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A County Council, A mother, A father and XYZ [2005] EWHC 31 (Fam)

Findings of fact in an alleged Munchausen by proxy case

Read a digest of this judgment

Case No: WR03C00142

Neutral Citation Number: [2005] EWHC 31 (Fam)

IN THE HIGH COURT OF JUSTICE

FAMILY DIVISION

Royal Courts of Justice

Strand, London, WC2A 2LL

Date: 18/01/2005

Before :

MR JUSTICE RYDER

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Between :

A County Council Applicant

- and -

A Mother 1st Respondent

- and -

A Father 2nd Respondent

- and -

X, Y and Z

(by their Children's Guardian) 3rd, 4th & 5th Respondents

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Miss L Meyer (instructed by A County Council)

Miss J Macur QC, Miss M Friel (instructed by Wright & McMillan Bennett) for the mother

Mr L Messling (instructed by Thursfields) for the father

Mr K Barker (instructed by Thomas Horton & Sons) for the guardian

Hearing dates: 6-29 September; 1 & 15 October 2004 and 17 January 2005

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Approved Judgment

I direct that pursuant to CPR PD 39A para 6.1 no official shorthand note shall be taken of this Judgment and that copies of this version as handed down may be treated as authentic.

.............................

MR JUSTICE RYDER

This judgment is being handed down in private on 18 January 2005 It consists of 38 pages and has been signed and dated by the judge. The judge hereby gives leave for it to be reported in the anonymised form agreed by the parties but in no other form.

The judgment is being distributed on the strict understanding that in any report no person other than the advocates or the solicitors instructing them (and other persons identified by name in the judgment itself) may be identified by name or location and that in particular the anonymity of the children and the adult members of their family must be strictly preserved.

Mr Justice Ryder :

Introduction:

1. X, Y and Z are the children of M, their mother.

2. X, who was born on the 16th November 1989, is now 15. His father is believed to have been L who both mother and F (the father of the two younger children) say died by suicide in 1990. It necessarily follows that X has never had knowledge of his birth father. As a consequence of these proceedings and in particular from August 2003 until very recently, X lived in foster care provided by a commercial company. He moved there after a 'voluntary placement' with F had broken down.

3. On the 15th November 2004 and after submissions made in writing, I approved a plan to move X back into his mother's care, where he will remain unless and until there is any altered welfare assessment of his needs.

4. Y was born on the 25th June 1994. He is 10 and lives with his father, F and his sister Z. Z was born on the 12th March 1996. She is 8 and lives with her father, F and her brother, Y.

5. Mother and F (who I shall where appropriate refer to as father in this judgment) were married on the 25th June 1995. Accordingly F has parental responsibility for the 2 younger children of the family.

6. Mother has supervised contact with each of the children, Y and Z, twice a week. Contact is available between X and F but X has chosen not to take this up.

7. The local authority is A County Council. Their formal applications are for care orders in relation to each of the 3 children.

8. Z's proceedings began by an application for an emergency protection order which was granted on the 10th March 2003. The application for a care order followed on the 11th March 2003. The first interim care order in respect of Z was made on the 17th March 2003 and that order has been renewed by agreement until today.

9. On the 20th August 2003 applications for care orders were made in respect of the two boys. No interim orders have been made in relation to the boys having regard to the voluntary nature of their placements.

10. This is a split hearing i.e. the intention of the case management undertaken by Mr Justice Kirkwood is that findings of fact should be made by this court so that any necessary assessments and reports relating to the welfare of the children can have regard to the facts as found. The welfare decisions relating to the children are to be made at a hearing in 2005.

11. At the outset of the proceedings F indicated his intention to care for all 3 children on a permanent basis and to apply for residence orders if appropriate. Whatever F may wish so far as X is concerned he is prepared to allow the present placement with his mother to continue for the time being. Notwithstanding this, he remains concerned about X.

12. M wishes to resume the care of all 3 of her children or in the alternative to exercise the least restrictive contact as may be commensurate with their welfare and placement.

13. M faces an outstanding criminal trial on a charge of child cruelty relating to Z which I understand is to be listed after the conclusion of this hearing.

14. The court's papers extend to 18 bundles including copies of all potentially relevant medical, healthcare and social care records (in total well over 5,000 pages). Unusually, almost all of the documentation is relevant and the majority of it was used extensively during the hearing.

15. 66 witnesses were warned to attend to give oral evidence and the case was estimated at 15 working days (but by the time the papers arrived the witness list had increased and it was already known to be likely to last for 18 working days). In fact there were over 20 days of evidence and submissions. The local authority gave notice that it would if necessary rely upon the evidence of up to 124 witnesses from the statements filed.

The Background:

16. F says that he met M in 1991. They were married one year after the birth of Y on the 25th June 1995. They finally separated in September 1999 and all three children remained in the care of their mother with extensive contact with and the significant involvement of F. A decree absolute of divorce was pronounced on the 11th February 2004.

17. As father says in his first statement to this court made on the 30th April 2003, although there were matters about which he disagreed with mother, for example, whether Y ever suffered from Dyspraxia or had any continuing need for glasses (he was initially prescribed them by an optician when aged 5 or 6 but effectively never used them), there were also matters about which at that early stage in these proceedings he agreed, namely:

i) 3 weeks after birth he and a friend of his, D, witnessed Z having a seizure

ii) he has seen Z having other minor fits but never a 'grand mal' fit

iii) Z suffered from 'wobbly days' that could last from a few hours to 2 to 3 days

iv) The wobbly days reduced in frequency from aged 5 to 7 i.e. between 2001 and 2003

v) Z regularly complained of pains in her hips and legs, and

vi) Z could be verbally abusive and aggressive to her parents and brothers during wobbly episodes.

18. Father was then of the opinion that mother had been influenced by other parents whose children had healthcare difficulties to the extent that there is a clear implication that he was then concerned that she was convinced that Z had mild learning disabilities and that she needed a wheelchair. As I shall in due course relate, the former conclusion was supported on more than one occasion in 1997 as an objective diagnosis by medical specialists. The need for the wheelchair remains in issue in these proceedings despite its professional prescription.

19. Over the period from 1999 to 2001 and as a result of his own care of the children father says that he came to realise that the children and in particular Z did not suffer any health problems when they were with him. As the medical history relates this period coincides with the lack of any significant history of seizures for Z (only two in 1999) and a significant improvement in all reported areas except her aggressive behaviour until a reported fall on the 14th June 2001.

20. In father's first statement to the police on the 11th March 2003 he was even more supportive of mother and more descriptive of Z's ill health. In this, his earliest statement of recollection, he gave details of the following:

i) Z's ill health all her life from a very early age

ii) A couple of apnoeic episodes

iii) Z's inability to hold herself up and her referral for suspected cerebral palsy

iv) Z's complaints that she had severe pain in the legs and hips that was ameliorated by Baclofen which is used to treat spasticity

v) Z's tendency to walk on her tip toes

vi) Wobbly days when Z could not control her limbs and when she was drowsy and appeared drunk: she would be aggressive and her eyes would bulge and turn to the sides

vii) Z's use of a wheelchair when she could not walk long distances.

21. He says that mother led him to believe that Dr S had undertaken a blood sugar test on Z and that the result was definitely diabetes and he says that he had witnessed mother undertaking blood sugar tests on herself, himself and Z that would be supportive of that proposition.

22. For reasons that I shall deal with in more detail, I have come to the conclusion that immediately after Z's proceedings began in March 2003 when the issues were as fresh and raw in his mind as they were ever going to be, F was an accurate if somewhat impressionistic reporter of his marriage and the children. He was still on balance an accurate historian one month later. Thereafter, as a consequence of being drawn into the police investigation and his own family's antagonism towards mother, his reliability and credibility were damaged.

The Precipitating Circumstance:

23. Z was admitted to the 'A' Royal Hospital on the 22nd February 2003 with a history of raised blood sugar levels as monitored by mother who is herself a diagnosed diabetic. She was discharged on the 24th February 2003 only to be re-admitted a day later.

24. It is alleged that between the 22nd February 2003 and the 7th March 2003 mother fabricated, falsified and / or tampered with urine test results and blood sugar test readings so as to suggest that and/or cause Z to be diagnosed as having diabetes.

The Issues:

25. The local authority make the following allegations:

26. Z is a child of normal medical health, in particular:

i) It is medically certain that Z does not suffer from diabetes mellitus

ii) It is clear that Z does not now suffer epilepsy

iii) Z is not suffering from ataxia or channelopathy

iv) Z does not suffer from any organic or neurological disorder resulting in reduced mobility or difficulty in walking

v) Z is not suffering with kidney or bladder problems (including incontinence)

vi) The removal of Z from the numerous medications prescribed has not resulted in any deterioration in her health, adverse consequences or re-occurrence of any neurological symptoms.

