England and Wales Family Court Decisions (other Judges)

This judgment was delivered in private. The judge has given leave for this version of the judgment to be published on condition that (irrespective of what is contained in the judgment) in any published version of the judgment the anonymity of the children, members of their family and others who are not directly named must be strictly preserved. All persons, including representatives of the media, must ensure that this condition is strictly complied with. Failure to do so will be a contempt of court.

Neutral Citation Number: [2025] EWFC 55 (B)

CASE NO:ZC23C50416

IN THE CENTRAL FAMILY COURT

Before:

 

HIS HONOUR JUDGE MARIN

 

Between:

 

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Mr S Miller and Ms E Wickham instructed by the legal department of the Applicant

Ms A Grief KC and Mr H Langford (instructed by Miles and Partners) for the First Respondent

Ms P Warner (instructed by Copperstone Solicitors) for the Second Respondent

Ms S Fisher (instructed by Nathanking Solicitors) for the Third Respondent

Mr G Ferguson (instructed by Matwala Vyas LLP) for the Fourth Respondent

Mr O Millington and Mr M Melsa (instructed by Campbell Chambers Solicitors) for the Fifth to Seventh Respondents

 

Hearing dates: 20 to 24 and 27 to 31 January 2025, 3 to 7 and 14 February 2025

Judgment: 4 March 2025

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Approved Judgment

 

HIS HONOUR JUDGE MARIN:

Introduction

1.                  On Saturday, 29 July 2023 at around 9.22pm, a little girl who I shall refer to as C arrived at the accident and emergency department of her local hospital. At that time, she was then five years and ten months old.

2.                  She presented with unusual behaviour symptoms including hallucinations, randomly urinating, intermittent crying and vacant episodes and rolling eyes. Tests revealed intoxication through Topiramate, a drug which had never been prescribed for C.

3.                  The hospital identified that C had presented with similar symptoms a year earlier when blood tests had revealed Topiramate in C's blood stream consistent with her having ingested a significant amount prior to admission to hospital.

4.                  The hospital called in social services at the London Borough of Lambeth ("the local authority") who became involved with the family as did the police.

5.                  On 8 August 2023, C was discharged from hospital into the care of her maternal grandmother together with her siblings. In September 2023, the local authority commenced these proceedings.

6.                  This judgment arises from a hearing which was listed to determine certain facts and then to decide what should happen to the children of the family.

The Family

7.                  Apart from C, there are three other children of the family who I shall refer to as A, B and D.

8.                  The mother of the children is M. She is thirty-six years old. She has brought up the children since birth and raised them as a single parent.

9.                  C is now nearly seven and a half years old. Her father is RG. Although they separated when C was very young, M said that they maintained a good friendship. RG has taken part in these proceedings. He described M as being a very good mother. RG also has a good relationship with the maternal family. M said that C has a bond with RG and wants to see more of him.

10.              A is C's older sister. She is fourteen and a half years old. Her father is DM. He has not engaged in these proceedings and his present whereabouts are unknown. Apparently, there have been times when he has taken part in A's life.

11.              A has had a troubled past. She has been bullied at school which led to self-harming and failed attempts to commit suicide. A has received help from CAMHS.

12.              B is a brother who is eleven and a half years old. His father is EF who has taken an active part in these proceedings. EF is fifty-one years old.

13.              B and EF have a strong bond. M and EF also have a good relationship and work together to make arrangements relating to B.

14.              The youngest child is D, a little girl who is nearly six years old. Her father is CB. He has not had any relationship with D and his whereabouts are unknown. He has therefore not taken part in these proceedings.

15.              In April 2024, B went to live with EF. A, C and D remain with their maternal grandmother, Mrs CD and her partner.

16.              Mr LD is the children's maternal uncle. If the children cannot return to M, he put himself forward as a carer under a special guardianship order. His assessment was positive. Mrs CD and her partner do not put themselves forward to care for the children.

The Issues in This Case

17.              The issues that fall for determination in this case are first, the matters contained in the local authority's threshold document; second, the welfare assessment of what arrangements are appropriate for the children; third, an issue relating to B's name.

18.              I start with the issue relating to B's name because although contested, it is straight-forward in substance. The issue is whether B's surname should be changed.

19.              EF's surname "F" is registered on B's birth certificate. In 2018, M changed B's surname by deed poll to her sole surname of "D". This was subsequently approved by the court and an order was made to reflect that change. EF wants B's surname to revert back to "F". M opposes the change. She proposes that the surname registered is "F-D" being a combination of both parents' names but with permission for B to be known by the surname "F".

20.              The threshold document runs to twelve pages. I summarise the findings sought by the local authority as follows:

a)                  C had never been prescribed Topiramate.

b)                 Regarding the events in July 2022:

i)                   M administered Topiramate to C or in the alternative, C found Topiramate in the family home which had been hidden by M or left in an unsecure place by M which C ingested, leading to her admission to hospital.

ii)                 Topiramate caused a number of serious effects and placed C in a position where she had to endure invasive procedures under general anaesthetic caused by Topiramate intoxication

iii)              M delayed seeking medical attention.

c)                  Regarding the events of July 2023:

i)                   M directly administered Topiramate to C which led to her presentations and admission to hospital or in the alternative, C found Topiramate in the family home which had been hidden by A or left in an unsecure place by M which C ingested leading to her admission to hospital.

ii)                 Topiramate caused a number of serious side effects for a period prior to admission to hospital.

iii)              At some point prior to admission to hospital, C collapsed which led M to administer CPR.

iv)               M failed to seek timely medical attention.

v)                 Blood tests showed an abnormally high level of Topiramate which were the direct cause of the various symptoms and presentations of C.

d)                 M failed to properly supervise and monitor the medication and the administration of Topiramate to A for whom the drug had been prescribed which led to A hiding Topiramate within the home.

e)                  From 3 July 2023, M started A on Topiramate which was left over from previous use but did not discuss with the hospital consultant whether there was a clinical imperative to re-commence taking Topiramate.

f)                  B and D were subject to passive exposure to Topiramate from December 2022 to October 2023 due to M not properly supervising A in the taking of her medication and/or failing to deposit Topiramate in a secure place.

g)                 The children's school attendance was poor having missed significant schooling due to alleged illness.

21.              M conceded most matters pleaded in the threshold document which in summary are:

a)                  Regarding the events of July 2022:

i)                   Ingestion of Topiramate was highly likely to cause most of the symptoms set out in the threshold document.

ii)                 C was subjected to intrusive investigations.

iii)              C's attendance at hospital must have been due to C ingesting Topiramate.

iv)               M did not seek immediate medical attention and delayed taking C to hospital but not for the length of time pleaded by the local authority (this matter being conceded by the local authority).

b)                 Regarding the events of July 2023:

i)                   Most of the symptoms and presentation of C are accepted although for one and a half days and not the three days pleaded by the local authority.

ii)                 At some point, C collapsed which led to the administration of CPR by B.

iii)              M should have acted sooner than she did to pursue medical advice.

iv)               Topiramate was in C's blood.

v)                 C's symptoms were caused by intoxication of Topiramate.

vi)               M accepts that Topiramate was found by C in the family home and the most likely explanation is that she found Topiramate tablets discarded by A.

vii)             M thought that she had a safe system in place for securing medication but accepts that A was able to access them.

c)                  M thought she had a safe system in place for the medication but accepted that C was able to access medication.

d)                 When A did not want to take Topiramate, she would often check by sometimes asking A to open her mouth but A often challenged this and M did not always insist or follow through.

e)                  M accepts that she did not do enough to ensure that A took Topiramate and that she would not secrete it. Medication was therefore available which C consumed.

f)                  M started A on left over Topiramate pills in July 2023. She gave half a pill twice a day and only had three to four pills in total.

g)                 A's treating neurologist had not recommended recommencement of Topiramate and no prescription was received.

h)                 B and D were passively exposed to Topiramate due to M failing to supervise or store the drug in a secure place.

i)                   M accepts that the children missed school due to migraine.

22.              What emerged from M's response to threshold was that the real issue was whether M had directly administered Topiramate to C. The local authority maintained that she had done so which M denied.

23.              There was discussion about whether it was necessary for the court to make findings on direct administration of Topiramate given M's wide-ranging concessions on the threshold matters.

24.              In the event, once the Guardian said that she felt unable to make a final recommendation without the court deciding the issue of direct administration, everyone agreed that this issue had to be addressed.

25.              The local authority's care plan for the children was the subject of much confusion and conflict during the hearing. Its final plan was only announced on the last day of the hearing.

26.              The local authority proposed that A should live with M irrespective of whether the court determined that M had directly administered Topiramate to C. B should live with EF. C and D should live with with Mr LD under a special guardianship order whatever finding the court made.

27.              As to the children's position, A had her own representation in this case. Through her Counsel, A said that she wanted to live with M. This was supported by the Guardian.  

28.              B told the Guardian that he wanted to stay with EF which EF welcomed. M wanted B to return to her care but would not stand in the way of B's wishes. M and EF work well together such that they were able to arrange times for M to spend with B. The local authority and the Guardian supported this outcome.

29.              The Guardian maintained that steps should be taken to ascertain whether C and D could return to M if no finding of direct administration of Topiramate was made against the M. If a finding was made, she supported Mr LD caring for the children. Absent any finding though, she advocated an adjournment to allow consideration and implementation of work to ascertain whether a return home could be achieved.

30.              RG supported the return of C to M but if not, he supported placement with Mr LD. He has a good relationship with the extended maternal family. He also wants contact with C.

The Litigation

31.              This case was heard over sixteen days. The local authority and the Guardian both instructed Senior and Junior Counsel; M was represented by Leading and Junior Counsel; the other parties each by Counsel.

32.              The case papers were contained in various bundles; a main hearing bundle, a medical bundle and what was referred to as the Z bundle which contained further evidence filed after preparation of the main bundle. As the case progressed, yet further evidence was served by the local authority as well as amended care plans for the children.

33.              The local authority filed a medical chronology which ran to ninety-three pages and all parties filed lengthy written opening and closing submissions. Together, this all ran to around four thousand three hundred pages.

34.              I am grateful to the parties' legal teams for the meticulous way this case was presented. The collegiate approach to matters between Counsel was appreciated and ensured that court time was put to the best use possible.

35.              I also praise the clarity of the parties' written submissions and in particular, the extensive and careful work put into the medical chronology. The parties can be certain that their respective positions were fully put forward by their legal representatives.

Some background

36.              Before turning to the evidence in this case, I need to provide some background to the events that led to these proceedings. I do so merely to set the scene for an understanding of the matters that fall for decision by the court and accepting that some matters are not agreed.

37.              The medical chronology prepared by the local authority and the expert evidence provide substantial detail of the children's health, their visits to doctors and hospitals for a variety of matters over the years and of the incidents that gave rise to these proceedings. I do not propose to repeat all of that information.

38.              I start in 2013 when A was nearly three years old. An out of hours doctor recorded that A was complaining of headaches. By 2015, the GP recorded that she had "recurrent right parietal/frontal headache 2-3 times per week since April 2015. There is associated sweating and vomiting."

39.              In 2017, a consultant paediatrician recorded that A suffered from "severe migraine with neurological deficit" and referred A to the Department of Paediatric Neurology.

40.              The headaches continued and in December 2017, a consultant paediatrician prescribed Topiramate for A recording that she suffered from severe migraines. The prescribed dose was 12.5 mg. In March 2018, this was increased to "25mg BD [1]"

41.              In 2019, B was seen by a consultant paediatrician who recorded that he had "headaches" and under outcomes noted that "lifestyle advice including early use of painkillers for headaches" and that if the headaches continued, he should be referred to a named paediatrician who worked in the paediatric neurosciences department.

42.              In January 2020, A still complained about headaches and said that she had five to six migraines every week and "can vomit with the headache but sometimes has aura."

43.              M also spoke with the GP the following month about B and recorded her telling him that "migraines getting more..." and that they were "...very similar to sister's pattern."

44.              In August 2020, a consultant paediatric neurologist recorded B suffering from a variety of problems including sleepwalking, blank spells, headaches, abdominal pain, sleepy during the day and episodes of losing movement. The hospital carried out various tests later that year.

45.               By November 2020, a neurologist recorded a formal diagnosis of migraine and noted that B complained of pains in his legs and stomach, his legs hurt, he cried and that these episodes occurred four to five times a week.

46.              During 2021, A and B's headaches continued with reviews by medical professionals.

47.              In early 2022, B attended hospital with a graze on his head, D had a bead in her right ear, C attended hospital as she fell off a chair onto the floor with significant swelling to the middle of her forehead and A continued taking Topiramate.

48.              Turning to the events of July 2022, M described in her statement how events unfolded and C was taken to hospital:

"On Tuesday 26th July 2022, I remember that [C] was fine during the day. I can't remember what we did. She would have gone to bed at normal bedtime, between 7-8:30pm. I think that day she took longer to go down. [D] would have gone to bed at the same time as [C]. [B] would have gone to bed around the same time, in his own bedroom and [A] would have gone to bed in her own bedroom a bit later. The two young girls shared a big bedroom. As they had the biggest room, the children would often all play in there together. As I said earlier, we rarely used the front living room and mainly stayed upstairs or in the kitchen.

44. I went to my bedroom after the children had gone to bed. I left my bedroom door open as per usual. Later on, I really can't be sure when, but sometime between 11pm and midnight, I heard [A] get up to go to the toilet and say to [C] to go back to bed and ask her why is she up. I could see [A] from my bed, but couldn't see [C], who was standing further down the hallway out of sight. I also asked from my bedroom why she was up and that she needed to go back to bed. [C] said that she had a headache. I said "you looked fine earlier on, go back to bed". I thought [C] was just pretending she had a headache, to delay going to bed because she wanted to sleep in my bed. 

