oxygen mask left at the foster carers home. The fact that she denied this when it can only have been hers, made me think that it was of some importance to her. Of course it may have been that she was covering up the fact that she had stolen it. There was also the possibility that the mother enjoyed the attention that she received in hospital. I remind myself that I must not speculate about the mother’s motivation for what I have found has happened.

270. I make findings: A 1 and 2. B 3 (1) and (2), 4, C 5, D (1) to (6), 7, E 8, 9, save for I have removed the words “deliberate or reckless” so it will read “the introduction…”, F 10, and 12, G 13, (1) (2) and (3) and 14.

271. In all the circumstances, at the relevant date, Hannah has suffered and is at risk of suffering significant physical harm, emotional harm and neglect attributed to the parenting provided by her mother, not being what it would be reasonable for a parent to give to her.