A Local Authority v S

In care proceedings involving alleged non-accidental head injury, the local authority bears the burden of proving the facts on the balance of probabilities. The seriousness of the allegation does not alter that standard. Medical evidence must be evaluated as a whole, by testing each proposed cause against the factual matrix and the evidence from all relevant disciplines. The triad of encephalopathy, subdural haemorrhage and retinal haemorrhage is not automatically diagnostic, but its significance depends on careful analysis of the individual findings, alternative explanations and the clinical history. Experts must remain within their fields, defer appropriately to specialists and use research with forensic accuracy. On the evidence, cardiac arrhythmia and choking were rejected as explanations for the collapse, while trauma provided the only probable explanation.

The local authority sought a care order under section 31 of the Children Act 1989 in respect of S, following the death of his thirteen-week-old sibling, Z. Z had suffered a sudden collapse while alone with his mother and died after resuscitation and intensive care. The evidence included subdural and extensive retinal haemorrhages, encephalopathy, prolonged cardiac arrest and an old subdural haemorrhage.

The central issue was whether Z’s collapse was caused by shaking or shaking-impact trauma, as alleged by the local authority, or by cardiac arrhythmia, choking, hypoxia, re-bleeding or another non-traumatic process. The court also considered the reliability and forensic soundness of competing expert evidence.

1. Standard and approach. The local authority bore the burden of proving the facts on the balance of probabilities. The seriousness of the allegations and consequences did not raise the standard of proof. The court had to evaluate the medical evidence critically, considering the reasons given, internal consistency, logic, accuracy, independence and the fit between expert opinion and the factual evidence.
2. The triad. The presence of encephalopathy, subdural haemorrhage and retinal haemorrhage was not, without more, diagnostic of non-accidental head injury. The findings had to be considered collectively, alongside the clinical presentation, post-mortem evidence, radiology and possible alternative causes. The court adopted the caution in R v Harris, Rock, Cherry and Faulder [2005] EWCA Crim 1980 that the triad remained a hypothesis requiring careful evaluation.
3. Alternative causes. A cardiac arrhythmia was rejected as the primary event because the evidence made short QT syndrome very unlikely and it could not explain the retinal haemorrhages. Choking was also rejected. The evidence showed that a child crying loudly was breathing, and the clinical presentation, clear airways and pink frothy sputum did not establish obstruction. The proposed hypoxia and cascade theory was speculative and lacked a sufficient evidential foundation.
4. Expert evidence. The court applied the guidance in Re LU & LB [2004] 2 FLR 263. Experts must keep within their expertise, defer to specialists in other disciplines and use source material accurately. Non-mainstream research was legitimate, but it could not replace rigorous forensic analysis. The evidence of Dr Cohen and Dr Squier was materially weakened by scientific preconceptions, reliance on inaccurate factual data and selective or misleading use of research.
5. Conclusion and order. The overwhelming evidence was that hypoxia without trauma did not explain the haemorrhages found. Trauma was the only probable explanation for the sudden catastrophic collapse and the triad. The court found that the mother had shaken, or shaken and thrown down, Z during a momentary loss of control. The threshold conditions under section 31 of the Children Act 1989 were established. The father was found blameless in relation to the injury.