45. I then heard from their voices that [C] must have moved a bit closer to my bedroom and [A] say again for her to go back to bed as we had something exciting planned for tomorrow so she needed to sleep. I called out for her to go back to bed again. [A] then walked out of sight towards the bathroom near to where [C] would have been standing. I heard a knock and [C] cry out really loudly. [C]'s cry was a cry of fear, like a scream, which made me jump out of bed. I heard [A] cry out that [C] was running in circles.

46. I immediately got up and went out into the hallway and asked what had happened. [A] said [C] had fallen back and knocked her head against [B]'s bedroom door. [C] was crying and I was trying to calm her down. The way [A] explained it to me was that it was like someone had pushed [C] and she had lost her balance. All I knew is that [C] was crying a lot and she doesn't usually cry. I didn't think [A] had pushed [C], as [C] would have said if she had pushed her. 

47. I was consoling [C] and she came into my bedroom. Immediately following the bump her behaviour was different, she was looking around and doing a few weird things, her head was going around looking left and right, like she was following something that we could not see. She came into my bed with me and after this initial behaviour she seemed to be ok. 

48. I called my cousin [CG] sometime after midnight. I am unable to find out the specific time as I lost my phone and had to get a new Sim card. I don't remember if I called [CG] on WhatsApp either; WhatsApp would often work when mobile reception wouldn't. At that time, I was also using [A]'s mobile at times as the signal was so bad in our house.  [CG] was someone I would speak to multiple times per day. When I spoke to her that night, she said to monitor as children have soft spots on their head and maybe [C] had bumped hers. At that point [C] was not acting weirdly. 

49. I have seen the transcript of [CG]e's call to 999 and where she says that she was "on the phone before and she was fine and now my cousin just called me back in hysterics that she had passed out" that is correct. The more concerning change came later. 

50. At some point later, [C] was saying that she couldn't see and it seemed like she was hallucinating because she was saying she could see things and reaching for objects that were not there, like a mime artist. At one point it was like she was trying to catch a butterfly which was not there.

51. I am not able to be completely accurate about timings. I can see from the notes of Dr [S] who saw [C] at 5.40am that I said [C] hit her head and was fine for two hours before the really altered behaviour happened. This is also consistent with what I had explained to Dr [H] the following year. Again, two hours was a best guess and given at a time when we had all had a terrible shock and I was so worried about [C] in hospital. So, whilst the head bump did happen at or around midnight, and our attendance at A and E was recorded as 4:13am, it was a period of at least two hours between the really altered behaviour started occurring after she had hit her head, including clenching her body and it was later again within that sequence that [C]'s eyes rolled back and she became floppy and was unresponsive for what I could estimate to be 3-4 minutes. It was this unresponsiveness that caused me to call [CG] in a panic - she says on the transcript I was 'hysterical' and I believe that is true. [CG]'s call to 999 was at 03.35:20 hrs and then I was spoken to by the operator. I had tried to call 999 before [CG] on both phones but there was no reception. I agree with the record of Dr [McC] that after [C] came round she continued to act deliriously which she did after an initial gasp and was a bit calmer for a few minutes before acting strangely again going to the hospital and on arrival. I was extremely scared and confused, I had never seen anyone act like that from a small knock to the head. It was very traumatic. I decided it would be quicker if we made our own way to hospital rather than waiting for an ambulance. [CG] came over so that the children could come with us and be supported while I dealt with [C]. As soon as she arrived in a cab we got in my car and she held [CG] in the back on the journey to the hospital."

49.              The emergency services telephoned M after speaking with her cousin:

"CALL OPERATOR: Hello. I'm just calling to find out some more information. Tell me exactly what's happened.

UNKNOWN FEMALE: Um, so my daughter, around, um, one o'clock, or no, just before one, around 12, she was, um, she's always been a child that doesn't sleep, but, um, it's when she was going in her bed, she, like, um - she tripped and she lightly banged her head. So it wasn't anything to worry about.  Um, since then, she's been acting very weird, as [inaudible]. Um, she just - she just went unconscious, and I had to just throw water and shake her and wake her up.  Literally, she lost conscience [sic] for about two minutes....

CALL OPERATOR: Are you with her now?

UNKNOWN FEMALE: Yeah, I'm holding her down because she's

acting very weird. 

CALL OPERATOR: How old is she?

UNKNOWN FEMALE: She's four years old.

CALL OPERATOR: Is she awake?

UNKNOWN FEMALE: Yeah, she's awake right now.

CALL OPERATOR: Is she breathing?

UNKNOWN FEMALE: Yeah, she's breathing.

CALL OPERATOR: And how long ago did this happen?

UNKNOWN FEMALE: Um, 12 o'clock.

CALL OPERATOR: Almost four hours ago.

UNKNOWN FEMALE: Yeah, almost four hours ago."

50.              M took C to hospital around 4.13am. The triage notes recorded:

"At 0000, hit back of head on back of door, nil LOC or vomiting at the time, mum then reports had episode of not being responsive at 0300 and has been acting not her usual self since. Mum denies bat chance she could have ingested anything, reports nil recreational drugs in home. Nil medications notes. Normally fit and well..."

51.              On 27 and 28 July 2022, C was prescribed various medications pending the results of blood tests to cover all possibilities of her symptoms and presentation including encephalitis. She was also put under anaesthetic for a MRI scan and lumbar puncture and had an EEG [2] and ECG [3].

52.              On 30 July 2022, a consultant on a ward round described C's condition as "suspected encephalopathic event of unknown aetiology" and noted that blood had been sent for "extended investigations."

53.              The hospital intended to discharge C home on 31 July. However, Dr W a consultant recorded that:

"...overnight [C] had said to mum that when going home 'her and Paddington bear will punch the man if he's at her house.' The Mental Health Team were asked to assess [C] and following assessment they concluded at that time that: there were no acute mental health concerns;...and that a differential diagnosis could be migraine with aura and hallucinations."

54.              C was finally discharged on 2 August 2022.

55.              The blood test results during that admission were only available sometime later after C was discharged. They revealed a level of 21 of Topiramate in C's blood at 6.27am on 27 July 2022 which was above the standard therapeutic range and later the same day a decrease in the level to 15.

56.              The treating consultant Dr McC filed a statement in these proceedings and remarked that this level of the drug was "consistent with [C] having ingested a significant amount of topiramate prior to admission."

57.              In September 2022, A was reviewed at the hospital for her migraine. Dr G her consultant wrote that:

"[A] has been on Topiramate for a number of years and continues to have headaches. She doesn't like the way the medication makes her feel, and even at low doses Topiramate can have cognitive side-effects. I think it would be reasonable to come of Topiramate and see if this is associated with any changes in her headaches ... I think psychology input is likely to be the most helpful for[A]."

58.              B reported to professionals the same month that his migraine persisted on a daily basis.

59.              In December 2022, Dr G reviewed C in clinic. His notes set out that:

"I reviewed [C] in clinic following a recent admission with collapse, confusion, possible hallucinations, tremor and agitation, resulting in a 1 week admission and treatment with antibiotics and antivirals until symptoms resolved and investigations came back negative.  Initial urine toxicology screen was negative as were investigations for encephalitis, but subsequent to discharge the results of her bloods showed a high topiramate level.  We discussed the high topiramate level in clinic today, and mum had not been aware of [C] taking her older sister's medication, but the lock for the cabinet with the medication in had been broken and we went through medicine storage and safety advice.  I advised [C] that she could have been even more badly hurt by taking medicine that she does not know and should never do this again, and [C] did not enjoy her admission or the various tests done.  I advised that I would be informing the health visitor via this letter as part of routine information sharing.  I would be grateful if [C]'s GP could ensure that this information is shared with the health visitor and if any further concerns raised on health visitor review then followed up.

I am pleased to hear that since discharge [C] has recovered well and since then has had ongoing pains, similar to her sister [A] who has migraines."

60.              M does not accept that Dr G told her about the high level of Topiramate in C's blood at this meeting. She believed that this information was communicated some months later in April 2023. Moreover, the letter to M's GP following the consultation was only sent in June 2023. Nothing turns on this point because by July 2023, M certainly will have known about the blood test results.

61.              The next salient event was on Friday 28 July 2023. C was fine when she woke up. Late afternoon, her siblings said that she was "going weird again."

62.              M described what happened in her statement as follows:

"75. Sometime in the later afternoon or evening, the kids said "[C] is going weird again" because was zoning out. [C] said "mummy I don't feel good, I feel weird" and "the world is upside down". She started to cry and say she could see colours. She said her stomach was hurting. It was like her eye sight was going and she said she couldn't see properly. I got her on the bed and felt for her temperature. She was saying "mummy, something isn't right", she was telling me how she was feeling. I did not assess that was as heightened as the year before. She went normal again and watched TV with me in my bedroom. I was giving her fluid, water and cuddles. I also gave her some coca cola as it was sugary (she was later found to have caffeine in her system, which I think must have come from the cola). She also said she felt a bit sick so I thought the sugary cola would help.

78. She was in my lap. I think I gave her Calpol as she felt very warm. She was alert telling me how she felt, it was not like the year before where she was screaming and had suffered a knock to the head. It was different this time. They had asked the year before if she had an infection, so it came to my head that maybe she was coming down with something because she felt warm. 

79. I think this must have been between late afternoon, like 5 ish. I tried to call [Dr G] via the outpatients line. I was worried about her as the symptoms had started again and she was crying. Her body had started to look tense and jerky. [Dr G] had told me in December 2022 that it was migraine related so I wanted to talk to him to see what I should do as if it wasn't migraine, she would need to go to a different department. 

80. I tried to call [Dr G] for advice via the KHC outpatients number..."

63.              When C woke up on Saturday 29 July 2023, M said that C "seemed ok."

64.              M set out what then transpired:

"I don't remember exactly what we did at home that day. We didn't leave the house because [C] was not well, [A] was still unwell and [D] too. My symptoms were also heightened, with leaking and bleeding, strong pains from my stomach, fatigue and aching joints; I think this impacted my ability to focus and think clearly as I was distracted by trying to manage this as well; I was under immense mental and physical pressure. [C] was sleeping on and off throughout the day and watching TV with me. She was complaining of a sore stomach and was still feeling hot. There were some moments with [C] where she was showing unusual symptoms. These symptoms included 'primal behaviour' like seeing colours, looking around, walking around naked, a bit of hallucinating ("I can see somebody there"). She was also crying on and off saying she didn't feel well. There were moments on the Saturday where she wasn't responding to me normally either.  I have to accept that looking back now, these are all symptoms for which a child should get medical advice for. I did not think to get it as I wanted to continue to assess it and follow advice from [Dr G] in my December meeting and more generally I believed this was a migraine and her symptoms were in keeping with that.  I was also unwell myself which I elaborate on a bit below and I think this impacted on my ability to think straight as I was finding the pain in my stomach and back, the bleeding from my bottom all happening simultaneously, quite preoccupying and difficult to manage. I had to really dig deep to try and support [C] but on reflection, should have asked for help far sooner.  

84. It was some time after 8pm when she said that she didn't feel well and that she was scared. Her pupils dilated and her eyes rolled back in her head. She went lifeless. I literally thought she was dead. I screamed and [B] woke up and came running in. He immediately started to perform chest compressions on her. I was crying and trying to find her pulse on her wrist and heart. [A] came running upstairs with water and put the fan on her face. I was crying and tried to blow air into her mouth. She appeared to me to be unconscious and this lasted for about 3-4 minutes. I was extremely scared and panicked. The children were also panicked and upset. [C] came around and was sitting up. I knew we had to get to hospital, so I started to get dressed and get [C] dressed. I couldn't move very quickly because my body was in a lot of pain.  I went into a state of fright, I froze during this time and went into a paralysis of thought through my panic; this meant I made very bad decisions about what to do. In hindsight, if I was having difficulty with the phone system I should have called my Mum to come over sooner and simply taken [C] to A& E much earlier. I thought the symptoms displayed were largely akin to her migraines and I was following previous guidelines from the GP to call them.  My judgement was off. I have to accept this. I also have to accept that the impact of my decision making could have been catastrophic for [C] and that it was also very traumatic for [B]. 

85. I tried to call 111 but it didn't go through and I just thought it would be quicker to make my own way in again. I called my mum and explained that I needed to take [C] to hospital so asked her to come over and look after the other children. Mum asked me if I had called an ambulance and I said no, not yet. I can't remember if I then tried to call 999. I called a few other people on the estate to see if they could come over to help, but no one answered their phones.

86. My mum managed to get over really quickly. She was about 15 minutes away in the car. She arrived and got the other children ready to take to her house. I left with [C] who was strapped into a car seat. She seemed ok in the car seat. We arrived at [the hospital] at 21:20 on 29th July 2023."

65.              On arrival at hospital, the emergency department triage notes record the history taken from M as follows:

"Triage Notes: Hx taken from mum.

3-4 minutes unconscious episode, full resuscitation with chest compression and threw water on her.

Mum says she may have seen a spirit hence this episode.

No tonic clonic movement, eyes rolled back, tongue was to the side, stopped breathing.

Same episode happened a year ago, mum said she was told by doctors she took her sisters epileptic medicine, declines this.

NIC and consultant informed...."

66.              C was admitted to hospital. The medical disclosure reveals C's presentation and progress.

67.              By 31 July 2023, Dr H a consultant paediatric neurologist had received test results that showed Topiramate in C's blood:

"Toxins: Urine toxicology screen was negative [sic]. Serum topiramate 21 initially.

Repeated and was 15 (note NOT taking topiramate). Salicylate and paracetamol levels normal...."

68.              Dr H recorded that the "history is classical of intoxication/poisoning. This needs to be ruled out first...She should not be on Topiramate at all."