27. While responsible for the care of all three children M has:

i) Reported falsified or fabricated blood sugar readings for Z, including the following:

a) 22/02/03 a reading of 14mmol

b) 24/02/03 a reading of 18.3mmol

c) 25/02/03 a reading of 14.4mmol

d) 25/02/03 a reading of 21mmol

e) 26/02/03 a reading of 26.4mmol

f) 26/02/03 a reading of 23.1mmol

g) 26/02/03 a reading of 22.2mmol

h) 27/02/03 a reading of 17.4mmol

i) 04/03/03 a reading of 15.2mmol

j) 06/03/03 a reading of 14.2

k) 07/03/03 a reading of either 14.7mmol or 14.2mmol

ii) Falsely reported to others including medical staff that Dr S had tested and found a high blood sugar reading for Z when she knew that he had not carried out any such test:

a) to Dr C as 21.1mmol

b) to nursing staff as 19mmol

c) to JG as above 20mmol

d) to Dr F on 27/07/03 as 21mmol

e) to F that Dr S had done a blood test and the result was definitely diabetes

iii) Produced urine samples falsely claiming that the samples were Z's, or tampered with Z's samples by mixing them with urine from another source or by adding substances to them in order to produce positive glucose readings: including on the following dates:

a) 25/02/03

b) 26/02/03

c) 04/03/03

d) 06/03/03

e) 07/03/03

(in the alternative, paragraphs (d) & (e) represent instances of Mother administering a non prescribed drug to Z)

iv) Exaggerated or falsely reported episodes of fitting/seizures in Z after the first six months in her life

v) Inappropriately fostered an atmosphere of illness or disability in Z by exaggerating, over-emphasising or contributing to the existence of her "wobbly days"

vi) Inappropriately fostered an atmosphere of illness or disability around Z and/or encouraged Z in presenting as unwell or disabled, in particular as to her mobility, including in the following ways:

a) the use of specialised buggies and/or wheelchair

b) the development of or persistence in toe-walking

c) the continued use of specialised footwear

d) the continued use of protective headgear

e) the continued refusal of Z to walk between December 2001 & January 2002

f) inaccurately reporting concerns regarding Z falling

g) approaching members of housing & education authorities on the basis that Z was a child with considerable disability

vii) Exaggerated and/or fabricated instances of urinary incontinence with respect to Z, including:

a) 15/04/02 reporting "long standing bedwetting" problems to the GP

b) reporting to school staff that Z was coming home with underwear that she had wet at school but was dry by the time she got home

c) 16/04/02 reporting to health centre worries regarding the number of 'accidents' Z is having (7 a day); when met out of school said to be wet, has red inner thighs & smells

d) 11/10/02 reporting to Nurse E Z was never dry – wore pull up pants in the day and nappies during the night, the wetness would vary between being damp or being soaked but that she would never be dry

e) 09/03/03 reporting to Nurse F that Z had a wetting problem and that it was like a dripping tap that couldn't be turned off and spoke of how when she collected her from school Z would smell of stale urine where she had been wetting herself

f) 09/03/02 fabricated an incident of bedwetting in hospital

viii) Exaggerated behavioural difficulties she experienced from Z or in the alternative struggled to manage Z's behaviour in a way not experienced by the School or Z's father

ix) Caused, facilitated or encouraged each of her children to present with a complaint of hip-pain when there was no underlying cause for such complaint and in the process falsely represented a diagnosis for X of Perthe's disease and for Z a diagnosis of Huntington's Chorea as follows:

a) X's presentation in June 1995 & January 1996

b) Y's presentation in December 2000 & March 2002 & November 2002

c) Z's presentation in January 2002

x) Unnecessarily and inappropriately administered pin prick blood tests to the other children

xi) In the alternative, it is alleged that the symptoms exhibited by Z and described by mother were caused by the careless or deliberate maladministration by her of prescribed medications at increased doses.

28. The local authority further allege that the harm caused to Z and or the likelihood of harm to Z flowing from the above behaviours of the Mother included the following:

i) The administration to Z of unnecessary pharmacological treatment

ii) The exposure to the potential side effects of such pharmacological treatment

iii) Unnecessary & invasive (albeit minor) procedures such as blood tests both pin prick & venous

iv) The provision to Z of unnecessary non-pharmacological treatment

v) Social stigmatisation

vi) Reinforcement of the 'sick role' in Z's mind

vii) Adoption by Z of the 'sick role'

viii) Unnecessary absences from school for medical appointments and treatments and potential consequences of such absences to her social & educational development

ix) Impaired social functioning (as a result of being in a wheelchair, wearing a helmet, wearing nappies; being given various labels of ill health by her mother)

x) The serious risk to her health of the prescription and administration of insulin had an incorrect diagnosis of diabetes been given

29. In all the circumstances of the case and on the balance of probabilities Z was the subject of 'fabricated or induced illness' (also referred to in the papers as 'Munchausen's Syndrome by Proxy').

30. In all the circumstances of the case and on the balance of probabilities the children Y and X were at risk of receiving the same care and treatment as their sister.

31. In so far as there is any logical order in which to consider the allegations that concern Z, they are probably best dealt in the order of their presentation with the exception of the precipitating circumstances of these proceedings. I shall consider the evidence under the following thematic headings:

i) The existence of diabetes

ii) The existence, nature and extent of seizures

iii) The nature and extent of 'wobbly days'

iv) The existence, nature and extent of ataxic symptoms and any neurological cause

v) The maladministration of medication

vi) The nature, extent and cause of behavioural difficulties and developmental delay

vii) The existence, nature and extent of incontinence

viii) The relevance of factitious illness or MSBP.

32. Mother denies that she has fabricated or induced any illness or that she administered medication other than that which was prescribed and in the manner it was advised. She denies false reporting of any symptoms. Importantly, she concedes that there is evidence that she tampered with Z's urine samples but she asserts that she has no recollection of doing so. She denies harm or risk of harm and does not agree that there are facts sufficient to satisfy the threshold criteria in section 31 of the Act.

33. Father accepts the experts' consensus that Z has suffered significant harm and that each of the children is likely to suffer significant harm in the care of their mother. I place on record the fact that there is no allegation against father hence the voluntary nature of the placements of the children with him.

Chronology and Medical History:

34. The allegations made against mother have to be seen in the context that many different medical diagnoses have been made concerning Z during her relatively short life. It is of course implicit in the allegations that mother has faced that some but not necessarily all of the diagnoses were based upon inaccurate histories provided by her.

35. The following is an extract in chronological form of some of the more important observations, records, examinations, test results and diagnoses that were in fact made by clinicians and others during the relevant period of Z's life. The table is extracted from the local authority's more comprehensive chronology to show the development of the various presentations from the initial history of complaint to the diagnosis (provisional or confirmed) over time. While there remains dispute about the accuracy of the history upon which any opinion or diagnosis is based in particular where that history comes exclusively from the mother (or mother and father where father relies only on mother), the chronology as extracted below is, I find, an accurate record of Z's medical history.

36. I shall comment further on the effect of the reliability of the mother upon the various elements of that history and for that reason the extracted chronology should not be relied upon without cross reference to the Judgment that follows.

12th March 1996

Z born (prematurely)

Approx 21st-25th April 1996

Father observes fit in car

Z admitted for 4 days to K Hospital History of 10 min convulsion

24th April 1996

EEG normal

14th May 1996

Z seen for review in outpatients by Dr F

History of fits – said to have been witnessed by Mother, Father, other relatives & colleagues of Father

18th June 1996

Z taken to GP

History of partial fits 3-4 x per day & generalised fit on day lasting 5 mins (grand mal fit)

18th-19th June 1996

Z admitted to hospital

No abnormality found

27th-29th June 1996

Z admitted to hospital

History apnoea attacks

July 1996

Z's cranial ultrasound scan – normal

2nd August 1996

Z admitted to hospital

History of 3 fits at home

No abnormality on neurological or general examination

12th September 1996

Z referred to Dr G (neurologist) & GG (physiotherapist) by Dr F

Non-specific neurological signs – mild head lag, moderate extensor thrust of neck, slightly stiff in arms & slightly exaggerated reflexes

24th September 1996

EEG normal

30th September 1996

CT scan normal

9th-10th October 1996

Z admitted with history of asthma

12th November 1996

Z first seen by Dr G

Evaluation at time =

  • Mild form of diplegia? going to be spastic, associated with prematurity & with a good prognosis
  • Unusual familial form of epilepsy
  • & peculiar unexplained posturing of head at night time

8th April 1997

Z seen by Dr G

On examination few abnormal signs… no evidence of cerebral palsy… may well have been a mild motor delay

21st June 1997

Z taken to GP after apnoea attack

History – found in cot by Father not breathing & grey in colour

On examination nothing abnormal

1st July 1997

Overnight sleep study at B Hospital

Reported to be normal

12th August 1997

Outpatients appointment – Dr C

"Clearly no neurological disorder or serious motor deficit. Signs however that mental development & speech and language development are delayed"

22nd September 1997

Outpatients appointment

"..cognitive development & speech and language clearly still delayed by 3/4 months …may be some ongoing intellectual delay/learning difficulty"

October 1997

Z referred to Clinic Speech Therapist

Alleged feeding difficulties

6th November 1997

EEG normal

28th November 1997

Z seen by Dr G

By this time no evidence of cerebral palsy

?intermittent ataxia (unsteadiness due to epilepsy or metabolic or chemical conduit)

27th January 1998

EEG report during a "wobbly attack" normal

24th March 1998

Z seen by GP

History of increasing frequency of fits – suffered series of seizures at nursery the previous day and 2 convulsions on day of attendance

7th April 1998

History given to GP Z having short lived absences where would become floppy and unresponsive did not go to sleep after these instances (wobbly episode)

12th May 1998

Z reviewed by Dr G

On examination mild hypotonia.? Wobbly episodes = ? benign paroxysmal vertigo

14th June 1998

Z seen in A&E then admitted

Struck head when lifted by dad – said to have had brief absence seizure

July 1998

Video of Z taken

Speech delay recently evaluated at 6-8 months

22nd November 1998

Z seen by Dr G

Few abnormal signs on exam other than mild floppiness ? channelopathy (to explain intermittent unsteadiness)- paraphrased in 2002 by Dr GR as "some form of ataxia due to calcium channel blocking"

27th January 1999

Parents meet with PC (psychologist)

Problems reported to be hitting, kicking, hair pulling throws self on floor, obsessive, will not sleep

24th February 1999

Ambulatory EEG over 3 days normal

16th March 1999

EEG normal

Unusual frequency mixture but nothing to suggest seizure disorder

17th March 1999

Child Development Unit full multidisciplinary review both parents attend

Dr C indicates no evidence of any consistent/typical neurological disorder – physical and mental development within normal limits

1st July 1999

Mother & Z seen by Dr C

Said to have suffered only 1 seizure this year about 1 week ago

September 1999

Mother & F separate

5th October 1999

Z said to have generalised seizure at home treated by rectal diazepam

14th January 2000

Z objects to the use of a nappy (for incontinence)

March 2000

Speech & language assessment

Understanding & expressive use of therapy = age appropriate – speech had some minor immaturities

8th May 2000

Mother sees educational psychologist re attack by Z

Also reported to GP who observed scratches & marks to face

17th May 2000

Z assessed by GS (paediatric physiotherapist)

Recommended piedro boots & carbon fibre insets be discontinued and that Z should use normal footwear

