A Local Authority v AA & Anor

Factual and Procedural Background

This judgment follows a fact-finding hearing held over eight days in November 2021 and two additional days in June 2022 concerning the causation of injury to a female infant, referred to as Y, who was nine months old on 7 October 2020, the date of the relevant incident. The Local Authority (LA) alleged in its Threshold Document that the Father caused Y's injuries by shaking her. On 7 October 2020, the Father called an ambulance, reporting that Y had fallen from a bed and required urgent medical assistance. Medical examination revealed subdural haemorrhage (SDH) and retinal haemorrhages (RH), injuries the LA asserted resulted from Abusive Head Trauma (AHT). The Father, supported by the Mother, denied shaking Y and maintained the injuries resulted from the fall.

The case involved expert evidence from multiple medical specialists, including neuroradiologists, an ophthalmologist, a neurosurgeon, and a paediatrician. The initial neuroradiologist became unavailable due to illness, leading to the instruction of a second neuroradiologist. Extensive academic literature on infant head injuries, particularly concerning head circumference and its relation to injury susceptibility, was considered. The parties agreed on the relevant legal principles, and the court engaged in a detailed evaluation of both medical and non-medical evidence.

Legal Issues Presented

1. Whether the injuries sustained by Y were caused by non-accidental injury, specifically shaking, or by an accidental fall from a bed.
2. The relevance and weight of medical expert evidence and academic literature concerning the causation of subdural and retinal haemorrhages in infants.
3. The credibility and reliability of the parents' accounts, particularly the Father's account of the events on 7 October 2020.
4. The applicability of medical conditions such as Benign Enlargement of the Subarachnoid Spaces (BESS) or Benign External Hydrocephalus (BEH) in explaining the injuries.

Arguments of the Parties

Local Authority's Arguments

• The injuries to Y, including SDH and RH, were consistent with Abusive Head Trauma caused by shaking.
• The medical evidence from several experts supported the conclusion that shaking was the most likely cause of the injuries.
• The presence of retinal haemorrhages and subdural haemorrhages are strong indicators of non-accidental injury.
• The Father’s account was challenged as potentially minimizing or concealing the true cause.

Father's Arguments

• The Father denied shaking Y at any time.
• He maintained that the injuries resulted from a fall from the bed.
• The Father’s demeanor was calm, consistent, and credible, supported by photographic evidence and the Mother’s account.
• The Father expressed remorse and distress immediately after the incident, as evidenced by his 999 call.

Mother's Arguments

• The Mother was not present at the time of the incident but supported the Father’s account.
• She accepted the Father’s version and had no reason to doubt it.

Table of Precedents Cited

Court's Reasoning and Analysis

The court conducted a detailed analysis of the evidence, both medical and non-medical. The medical evidence was contentious, with initial expert consensus favoring shaking as the cause of Y’s injuries. However, one neuroradiologist changed her opinion to favor a short fall, though her evidence was later partially discounted due to her illness and inability to justify earlier reports. A replacement neuroradiologist concluded shaking was more likely but did not exclude a short fall.

The court carefully considered extensive academic literature addressing the causation of subdural and retinal haemorrhages, including studies on infants with large or rapidly growing heads and conditions such as BESS and BEH. The literature indicated that while shaking is commonly associated with such injuries, there are rare cases where short falls may cause similar findings, especially in infants with larger heads.

The court also evaluated the credibility and demeanor of the parents, finding the Father to be a calm, consistent, and honest witness. The absence of “red flags” such as substance abuse, domestic violence, or mental health issues further supported his credibility. The court noted the Father’s distress in the emergency call, which was inconsistent with deliberate deception.

The court weighed the absence of other physical signs of shaking (such as bruises or fractures) and the normal family context against the medical evidence. It found that while the medical experts generally favored shaking, the possibility of a short fall causing the injuries could not be excluded on the balance of probabilities, especially given the relatively slight nature of the injuries and the academic support for such a possibility in exceptional cases.

In sum, the court applied the legal principles requiring the LA to prove its case on the balance of probabilities, considering all evidence in context, and was mindful of the need to allow for unusual or unknown causes.

Holding and Implications

The court concluded that the Local Authority's Threshold Document was not proved. It found, on the balance of probabilities, that the Father did not cause Y’s injuries by shaking her.

The direct effect of this decision is that the allegation of non-accidental injury by the Father was not established, and the Father is not found responsible for shaking Y. The court did not set any new legal precedent but reaffirmed existing principles regarding the assessment of complex medical evidence and the importance of considering alternative explanations in child abuse cases.