69.              On 4 August 2023, the clinical notes recorded:

"Are symptoms keeping up with topiramate digestion? - Yes

Is it possible any other reason to cause high topiramate levels? - Unlikely but we need to call the lab ho runs the test to ask about sensitivity, spesificty and cross reactivity of the essay.

At this moment, if she is clinically well no need for interventions

Repeat levels would help to see topiramate is clearing out of system."

70.              The same day, the clinical notes document a discussion between Dr H and Dr R, another consultant:

"We still are awaiting metabolic tests.

I note provisional topiramate level is 5. She should not have any topiramate in her blood stream at all, so this is a significant result. Mother denies that the tablets could be obtained by children as they do not know where they are and the cupboard is locked. I asked if the young person taking the topiramate hated them and spat them out / hid the tablets, so [C] could find them and take them. [Dr R] had already asked the family this question and the answer was "no". Therefore, we need to consider an intentional ingestion rather than accidental given this information."

71.              Later the same day, Dr R recorded that she had spoken to a clinical biochemist who confirmed that there were no conditions that caused high Topiramate levels falsely.

72.              Meanwhile, the hospital notified social services about C who was eventually discharged on 8 August 2023. C together with her siblings were placed with the maternal grandmother.

73.              The same day, 8 August 2023, the GP recorded that M contacted the surgery to request a new prescription for Topiramate for A. She said that A's migraines were not improving. The GP noted that M informed him that she had contacted a neurology secretary at the hospital and that it had been agreed that A would start on Topiramate. A had stopped taking Topiramate already in January 2023. M said that she had been giving A Topiramate since 3 July 2023 using left over medication.

74.              Mr G a social worker at the local authority spoke with A on 8 August 2023. She told him that she took medication for her migraine and used an inhaler for asthma. A did not like the medication and did not take it sometimes. M gave it to her and she would pretend to take it, put it in her mouth and leave it under her tongue. When M had left the room, she would flush it down the toilet. She was supposed to have one tablet in the morning and two in the evening.

75.              However, in October 2023, A sent an email to the Guardian which set out a different scenario regarding her approach to Topiramate, namely that she had secreted Topiramate around the house.

76.              Meanwhile, during these proceedings in March 2024, the local authority applied to the court to remove the children from the care of the maternal grandmother, into foster care. The application was made due to results of hair samples which showed that the children had been exposed to other drugs as well as Topiramate. The results though were contested.

77.              I do not propose to say anything more save that a judge made the order sought by the local authority and that decision was overturned by the Court of Appeal in a decision reported as Re D (Children: Interim Care Order: Hair Strand Testing) [2024] EWCA Civ 498.

78.              The relevance though of this whole episode is twofold; first, that it caused much upset to the family and second, as I shall explain later, the Court of Appeal's decision was seemingly rejected or sidelined by the local authority.

79.              I turn now to the evidence which can be divided into the medical evidence, social work evidence and lay evidence.

The Medical Evidence

80.              The medical evidence comprised experts instructed in the case and treating doctors.

81.              Statements were filed from five treating doctors, none of whom were called to give evidence although some had been on stand-by to do so and were released at the last moment.

82.              Dr McC is a consultant paediatrician who cared for C when she was admitted in July 2022. He explained the nature of his involvement in C's treatment and referred to the blood test results which showed that she had a level of Topiramate in her blood that was above the standard therapeutic range which was consistent with C having ingested a significant amount of the drug prior to admission.

83.              Dr W is a consultant paediatrician who was involved in C's care during both of her admissions in 2022 and 2023.

84.              He dealt with the history of both admissions. Dr W confirmed that the Topiramate level blood result was not available until after C was discharged from hospital in July 2022.

85.              Dr G is a consultant paediatric neurologist. He was the treating doctor for A, B and C at various times. He met C for the first time when she was admitted to hospital in July 2022. A and B were under his care since 2020.

86.              Dr G said that his "clinical suspicion" was that when admitted in July 2022, C was suffering from acute intoxication although treatment was started for other possible causes until that was excluded. C's condition improved and she was therefore discharged from hospital before the test results were known.

87.              He reviewed C in clinic on 21 December 2022. Dr G said that he discussed the test results with M at that meeting and that she was surprised and did not initially believe the result "until I showed her the numbers on our computer system."

88.              Dr G said that he explored with M how C could have accessed the medication and the importance of ensuring that there was no future occurrence. He told M that he would write to her GP to request a review by the health visitor to provide information on safe storage of medication.

89.              As I have said, M denied being told about the blood test results at that meeting. She said she was told a few months later. However, Dr G was not called to give evidence as ultimately, nothing would turn on whether M was told in December 2022 or some time later in April 2023; the fact remained that M knew the results by the time C was admitted again to hospital in July 2023.

90.              Dr G was not involved when C was admitted in July 2023. He saw her in October 2023 in clinic by which time C was living with her grandmother. He was told that C did not have ongoing headaches which required analgesia and that she had a good school attendance.

91.              Regarding A, she had been prescribed Topiramate by a colleague prior to 2020. He reviewed her in November 2023. A told him that she had frequent milder headaches and infrequent severe headaches. She had not used painkillers since July 2023 and had been to school.

92.              This led Dr G to comment that as A did not require regular medications or painkillers and was able to attend school, there was a concern that the previous use of analgesia and Topiramate "may have been avoided by addressing and managing triggers in a different way."

93.              He reviewed B in November 2020 when he had been referred for headaches which were consistent with migraine and also referred him to the sleep clinic. He also felt that "it would be important to address environmental triggers of migraine."

94.              Noting the children's improved school attendance since they were staying with the grandmother, Dr G said:

"I would be concerned that there had been over reporting of symptoms and over medicalisation of a problem (migraine) which it appears could have been managed with lifetstyle/environmental interventions."

95.              Dr H is a consultant paediatric neurologist. He treated C in July 2023 and his statement deals with the events of that admission.

96.              Regarding how C ingested Topiramate, he said:

"I remember subsequently talking to [Dr R] in person on the ward. I told her that my opinion was this a toxicology issue. I pointed out the previous topiramate results and said I was worried this was the most likely explanation. I explained that [C]'s mother had categorically stated there was no way [C] could get tablets, and I had given her the opportunity to explain if the medicine cupboard was every unlocked. She said no. I asked whether [C]'s sister had ever spat out tablets or hidden them places that [C] could find them. I was told by [C]'s mother this was not possible. [Dr R] said to me she would be surprised if it was a poisoning from her interactions with [M]. I reiterated my opinion that no other diagnosis makes sense in this situation and we should ensure topiramate levels are sent and to keep an open mind."

97.              Dr SG is the family GP. His statement set out A's medical history and confirmed that she stopped taking Topiramate in January 2023 following a decision in September 2022 to wean her off the drug.

98.              He said that on 8 August 2023, M telephoned the surgery asking for a new prescription as the migraines were not getting better saying that she had contacted a neurology secretary at the hospital and it had been agreed that A would start Topiramate. Dr SG found this request "very unusual as such decisions are made by consultants not secretaries and a letter would have been sent to us, but no letter had been received."

99.              Dr SG said that he would need to be in touch with the neurology department. The hospital replied on 7 September 2023 stating that A could start on Topiramate. That advice was received from another doctor as the treating consultant was away and Dr SG said this this "puzzled me as Topiramate hadn't been working for her and caused cognitive side effects and that was the reason she had been weaned off it." Dr SG did not issue a prescription due to safeguarding concerns.

100.          Dr SG's statement also referred to the medical histories isHof B, C and D.

101.          Dr Velayutham is a consultant paediatric neurologist. He prepared an expert report in April 2024 but was not called to give evidence.

102.          His report provided a neurological profile of the children including headaches and migraine. It also addressed the common side-effects of Topiramate.

103.          In reply to a question about whether the children's neurological condition had changed since they were in the care of their grandmother, he opined that:

"There is reported reduction of headache symptoms, less use of analgesics and better sleeping pattern in all the children since placement with maternal grandmother's care. Better care and environment are some of the reasons for these improvement in my opinion."

104.          Dr Pippon-Young is a clinical psychologist. She prepared a report on M in December 2023. She was not called to give evidence.

105.          She recorded that M was "polite, cooperative and generally forthcoming with information" and that M felt that it was reasonable that the local authority was involved given the circumstances. M discussed the events that C being admitted to hospital and referred to the children's poor school attendance as "very embarrassing." M spoke about her family saying that relationships were "all fine" as well as her relationships with the children's fathers.

106.          M referred to the local authority's concerns about her spiritual beliefs, such as using red ribbons to ward off demons and telling the children that C's symptoms were due to evil spirits. M said that red ribbons stemmed from Jamaican cultural practice but did not mean that she believed in demons or spirits. She felt this had been taken out of context. She noted that M had a history of "anxiety with panic attacks triggered by stressful life events."

107.          At the time of assessment, Dr Pippon-Young believed that M presented with "mild anxiety and stress" as well as her physical health problems which were "painful and debilitating for her."

108.          Dr Pippon-Young concluded that M did not have a learning disability although her intellectual ability was around the low average to average age. She also had no personality disorder or severe psychological difficulties presenting as "generally emotionally stable and resilient."

109.          She commented that:

"I identify [M] as some who has rather low 'mentalising' capacity; that is emotional literacy skills to interpret thoughts, feelings and behaviours in herself and others. I also suggest that [M] is mildly avoidant in her psychological style. This means she tends to avoid and detach herself from difficult emotions and experiences, preferring to push them aside. This can make her appear rather pragmatic and measured in her interactions with others, even when discussing emotive topics."

110.          Moreover:

"I identify some concerns about [M]'s insight into her children's emotional needs and possibly anxiety driven health related behaviours towards her children.  I suggest [M]'s psychological profile would be consistent with someone who might over-interpret physical health problems in her children and be invested in medical explanations for their presentations.  I also suggest [M]'s physical health problems could, at times, make it more difficult for her to meet her children's."

111.          She concluded that:

"7.4.2 What I can say is that many elements of [M]'s parenting capacity do not appear problematic. [M] can evidently ensure that her children's basic needs are met, and she has parented alone for many years with minimal Social Care involvement previously. [M] also evidently suffers from considerable physical health problems, which would be expected to make the parenting task more difficult, particularly as she is largely a single parent. She does seem to have managed fairly well but I wonder if [M]'s physical health issues have reduced her overall parenting capacities at times; for example, ensuring the children's regular school attendance and punctuality because she is too tired and unwell to take them to school herself. 

7.4.3 Where I also have some concerns is in the areas of emotional attunement and possibly anxiety-driven health related behaviours.  As mentioned, I believe [M] struggles with mentalizing and I found her insight into her children's emotional needs was rather limited.  I suggest [M] could find it hard to take her children's perspectives and to identify what they might be thinking and feeling, particularly when these are more nuanced.  I found [M] showed a surprising lack of outwardly expressed concern or reaction during interview to [C]'s experiences of Topiramate exposure, which must have been highly distressing for [C]. I would say [M]'s presentation in this regard is consistent with her rather detached, avoidant psychological style. It does, however, lead me to question how well [M] can connect with her children's experiences and emotions.

7.4.4 I also believe [M]'s tendency towards anxiety and worry about health could have implications in terms of how she understands the children's physical health needs and presentations. For instance, there are some concerns in the court documents that [M] could have over-interpreted the children's medical needs.   As mentioned, [M] has a history of stress related health problems herself, and it seems plausible that she might transfer this onto her parenting and understanding of her children's needs.   

7.4.5 Finally, I would mention [M]'s protective capacities and the concerns about the delay in taking [C] to hospital, even when she was seriously unwell.  I find this a rather perplexing and worrying aspect of this case at this stage.  I do not think this delay relates to cognitive issues; i.e. that [M] did not understand that [C] needed hospital treatment. It is also incongruent with [M]'s narratives of herself as an attentive and highly committed parent who is invested in physical explanations for her children's difficulties.  Her psychological profile does not easily account for this either as [M] is not obviously lacking in empathy or protective capacities elsewhere (e.g. in relation to [B]'s father).

One possibility is that it could link to a "freeze" response in response to severe stress and panic. Finally, it could be that [M] was actively trying to avoid taking [C] to hospital (e.g. se she knew she had given [C] Topiramate inappropriately or was worried about authorities becoming involved for another reason). This latter possibility, if proven by the court, would have significant implications for my understanding of [M]'s parenting capacity.  As the facts have not yet been determined, I would respectfully suggest that I comment upon this further following the fact-finding hearing, particularly if findings are made that implicate the mother in giving the children unprescribed medication and/or that [M] deliberately delayed medical treatment for [C]."

112.          Dr Pippon-Young recommended that M engage in a pain management programme and that consideration should be given as to how M and the children could be supported practically if the children returned home.

113.          Dr RS is a clinical fellow in paediatric emergency medicine. She was involved in C's care when she was admitted to hospital in July 2022. She filed a statement and gave oral evidence.

114.          Dr RS described C's presentation, her examination and diagnosis.

115.          She said that M told her that C hit her head on a door and was initially fine. However, two hours later, she acted bizarrely and was hallucinating and confused. M also said that C was acting "possessed." M also told her that she had seen C with mometasone furoate spray and Topiramate from a blister pack although it was not clear if C had ingested the medication.

116.          Dr Nicola Cleghorn is a consultant paediatrician. She prepared an expert report in the case and gave oral evidence.

117.          Her report filed in June 2024 reviewed the current health and developmental progress of the children and provided a paediatric overview of the children.

118.          Dr Cleghorn also considered the issue of perplexing presentations and fabricated or induced illness. She reached no adverse conclusion. She noted that attendances at emergency settings had been for appropriate issues and there was no evidence of M seeking medical opinions outside of the framework of her GP and the paediatric service.

119.          She made general comments about the children's attendances at hospital and considered C's admissions to hospital in 2022 and 2023.

120.          Dr Cleghorn recorded that since living at the maternal grandmother's home, the frequency and severity of migraine in A and B had improved.