5th March 2001

Z seen by GS

Observed good heel toe gait

14th June 2001

Z presented to A&E K Hospital

Following fall, fits 2 days previously, banged her left knee while her legs were in spasm no swelling or deformity seen

2nd October 2001

Mother requests wheelchair from occupational therapy

28th December 2001

Z seen at MIU K Hospital

Fell hurting her left leg – impression = soft tissue injury

29th December 2001

Z seen at MIU K Hospital

Pain in left leg

History screaming all night with pain & refusing to weight bear

11th January 2002

Z seen in soft tissue clinic by Dr AM

Reference to Huntington's Chorea appears

After 2 weeks of soft tissue injury would expect her to walk

14th-16th January 2002

Z admitted to A Hospital

Z said to be suffering from Cerebella Type Ataxia

X-ray of hips normal

8th March 2002

Observations by JG (physiotherapist)

Full mobility and heel toe gait unless aware of observation

21st March 2002

Professionals meeting: Dr C, Dr GR & LS

Dr C concerned that his concerns about possible fabricated and/or fictitious illness should be on record

15th April 2002

History given to GP of continuing hip pain for longstanding bedwetting – urine culture to be undertaken

24th-26th April 2002

Z admitted to WRH after fall from scooter discharged then readmitted

Following reported vomiting x 2 & 7 min seizure

4th-7th May 2002

CT head scan under general anaesthetic - normal

9th May 2002

Re-newed diagnosis of channelopathy by Dr G

14th June 2002

JG assessment

no signs of ataxia or increased muscle tone and soles of piedro boots worn evenly at ball of foot and heel

19th August 2002

Z seen by Dr SH (cons paed nephrologist)

Blood & urine tests normal

27th August 2002

Kidney ultrasound scan normal

12th November 2002

Z seen by Dr G

?intermittent ataxia – uncertain whether migranineous in origin or epileptic

22nd February 2003 to 7th March 2003

The high blood sugar readings for Z

22nd-24th February 2003

Z admitted to A Hospital

25th February 2003 to 7th March 2003

The urine samples for Z that have positive glucose readings

25th February 2003

Z seen by GP Dr S

Z re-admitted

26th February 2003

Z re-admitted

Blood sugar tested on ward normal

6th March 2003

Multi agency strategy meeting recommendation

Z be admitted to hosp

Urine test negative

10th March 2003

EPO obtained

11th March 2003

Application for a Care Order re Z

The Evidence and Findings:

37. I have presented my findings and the materials that I have relied upon in a necessarily abbreviated form. This has the effect of disguising the very significant debate that there has been between the experts, between the parties in cross examination and otherwise outside of the formal hearings in these proceedings, as to the significance of the circumstantial material and the many volumes of records that have made in the social, health and educational care arenas about the children, primarily Z.

38. I am asked to draw the inference that that material is for the most part adverse to the mother and supportive of the case that is very ably presented on behalf of the local authority by Miss Meyer. It is a mark of the thorough and detailed cross examination of Miss Macur QC and Miss Friel on behalf of the mother that I am able to say that the most significant part of the potentially adverse material is now to be regarded as of neutral or no significance.

39. I have been given very significant assistance by all of the advocates to each of whom I pay tribute for their careful and cogent analyses. In addition to Miss Meyer, Miss Macur and Miss Friel, F has been represented by Mr Messling and the children's guardian has been represented by Mr Barker.

40. I make it clear for the avoidance of doubt that where I have not felt it necessary to make a specific finding on an issue or a record identified by the local authority or the mother that is because either the evidence that the material is adverse or positive is simply not cogent enough to permit of that finding or I decline, having regard to the overall context of the materials I have heard, to draw the inference asked of me.

41. That is not the same as finding that in respect of any of those allegations, I exculpate the mother. Unless I have said so, there is equally insufficient cogent evidence to make that finding. I well appreciate that so far as the law of evidence is concerned a fact that is not found is not a fact and that has the clear implication that I would not be able to rely upon the same in my assessment of the likelihood of harm – a process that must depend upon the facts found. However, the material relevant to the section 1(3) assessment of risk is somewhat wider and, where appropriate, I have expressed my opinions for the purpose of assessment at the welfare stage of any matters that remain in question.

42. In doing so I have followed the dicta of Lord Nicholls of Birkenhead in Re O and N; Re B (Minors) [2003] 2 WLR 1075. Assessors who consider this Judgment for the purpose of their advices should be alert to identify matters that they rely upon that are not contained herein so that all parties and the court might know the basis of their advice.

43. The primary purpose of this Judgment is to make findings of fact that inform the decision as to whether the threshold is satisfied in respect of all or any of the children and the future consideration of the welfare of each of the children. I have at all times had regard to the well known principles regarding the standard of proof and the satisfaction of the threshold question described by Lord Nicholls of Birkenhead in Re H (Minors) (Sexual abuse: standard of proof) [1996] AC 563 at pages 585 to 591 and Re O and N; Re B (Minors) supra at paragraphs 16 and 17. The cogency or quality of the evidence that is needed to prove serious allegations is not to be equated with a burden on the local authority to prove those allegations to the criminal standard: Re U (Serious Injury: Standard of Proof); Re B [2004] 2 FLR 263 at paragraph 13.

44. Further, I remind myself that a factual decision must be based on all available materials i.e. be judged in context and not just upon medical or scientific materials, no matter how cogent they may in isolation seem to be. Just as best interests are not defined only by medical or scientific best interests (see for example Re A (Male Sterilisation) [2000] 1 FLR 549 at page 555) likewise, investigations of fact should have regard to the wide context of social, emotional, ethical and moral factors (see also Re H supra at page 591 and Re U (Serious Injury: Standard of proof); Re B supra at paragraph 26).

45. This is a complex case where it is not possible to say with certainty that Z has or has not suffered from all of the conditions with which she has apparently presented, even were it to be appropriate to do so, which in these proceedings it is not. I make no apologies for having had to choose between equally cogent but different professional opinions and where I have done so I have identified my reasons. In permitting the admission of expert evidence, the court expressly determines that there is a need for a particular skill and expertise which the court does not possess. It does not follow that an eminent opinion so admitted (and even if agreed to by others equally eminent) is sufficient to bind a court.

46. I am well aware of the cautions that have been repeatedly expressed about the court declining to follow un-contradicted expert evidence or preferring lay evidence in the face of cogent medical analysis. I have not forgotten those cautions (see, for example Re B (non accidental injury: compelling medical evidence) [2002] 2FLR 599, but I have at the same time adopted the wise dicta of Stuart-Smith LJ in Loveday v. Renton [1990] 1 Med LR 117 at 125:

"In reaching my decision a number of processes have to be undertaken. The mere expression of opinion or belief by a witness, however eminent, that the vaccine can or cannot cause brain damage, does not suffice. The court has to evaluate the witness and soundness of his opinion. Most importantly this involves an examination of the reasons given for his opinions and the extent to which they are supported by the evidence. The judge also has to decide what weight to attach to a witness's opinion by examining the internal consistency and logic of his evidence; his precision and accuracy of thought as demonstrated by his answers; how he responds to searching and informed cross-examination and in particular the extent to which a witness faces up to and accepts the logic and proposition put in cross-examination or is prepared to concede points that are seen to be correct; the extent to which a witness has conceived an opinion and is reluctant to re-examine it in light of later evidence, or demonstrates a flexibility of mind which may involve changing or modifying opinions previously held; whether or not a witness is biased or lacks independence"

47. Likewise, I have been careful to separate out from the opinion of various professionals: medical, healthcare and social care, evidence that is no more than an opinion of propensity and which has not assisted me to resolve the factual issues, including the diagnoses that are central to this hearing. The assessment of adult credibility as to the responsibility for harming a child remains the function of the court: Re CB and JB (Care Proceedings: Guidelines) [1998] 2 FLR 211 at 217-8.

48. I venture to suggest that if a court considers the broader context of expert evidence, that is the social, educational and healthcare history, with the rigour described above, there must surely be less likelihood of inappropriate reliance on what may transpire to be insufficiently cogent and sometimes frankly incorrect expert evidence even where it is un-contradicted.

49. Although it is ancillary to the primary purpose of this Judgment, it is of note that I have come to the conclusion, at least so far as the facts of this case are concerned, that where it is the established best clinical practice within a particular specialism for that expert to take a history from a patient and/or carers, than that should also be the starting point for that expert when he or she is appointed forensically to act for the court. Paper overviews can artificially limit the contextual material upon which opinion and in particular diagnostic opinion is given and can reduce the quality or cogency of the forensic expert's opinion by his or her reliance on multiple hearsay. To that extent I agree with the analysis of Professor Tim David as discussed in a recent article on forensic evidence in family proceedings: Arch Dis Child (2004) 799-804. The simple point is that forensic medical practice should mirror clinical medical practice unless there is a very good reason to the contrary which, if relied upon, should be overt. Wherever possible, a forensic practitioner should rely upon the available primary data and for the paediatrician that would usually include seeing the patient and carers. Whether my conclusion is one that is of general application must be the subject of further inter-disciplinary professional debate: it is after all lawyers and courts who have control over the manner of instruction of forensic experts.

Diabetes:

50. Mother concedes that there is clear evidence that she tampered with Z's urine samples by producing false or mixed urine samples on behalf of Z so that they contained glucose thereby suggesting that Z may be suffering from diabetes. That happened on 6 separate occasions over a period of 11 days. She remains resolute in her evidence that she has no recollection of doing so. It is accordingly very difficult to deduce what her intention may have been. Having heard mother in evidence, I find that there can be no doubt, that as mother was herself an insulin dependent diabetic, she knew of the consequences to Z of her being prescribed insulin if she was not in fact diabetic.

51. Z came within a day if not hours of such a prescription being made. There is no evidence before me to suggest that mother did not know of that fact.

52. Mother makes no similar concession in relation to the series of inexplicably high blood sugar readings that were presented by her as relating to Z.