121.          Her report contained the following observations and comments:

"8.5.3 On both admissions [C] had measurable topiramate levels in her blood. This was despite her not being on topiramate and the expectation that if a child is not on this drug then the level should be zero. I note that the treating clinicians had detailed discussions with the clinical biochemistry team about the possibility that either another substance, or a medical condition, or a machine error might have led to an erroneous positive result and the conclusion was that this was not the case. 

8.5.4 At the age she was at the time [C] may have been able to open a child proof cap, although I am aware that the standard is for these not to be able to be opened by the majority of children aged over 5y. 

8.5.5. However, I would not have expected her to have been able to easily swallow the tablets unless she had had pill training (which is done with some children with chronic and severe disorders where medication is either unpalatable in liquid form or cannot be formulated in liquid form). If she had chewed the tablet then this would have been bitter and so I would have expected her to spit it out. However, if the tablet or tablets  were crushed and given in some other substance then this could have been swallowed by [C].

8.5.6 Therefore for [C] to have had measurable levels of topiramate in her blood she would have been expected to ingest it. If she ingested tablets on her own, she would have needed to access the tablet bottle (which was reported to be locked away), open the child safety top (which is standard on pharmacy dispensed bottles), either swallow down a number of tablets (which would be difficult for a child of her age to do) or chew and swallow the tablets (which is unlikely given their bitter taste) or crush the tablets and mix them in with some other food (which she would have had to access herself). While each of these exists as a possibility I think they are highly unlikely to be the case all together. For this reason I think it is more likely that [C] was given topiramate by someone else. I am not able to say who that might be. 

8.5.7 I have seen a report by the Forensic toxicologist, Dr Douse. He has described a scenario where topiramate tablets were secreted around the house by [A] instead of her swallowing these. This then raises the possibility that [C] would pick up these tablets and ingest them herself. This is possible, the tablets are pink and so could be an attractive option for a child to pick up. However, as noted above, the tablets are bitter tasting and I would not expect that a child would choose to swallow more than one of these on repeated occasions even if she was capable of swallowing tablets at that age."

122.          Dr Cleghorn confirmed in her oral evidence that the sections in her report in bold type (including the extract in the preceding paragraph) were her amendments to her report once she had seen Dr Douse's report.

123.          However, once she saw written answers that Dr Douse provided, her oral evidence changed dramatically. Her report concluded that it was "more likely" that Topiramate had been administered by "someone else" although in her oral evidence, she accepted that there were various possible explanations for Topiramate being found in C's blood which included direct administration, C accidentally swallowing a tablet or being exposed to the drug at the family home.

124.          Dr John Douse is a forensic toxicologist and chemist. He prepared a report in January 2025, answered written questions put by the parties after the filing of his report and gave oral evidence.

125.          The following emerged from his evidence relevant to the issues to be decided by the court; I have preserved in some instances Dr Douse's language given the precise way he wrote his report and the manner in which he gave his oral evidence:

a)                  If tablets were secreted by A sublingually in her mouth and then around the family home in concealed locations, the potential for the home to have become extensively contaminated with Topiramate was likely to have been high.

b)                 The lack of significant high-level traces of Topiramate in A's hair (and which would have been expected as a result of the continuous, long term, daily prescribed oral ingestion of Topiramate) might be expected to have had the potential to possibly demonstrate, on the balance of probabilities, that A may possibly have avoided orally ingesting this drug, possibly even completely. A not having side effects also supported this view.

c)                  A repeatedly stated that it was habitual that she (presumably over the extended period that topiramate was prescribed (5 years)) had been in the habit of secreting the various prescribed pharmaceutical formulations of Topiramate given to her under M's supervision and observation sublingually in order to conceal from M the situation that she had not swallowed them.  The various forensic toxicological analyses performed appear to have supported the likelihood of this situation.

d)                 A also stated that she had been in the habit of either disposing of Topiramate by flushing down the lavatory or by secreting them around the house. One motivating pressure for the secretion of significant amounts of Topiramate formulations around the house was a desire reported by A to accumulate a sufficient quantity of medication in order to commit suicide as a result of having been bullied at school.

e)                  Moistening of the tablet formulations by prolonged exposure to saliva would have been likely to have caused them to commence disintegration (which they are designed to undergo rapidly following moistening upon ingestion). The tablets would be expected to disintegrate by crumbling to a powder when stored around the house under these circumstances.

f)                  Secretion of disintegrating tablets, potentially in such numbers being two 25 mg tablets per day with the potential of 3650 tablets over a five-year period and potentially further added to by authorised recommencement of prescription in July 2023 could have possibly provided a source of  significant and prolonged contamination of the surfaces within the family home by  Topiramate.

g)                 The presence of Topiramate detected in the washings from the toenails from the children (which included those who had not been prescribed the drug) had the potential to suggest that on the balance of probabilities, the traces detected in the toenails are more likely to have arisen as a result of external contamination such as from surfaces within the home.

h)                 The unusual and severe adverse side effects suffered by C had the potential to correspond to the adverse side effects of Topiramate that have been reported in the peer-reviewed scientific literature.

i)                   It is quite unusual for such a significant number of such severe and often not frequently encountered side-effects to occur altogether in one patient.

j)                   The potentially unique combination of severe adverse side effects exhibited by C may indicate that some form of therapeutic dose may possibly have been ingested by C.

k)                 Topiramate is not recommended for use in children for migraine and therefore it has not been possible to perform clinical trials, which could establish a therapeutic dose that might cause the onset of adverse side effects if either the therapeutic dose was exceeded, or the child might have had an existing pharmacogenetic sensitivity to Topiramate.

l)                   It is possible that therapeutic ranges of the expected levels of Topiramate utilised by the medical doctors in this case may have had to have been derived from clinical trials of adults and therefore in the case of C, a potentially significantly smaller dose of ingested Topiramate could have elevated her blood levels to those described as being the normal expected therapeutic ranges. 

m)               The exact number of Topiramate tablets orally consumed cannot be estimated with any true accuracy. However, the levels detected in C were noted to have been either in the therapeutic range or in the slightly supra therapeutic range.

n)                 C could have ingested crumbled remains of tablets, for example by contamination of her hands, or by ingesting partially disintegrated tablets, for example due to the reported  possible tendency of young children to copy the behaviour of older children in  the family.

o)                 The pharmaceutical formulations of Topiramate provided to A may have not always been in tablet from but in capsule form.

p)                 Topiramate has been reported to be a significantly bitter compound and complaints have been made to the manufacturers in this regard. In response, the manufacturers created some formulations containing sucrose in order to mask and also shield the active ingredient against detection by the taste buds during ingestion. One formulation is noted to be small spheres coated in sugar (known as "sprinkles") and contained in a gelatine capsule, intended for addition to food. It is possibly significant that in one interview, A stated that the formulations administered may have included not only tablets but also capsules. Such capsules might have presented a more attractive ingestion experience due to the sensation of sweetness prior to swallowing.

q)                 Topiramate commonly causes alteration in taste sensation (dysgeusia) and may even also have the potential for loss of both the sensations of taste and also perception of aroma (smell) in children. This could have the potential to render the flavour perception to a child more favourable and hence the ingestion of Topiramate tablets potentially more possible.

r)                  The fact the children had different fathers may account for A not suffering the same side effects as C from the drug.

s)                  Topiramate tablets were very small around 7mm diameter with a modern polymer film that made them easier to swallow.

126.          Dr Cleghorn and Dr Douse's evidence was sound and reliable, given by professionals who had put a lot of effort into their work for this case. By the end of their evidence, there was no real dispute between them. In the context of the case presented at the final hearing (the local authority's threshold document having been amended along the way) Dr Douse's evidence was highly relevant.

127.          I note that earlier in this case, there was talk of arranging an experts' meeting. For reasons unknown to me, this idea was not pursued which is a pity as had they been provided with an opportunity to discuss matters a few weeks before the hearing, much time could have been saved and it may have been unnecessary for them to give extensive evidence.

128.          Dr RS did her best to assist the court. I understand that in respect of C who she saw for a matter of minutes a long time ago in a busy hospital setting, the passage of time made it difficult for the court to gain much from her evidence. There were deficits in her evidence which overall was not helpful.

129.          The other medical evidence that I have referred to was helpful but not controversial in any way.

The Social Work Evidence

130.          Mr Eric Dooley is an independent social worker. He carried out three assessments in this case; a parenting assessment of M, a special guardian report in respect of M's brother Mr LD, and a parenting assessment of B's father EF. He also gave oral evidence.

131.          His report on M considered a wide range of matters including M's upbringing and family, past relationships, her education and health and the local authority's concerns.

132.          The report noted that:

a)                  M engaged well during the assessment.

b)                 M's upbringing was secure and did not include childhood adversities. M attended school and progressed to higher education although she did not complete her studies for a variety of physical and emotional reasons. M's school progress seemed to contradict that of the children's school attendance which was poor.

c)                  There were questions about M's ability to form supportive relationships and her ending relationships to protect her mental wellbeing. There was a question about whether M was careful enough in forming relationships.

d)                 M formed intimate relationships soon after previous relationships ended, and this may not have afforded her the emotional space to reflect and be mindful of future pitfalls.

e)                  The children all had a below average school attendance. M's health situation may have contributed to the children's poor school attendance.

f)                  M's account of how Topiramate was found in C's system appeared "inconsistent and mutable."

g)                 M's ability to safeguard the children's health was a matter of significant concern. Her failure to seek immediate medical attention when C displayed "troubling symptoms" was "extremely concerning."

h)                 M had a good knowledge of the children's basic care needs and understood the need to supervise the children to safeguard them when inside and outside the home.

i)                   M is a loving mother to the children. She was warm and tactile with the children and could support their education.

j)                   M had adequate parenting skills in most areas. However, M's ability to seek medical care, act appropriately in managing childhood illnesses, storing and dispensing medication was a cause for significant concern.

k)                 M struggled to understand some aspects of A's behaviour. She understood that A had experienced bullying and had attempted suicide but did not supervise her medication effectively and acknowledged that A overdosed twice and was storing medication to overdose again.

l)                   If the court found that M had deliberately harmed the children including giving unprescribed medication to C and delayed seeking medical help because she believed that C was possessed by evil spirits, it was difficult to consider any intervention that may assist M to make changes in the children's timescales.

133.          In his oral evidence, Mr Dooley made a number of positive points about M and her relationship with the children. He referred to the attachments between them and her emotional attunement to the children referring to them as "amazing children" who were "a pleasure to be around." Mr Dooley also recognised the concessions made by M in these proceedings.

134.          Mr Dooley opined that if the court did not make a finding that M had directly administered Topiramate to the children, the possibility of them being returned to M's care should be investigated. He gave some parameters of how this would look in terms of support such a respite care being provided as well as a family support worker, an acceptance by M that she did not do her best for the children in the way she stored medication and her working with the local authority. In this regard, he referred to a "reset" in relations between M and her family with the local authority.

135.          The reports prepared by Mr Dooley regarding Mr LD and EF were not controversial and accepted by the parties.

136.          Mr Dooley's report about Mr LD was positive. If the children could not return to M, he had no issue with Mr LD caring for them.

137.          His report highlighted many issues including the fact that LD had no adverse childhood experiences; he was not in a relationship at present but would hold the children's best interests in mind when thinking about the challenges of a future relationship; the children had a "close supportive relationship" with him such that they could confide in him and were not oppositional or insecure; he was insightful to the safety needs of the children and could meet their health and basic needs. In respect of his parenting capacity, Mr Dooley noted that "Impressively [LD] seems to have adapted and to date to be meeting the children's needs."

138.          Mr Dooley's parenting assessment of EF was also positive. He noted that B and EF had a "strong relationship," that he was "warm and nurturing" with B and was a "loving father."

139.          Overall, Mr Dooley concluded that EF had "good parenting knowledge and, in most areas, he seems to display adequate parenting skill." He went on to say that EF could provide B with "adequate meals; ensure he is appropriately dressed and appears more mindful of his medical care as well as education and stimulation." EF's ability to safeguard was "adequate."

140.          The report highlighted some negative matters such as a conviction for assault eleven years ago although EF explained the reasons behind this and was remorseful about the incident. Mr Dooley was also not given permission by EF to involve his partner in the assessment although he noted her employment as a midwife which suggested positives. However, overall, Mr Dooley had no problem recommending EF as a carer for B.

141.          Mr G was the social worker who first worked with the family. He filed statements and gave oral evidence. He spoke about his dealings with the family, his assessment of matters and concerns he had. Mr G also discussed with A the email she sent to the Guardian in October 2023.

142.          Ms LP has been the allocated social worker for the family since October 2023. She filed statements and gave oral evidence.

143.          Her evidence set out her dealings with the family and crucially the care plans proposed by the local authority which she had signed.

144.          Ms LP's latest statement made in December 2024 explained the basis for those care plans. However, her oral evidence departed from the care plan which had been agreed by senior management at the local authority.

145.          This led to Ms AH, a senior manager, filing a statement and giving evidence. I shall return to her evidence later.

146.          Ms CT is the Guardian who represented B, C and D. As I have said, A was separately represented. She filed a final report on 17 January 2025. Her detailed report considered the evidence and assessments in this case in some detail and weighed the various options available for the children's care. However, she was concerned to know the court's findings about whether M administered Topiramate to C before she could make final recommendations.

147.          In fact, given Ms LP's evidence and the apparent change of care plan by the local authority and events that unfolded during the hearing, the Guardian was only able to formulate and explain her recommendations at the point when she gave evidence.

148.          She agreed that B should live with EF. She also believed that whatever the findings about direct administration of Topiramate to C, that A should return to M's care given her age. If no finding of direct administration was made against M, then the proceedings should be adjourned for three months to allow work to be undertaken to ascertain whether C and D could return to M or just A alone.

149.          Mr Dooley was an impressive witness. I found his evidence to be based on firm foundations and practical. He was also very helpful in explaining how to shape any return of the children to M's care.

150.          Ms CT, the Guardian, came across as a committed guardian whose advice was sensible and professional. She was not afraid to voice her concerns about the local authority and made very constructive suggestions for the way forward.

151.          I found Mr G's evidence to be unreliable and flawed. I shall explain why later.

152.          Ms LP was described by the Guardian as a social worker who had done good work with the children which I accept.

153.          I was also impressed by the fact that despite the care plan, she was prepared during her oral evidence to accept that if the court found that there had been no direct administration of Topiramate by M to C, then consideration should be given to the children returning to M's care. This was a significant departure from the care plan which she prepared, and which was sanctioned by senior management.

154.          However, there were flaws in her evidence. The question of reunification of the children had not been actively considered by her at an earlier stage and the drug test results discredited by the Court of Appeal still played some role in her thinking.

155.          That leaves Ms AH's evidence. In every respect, what she said was flawed and immensely worrying. I shall return to this later when I deal with the welfare aspects of this case.

The Lay Evidence

156.          The only lay evidence was that of M and EF.

157.          EF set out his position regarding the change of B's name. He said that B wanted to have the same surname as his father which he supported. He had no problem making arrangements with M about contact or other issues.

158.          M filed one detailed statement which contained various exhibits. She gave her evidence over almost two days and had the opportunity to set out her position in relation to the issues in this case. In short, M accepted a substantial part of the threshold documents save for the allegation that she administered Topiramate to C.

The Law Relating to Fact Finding

159.          I turn now to the law relating to the fact finding part of this hearing.

160.          The parties have made extensive submissions on the legal position and referred me to various authorities. I have considered these in detail. What follows therefore is a distillation of the main points.

161.          To state the obvious, these proceedings are public law proceedings where the local authority may ultimately seek a care or supervision order. If so, it must pass what is called "the threshold". This is found in section 31(2) of the Children Act 1989, which provides that:

 

"(2)A court may only make a care or supervision order if it is satisfied:

                            (a) that the child concerned is suffering or is likely to suffer                                                       significant harm;   and

 

                             (b) that the harm or likelihood of harm is attributable to:

                                      (i) the care given to the child or likely to be given to him

                                      if the order were not made, not being what it would be                                                              reasonable to expect a parent to give him."

 

The other limb of the test at section (2)(b)(ii) is not relevant in this case.

162.          When determining the allegations made by the local authority in its threshold document, the court needs to have in mind certain matters.

163.          The burden of proof in respect of the allegations falls on the local authority who brings these proceedings and who have identified the findings that it asks the court to make.

164.          Where a matter has to be proved, the burden of proof is the civil standard, namely the balance of probabilities. To quote Lord Hoffman in Re B (Children) (2008, UKHL 3520):

"...If a legal rule requires a fact to be proved (a "fact in issue"), a judge or jury must decide whether or not it happened. There is no room for a finding that it might have happened. The law operates a binary system in which the only values are 0 and 1. The fact either happened or it did not. If the tribunal is left in doubt, the doubt is resolved by a rule that one party or the other carries the burden of proof. If the party who bears the burden of proof fails to discharge it, a value of 0 is returned and the fact is treated as not having happened. If he does discharge it, a value of 1 is returned and the fact is treated as having happened".

165.          There is no obligation on M to provide, much less to prove, an alternative explanation for the allegations made (see Lancashire -v- R, W and N [2013] EWHC 3064). The burden of proof cannot be reversed (see Re M (Fact Finding: Burden of Proof [2012] EWCA Civ 1580). The seriousness of the allegation or consequences of fact finding do not affect the need to make findings on the balance of probabilities (see Re BR (Proof of Facts) [2015] EWHC 41).

166.          Findings of fact must be based on evidence. As Lord Justice Munby (as he then was) observed in Re A (A Child) (Fact-finding hearing: Speculation) (2011 EWCA Civ 12):

"...It is an elementary proposition that findings of fact must be based on evidence, including inferences that can properly be drawn from the evidence and not on suspicion or speculation."

167.          I also have regard to the comments of Dame Elizabeth Butler-Sloss P in Re T (2004) EWCA Civ 558 regarding the need for the court to survey to wide canvass of evidence:

"...Evidence cannot be evaluated and assessed in separate compartments. A judge in these difficult cases must have regard to the relevance of each piece of evidence to other evidence and to exercise an overview of the totality of the evidence in order to come to the conclusion whether the case put forward by the local authority has been made out to the appropriate standard of proof.

168.          The evidence of M is of the utmost importance. It is essential that the court forms a clear assessment of her credibility and reliability. She must have the fullest opportunity to take part in the hearing and the court is likely to place considerable weight on the evidence and the impression it forms of them (see Re W and another (Non-accidental injury) [2003] FCR 346).

169.          I direct myself to the fact that M may have had particular reasons for lying and that those lies do not necessarily mean that her evidence is also untruthful about other matters (R v Lucas, 1981 1 QB 720).

170.          I also recognise that human memory is not infallible (see Gestmin -v- Credit Suisse [2015] EWHC 3560). In Lancashire County Council v The Children [2014] EWFC 3 Mr Justice Peter Jackson (as he then was) opined that:

"...I would only add that in cases where repeated accounts are given of events surrounding injury and death, the court must think carefully about the significance or otherwise of any reported discrepancies. They may arise for a number of reasons. One possibility is of course that they are lies designed to hide culpability. Another is that they are lies told for other reasons. Further possibilities include faulty recollection or confusion at times of stress or when the importance of accuracy is not fully appreciated, or there may be inaccuracy or mistake in the record-keeping or recollection of the person hearing and relaying the account. The possible effects of delay and repeated questioning upon memory should also be considered, as should the effect on one person of hearing accounts given by others. As memory fades, a desire to iron out wrinkles may not be unnatural - a process that might inelegantly be described as "story-creep" may occur without any necessary inference of bad faith."

171.          Medical evidence must be considered in the context of all the evidence.

172.          In A County Council v K D & L [2005] EWHC 144 (Fam) Mr Justice Charles observed that:

" 39. To my mind it is important to remember:

i) that the roles of the court and the expert are distinct, and

ii) that it is the court that is in the position to weigh the expert evidence against its findings on the other evidence, and thus for example descriptions of the presentation of a child in the hours or days leading up to his or her collapse, and accounts of events given by carers. ...

44. ....in cases concerning alleged non accidental injury to children properly reasoned expert medical evidence carries considerable weight, but in assessing and applying it the judge must always remember that he or she is the person who makes the final decision."

173.          This view was endorsed by Mr Justice Baker (as he then was) in Re JS (A minor) [2012] EWHC 1370.

174.          When assessing expert evidence, I also have in mind that cases involving a multi-disciplinary analysis of the medical information conducted by a group of specialists, each bringing their own expertise to bear on the problem, the court must be careful to ensure that each expert keeps within the bounds of their own expertise and defers, where appropriate, to the expertise of others (see Re S [2009] EWHC 2115 (Fam)).

Discussion and Conclusion on Threshold

175.          I turn now to my conclusions. I do so based on the totality of the evidence and having given careful consideration to the evidence and the extensive submissions of the parties. I have also stood back and considered the whole of the evidence with care and surveyed the wide canvass of evidence before the court.

176.          I remind myself that M has conceded a large part of the threshold document. There is no doubt that the conceded matters alone evidence a serious failure in the safeguarding and care of the children and in particular of C. These matters alone pass the threshold for the court to consider public law orders in this case.

177.          Thus, the fact that I shall not dwell on the accepted issues must not detract from their seriousness and the need for them to be considered in any welfare analysis.

178.          That leaves the issue of whether M directly administered Topiramate to C in July 2022 and/or in July 2023. In my judgment, the local authority has failed to prove that she did so.

179.          The starting point is to say something about M. 

180.          I am in no doubt that the bond of love between M and the children is strong.

181.          The Guardian referred to M as having done a good job bringing up the children outside of the events in these proceedings.

182.          Mr Dooley's parenting assessment made several positive observations about M. She was a loving mother; she spoke calmly to the children; she set boundaries and was consistent in maintaining family time with them are some examples.

183.          As I have said, in his oral evidence, he referred to the attachment between M and the children and her being emotionally attuned to the children's needs. He referred to the children as "amazing children" who were a "pleasure to be around."

184.          However, M's life is not easy.

185.          She is not a well lady. M referred to it as being "disastrous" which was no understatement.

186.          In a letter from her GP dated December 2023, he said that she was diagnosed in 2021 with ulcerative proctitis, a condition he described as being "caused by inflammation of the colon (large bowel)". The symptoms are rectal bleeding, loose stools, the passage of mucus rectally, abdominal pain and intermittent stool incontinence. Other associated symptoms are of bloating and excess flatulence. 

187.          She also suffers from asthma where she has what the GP described as "prophylactic treatment i.e. inhaled steroid treatment".

188.          M has had bouts of eczema, migraine, anxiety, required antidepressant/anxiolytic medication (citalopram) and talking therapy. She has joint and back pain and has been referred to the musculoskeletal service at the hospital.

189.          Indeed, during the hearing, M's health affected her ability to participate such that the court made special arrangements.

190.          The first week, she was only able to attend remotely as her ulcerative proctitis made personal attendance impossible. During the second week when she gave evidence, the court provided a dedicated room with its own toilet and a bed so M could take rest and have appropriate facilities on hand. For the rest of the hearing, M attended in person on some days and other days remotely.

191.          M also took on responsibility for helping family members. She referred to an uncle who was ill in 2023 for whom she was arranging help. She suggested that the family at that time left her to get on with that responsibility.

192.          M also had to deal with A who tried to commit suicide and harm herself and everything that came with such a situation. A was also unwell with migraine which was treated with Topiramate which she did not want to take and M had to deal with that situation as well.

193.          The real question about M is whether she was telling the truth. I find that overall she did.

194.          She accepted the substantive issues raised on the threshold document apart from the allegation that she directly administered Topiramate to C. She accepted she had failed all her children and not just C. I had the advantage of seeing her give evidence over almost two court days. She answered questions openly and frankly. She accepted where she could have acted differently without argument, for example in not going to hospital earlier and taking better steps to secure medication. She also firmly rejected the repeated suggestion that she deliberately tried to harm C and that she treated C differently to the other children.

195.          I accept that there were some inconsistencies in M's evidence. However, they must be set against the ability of anyone to accurately recall matters as time passes, Dr Pippon-Young's finding that M's intellectual ability was around the low to average range and that M had "some weaknesses in her verbal memory and possibly her processing speed." Indeed, Dr Pippon-Young referred to the M requiring "minor adaptions" to assist her which would not have been present when she spoke to doctors or other professionals during the course of what must have been a very difficult time for her. Coupled with Dr Pippon-Young's conclusion that M presented with "mild anxiety and stress linked to her current life stressors" the court needs to approach what M said on various occasions with appropriate care. This would certainly include statements she made to medical professionals at the hospital.

196.          Outside of statements made by M to medical professionals, there is M's evidence about cleaning the house. She painted a picture of such thorough cleaning that one could easily place doubt on the possibility of any trace of Topiramate being found. However, when set against M's health and abilities, it was clear that what M saw as a perfect cleaning job could not have been the reality of what she had done. That did not mean though that she was lying.

197.          Thus said, to reach any conclusion about M and her evidence, an isolated and forensic approach is inappropriate; it is necessary to look at her life in terms of her difficulties, her achievements and everything the court knows about her in the round and only then reach a conclusion about the veracity of her evidence.

198.          In this regard, the picture emerges of an anxious woman who is sick and suffers from debilitating illnesses which causes pain and much personal discomfort who has brought up children who have been described by professionals in such positive terms; children who love her and whom she loves very much; a mother who has failed in her personal relationships but did not appear to be bitter about her life and who has tried to help others and even managed to get on well for the sake of her children with two of their fathers despite the history between them.

199.          In my judgment, what emerges is a person who has satisfied me that she told the truth to the court and who would never have tried to harm any of her children.

200.          In considering whether there was direct administration of Topiramate, the Guardian helpfully suggested some questions that the court needed to consider before arriving at its conclusion. I shall adopt that approach.

201.          The starting point is to determine whether there were Topiramate tablets in the family home that C could have found in July 2022 and July 2023.

202.          Forensic test reports on B and D's hair and toenails revealed that for significant periods of time in 2023, there was a passive exposure to Topiramate. Dr Douse felt that "on the balance of probabilities", the traces on the toenails were more likely to be the result of external contamination. This would be consistent with loose tablets being at the family home.

203.          Originally, Dr Douse believed that the tablets around the house had been secreted by A sublingually, that is under her tongue. However, in his oral evidence he said that if the tablets had not been in contact with saliva and just hidden around the house, the extent to which they would deteriorate would depend on the degree of humidity. The drier the environment, the longer the tablets would not disintegrate. There was no evidence of what level of humidity was present in the family home.

204.          Stopping at this point, Dr Douse's evidence together with the test results appears to be sufficient to establish that Topiramate tablets were more likely than not to be present around the family home.

205.          However, evidence from other sources was also available which I should mention.

206.          First, what A had to say about this matter.

207.          On 8 August 2023, Mr G spoke with A. His case note recorded that A told him that she flushed Topiramate down the toilet:

"[A] shared that since she was 7 years old she has been taking different medications. [A] stated that since September last year she stopped taking medication [A] expressed she doesn't like taking medication. [A] said, "I don't take it sometimes". [A] stated that her mum gives her the medication and she pretends to take it. She puts it in her mouth and keeps it under her tongue. She takes it out when mum leaves the room and flush it in the toilet."