53. So far as they are concerned, the evidence can be summarised shortly. Mother was at all times in control of the BM machines that were used to take the electronic readings of the blood sugar levels. I have no doubt that in common with many other diabetes sufferers, she failed to enter the date/time electronic data that would have helped to provide an analysis of the records that the machine keeps. I accept the technical evidence that the records will be internally accurate (i.e. consistent) once a machine is calibrated and that those readings cannot be manipulated by deletion or sequence alteration. There is of course the possibility that out of date 'sticks' can be used which will affect the accuracy of readings but I have considered that possibility in my analysis of the records.

54. The records clearly demonstrate that the BM readings taken varied very considerably. As almost all of the readings relate to mother's own diabetic condition, one can hypothesise that her own blood sugar levels vary considerably and that her own condition is relatively unstable. From her own evidence I can deduce with some certainty that she is well aware of that fact and indeed she has in the past required hospitalisation when she has become hypoglaecemic and unstable.

55. There are 3 conclusions that can be demonstrated from the records of readings a) the test results alleged are not usually reflected by the exact readings or sequence of readings that exist b) some of the readings that were alleged to have been made simply do not exist and c) the readings that are alleged to originate from Z would just as easily have come from someone else who had been using the machine with a diabetic condition, namely mother.

56. Dr B advised the court that a childhood illness such as a temperature peak could cause an increase in blood sugar and that that may account for one or more of the test results when Z was ill (and I add as a matter of logic may have accounted for the test results that father and 2 nurses say they observed). This would be an unlikely event but one I do not exclude even though the illness would ordinarily be expected to be severe. In any event, I have come to the conclusion that that explanation even if applicable to the illness that Z suffered for part of the material time would not account for all of the discrepancies in the recorded results and the recollections of the same.

57. Having regard to mother's concessions in relation to her tampering with the urine samples and her lack of memory of the same, I find that it is probable that over what was roughly the same period she transposed her own test results for those allegedly relating to Z or falsely reported some of the readings she said she had taken from Z.

58. What is most concerning about this conclusion is that the course of conduct that she impliedly admits in relation to the urine samples is replicated in respect of the blood sugar results. The latter are minor but invasive processes that were not necessary. They would not ordinarily lead to harm, physical or emotional, and could in some circumstances be justified as a response to a reasonable apprehension that a child was suffering from diabetic symptoms.

59. Taking the urine tampering and blood sugar fabrication together, I find it to be less likely that mother cannot remember either process. In fact as to the blood sugar readings she continues to assert a positive version of evidence that I reject i.e. she has a memory that I regard as false. I have come to the conclusion on this aspect that father was correct in his earliest witness statements, namely, that mother was over influenced by the advice and/or healthcare presentations of others and that she convinced herself that Z was exhibiting symptoms of diabetes. She fabricated some of the test results to cause Z to be investigated.

60. Having regard to the fact that she made no attempt to alert anyone to the fact that the results were false and the sustained nature of the fabrication, I am forced to infer that she would have been prepared to see the diagnosis confirmed and the insulin administered. Mother did say to Nurse E "I sometimes wish I could give her some of my own insulin". I have decided that was more an expression of desperation than intent but it evidences mother's lack of objectivity at the relevant time.

61. It is not necessary for me to descend to the detail of each deception but simply to provide the clearest example of her lack of credibility on this point: that is the blood test result allegedly undertaken on the 25th February 2003 by Dr S, the general practitioner. Dr S told me very clearly that he had taken what mother said to him on trust, Z did not look well, in particular, she looked like she had a severe viral infection and was drowsy and uncommunicative: symptoms that he thought were consistent with diabetes if mother's reported blood sugar readings had been correct. On that basis he decided that Z needed urgent assessment for which he provided the referral (factors that are also relevant to mother's increasing concern about her daughter). He did not independently test Z, nor did any of his staff and mother's continuing assertions to that effect were all false.

62. Mother's continuing and repeated false assertions that Dr S had tested Z when he had not are worrying not just as to the sustained nature of the fabrication but also as respects her continuing belief system.

63. It is certainly the case that Dr S said that Z may have diabetes and that after admission the admitting doctor Dr C said it looked like Z was diabetic but those observations were in the absence of any objective test results upon which the doctors could rely. It is also Dr C's evidence that in fairness, mother may not have said to her that Dr S had taken the blood sugar reading at the surgery. However, Dr F's evidence was clear and I accept it: he said that he told mother in terms that Z did not have diabetes before she was discharged on the 28th February 2003 and yet mother went on thereafter to assert that she did have diabetes.

64. It is clear beyond doubt that Z does not have diabetes. That has now been confirmed by independently monitored test results. As I understand it no-one including mother now asserts that she does have that condition. I find as a fact and in accordance with the unanimous medical opinion that she never suffered from diabetes. I also find in accordance with the evidence of Dr S and Dr C that Z was quite poorly by the time of her admissions in February and that mother was entirely reasonable in her desire to discover what was wrong. It was of course entirely unreasonable for mother to fabricate and tamper with urine and blood sugar samples in her belief that Z was suffering from diabetes.

65. In so far as it is relevant and to exclude the possibility, I agree with Dr R a consultant paediatrician with a specialist interest in pharmacological issues, that it is presently outside of recorded scientific knowledge for any of Z's prescribed medications including Baclofen to produce as a side effect raised blood glucose levels unless Z was also a diabetes sufferer. The reported blood glucose levels could not have been caused by the concurrent use of Z's prescribed medication, even if that medication had been maladministered unless there was a predisposition to that effect and that predisposition would have been diabetes which has been eliminated.

Epileptic Seizures:

66. The history of Z's seizures begins with an account given by father. On the 21st-25th April 1996 he says that he observed a minor seizure while both he and Z were travelling in a car. He says he saw Z's hands and face twitching. He called a friend and work colleague to have a look. That friend said that he thought it was a seizure. That fact is confirmed in his first witness statement to this court.

67. Shortly before that statement was written and coincident with the local authority's application for a care order on the 11th March 2003, father told the social worker JE that he had seen Z having fits and that he would not say that he had witnessed something he had not. In his first police statement of the same date he said that on a couple of occasions she had stopped breathing and had gone blue i.e. she had had apnoeic episodes and as Dr F reminded the court an apnoeic episode may be the only sign that a fit is about to happen.

68. I accept father's first and earliest recollection as set out above.

69. The General Practitioner Dr S confirmed that he had diagnosed epilepsy in Z. She was prescribed Epilem and thereafter Tegretol to control her seizures. On the evidence of Dr M, that anti-convulsant therapy was continuously prescribed to Z until March of 2003. The diagnosis was confirmed by Dr F a consultant paediatrician and by Dr G a consultant neurologist.

70. Father has always said that he did not observe any fits after Z had reached the age of 2. Z was not observed having seizures in school although on a number of occasions she appeared detached and glazed or unresponsive in her expression. It is arguable that on an isolated occasion a doctor in the general practice observed twitching but that would not be of sufficient significance to determine one way or the other the nature and extent of any seizures that occurred.

71. Following her admission to hospital on the 6th March 2003 Z has not had an observed seizure and has had her anti-convulsant medication reduced until it was eventually stopped: without any known adverse consequences.

72. It was plain and obvious that despite the very restricted way in which the experts' consensus described the diagnosis of epilepsy, there was agreement with Dr C (another of the consultant paediatricians with extensive input into Z's clinical care) that there was no reason to suppose that Z did not have epilepsy at some stage.

73. If that is right and having regard to the Local Authority's opening concession based upon the Experts Meeting namely, that no one seeks to assert that mother fabricated a history of seizures during the first six months of Z's life, what is the nature and extent of the seizures thereafter and until the 6th March 2003?

74. The following evidence that I have heard and which I accept is relevant:

i) It is said by Dr C that seizures were not observed by any independent professional (save possibly once by a GP);

ii) As more than one expert said it is not unusual for an epileptic not to be observed having a seizure by any of the treating clinicians;

iii) All investigations as to epilepsy have been normal that is no neurological or neuro-developmental abnormality has been detected;

iv) The existence of epilepsy cannot be excluded by the absence of normal inter-ictal (between fit) EEG results nor by other normal investigations;

v) An ambulatory EEG taken during a wobbly episode was normal thereby confirming that the wobbly episodes were not epileptic seizures

vi) There would have to be sufficient concern to continue medication in the absence of such objective reporting or abnormal test results and likewise significant concern to start new medication in the context of negative EEG findings which were themselves taken during a "wobbly attack";

vii) The seizure frequency and combination would be regarded as unusual;

viii) Children grow out of fits and that is natural;

ix) As late as July 1999 it was the settled view of the treating clinicians that Z suffered from an atypical form of epilepsy.

75. Having regard to the above I have come to the conclusion and I find that Z exhibited minor seizures after the first 6 months of her life and for not less than the first 2 years of her life. She had an almost symptom free year in 1999 and no reported seizures until a fall in June 2001. Thereafter she is reported as having seizures again. Similarly after the 24th April 2002 when Z fell from her scooter she is reported to have had seizures.

76. The severity of this fall may be relevant: she was described as being badly injured, she knocked out her 2 front teeth and suffered concussion. Dr R pointed not only to the effect of each accident as being more likely to make a child predisposed to fitting to have a fit (i.e. both as a possible trigger of a fit and exacerbation of a condition) but also that the records showing that Z vomited and that would compromise the effectiveness of the medication that might otherwise prevent a fit. It is also of note that if there are fits after a fall when medication has been compromised that would suggest that there is an underlying condition.

77. Z was medicated for epilepsy throughout. There was a history reported by Dr C and not put into issue by any cogent evidence, that there was a family history of unusual epileptic presentation in relation to X from the age of 14 months to 3 ½ years.

78. On balance I have concluded that Z's epilepsy was resolving before she had the first fall and did resolve at a point that is unknown (masked as it would be by the medication) but some time after the second fall. Z no longer presents with any epileptic symptoms. I find as a fact that there was a genuine underlying condition that Z like her brother was growing out of when she had 2 falls both of which triggered seizures and interrupted the resolution of the condition.