208.          However, on 12 October 2023, A sent an email to the Guardian which I have already mentioned. This email was significant as it referred to A hiding medicine around the house. The full email was in these terms:

"Hi its me [A] I haven't been able to call you but i needed to tell you that i I was hiding medicine around the house since y5 when i started getting bullied at school I didn't feel happy I felt sad and I wanted to die. When my mum found out she threw all the ones she found in the bin but I don't know if she found all of them and my memory is blurry so I don't  remember everywhere I put them so mabye she didnt find them all. [C] might have found it and taken it maybe she's not silly but I don't know she loves to touch stuff especially my things. The last time my mum found medicine was at the end of May after my sister [D] birthday party when she was tidying up she found it in the sitting room underneath the speakers she threw it in the bin. She never saw it before because we hardly go in the sitting room were mostly upstairs with my mum or in our own rooms. Please I hope I'm not in trouble."

209.           As a result of the email, Mr G spoke with A on 24 October 2023 to understand her position, especially as it came on the day of a court hearing which might have cast doubt on its reliability.

210.           Mr G's statement set out in detail what transpired:

"5. Discussion with [A] regarding her email to Guardian [4] I explored with [A] whether she wrote the email herself and what prompted her to write the email. [A] said, "I did not say it before because I don't like talking and sometimes my memory goes blurry". [A] added, "I did not say it before because I don't want to get in trouble. I thought if I say that they will call the police and I will be arrested".  

6. I asked [A] to explain what she actually did regarding hiding the medication at home, why she did that and where she had been hiding it. [A] told me that she used to get bullied by a girl in school when she was in Year 5. She got sad because of that. When she came home from school she took the paper clip, unfolded it and used it to open the medication box kept in her mother's wardrobe. [A]added that she would take a few of the medication and hide it in different places. 

7. I explored further with [A] where she hid the medication. [A]said, "In my room, under my bed". I asked if there were any other places. [A] said, "I don't remember the other areas". [A] disclosed that after her sister [D]'s birthday in May this year (2023), her mother found a pack of two tablets in the living room under the big speaker. [A] added that her mother previously found the tablets in other areas in the house and threw them in the bin. [A] said, "maybe [C] might have found it somewhere, but I don't know

8. I asked whether her mum talked to her about the tablet she found in the house. [A] said, "my mum always talked to me about the tablets she found in the house and asked if there is more. I say I don't know, but I think you have found all of them". [A] shared that she stopped hiding the tablets when her mum found the first set and told her. [A] stated that the tablets found under the speaker in May 2023 are the most recent her mother found, but she thought they had been there a while before May.[A] said, "I did not hide it there in May, but before".

9. I asked [A] if she discussed the email with anyone before writing it and sending it to the Guardian. [A] said "I discussed it with no one before I sent it."

211.          I take care when approaching Mr G's evidence.

212.          He said that he was careful to ensure that his notes of meetings were typed up by him quickly; within a few hours or if the visit was late at night, the following day unless a weekend intervened.

213.          However, his visit to A on 8 August 2023 was not entered onto the local authority's computer system until 19 October 2023. It seems a fair assumption that a gap of over two months would be sufficient time for a busy social worker to not record matters accurately. Mr G had no answer as to why it took so long to finalise his record and how he could say that he always finalised his notes soon after a meeting. It is therefore difficult to rely wholly on Mr G's notes of the August meeting.

214.          When M was told by the hospital in 2023 that Topiramate was found in C's blood, she telephoned A and B by telephone on loudspeaker and asked if they had given C Topiramate. The conversation seems to have been rather demanding and not a pleasant or passing enquiry. It also preceded Mr G seeing A on 8 August 2023. It was suggested that this may have made A feel responsible for C's situation and inhibited her from being open to Mr G especially considering A's then age of thirteen years old and her vulnerabilities.

215.          Regrettably, A was never subjected to an ABE interview or any other formal interview process other than Mr G visiting her. She was therefore never provided with a formal forum wherein she could be asked relevant questions and given an opportunity to explain the discrepancy between her alleged comments to Mr G in August 2023 and her email to the Guardian in October 2023 or for that matter, for anything to be explored with her. Given the seriousness of the allegation of direct administration being made against M, this would have been a sensible course to take.

216.          Moreover, no one including the local authority ever formally challenged the contents of the October 2023 email. A is separately represented and those advising her were never told that she was not believed. In the absence of any challenge, her narrative of events as recorded in the October 2023 is unchallenged.

217.          Indeed, a situation whereby A was hiding tablets, feeling responsible for C finding one or more of them and becoming ill, being challenged by M about matters, hiding her actions from Mr G, a stranger, and then feeling guilty and informing the Guardian some months later does make sense when measured against a vulnerable thirteen year old girl who had a history of unhappiness at school and suicide attempts. This possibility is also strengthened by the fact that the email to the Guardian was sent on a day when there was a case management hearing at court which A would have known about. In other words, it is entirely possible that what A said in her October 2023 email was true and represented what had happened, namely that she had secreted Topiramate tablets in the family home.

218.          M's evidence was contradictory on this issue. In her oral evidence, M said that she had found Topiramate in 2020 in a blister pack in A's bedroom around her bed and that in 2023 she found a tub after D's birthday party in the sitting room. However, in a written reply to the threshold document, she referred to finding medication on one occasion only in 2022.

219.          In her oral evidence, she said that she never found loose Topiramate tablets around the house yet in her statement, she said that:

"35. I came to realise that [A] was not taking the medication because I found the odd Topiramate pill on occasion though I just can't say exactly when that happened."

220.          M also referred to two occasions when she found A trying to take an overdose on Topiramate tablets and CAMHS recorded being told by M that there had been three attempts when M had taken pills out of A's mouth and hand.

221.          I refer to my overall view of M and her evidence. I do not regard these inconsistencies as being fatal to believing the M's evidence on the substantive issue of whether she directly administered Topiramate to C. It would be easy for the passage of time and pressure of being questioned to produce conflicting answers in the M's situation. However, it does not help with the enquiry on this discreet issue.

222.          M said that she was particular about cleaning the house. I have already mentioned this when discussing my view of M.

223.          In reply to questions from Counsel for the local authority, M confirmed that she cleaned every nook and cranny, made sure the floor was properly scrubbed and cleaned with a mop, used hot water with detergent to clean and felt that given her high standard of cleaning, she would have found or noticed any medication.

224.          However, given M's health as I have described it, there is no way that she could clean to such a high standard as to remove all traces of Topiramate in the family home or detect loose tablets.

225.          When visiting the family home on 10 August 2023, Mr G recorded that it was clean. However, there is a difference between being ordinarily clean and the level described by M who referred to herself as being "OCD" about cleaning.

226.          M may have aspired to a high level of cleaning and she may even have thought that she reached that level but from what we know of her situation, I do not accept that the family home was cleaned by her to such a level that would remove all traces of Topiramate even if that were possible.

227.          What therefore emerges is that the scientific evidence demonstrates that Topiramate was around the family home; A's unchallenged October 2023 email on the balance of probabilities reflects the true situation about A's disposal of Topiramate and there were therefore tablets in one form or another around the house.

228.          This leads to a second question of whether C could have accessed the medication.

229.          If tablets were lying around the house on the floor in one form or another, then C would certainly be able to access them.

230.          However, what if the tablets were in a container of some sort? Dr Cleghorn commented that:

"8.5.4 At the age she was at the time [C] may have been able to open a child proof cap, although I am aware that the standard is for these not to be able to be opened by the majority of children aged over 5y."

231.          M said that the tub of tablets she found in May 2023 had no child proof mechanism but even if it did, Dr Cleghorn's view was that it could still be opened.

232.          In her oral evidence, Dr Cleghorn also said that blister packs had to be child resistant, that it took a lot of dexterity to push the tablet out of the pack and to peel open the foil although it was still possible to do so; however, children would not open large numbers as it was time consuming.

233.          Accordingly, I have no difficulty concluding that C could have accessed Topiramate from a container or blister pack and certainly if a tablet or capsule were loose on the floor.

234.          On the basis that Topiramate was available to C, the court needs to consider the likelihood of C ingesting Topiramate by herself in July 2022 and July 2023.

235.          Dr Cleghorn said that she "would not have expected her to have been able to easily swallow the tablets." However, Dr Douse said that the tablets were "very, very small" around 7mm in diameter with a "modern polymer coating" which made them easier to swallow. This comment seemed also to fit with the picture of the tablets produced by M. In her oral evidence, Dr Cleghorn conceded that C might have thought they were sweets and agreed with Dr Douse.

236.          Dr Cleghorn's initial report also stated that if C "had chewed the tablet then this would have been bitter and so I would have expected her to spit it out. However, if the tablet or tablets were crushed and given in some other substance then this could have been swallowed by [C]."

237.          Dr Douse dealt with the issue of bitterness in his written evidence and reached a conclusion that deflected this being an issue, namely:

"13. It is noted that Topiramate has been reported to be a significantly bitter compound and that complaints have been made to the manufacturers in this regard.

14. In response the manufacturers have created some formulations containing sucrose in order to mask and also shield the active ingredient against detection by the taste buds during ingestion.

15. One formulation is noted to be small spheres coated in sugar (known as "sprinkles") and contained in a gelatine capsule, intended for addition to food. ...

17. It can be seen that such capsules (e.g. chewed in order to rupture the containing  gelatine shell) might possibly have presented a more attractive ingestion experience due to the sensation of sweetness prior to swallowing.

18. The situation is also further complicated, as it has been reported that topiramate commonly causes alteration in taste sensation (dysgeusia), and may even also have the potential for loss of both the sensations of taste and also perception of  aroma (smell) in children. (Cleveland Clinic, Dysgeusia, 2024), (A Ghanizadeh, Eat Weight Disord, (2009, (14), 137).

19. It remains unknown at this time as to whether the alterations in taste sensation are necessarily always predictable as necessarily being adverse for each individual person. (ibidem).

20. Such a situation could be seen to have the potential to render the flavour  perception to a child possibly more favourable and hence the ingestion of topiramate tablets potentially more possible. ...

27. It should also be noted that topiramate tablet formulations often contain starch (in addition to lactose), and that therefore the effect of prolonged contact with saliva (which contains a very effective enzyme (salivary amylase) capable of converting starch to a sweet tasting disaccharide sugar (maltose)), might be to further sweeten the disintegrated remains of the tablets (further than that already achieved by the presence of lactose, following their secretion around the house..."

238.          Dr Douse also noted that if the tablets had been moistened by prolonged exposure to saliva, it would cause them to "commence disintegration...by crumbling to a powder when stored around the house." This in turn "could be seen to have possibly provided a source of significant and prolonged contamination of the surfaces within the household by topiramate." He concluded that:

"In addition to the issues with detection in hair samples of the other family members, this situation could also have provided the opportunity for the child [C] to have ingested crumbled remains of tablets e.g. by contamination of her hands, or by ingesting partially disintegrated tablets, e.g. due to the reported  possible tendency of young children to copy the behaviour of elder children in the family..."

239.          Dr Cleghorn accepted the possibility that C could have picked up Topiramate dust and changed the view in her original report which concluded that there had been direct administration, to agree with Dr Douse as to the possibilities of ingestion.

240.          Although M said that she had not seen C try to swallow a tablet and she had only given her liquid medicine, this does not necessarily mean that C could not have ingested Topiramate. M also said that A had never complained that Topiramate was bitter to taste.

241.          It is clear from Dr Douse's evidence as supported ultimately by Dr Cleghorn that it was entirely possible that C was able to ingest Topiramate on two occasions in July 2022 and July 2023.

242.          Obviously, this still leaves open the question as to why B and D never suffered the same fate by finding Topiramate in some form; why nothing happened between 2020 and before July 2022 during which time A was resistant to Topiramate and how one approaches a situation where the same child took Topiramate on two occasions.  Suffice to say that at this point of enquiry, the court can be satisfied that it was entirely possible for C to ingest Topiramate.

243.          When assessing how much Topiramate needed to be taken to cause such an extreme reaction to C and how long would it take for the drug to react the way that it did, the starting point is to recognise that Topiramate is really a drug used for adults.

244.          As Dr Douse said, there had been no clinical trials with children which would establish a therapeutic dose that might cause the onset of adverse side effects.

245.          Dr Douse also stated that it was not possible to accurately establish the exact number of tablets ingested by C although the levels detected were either in the therapeutic range or in the "slightly supra-therapeutic range" as doctors derived the therapeutic range from clinical trials of adults. Thus, a smaller dose could have elevated C's blood levels to those described as being the normal therapeutic range.

246.          Dr Cleghorn suggested that one tablet could be sufficient to cause toxicity and Dr Douse observed that C could have ingested crumbled remains of tablets.

247.          Thus, the level of Topiramate in the various blood tests does not necessarily provide the answer to the question of how much was taken. The expert evidence is clear that it could have been from one single tablet.

248.          Dr Douse said that C would have been at her peak plasma level, that is the highest level of concentration in her bloodstream after administration and at the maximum level of the side effects of the drug, within two to three hours of ingestion. This conclusion does not contradict Dr McC's comment that C's symptoms could have been caused by the sudden introduction of Topiramate into her system, on the basis that his reference to sudden allows for two to three hours.

249.          Accordingly, the court can find that C could have found loose Topiramate, ingested it and that this caused the side effects described in the evidence.

250.          That leaves the question of whether Topiramate was directly administered to C by M.

251.          Many points were made against the M of which I shall address the main ones.

252.          First, M was accused of believing in demons, spirits and practices such as tying red ribbons on a hand. The local authority maintained that these beliefs were unacceptable and also precluded her from seeking medical help for C.

253.          This issue was so prominent that it was even transposed by Mr Dooley into his report. It was found in Dr RS's note recording M as saying that C was "possessed" and Mr G used this issue to suggest that M's beliefs would have a negative impact on her ability to meet the children's needs.

254.          M maintained that whilst her parents believed in spirits, she did not. She also explained how some practices such a wearing a red ribbon were simply customary in her culture.

255.          Mr G's evidence on this issue was unreliable.

256.          In his statement, he referred to a visit on 4 August 2023 when he recorded that M told him that "red ribbons have to do with the Caribbean traditional beliefs that they drive away evil spirits."

257.          His statement also referred to M's "traditional belief around demons being driven around by red ribbons" and concluded that this "may have delayed her from taking prompt and lifesaving actions such as seeking immediate medical attention for [C]." He went on to express his concern that "if nothing changes such beliefs could have negative impact on [M]'s ability to meet her children's immediate health needs and there is a risk of the children growing to normalise, accept and adopt such beliefs."

258.          When Mr G was cross-examined about this issue, he accepted that M was telling him what the Caribbean traditional belief was as opposed to saying that she believed it, that M did not mention demons to him and that his evidence did not faithfully record that M had ever indicated that she believed in these things.

259.          Mr G's evidence and more significantly, his assessment of M was therefore flawed. Its effect though was dramatic as it filtered into Mr Dooley's report and into the general view of the local authority about M which seemed to turn the matter into something sinister.

260.          Many people hold beliefs about matters spiritual; even if M had said that she held beliefs about spirits and the like, the local authority could have investigated further and produced a reasoned assessment of the position and how such beliefs would affect M's parenting. Moreover, many religions advocate the wearing of particular garments or as in this case a red ribbon as a good-luck charm which from a child welfare perspective is harmless.

261.          I also do not place weight on Dr RS's note that M said that C was "possessed."  I shall return to the value of her notes later.

262.          I accept what M said about her beliefs; indeed, there was nothing to rebut it. It seemed to me that the whole issue of demons and spirits was misplaced in this case. There was certainly nothing to prove that M delayed taking C to hospital and seeking medical treatment because of these beliefs even if she held them which I do not find anyway. I also see no harm if someone placed a red ribbon for whatever reason on C.

263.          Second, Dr RS recorded in her notes in July 2022 that:

"M had seen C with Mometasone furoate spray and Topiramate milpharm 25 (Appears to have three blisters open)."

264.          Dr RS said that the words in brackets meant that she saw the blister packet open herself in the hospital.

265.          The local authority drew the court's attention to the fact that M did not mention this to anyone. Thus, when she arrived at hospital at around 4.13am, the triage notes recorded that:

"At 0000, hit back of head on back of door, nil LOC or vomiting at the time, mum then reports had episode of not being responsive at 0300 and has been acting not her usual self since. Mum denies bat chance she could have ingested anything, reports nil recreational drugs in home. Nil medications notes. Normally fit and well, NKDA, imms UTD, nil SS. declared. O/e GCS 13/15, PEARL 5+, brady cardic, normotensive, o2 sats 100%, for examination."

266.          This note records M's denial that C could have ingested any drugs and there was no mention of her seeing C with any medication as she told Dr RS.

267.          M maintained that she never told Dr RS that she had seen C with medication. M said that she had been asked by someone, not necessarily Dr RS, whether C had access to medication at home and was then asked to bring that medication to the hospital. M did so and sent a picture to her cousin who remained at the hospital from her car. She was not happy at having to go home but did so as she was told to do so as she lived locally.

268.          I accept M's version of events and in particular that she did not tell Dr RS that she had seen C with medication.

269.          I find that Dr RS's note was not reliable. She accepted that she did not take a verbatim note and that it was possible that she had not properly recorded what she was told. It was also possible that she mixed this up with M being asked to bring in the medication that she had at home.

270.          The notes themselves also make no sense. Reference is made to an "initial clinician time" of 5.40am. The note was signed by Dr RS at 6.35am. Dr RS said that she spent one or two minutes with C which certainly does not fit with the time range in the notes of 55 minutes. Furthermore, Dr RS recalled that a nurse was taking a second set of observations when she saw C. If so, the 5.40am "initial clinician time" must be wrong as the notes recorded the nurse's examination at 5.02am.

271.          There is also no record that M told anyone else that she had seen C with Topiramate and the nasal spray.

272.          M was also never challenged in cross-examination about the photographs she produced. It was never suggested to her that they were taken on another occasion or stage-managed for these proceedings, for example.

273.          Third, M was also accused of minimising the impact of Topiramate on C by not providing Dr RS with a full history of what had happened to C as M described in her statement.

274.          M's statement obviously goes into detail. I have already questioned the accuracy of Dr RS's notes. However, the note records that "2 hours later reported starting acting bizarrely/hallucinating/confused...". The note is succinct and thus not necessarily wrong in this respect because "acting bizarrely" could well include more than just one presentation when M mentioned others to Dr RS.

275.          Dr RS also recorded that M "denies LOC [5]" although there was a reference to the ambulance service being told that C had been unconscious.

276.          This led to a series of questions in cross-examination where it was put to M that by referring to C passing out rather than being unconscious showed how M was minimising what she had allegedly done to C.

277.          I do not accept this because it was clear that these phrases held no real difference in meaning to M. This view is also reinforced by Dr Pippon-Young's view of M's intellectual abilities.

278.          The final point on this issue is that Dr RS's record that M denied C being unconscious was in the narrative in the notes which clearly referred to events at midnight at which point C had not lost consciousness. The note on a new line in the notes thereafter described presentations next to a new time of 2pm so on that basis, the note could fit with what M said.

279.          Four, Mr G referred to a letter from the GP which contained information from the hospital and said that M told them that C "accidentally took her elder sibling's topiramate."

280.          Mr G's statement referred to M maintaining that this was not true, the inference being that she was not telling the truth. He then checked with the GP who replied that what he had written was done so in error.

281.          This did not stop Mr G in his oral evidence from stating that he did not think M was correct to deny that she made this statement to the hospital and when shown the GP's correction letter, he said that he did not remember.

282.          I found Mr G's whole approach worrying. I have already set out why his evidence on M's alleged beliefs and his record taking were flawed and the consequences that followed. In this instance, there seemed almost to be a presumption of guilt against the M on his part.

283.          Five, I reject the suggestion that C was treated differently by M to the other children.

284.          I have referred to Mr Dooley's evidence that the children all had a strong attachment to M. Dr Cleghorn did not raise this issue in her report which contained considerable detail about the children and their medical profiles.

285.          M said that in July 2022, she thought that C was pretending to have a headache as an excuse to sleep in M's bed which suggested that sleeping with M was likely to have happened in the past.

286.          Dr Pippon-Young referred to M as having illness anxiety, in other words being overly concerned about her health and that of the children. Indeed, the children were often seeing doctors.

287.          This seemed to go against M's conduct in July 2022 when she waited at least two hours before taking action to go to hospital and in July 2023 when she took at least one and a half days to seek medical help. It also did not explain why C had only three medical entries in her notes prior to being admitted to hospital in 2022 yet M said that C had headaches since she was 3 or 4 years old and that they could last for a few hours.

288.          M accepted that she had badly failed C in 2022 and 2023. She did nothing to conceal her serious errors when she gave evidence.

289.          She said that she had mentioned C's headaches when speaking to doctors about the other children. I can accept this as parents often speak about one child during a consultation about another child.

290.          I also refer to M's health which was in a bad place in 2022 and 2023. My view is that in July 2022 and July 2023, M was too wrapped up in her own situation and needs and put herself first before C. This was entirely wrong but not evidence of treating C differently to her siblings.

291.          Six, M was also accused of not making a connection between the events of July 2022 and those of the following year when she should have realised that C's symptoms were similar and must have been from Topiramate such that she needed to seek medical help immediately.

292.          When C was discharged from hospital in August 2022, the blood tests had not provided a definite conclusion that Topiramate was the cause of C's symptoms. The view was that C's situation was migraine related.

293.          There is a conflict of evidence as to when M was told that Topiramate was the cause of C's symptoms as I have recounted.

294.          Dr G maintained that he mentioned it at a consultation in December 2022 which M denied. She believed that Dr G told her in April 2023 although M wanted to see this in writing as she was clearly sceptical about this conclusion. It was not until June 2023 that M received a letter from the hospital confirming the position. Thereafter, M refused to accept that Topiramate was an issue which she accepts was an unreasonable view to take but one that she held at that time.

295.          On M's behalf, it was submitted that this provided a good reason why M did not appreciate in July 2023 that C's presentation and events generally were similar to the previous year and immediately take C to hospital. Instead, M seemed to attach herself to a mistaken view that C had migraine or was unwell with something else.

296.          Although M should have made the connection between what was happening to C in July 2023 and the events of the previous year, I can accept that M blinded herself to the reality of what was unfolding in July 2023. This is certainly a matter to consider when looking at the risk of the children returning to M but not something that counts towards a consideration of direct administration of Topiramate to C.

297.          Seven, if M administered Topiramate to C in July 2022, it made no sense to then produce the drug to the hospital as she did when it was obvious that they would carry out tests to ascertain if C had taken the drug.

298.          Eight, in July 2023, if M had administered Topiramate the previous year or even if it had been administered in July 2023 for the first time, it made no sense to take C to the same hospital in 2023 when they would see C's notes and immediately realise the similarity in presentation and test C for Topiramate and then demand an explanation for its presence in her blood stream.

299.          Nine, if Topiramate in the home was bitter tasting, M would have known that A did not like taking it and made a fuss. It seems inconceivable that she would therefore try to administer it to C which might prompt the same reaction especially as C may well have been aware of A's reaction to it from her own lived experience in the family home.

300.          Ten, I derive nothing from M trying to obtain a prescription for Topiramate from the GP in August 2023 for A. I accept that her explanation about telephoning the doctor's secretary made no sense, but this happened at a time when C was in hospital and I do not feel that it is a connected incident such that it sheds light on the issue of direct administration.

301.          Eleven, crucially and perhaps surprisingly, M was never asked how she administered Topiramate to C. Such a question seemed to be obvious if it was alleged that M directly administered Topiramate to C. I can only conjecture that the question was not put given M's firm denial of direct administration.

302.          Twelve, there was also no answer provided as to how it transpired that C never told anyone that M gave medication to her. C was seen by many doctors during her admissions and there were times when she was feeling better when she could have said something but she did not.

303.          Thirteen, M's story remained basically the same throughout the many questions put by doctors. It is known that doctors often repeat questions to parents in situations where they are concerned about safeguarding. However, M remained adamant in the face of questioning that she did not administer Topiramate directly to C.

304.          Taking everything together, when looking at all the evidence and the wide canvass, there is nothing in my judgment that permits a finding on the balance of probabilities that M directly administered Topiramate to C in either July 2022 and/or July 2023.  The local authority has failed to prove its case.

305.          Having said that, the admissions made by M cannot be ignored. As I have said, they demonstrate serious failings on her part. That M was unwell and unable to prioritise the children might explain some matters, but it cannot be an excuse for what transpired.

306.          Nonetheless, I am satisfied that the threshold is passed in this case to allow the court to make public family law orders.

307.          I must therefore now consider the local authority's care plan and the parties' responses and arrive at a welfare decision for the children.

The Law Relating to Welfare

308.          The legal foundation for welfare decisions is found in the Children Act 1989. 

309.          Section 1 (1) of the Children Act 1989 provides that:

"(1)        When a court determines any question with respect                   to—

(a)     the upbringing of a child; or

(b)     the administration of a child's property or the application of any income arising from it,

the child's welfare shall be the court's paramount consideration."

310.          Section 1(3) sets out matters to which the court must have regard:

"(3)       In the circumstances mentioned in subsection (4), a court shall have regard in particular to—

(a)     the ascertainable wishes and feelings of the child concerned (considered in the light of his age and understanding);

(b)     his physical, emotional and educational needs;

(c)     the likely effect on him of any change in his circumstances;

(d)     his age, sex, background and any characteristics of his which the court considers relevant;

(e)     any harm which he has suffered or is at risk of suffering;

(f)      how capable each of his parents, and any other person in relation to whom the court considers the question to be relevant, is of meeting his needs;

(g)     the range of powers available to the court under this Act in the proceedings in question."

311.          I also mention the rights of the parties and the children under Article 8 of the European Convention on Human Rights as incorporated into English law through the Human Rights Act 1998 and the need for my decision to be a proportionate and necessary interference with a party's rights.

Discussion and Conclusions on Welfare Issues

312.          Having considered the evidence before the court on welfare, I have reached the conclusion that the court cannot make final orders now and the welfare part of this case will need to be adjourned to another hearing. I shall explain how I have arrived at this decision.

313.          I start with B. No one disagrees that he should remain living with EF and that the court should make a lives with order. I also accept that there is no need to make any formal order that B spend time with M because that already takes place and M and EF are able to make arrangements between them.

314.          This arrangement is entirely in B's welfare interests. He wants to live with EF, he is thriving there and happy whilst also seeing M regularly. EF is able to meet B's physical, emotional and educational needs. B's health has improved whilst living with EF. The assessment of EF was positive.

315.          However, I do not propose to finalise these orders now as the court cannot address the issue of sibling contact until it finalises the position for A, C and D. This will be done at the final hearing. I believe that B's welfare interests are best served by this purposeful delay in formalising his arrangements.

316.          That brings me to A, C and D. The evidence leads me to the inescapable conclusion that the court cannot make any final decision relating to them now.

317.          I have reached the regrettable conclusion that this is a case where the local authority has shown itself to be incapable thus far of making child focussed welfare decisions which are based on firm foundations in this case.

318.          It says much about the local authority that even on the final morning of the hearing at the point when their Counsel was to make his final submissions to conclude the case, that Counsel still awaited final instructions on the care plan for the children and needed to ask for a short break for that to happen.

319.          Counsel for the local authority should never have been placed in such a position on the sixteenth day of the case any more than the court and the other parties. This alone said so much about the local authority's inability to plan for the children.