79. If and in so far as mother has reported a greater frequency or severity of epilepsy than that which I have found, an explanation is necessary. As I shall describe in due course, both mother and father were and are inexact in their distinction between seizures and wobbly episodes. I have come to the conclusion having listened to both of them that outside of the seizures I have described, much of what mother was reporting was a confusion between genuine seizures and wobbly episodes. In addition, having regard to what Dr R said in evidence, I think it is probable that mother has to some extent exaggerated what were wobbly episodes so that they have been reported as and construed to be seizures. I do not believe this to have been deliberate or malicious exaggeration but an ingrained attitude of over dramatic description i.e. she is not an objectively reliable medical historian as to detail.

80. As I shall describe later in this Judgment, I also believe mother to be an unreliable administrator of medication. Dr R considered this possibility in some detail. In essence although this may have masked and confused the nature and extent of the epilepsy it would not be relevant to the underlying existence or causation of the symptoms and I therefore leave this element to be re-considered in relation to its effect on other conditions and symptoms.

Wobbly Days:

81. It should be noted that no-one suggests that Z has never presented with wobbly episodes or days. The essential allegation is that Mother exaggerated or contributed to the cause of the episodes. It is Dr C who says that it is highly probable that these episodes may have been accidentally or deliberately induced as there is no coherent neurological diagnosis for them.

82. Although the forensic and clinical experts have been careful to try and separate wobbly days from epileptic seizures this is necessarily a subjective process, relying as they do upon non-medically trained observers, primarily mother and in respect of the incident in the car, father and his friend.

83. Both mother and father confuse the two presentations in their written and oral evidence. In oral evidence before me father described the initial fit as a wobbly episode and overtly suggested that the seizures that mother claims to have observed were also wobbly episodes. Having regard to the volume of evidence about wobbly episodes, I find it to be significant that, as Dr C confirms, the only date upon which mother presented Z as having a "wobbly day" was the day of the fit in October 1999 when the child was given rectal Diazapam by her (following advice she was given as to what to do). On that occasion the effect of the medication would also have been relevant.

84. It is much more likely that mother has never made any real distinction between seizures and the wobbly episodes. Despite this, there is no doubt that wobbly episodes have been observed by any number of people in any number of contexts. The following is a composite description culled from the uncontested evidence. On such a day Z would not be "as with it" as the other children. Her eyes would not follow events and would appear glazed. She would not be concentrating and would have slurred speech and a clumsy gait. At times she could not control her limbs and would usually be described as drowsy and sometimes very sleepy. She had the demeanour of a person who was drunk. Sometimes her eyes would bulge and turn to the sides and she would get aggressive.

85. Having regard to the foregoing, it is probable that Z presented with symptoms that might be confused by some with minor seizures or "absence fits" or indeed the period leading up to a seizure which has sometimes been characterised as a glazed and unresponsive absence.

86. It was initially said that Z never had wobbly days in school. That is clearly wrong and the proposition became that she never became wobbly in school and that on days that she presented as such she would arrive in the company of her mother already exhibiting the symptoms. At least one witness from the school agreed that in respect of recorded symptoms in November 2000 she believed their onset to have occurred at school.

87. The primary objection to a finding that Z suffered wobbly episodes is that there is no coherent neurological diagnosis for the same in that an ambulatory EEG performed during one of her wobbly episodes conclusively excluded the possibility that it was a seizure disorder (by cause or as a contributory factor). It is said that no other reason can be postulated or that all other reasons have been dismissed. That is not an accurate description of the medical evidence.

88. The nature and extent of the wobbly days cannot seriously be in doubt and with that in mind I turn to one specific neurological presentation, namely ataxia and the arguments concerning whether Z had an underlying neurological disorder.

Ataxia and Neuropathology:

89. From a very early age Z has been described as being ataxic. As all of the medical and healthcare witnesses before me have been careful to explain, ataxia is a description of symptoms rather than a label for a neurological disorder. A great deal of speculation has taken place in an attempt to identify what the underlying neurological disorder might be. That speculation has, in part, crystallised into the questioning of the ataxic symptoms themselves: on the basis inferred by the experts that without an agreed neurological disorder the symptoms must have been unreliably reported or otherwise caused.

90. Again I start with the father's account. He says that as a baby Z was unable to hold herself up to the extent that she was referred for investigation as to a suspected link with cerebral palsy and that later she had a tendency to walk on her tip toes. Dr C asserted that on the basis of her abnormal posture alone she would have been referred for neurological examination.

91. Z has been described as walking with her feet turned in and at times dragging one or both of her legs. Her legs have given way, she has had rippling or bulging muscle contractions in her legs and she has had pain such that she has cried. This is the evidence of family acquaintances, father, the GP and a physiotherapist and I accept it.

92. The description of ataxic symptoms continued beyond March 1999 but the symptoms were episodic rather than constant. There have been no symptoms after the 6th March 2003 except on two or three occasions when Z complained of pain in her legs of the kind that she had not had since living with her mother, complaints that were recollected by the social worker who did not take any action on them and to the paternal grandmother.

93. A retired physiotherapist, GG, who had provided therapy for Z from September 1996 to December 1998 gave evidence to me. She confirmed her written evidence to this effect: Z had a mild head lag, moderate extensor thrust (constant pushing back of her hips) associated with a spasm during sleep, exaggerated reflexes, stiff arms and normal legs when first referred. By 1997, although she was much improved, she was dragging her left leg when crawling and was clenching her toes when standing. As she developed, she fell over repeatedly and toe walked. She had significant feeding difficulties associated with her fine head control. By mid 1998 Z is described as having aching knees and problems with her muscle tone and balance.

94. Z was prescribed Baclofen which is a drug which helps to alleviate neurological spasticity. Father confirms that Z was in no pain while she took this drug.

95. Dr C noted ataxic symptoms on examination. Z has been seen to demonstrate a degree of ataxia by more than one professional healthcare and education care observer and by more than one independent medical observer. Those observations include confirmation by a physiotherapist. I have no doubt that other equally professional observers have not observed ataxic symptoms in similar professional and social contexts e.g. an ability to run without dysfunction, inco-ordination or pain, a normal heel to foot toe strike, both abnormal and normal wearing of the soles of her footwear, but none of that goes to undermine the clear, recorded observations of ataxia that there have been which accord with the evidence of father and are at least to that extent consistent with the evidence and reports of mother.

96. What is the relevance of the complaints of pain? There were complaints by Z of aches and pain in her hands, legs and knees, but also a much more vividly described pain which is spasmodic like a cramp and which caused her to cry out and scream. The complaints of pain which are supported by the evidence of father and by independent observers are analysed later in this Judgment. I simply record here that I find that Z did regularly experience both aching pain and severe pain and that that is corroborative of the existence of a mechanism for ataxia i.e. there is an underlying problem not just an overlaid presentation.

97. Z is not suffering from ataxic symptoms now but I find as a fact that Z did suffer from ataxic symptoms on an intermittent basis until 2001 with at least one further example in November 2002. She has continued to complain of pain in the legs including after her separation from her mother's care.

98. As to the cause of these symptoms, it is accurate to say that the earliest hypothesis was that Z might have mild cerebral palsy. There is no evidence of that in her recent examinations and it necessarily follows that Z never had cerebral palsy.

99. Dr GR is one of the consultant paediatricians who has worked with the family and who has remained opposed to the view that all of Z's symptoms were fabricated or exaggerated. She pointed to the reasonableness of the hypothesis that Z as a premature child born to a diabetic mother may have foetal abnormalities including cerebral palsy and that Z's gait, her documented and observed toe scrunching and toe walking were also consistent with that hypothesis.

100. It was not wrong of mother to repeat this working diagnosis (among others) particularly as she became more frustrated, as I find she did, by the lack of any firm diagnosis for Z's presentation.

101. The diagnoses of cerebella ataxia and channelopathy ataxia and the description of the neurological mechanism that is known as a channelopathy came from Dr G, a consultant neurologist who gave cogent evidence to me. It was Dr G who suggested that Z might suffer from a benign paroxysmal vertigo which could be a channelopathy that would cause the episodic ataxic symptoms with which she presented. These diagnoses were rejected by the experts meeting but in the final event in cross examination both Dr E and Professor H, two of the court's forensic experts agreed that they would have to defer to Dr G's knowledge and expertise.

102. Dr G has significant experience of childhood neurology. He has experience of intermittent ataxia and a particular causative mechanism that he describes as being migraneous in origin. Channelopathy is a description of the mechanism of transmission. In essence the cause is a chemical imbalance that is now recognised by a growing, responsible and eminent body of experts. It would not be known to some general paediatricians (as opposed to neurologists) unless they had experience or a special interest.

103. Dr G, Dr E and Professor H agree that if Z is affected by a channelopathy it could spontaneously resolve, re-appear or have been episodic in its effect.

104. Dr E and Professor H initially excluded this condition as a possibility on 2 bases: a) its rarity, which it transpires is more to do with its identification than its occurrence and b) the effect on the diagnosis of the conclusion that mother fabricated the diabetic symptoms.

105. I have come to the conclusion that there is insufficient cogent evidence to exclude this as a possible diagnosis. It remains a working diagnosis and there are very good health care policy reasons why I should not exclude something on the basis of propensity when it may remain of relevance to treatment and diagnostic options for Z's later life.

106. In finding that the ataxic mechanism could be a channelopathy, I am not finding as a fact that it was the cause or the only cause and there remains the allegation that even if there is a genuine underlying condition for Z's neurological presentations, the symptoms she displayed were either exaggerated or exacerbated i.e. induced by over medication. So far as exaggeration is concerned, I have already set out my conclusion having listened to mother in evidence and having compared her recollections with the many records that are available to me. In respect of the ataxia, in the same way as with seizures and wobbly episodes, mother's accuracy has to be doubted. I emphasise that I am not finding that she deliberately fabricated but that her language is not accurate as to detail (as distinguished from the happening of an event) i.e. she has an attitude to illness that predisposes her to describe events that have happened in a dramatic way.