320.          To understand my concerns about the local authority, it is necessary to provide some background.

321.          At the outset of this hearing, the local authority's care plan was for B to live with EF and for the other children to live with Mr LD under a special guardianship order.

322.          When he gave evidence, as I have said, Mr Dooley outlined many positive features of M's parenting some of which I have mentioned. Crucially though, he said that there was room for a safety plan to be implemented to reunite the children with M if the court found that Topiramate had not been directly administered by M to C as is now established.

323.          I refer to his reference to a "reset" between M and the local authority which was necessary after the upset caused by the proposed removal of the children which was halted by the Court of Appeal.

324.          Mr Dooley outlined the need for a proper acceptance by M that she had not taken good enough steps to store medication and the need for a robust package of support in the form of a family support worker, respite care, family involvement and steps to address M's own health conditions.

325.          This evidence was novel in that nowhere in the local authority's planning had there been any real thought about the possibility of the children returning home. This prompted the court to raise the question of how it could approach any welfare analysis as explained in Re B-S (Children) [2013] EWCA Civ 1146 when all options for the children had not been explored.

326.          Meanwhile, Ms LP the allocated social worker gave evidence. Her starting point on welfare issues was as set out in the care plan presented at the start of the hearing which was to rule out any return home of the children.

327.          Not surprisingly, she was asked about Mr Dooley's evidence and his recommendation of the type of support and planning that could be put in place to allow the children to return home.

328.          During her cross-examination, it became clear that Ms LP had not understood the significance of certain matters being excluded from the threshold document such as the discredited expert evidence on illicit substances; she had not considered the concessions on threshold made by M in any great detail or understood their significance in the context of care planning; she had not even discussed the Guardian's final analysis with the Guardian to try and understand why the Guardian was in difficulty making final recommendations.

329.          However, to her credit, Ms LP was honest enough to accept that there needed to be consideration of a support plan to allow the children to return home. Whilst such a plan ultimately might not be approved by the court or be able to work, she accepted that it needed to be considered. In other words, she departed from the local authority's formal position.

330.          The Guardian referred to Ms LP as having done good work with the family. Indeed, my view of her is that she was committed to the family and her honesty when giving evidence in recognising the deficit in the care planning for the children said much about her.

331.          However, this evidence set off a train of events. After giving her evidence, at 4.27pm on 28 January 2025, Ms LP sent a Teams message to Ms AH a service manager at the local authority saying:

"I feel really bad because the position in evidence that I gave is different, I've agreed that if no findings against mother then kids can go home - I was questioned by all as this was the view of CG and ISW...

Maybe we should speak."

332.          At 4.30pm, Ms AH replied that she would speak at 5pm. Meanwhile, Ms LP set about preparing a support plan in the event that the children could return to M which could be considered by the court.

333.          Meanwhile, Ms AH filed a statement and gave oral evidence. She addressed Ms LP's evidence as follows:

"I understand that there may be some confusion regarding the Local Authority's position, following the oral evidence provided by the Social Worker when giving live evidence during the current final hearing. I therefore seek to clarify the Local Authority's position. I have also discussed this with other Senior Managers within the Local Authority as appropriate and information has been shared with both the Director, Mr [B] and Executive Director [AC]."

334.          For my part, there was nothing confusing about Ms LP's evidence. She simply set out her position and accepted a change in position on the care planning for the children.

335.          What Ms AH's statement did though was to effectively revoke Ms LP's position and revert to the original care plan which did not provide for the children to return home on any account.

336.          However, her statement went on to say:

"In discussion with Ms [LP], with regard to her oral evidence and the proposition that was put to her, she confirms that she stated under some pressure, that what was being proposed could have been considered. However, decisions regarding care plans for children are made at care planning meetings held within the Local Authority and are ratified by senior managers and therefore unfortunately Ms [LP] did not have the authority to agree to any change of care plan and perhaps the court might have adjourned to allow this to happen."

337.          The suggestion that Ms LP was put under pressure was utterly wrong. She was not. She was not subjected to hostile or aggressive cross-examination. She was simply asked about Mr Dooley's evidence and gave her own view.  As to the suggestion that the court should have adjourned the hearing, no request was made by the local authority or anyone else including Ms LP who simply answered the questions put to her.

338.          I regard Ms AH's evidence thus far to have been an unacceptable attempt by a senior manager to distance the local authority from the views given on oath to the court by the allocated social worker whose primary focus was on what was best for the family and who proffered a view that senior management did not welcome.

339.          I remind myself that Ms AH is a senior member of the local authority. In presenting her position, she represented some of the highest levels at the local authority with whom she had consulted.

340.          Overall though, I am sorry to say that Ms AH's evidence demonstrated failings at a corporate level by this local authority. The failure to properly analyse the evidence in this case and to consider all options for the children is deeply concerning.

341.          I was left with the impression that returning the children to their mother was something that seemed to be unthinkable to the local authority. However, this should have been the first consideration in their minds; to see if there was a safe way for the children to go home to the mother they love and to the mother who loves them. To my mind, the local authority seemed to have decided that this was simply never going to happen. It was as if M was written off.

342.          Ms Grief KC emphasised this point when she demonstrated how a comparison of the care plans as amended by Ms LP and the amendments inserted by a senior executive in a plan ultimately signed by Ms AH removed references to supporting M and added words to suggest that the only reason A wanted to return home was because she would have her own bedroom.

343.          There were also other worrying deficits in Ms AH's evidence. She accepted that she had not read a note of Ms LP's evidence so when she met her and senior management, she had no idea of what exactly had been said and its meaning in the context of the case.

344.          Ms AH accepted that she kept no notes of the various meetings held by the local authority after Ms LP's evidence on 28 January 2025 and leading to Ms AH's evidence on 31 January even though these were important meetings.

345.          She had not read key documents in the case filed since December 2024; she had not considered the difference in planning if there was a finding of direct administration as opposed to no finding, taking into account M's concessions on the threshold; she could not address why A should not return home if no finding of direct administration was made in circumstances where both Mr Dooley and the Guardian recommended a return home even if the court found that M had directly administered Topiramate to C; despite asserting that the local authority could not guarantee the children's safety if they returned home in her statement, she could not explain why this was so in the face of the evidence of risk management that could be put in place or certainly considered; she had regard to flawed substance testing results even though they had been discredited by the Court of Appeal on the basis that from a social work as opposed to legal basis they were in some way helpful.

346.          The only other point to be made is that Ms AH's statement referred to an adjournment after the fact finding part of the case was completed to allow for planning whilst at the same time maintaining that the care plan was for a final order in the form of special guardianship orders for A, C and D and for B to live with EF. She was content to state that a return of the children to M could be considered outside proceedings. Given the approach that I ascribe to the local authority, I would have no faith about that process.

347.          What emerges therefore is a local authority that seems to have failed to carry out any meaningful evaluation of the evidence not only in legal terms but more importantly in social work terms. Matters such as M's concessions on threshold which represented a major development in this case and significant evidence given by Mr Dooley do not appear to have been given any serious consideration.

348.          Quite frankly, I find myself at a loss to describe how unacceptable all of this is to the court. What I am clear about is that it must lead to a conclusion that the court cannot make any final welfare decisions for A, C and D at this hearing until all options for their future have been fully considered and the court is in a position to evaluate whether there is a risk in them returning home.

349.          I therefore see the way forward as follows.

350.          There must be a full analysis of all options available to the children for the court to consider. The option of a return of the children to M must be included and considered seriously and in depth.

351.          Any analysis must consider each child separately. I am aware that the Guardian advocated for A to return whatever finding was made by the court but this needs to be investigated in more detail. The court must be satisfied that if A returned alone or pursuant to a different timetable to the other children, that she would be free to live as a teenager and not as M's carer and that there would be safe systems in place for medication and more generally to cater for A's health issues and overall well being. A transition plan would also need to be put in place which might be different to that of C and D.

352.          I agree with the Guardian's proposal of forming a multi-disciplinary team to approach the issue of A, C and D returning to M.

353.          This team would consider M's level of understanding of the serious threshold findings made by the court and any work needed to address those issues; what support for M is required; what support for the children is required; what safeguards are necessary and the role of the wider family. That work would also have to advise if any return to M is possible.

354.          I am also clear that this team must be entirely independent of the local authority but will work with them as appropriate. Sad to say, given what has transpired, I understand why the Guardian said that she did not "have faith to say that the court can trust the local authority."

355.          This team would also need the participation of a psychologist and medical input about management of M's health in terms of her role as a mother.

356.          The conclusions of this work would then inform a decision as to whether A alone or all the children could return home and if so, on what basis and whether a testing period was necessary to see if the arrangements could work in practice.

357.          If the result of this work is that a return home is not possible for all or some of the children, at least that option will have been considered fully by the court.

358.          The court would then want to consider whether a shared-care arrangement between M and Mr LD could work in some form or what other arrangements could be put in place to allow A and/or C and/or D to maintain a strong link with M even though the family appear to work well together.

359.          The Guardian proposed a time frame of three months to undertake this work and that seems reasonable to me.

360.          Accordingly, I shall list a hearing so that the way forward can be discussed and planned. I would ask the parties to suggest an appropriate time-frame for this hearing as I recognise that time will be needed to source the appropriate professionals who will be undertaking the necessary work to go forward.

The Law Relating to Change of Name

361.          The final issue is B's name.

362.          The law is settled and is found in the decision of the judicial committee of the House of Lords in the leading case of Dawson –v- Wearmouth (1999, 1 FLR 1167).

363.          It is instructive to set out Lord Jauncey's observations, namely:

"A surname which is given to a child at birth is not simply a name plucked out of the air. Where the parents are married the child will normally be given the surname or patronymic of the father, thereby demonstrating its relationship to him. The surname is thus a biological label which tells the world at large that the blood of the name flows in its veins. To suggest that a surname is unimportant because it may be changed at any time by deed poll when the child has obtained more mature years ignores the importance of initially applying an appropriate label to that child....

In Re WG (1976) 6 Fam Law 210, where the facts were similar to those in Re T (above), Cairns LJ giving the judgment of the Court of Appeal said that:

"'... it should be realised that the mere fact that there had been a divorce, that the mother had remarried and had custody of the child, and had a name different from that of the child, was not a sufficient reason for changing the child's surname. The courts recognised the importance of maintaining a link with the father, unless he had ceased to have an interest in the child or there were some grounds - having regard to his character and behaviour - which made it undesirable for him to have access to the child at all.'

364.          He also went on to say that:

"....I accept, of course, as the authorities make clear, that the changing of a child's surname is a matter of importance and that in determining whether or not a change should take place the court must first and foremost have regard to the welfare of the child. There are many factors which must be taken into account, not only those pertaining to the present situation but also those which are likely to affect the child in the future. Just as the fact that the mother happens to bear a different surname from the child is not a sufficient reason for changing the child's surname...so the fact that mother and child bear the same name should not necessarily be sufficient reason for refusing a change if there are valid countervailing reasons."

365.          Lord Hobhouse commented that:

"...It has often been observed that the use of surnames is among the questions which give rise to the most deeply felt disputes between parents. As in other areas, the parents are liable to see the question raised as reflecting upon their own rights. It is clear from the arguments which have been advanced in the courts below and even to some extent your Lordships' House that the father and mother see the present dispute largely in such terms. They are mistaken. Once the dispute has arisen, the paramount consideration is the welfare of the child. The attitude and views of the individual parents are only relevant insofar as they may affect the conduct of those persons and therefore indirectly affect the welfare of the child."

366.          I was also referred to the decision in Re W, Re A, Re B (Change of Name) [1999] 2 FLR 930.

Discussion and Conclusion on Change of Name

367.          I do not propose to repeat the submissions made by the parties on this issue. In summary, B wants to use EF's surname of "F" only; M says his surname should have both parents' names but she would be prepared for B to use the surname "F" for everyday matters; the Guardian was attracted to M's position but said that B desperately wanted to be called by his father's surname. EF believed that B's wishes should be respected especially as that was his original surname before M unilaterally changed it in 2018.

368.          I recognise that this is an emotive issue, but the guiding principle must be B's welfare interests which are paramount.

369.          I have decided that B should be known in official documents as "F-D" to reflect both parents' names. However, he can be known by the surname "F" in his daily life which includes how he is addressed (but not registered) at school and how he is recorded in the class register and other daily papers in school life.

370.          I recognise that B's wishes and feelings are to be known solely by his father's surname. However strong this feeling, there is a wider picture which needs to be considered and B's views cannot in my judgment be determinative. By allowing him to be known by his father's surname everyday though, he can use the name he wants in his daily life.

371.          B is not going to live with M. However, I feel that he needs to retain a link with his biological mother as well as his siblings. Casting off M's surname would therefore not be in B's welfare interests. He needs to retain some identity of his mother going forward into the future as well as the link with his siblings and the wider family.

372.          EF was somewhat fixed in his view. I did not feel that he appreciated the significance of a name and its role in the identity of a child. This view is likely to have been recognised by B whose age in my view does not allow him to appreciate the wider picture relating to this issue.

373.          Although other issues will not be concluded at this hearing, I see no reason why this order should not be made now. I also suggest that the Guardian explains the court's decision to B.

Post Judgment Matters

374.          That is my judgment. If any points arise from the judgment, I would ask that they are sent to me by email in the next seven days. My intention is to consider them on paper in the first instance. Thereafter, as I have said, I shall fix a hearing so the way forward can be planned. I would also ask the parties to agree an order that reflects this judgment.

375.          The rules of court were recently amended to allow accredited journalists to attend children's cases in court if a transparency order is made. I made such an order in this case as a journalist from the BBC attended on some days of the hearing which I very much welcomed. I asked the parties to provide the journalist with documents so that she could follow the case. In the circumstances, it only seems correct that a copy of this judgment should be made available to the journalist. If any party objects, I should be told so that I may consider the way forward.