107. I shall consider the possibility of over medication or maladministration separately.

108. Of the remaining allegations there are a number that I can make findings about and some that I should comment upon even though I make no finding, as follows:

i) The prescription and use of the wheelchair and helmet is to some extent a red herring. If Z was having a wobbly day with the severity that that has on occasion been recorded to be, she would have needed an aide to her mobility and, for that matter, the safety net that it and the helmet provided for her. That the wheelchair was also used by Z, mother and father for convenience rather than as a necessity was plain on the evidence and that would accord with the observations that Z did not want to use the equipment at times and also did not need it at times;

ii) I have little doubt that mother did speculate as to whether Z had Perthes, not least because she had been told by medical staff that X had had mild Perthes (fluid on the hip) and I do not think in that context that she is to be criticised for that speculation;

iii) It was also alleged that mother had suggested that Z had Huntington's Chorea. The relevant medical practitioner to whom this was allegedly said was a Dr AM. Dr AM was an impressive oral witness but his clinical notes were some of the worst I have seen. I was unable to say having regard to those notes and the manner and in particular the order in which they were written by him how it was that Huntington's Chorea came to be discussed. I certainly do not have enough cogent evidence to suggest that it was mother alone who raised it. Similarly, although I was satisfied that channelopathy ataxia had been discussed between the mother and Dr AM, Dr AM told me that he had never heard of it. I propose to draw a veil over these discussions and can make no findings at all.

iv) In respect of the December 2001 injury that caused Z to complain that she could not walk: Dr K was clear in his evidence that the soft tissue injury he diagnosed in accident and emergency was genuine. Its effects and in particular Z not being able to walk lasted longer than might have been expected. If anything this incident is an example of exaggeration of a complaint by mother or by mother and Z rather than a fabrication and I do not believe that too great a significance should be attached to it.

Medication:

109. By the 7th July 1999 Dr C was beginning to think that mother might be over administering medication to Z and that that could be the cause of her symptoms. Despite these thoughts the records made in July 1999 still indicate that the clinicians thought that Z had an atypical form of epilepsy and as I have already noted her medication was not withdrawn until 2003. Z was specifically screened after her seizure on the 5th October 1999 with the result that it was confirmed that there was no overdose of any medication for which she was screened and a Baclofen trace test was normal.

110. Dr G paid particular attention to the video recordings of Z's gait when she was aged 2 ½ . He was clear that they showed an unsteadiness in the lower limbs but not in the upper limbs. The significance of this is that her unsteadiness at least during the recorded period was not drug induced.

111. The oral evidence of Dr R was some of the most considered and impressive that I heard. He was able to give objective and reasoned options to the court as to the possible causes of the presentations and symptoms that I have found to have existed. In particular, he re-stated his written conclusions that convulsions, ataxia, incontinence, unco-ordination, slurred speech and behaviour problems could all have been caused or contributed to by over medication. Having come to the conclusions that I have, I return to this evidence in relation to whether this may have been a contributing factor.

112. It is unlikely, he put it as extremely rare, for different medications to produce the same adverse consequences if administered in appropriate doses, but he agrees that it is more likely and indeed sufficiently likely to be probable that some of Z's signs were caused by medication used in higher than prescribed or dispensed dosages. Dr R would go so far as to say that most of the signs reported could have resulted from increased dosages at certain times i.e. some of the episodic presentations could be accounted for by episodic increases in medication.

113. Mother conceded that she was not careful with her own medication to the extent that when she was presenting Z at the hospital in February 2003 she was herself hypoglaecemic. I believe her machine readings confirm this with the result that she was jittery, panicky, confused and not concentrating.

114. I have come to the conclusion that it is likely that mother was careless in her administration of Z's medication. She would forget, just as she would forget her own and she would administer medication as a response to the symptoms she observed as a reflex reaction rather than in a controlled manner. Having regard to the ways in which Z's medication worked as described by Dr R, this would lead to periods of over medication and under medication. This was not a deliberate course of action, it is in the nature of the way in which mother responds to stress. She is haphazard and overwrought.

115. Dr R was clear that anti-epileptic medication can have the side effects of wobbliness, unsteadiness, lethargy and sleepiness because the medication affects the central nervous system. He does not exclude the possibility of an underlying medical disorder that caused an acute ataxic episode on one occasion. If I apply the essential logic of his argument to the evidence of Dr G, which I accept, then it is equally likely for there to have been an underlying medical disorder that caused repeated ataxic episodes. Dr R said in oral evidence that the changes to anti-epileptic medication and the continued reporting of the same adverse side effects despite those changes would tend to support the argument that there was a genuine underlying condition.

116. Dr R was careful to point out the stimulating effects of the maladministration of anti-epileptic medication and although he gave very detailed scientific descriptions and mechanisms, his short point, which I accept, is that it is unlikely that maladministration of this medication caused Z's wobbly episodes. That is different from whether mother's careless administration could account for some of the presentations at school and for an exacerbation of Z's underlying episodic neurological condition. I have decided that Dr R's evidence is cogent on the point. Deliberate it cannot be said to be but careless it probably was and the resulting maladministration would on occasions have contributed to Z's symptoms.

Behaviour and Developmental Delay:

117. Aside from any other reported presentations, Dr C agrees that there have been independent observations both of Z's behavioural problems and her global developmental delay. In oral evidence he confirmed that Z had had a developmental disorder and it was not mother who had said as such and that it was on the basis of his impression of the disorder that Z was referred to a psychologist.

118. From at least 1997 there had been observed a delay in speech and language cognitive development and in March 1999 that was characterised as a mild speech delay with slightly below average intellectual development. By July 2000 Z is described as coping well in school without problems and was within normal limits developmentally and in terms of her speech, although as late as the 10th October 2002 the speech therapist thought she was under performing as respects her true potential and that that under performance amounted to a delay of over 40% having regard to her chronological age.

119. Whether or not the behavioural problems were linked to Z's developmental delay would be a matter upon which I could only speculate and that I will not do. What is clear is that both mother and father were having a terrible time with her at home. She was screaming at night and having sleep problems as well as acting out aggressive behaviour during the day. There is no cogent basis to doubt that she caused the scratches to mother's face in May 2000, which Dr S the GP confirmed were consistent with the complaint. Z was described by father as a brat for her behaviour towards all members of the family (not just her mother).

120. In school in 2000 her behaviour was recorded as being rude, aggressive, obstinate and angry. The psychologist to whom the family was referred was of the view that the behaviours described by the parents were independently observed and confirmed.

121. Accordingly, I find that there is no basis to assert that Z's developmental delay and behaviour was fabricated or exaggerated. Her developmental delay has resolved and would not now be expected to provide a continuing measurable difficulty and that is a tribute to all who were involved in her health and educational care, including her parents.

122. I am unable to make much of the records relating to feeding problems save to say that she was independently observed to be a difficult feeder in the school and by the first physiotherapist who was concerned about the effect of her head posture. She was prescribed dietary supplements in 2001 that were almost certainly not needed for the length of time they were used. They were discontinued by the GP on the advice of Dr GR in April 2002. I do not believe this to be an issue of significance.

123. It may be that the style of mother's care and in particular what I have found to be her erratic administration of medication exacerbated Z's behaviour problems. It is of note that at least one and probably more than one of the prescribed medications can cause behavioural side effects, but that is very different from saying that mother fabricated or induced the same.

Incontinence:

124. This is perhaps the most subjective of all of the medical and social complaints. I have deliberately considered it after coming to some conclusions about the other medical and social issues in the case.

125. I accept the advice given to the court that incontinence has to be considered from the perspective of what is abnormal and Z during the relevant time would be both a child with developing continence (as to which there is a significant range of normality) and a child who had conditions and medication that might impact upon her medically or at least socially in her ability to be continent. Dr C confirmed that what was abnormal and what mother's perceptions of normality might be were never discussed with her.

126. The context of the reports of incontinence given by mother to various professionals is allegedly that none of the school staff had observed any incontinence nor had Z's father. Further, there is no evidence of congenital or constitutional bladder or kidney abnormaility nor any reported enuresis since 11th March 2003.

127. There is independent evidence to support the fact that Z did have minor but repeated stress incontinence (dribbling) and that the school's management of that was not the same as was recommended by the incontinence nurse with the inevitable opportunity for a lack of routine and accidents. There is some evidence at least from one reliable former acquaintance that there were more significant wetting problems that were observed on and after collection of Z from school.

128. I have come to the conclusion that mother had an unreasonable expectation of Z's developing continence that in the context of her other presenting conditions was raised to the level of a problem. Associated with this was stress incontinence that at times would be a genuine problem e.g. in the context of the stress that surrounded Z, her medication, healthcare referrals and mother's attitudes to the same, it was an almost inevitable consequence.

129. Eneuretic incidents were therefore not that likely in the settled circumstances of the school unless on a day or days the routine was poorly managed by Z or the school or Z was affected by the stress of others. As the detail of the evidence was unfolding, I wondered more than once whether the more significant incidents of incontinence occurred at the time mother was collecting Z from the school. That would account for the relative lack of adverse comment but the fact of the accidents the mother and her friends say they repeatedly observed.

130. I have therefore concluded that there was a problem with stress incontinence and that there were incidents of 'full accidents' but that the latter were more likely a response to mother's unreasonable expectations or the confused regimes that were described to me. There can be little doubt that mother's description of the problem was, as ever, over dramatic.

131. I do not think there is cogent enough evidence to say that mother fabricated the wet bed discovered by nursing staff on the 11th March 2003 although I accept that with a settled routine there was no incontinence thereafter.

Father's Evidence:

132. Father's oral evidence to me in clear contrast to the relatively balanced and simple record of his March and April 2003 statements, was self serving, dismissive of and antagonistic to mother. I was unable to rely on a great deal of what he said where that differed from his earliest witness statements. I have to ask the question what had changed the man who after his separation from mother was supportive to the extent that despite his recorded concerns about her, was intimately involved in continuing family life even to the extent that some thought he was continuing an episodic relationship with her?

133. Having now heard him and his parents give evidence, I have come to the clear conclusion that perhaps of necessity they developed a protective barrier around the children and themselves so as to exclude mother as a dangerous person. They have to and do justify that to themselves and to the outside world. Their defensive reactions and antagonism may be natural in the face of the significant local authority and police investigations into the care of Z but are neither objectively based nor helpful to the fact finding process. Ultimately, their attitudes may not safeguard the children's emotional welfare.

134. The incident of the allegedly doctored birthday cake provided by mother during contact is perhaps a case in point. Z was ill after eating the cake, something that seems almost certainly now to have been the result of over excitement or stress. Father and other witnesses seriously questioned whether mother may have used an opportunity to poison her child. It transpired that mother had purchased the cake and delivered it under supervision and that she had not had the opportunity to do anything to it.

Mother's Evidence:

135. It may be that that which I have described as fact would be more than any reasonably competent parent could be expected to deal with on their own or even with the support of a father who was certainly heavily involved even when separated from the family. Those must be issues to be investigated and assessed for the next and final hearing in this matter. What is certainly apparent is that mother did not misuse or become over reliant on her medical general practice nor did she initiate healthcare forum shopping to attempt to obtain greater or different medical interventions from alternative specialist referrals.

136. I am urged by the local authority to conclude that mother was deceitful, manipulative and that she exaggerated symptoms. In any event, I am asked to say that she is an unreliable historian and that she failed to heed professional advice given to her.

137. Mother fails to be honest with the court at least about the false blood sugar readings. Knowing as she says she does about the urine samples, one might have thought she would have agonised long and hard about how it is that there came to be high blood sugar readings. As I have found, although some of the readings may be accounted for by actual readings taken of Z when she was very poorly, the reality must be that the other high readings were either a total fabrication or more likely readings provided by mother testing herself. To this extent she is not only failing to be honest with the court she is exhibiting a worrying lack of insight into what she has done.

138. In the final event I have come firmly to the conclusion that mother is predisposed to use language that exaggerates and that she is not a reliable historian about the detail of medical matters. I have not found that this involved any deliberation aside from the fabrication of the diabetes test results. Even in this regard it is at the moment impossible to be clear what her intention may have been: a cry for help for herself, for her child (i.e. for medical assistance) or in respect of her care of that child. These are at one end of a spectrum that logically extends to a mother who was prepared to take a risk with the health or life of her child because she was so enmeshed in the idea that her child was ill when others were seriously questioning the basis for that illness or at least its continuing basis.

139. Mother has also been careless in her management of medication so that some symptoms would have been induced. Again I do not find that she was deliberate in what she did but her omissions must have been repeated rather than isolated.

The Evidence of LS and JG:

140. LS is a team leader working with children who have special needs. She is a nurse, midwife, health visitor and legally trained manager who has an extensive knowledge of education special needs practice. Her records demonstrate a careful attempt from the start of her involvement in 1999 to bring together that which she was told by others. The apparent objectivity of the written process is however sadly undermined by her fervent quest revealed by careful and sustained cross examination to prove that mother is someone who fabricated her child's symptoms.

141. Her apparent objectivity was damaged by her lack of acknowledgement of the genuine debate between paediatricians and paediatric specialists about the nature of Z's pre-1999 symptoms i.e. she had taken on board the very genuine and principled concerns of Dr C about the quality of mother's reporting but failed to weigh in the balance the rest of the pre-1999 material where it differed from her own impression.

142. Impressive though LS's child protection practice may be, I have come to the clear conclusion that she forgot that child protection is but one (even if a major) component of a child's needs and that multi disciplinary good practice involves not just the right to challenge the opinions of others (no matter how well qualified or senior they may be) – something I do not hesitate to agree with her about - but also a constant process of re-appraisal having regard to the information that is available. That process must include information from parents and the professional opinions with which one disagrees!

143. I need not dwell on her evidence because it is by and large secondary i.e. it relies upon the facts and opinions recorded by others. Where LS made her own observations, I do not believe them to be inaccurate, far from it. They simply lack the specialist analysis that others possessed. LS substituted her personal belief for the skill and expertise that she, like this court, needed to have regard to. Her personal belief was so strong that she was openly distressed at the challenges that were put to her in cross examination. The complexity of this case caused to her to loose her objectivity and she was entitled to and needed better specialist support.

144. JG was only involved from January 2002. She never saw ataxic symptoms. She never saw Z on a wobbly day and as a consequence she was concerned to discuss possible neurological bases for what would have to be intermittent or episodic symptoms that she had not seen. She was equally concerned that the passage of information between acute and community units and their paediatric, physiotherapeutic and orthotic services was less than comprehensive and that with a child like Z with the number of professionals involved that could lead to significant misunderstandings.

145. None of that is unprofessional, indeed quite the contrary. The overlay or context in which it occurred sadly made it into an adversarial and antagonistic process. Again, having heard her more than once in evidence, I do not believe this is JG's fault. She came in to a complex case where clinicians already disagreed and where LS had a clear working hypothesis of fabrication. Added to that there was still no diagnosis that JG was given (she neither had explained to her nor would have known of channelopathies) and there was no strategic care plan that would have required the need for multi-disciplinary co-operation between acute and community services as well as between different groups of professionals. As Dr GR rightly pointed out, the care plans that I have seen that existed before these proceedings were taken were useless.

146. It may be that JG would have been able to resolve these issues over time, though I doubt it without the strategic co-operation that was necessary, but sadly she became involved in a personal dispute with the mother that was fatal to their professional relationship. JG believes that her professional integrity was questioned by mother and that the vehicle for that was communication through her (JG's) son. I have no doubt that mother complained about JG and that there was nothing in the substance of the complaint. There is insufficient evidence for me to say that mother's complaint was deliberately false in the sense that she used it to divert a professional from her investigations but JG's reaction was very understandable and I do not criticise her for it. It is probable that the complaint was an example of mother's increasing level of panic and frustration at the lack of consistent or conclusive diagnosis and she wrongly interpreted JG to be 'the enemy'.

147. In oral evidence, JG was able to help the court fill some of the gaps in evidence using her knowledge of Z and her skill and expertise as a physiotherapist. She confirmed that a diagnosis such as cerebral palsy would have been considered because that condition involves an altered tone or spasticity. There can be different alterations in tone, high and low and different presentations at the same time i.e. in combination. Z's altered gait and presentation would have been a low tone or floppy upper trunk together with high tone in her lower limbs. Z's altered posture would involve muscle contraction at rest in her legs. The alteration in soft tissue over time can itself lead to pain for a number of reasons but one is perhaps more obvious than the rest, increased muscle tone can alter the blood supply to limbs such that the child could experience severe cramp pains that would cause her to scream. The medical record that sets out the independent observation of Z's thigh muscles rippling and bulging may be indicative of the extent of the tonal problem she experienced.

148. The hypothesis set out above can be no more than that because it could not be tested with those who have more specialist skill and expertise but I record it rather than make a finding so that others can consider a possible mechanism for the symptoms that I find Z did present.

The Evidence of DC LM:

149. Police officers are not doctors, nurses, physiotherapists, teachers or social workers. Their child protection expertise has to be seen in the context that it is (rightly) focused on the protection of people from criminal acts and the investigation and prevention of crime, functions to which they are and should be dedicated. In common with every other form of child protection professional, a police officer will only have a part of the complex mix of skills and expertise that are required to investigate, analyse and make decisions in the child protection arena. That is one very important reason, among others, why multi-disciplinary working is so important.

150. Time and again in many different contexts, the family courts and the reports of inquiries and reviews arising out of tragedies (both of over zealous action and negligent inaction) have emphasised that child protection is but an element of a more sophisticated analysis of welfare that also includes the needs of the child throughout childhood into adulthood. That sophisticated analysis should rarely if ever be in the hands of one professional or one professional group.

151. Social services and education authorities have statutory duties but so do the police, CAFCASS, health service bodies and so on. Some of those duties vest in individual professionals who are in any event bound by strict professional codes of conduct and/or central Government guidance. No one professional should assume the skill and expertise of others, to do so can lead to an arrogance of self belief in one's own perception of right that leaves no room for the questions or opinions of others, each from their different training and perspectives. The contrary proposition is equally valid, to fail to pursue the factual or professional leads of others simply provides the opportunity for a tragedy born in a cloud of unknowing.

152. I am not, I hope, so naïve as to assume that there will always be a consensus of view among any one professional group, nor should there be. The same processes apply at that level: most particularly social workers must be allowed to differ and debate among themselves and with parents. Medical practitioners must engage in scientific debate from their different specialist expertise and with the parents of the child who is a patient. All professionals should collect and share the essential information for their analyses, namely their histories and chronologies of information and likewise their different opinions should be discussed and recorded.

153. In so far as DC LM fell into error it was for the same reason as LS i.e. by her overriding belief that she was right or perhaps more accurately put: that most other professionals had failed to grasp what DC LM clearly believed from the materials collated in the police investigation namely, that mother was a dangerous woman. She might still be regarded as correct at least in so far as the diabetes allegations are concerned and she and the prosecuting authority are entitled to pursue their statutory functions without interference from this court. If she is wrong, in whole or in part, a valuable opportunity for joint working was lost. In fairness to DC LM the strategic issues are not for her, she did not manage the criminal investigation.

154. Joint working is not simply talking to those professionals with whom one agrees. It involves talking to representatives of all points of view on the record. Sometimes that will require a strategic decision as to whether the need for the provision of services for a child is more important than the preservation of the integrity of criminal evidence pending a criminal trial or indeed the very pursuit of that trial. Decisions of that kind and the management and strategic discussion of issues of that nature are described in the central Government guidance: Complex Child Abuse Investigations: Inter-Agency Issues which is issued under section 7 of the Local Authority Social Services Act 1970 and is binding on local authorities.

155. I acknowledge that an individual case involving one mother and her child or children would not normally be regarded as complex but its factual content may be just as complex and allegedly systemic as any circumstance of multiple institutional abuse and its ramifications for both nuclear and extended families may be just as serious. In this case there should have been formal inter-disciplinary strategy and planning or management meetings and such meetings as there were should have been more honest in their acknowledgement and appraisal of different professional perspectives. The overviews of the case should not have been left to LS and DC LM: they should have been in the hands of more senior colleagues and a inter-disciplinary strategic system.

156. Strategic discussions at all levels in his case could have isolated the more reliable elements of the histories that were available and would have helped to provide a more informed information base for diagnosis. They may even have been able to prevent the crisis that eventually unfolded.

157. There are very real issues that this case has highlighted arising out of the circumstance when a local authority that has not had the strategic shared control of the investigations but is forced on costs grounds to adopt the witness statements of the many police witnesses as their primary case. The social work analysis is almost completely disempowered and the context that becomes known from the taking of evidence is lost.

158. The police investigation was insufficiently objective to be a proper medium for this court's purposes: it reflects the adversarial nature of the criminal process not the essentially inquisitorial nature of this process. The ramifications of the problem I am identifying are significant. I do not propose to do more than identify the problem and urge inter-disciplinary discussion of it to lead to informed recommendation in due course.

159. The influence of the police investigation on father and his evidence was patent. For my part I believe it was a significant error to present this father with a detailed summary of the collated evidence prepared by a police analyst. What resulted was not an accurate recollection of fact but a contrived artifice that mixed partial recollection with ex post facto rationalisation. It was not an appropriate methodology to adopt with a non-professional witness. I have seen the materials that were presented to father and the resulting detailed final police statement: the effect of the one on the other cannot be doubted. I am unable to place reliance on that document and that has had significant consequences because of the regard that was had to its content by the experts in this case.

160. My attention was drawn to a letter written by DC LM that was intended to be and was construed to be an instruction to refer all medical investigations or complaints relating to Z to her new GP. As a child protection mechanism there would be some merit in trying to ensure a consistency of approach having regard to the alleged history under investigation. Sadly, I was forced to come to the conclusion that the purpose of the instruction was not to protect Z's welfare but to try and protect the integrity of the police case as she saw it against the mother.

161. The letter is just an example of the problem I have posed. If it needed to be written, it should have been written by those with parental responsibility, which in the context of this case would have been the local authority. I might add that, with a degree of caution and care that was commendable, the local authority's solicitor flagged up her concern about what had occurred. The meeting that preceded it was not a confidential risk analysis but a professionals meeting and its existence and content were disclosable events to this court and to the parties.

162. I have considered long and hard what I should do about the incident of DC LM discussing her evidence with a more senior officer overnight and while still under oath. She initially denied that she had done so until an informal transcript was put to her in cross examination. That was unacceptable. She then opined in answer to a question put by me that the senior officer was not a witness in this case and she would have done the same if she had been giving evidence in a part heard criminal trial.

163. DC LM is fortunate that no harm was done to this court's process and I shall leave what I regard as being a fundamental lack of professional insight to her superior officers who can better assess the competing duties upon an investigator who is also a witness having regard to her own Force Regulations.

Factitious Disorder:

164. So far as X and Y are concerned, a paediatric overview report was obtained from Dr W, a consultant paediatrician at Sheffield Children's Hospital. He came to the conclusion that although there were above average attendances at the GP and admissions to hospital both X's and Y's illnesses appeared to be genuine and there was no evidence to suggest fabricated or factitious illness in either. After reconsideration of the material relating to Z, Dr W's concerns as to the possibility of factitious and fabricated illness was raised but not sufficiently to dislodge his primary conclusion.

165. It is agreed that concerns relating to mother and Z which were variously described as Munchausen's Syndrome by Proxy (MSBP) or Fabricated and Induced Illness (FII), were raised as far back as 1999. The concerns are again recorded in August 2000 and July 2001 and were formally noted by medical professionals in March 2002.

166. It is clear from the papers that by the summer of 1999 Dr C began to suspect that at least a contributory factor in Z's atypical presentations was the possibility that mother may be exaggerating or fabricating her symptoms. He undoubtedly initially expressed that in the previously conventional terminology as a possibility that mother was suffering from MSBP. Dr C confirmed in oral evidence that he had shared his concerns with Dr G in particular that "things didn't seem to be quite right". That concern appears to have been communicated to the General Practice in that a note exists dated the 15th June 2001 to the same effect. Dr C confirmed that he was responsible for a phone call to Dr Z at the surgery in order to obtain a greater degree of alertness from them as to the possibility.

167. Within the General Practice a conversation had taken place prior to Dr C's telephone warning on 15th June 2001. The fact that they were alerted to a possible problem certainly led to continuing analysis such that by 14th October 2002 there was a subsequent conversation with Dr GR over the possibility that mother was over-medicalising Z. The evidence of the GP, Dr S, which I accept is that mother was always appropriate and not overbearing. Indeed, whatever concerns may have been communicated to the surgery, there were frankly not seeing much of Z there.

168. In oral evidence Dr C helpfully summarised this issue at least for the purposes of this case. He asserted that so far as diagnostic criteria and internationally accepted disease definitions are concerned, there is no accepted definition for Munchausen's Syndrome by Proxy or Factitious and Induced Illness precisely because it is not a disease. As Dr R put it, the label is a convenient child protection description of a modus operandi where it is thought that physically, psychiatrically or psychologically a carer is responsible for the presentation of symptoms in a child that would not otherwise have occurred.

169. Dr C was clear that all that a paediatrician can and should do is to give an opinion upon whether a particular symptom is a fabrication, an exaggeration or is otherwise induced. That is done by reference to the standard methodologies of obtaining the medical history, by professional examination, objective and subjective tests and finally differential diagnosis.

170. So far as mother is concerned and despite Dr C's increasing concerns, at no stage was there a suggestion that Z be admitted to hospital or otherwise medically managed to facilitate the withdrawal of her medication prior to March 2003. Further, Dr C confirmed in cross-examination that he had continued to give mother flexibility in relation to the dosage of certain of the drugs that were prescribed for Z. This position continued despite Dr C considering the hypothesis that mother may be inducing symptoms in Z by her use of the medication that had been prescribed.

171. Dr GR had clearly come to the conclusion by the 21st March 2002 that she was disinclined to form the view that any over-medicalisation in Z's symptoms by mother was abusive to the child. This was in contradistinction to the opinion of LS who thought that her views had been given insufficient weight and who by then had concluded that the suspicions should be regarded as a high level of concern.

172. Dr C confirmed in evidence that essentially mother's problems were regarded as "attitudinal" and I formed a clear conclusion that Dr C was right to have recorded in his evidence that it was possible that mother inappropriately managed Z and that the reason was to do with her attitude i.e. the way in which she discussed Z and demand led the prescription of equipment for Z. To the extent of the findings that I have set out above, I agree with Dr C. Where the line should be drawn and indeed was drawn in oral evidence by Dr C was as respects Z's medication which was to use his terminology "doctor led". For this mother is not to be criticised. An example of this is mother's appropriate behaviour in accepting the need to decrease the dosage of Sabril and thereby reduce Z's behavioural problems and head banging.

173. If and in so far as Z was 'over medicalised' this was a consequence of her complex needs and symptoms and mother's increasingly frustrated and over dramatic attitude to them. The real issue in this case is the management of a mother who wanted health care support and assistance and arguably social and educational care and assistance and felt that she was unable to obtain it without resorting to dramatic effect. The diabetes episode was a clear fabrication but to re-interpret all that had gone before on the basis that 'once a fabrication: always a fabrication' is superficial.

174. I have considered and respectfully adopt the dicta of the Supreme Court of Queensland in R v. LM [2004] QCA 192 at paragraph 62 and 66. I take full account of the criminal law and foreign jurisdictional contexts of that decision but I am persuaded by the following argument upon its face that is as valid to the English law of evidence as applied to children proceedings.

175. The terms 'Munchausen Syndrome by Proxy' and 'Factitious (and Induced) Illness (by Proxy)' are child protection labels that are merely descriptions of a range of behaviours, not a paediatric, psychiatric or psychological disease that is identifiable. The terms do not relate to an organised or universally recognised body of knowledge or experience that has identified a medical disease (i.e. an illness or condition) and there are no internationally accepted medical criteria for the use of either label.

176. In reality, the use of the label is intended to connote that in the individual case there are materials susceptible of analysis by paediatricians and of findings of fact by a court concerning fabrication, exaggeration, minimisation or omission in the reporting of symptoms and evidence of harm by act, omission or suggestion (induction). Where such facts exist the context and assessments can provide an insight into the degree of risk that a child may face and the court is likely to be assisted as to that aspect by psychiatric and/or psychological expert evidence.

177. All of the above ought to be self evident and has in any event been the established teaching of leading paediatricians, psychiatrists and psychologists for some while. That is not to minimise the nature and extent of professional debate about this issue which remains significant, nor to minimise the extreme nature of the risk that is identified in a small number of cases.

178. In these circumstances, evidence as to the existence of MSBP or FII in any individual case is as likely to be evidence of mere propensity which would be inadmissible at the fact finding stage (see Re CB and JB supra). For my part, I would consign the label MSBP to the history books and however useful FII may apparently be to the child protection practitioner I would caution against its use other than as a factual description of a series of incidents or behaviours that should then be accurately set out (and even then only in the hands of the paediatrician or psychiatrist/psychologist). I cannot emphasise too strongly that my conclusion cannot be used as a reason to re-open the many cases where facts have been found against a carer and the label MSBP or FII has been attached to that carer's behaviour. What I seek to caution against is the use of the label as a substitute for factual analysis and risk assessment.

179. In the final event, I agree with Dr GR: Z was referred to different specialists with apparently true symptoms that included epilepsy, ataxia, and developmental delay. Mother over dramatised Z's medical needs but it was not until the escalation of the precipitating circumstances that she was abusive to Z.

180. I shall hear submissions at the conclusion of this Judgment upon the existence of the threshold in respect of each child having regard to the facts I have found. I shall likewise hear submissions as to whether there needs be any alteration in the status quo of the care of the children pending the final hearing of this matter.

181. For the record I am of the view that this is not a case of personal mismanagement by any healthcare or social care practitioner. Z had a combination of atypical medical complaints that by their very nature were viewed differently by the different specialists who had to consider them. Such a position is compounded when suspicions and hypotheses are genuinely formed on the basis of an apparent inconsistency of description, treatment and observation and where generic labels such as Munchausen Syndrome by Proxy are used to describe that which should more helpfully be recorded in clear factual terms.

182. It has often been said and I repeat it again for the record that the welfare of the child cannot be deduced from any one sole professional perspective: welfare is not just medical best interests nor is it restricted to education or social care. It is a multi-faceted concept. This case should have been managed from at least 1999 by multi-disciplinary strategy meetings to which the parents should have been invited.