Interim care orders granted for three young children where one had unexplained injuries – 2020vol1#26

Interim care orders were granted for three children of pre-school ages in the District Court in a provincial city and a rural town. Child A suffered a serious burn injury and an unexplained, untreated rib fracture was diagnosed while being treated in a regional hospital. An interim care order was granted for A in the provincial city district court. The Child and Family Agency (CFA) told the court that a full child protection assessment of all adults caring for the children would be required.

Two younger siblings, Child B and Child C, were deemed to be at possible risk as they were in the care of the same adults as Child A. Interim care orders were granted in respect of Child B and Child C in a rural town district court.

Day one: Provincial city district court: Child A

The mother’s lawyer told the court that A’s mother was present in court but that the father, who plays very little part in the child’s life, was currently in prison. The mother’s lawyer said there was some ambiguity about the understanding of the events that took place on the night of A’s injury.

When the judge asked for clarification, the mother’s lawyer told the judge that the social worker had believed that the child’s mother had changed her story a number of times. A suffered a serious burn injury after getting scalded by hot water in the bath and the social worker was told that the child’s grandmother was present at the time of the incident. However, the child’s mother later reported that the grandmother was only present later in the evening after the incident had taken place.

The paediatrician who was responsible for the care of A in the regional hospital reported that the child had been seen by a hospital registrar and nursing staff. Child A’s mother had described to the hospital staff how the burn injury had happened. She said she left Child A in the bath upstairs while she brought Child B and Child C downstairs as they had already been bathed. She said she had used the shower nozzle to refill the bath and had heard C crying downstairs and went down to check.

The paediatrician told the court that when she had contacted the doctor who had initially dealt with A’s care in the local hospital near the child’s home, she had been informed that it was A’s grandmother who had been bathing the child. She said that when she further questioned A’s mother about the incident, the mother had become very defensive and had said: “I told you already.” The paediatrician reported that she had found it very difficult to obtain a free-flowing narrative of the incident from the child’s mother.

The mother had described to the paediatrician how A was sitting in the bath with her feet facing the taps. The mother told her she was only downstairs for one minute to check on Child C who was crying, but that when she returned to the bathroom the tap was on in the full position and A was standing on the far side of the bath crying.

The paediatrician said she had concerns about the timeline of the incident. She was concerned about the serious level of burning that had occurred after only one minute. She told the court that in accidental burn incidents, the burns are usually more to the front whereas in the case of Child A there were severe burns to the buttocks and yet no burns to the feet.

Judge: “If the child stood with her back to the taps could this happen?”

Paediatrician: “I can’t exclude it.”

Judge: “It is an unusual area to be burned? How do you think the burns occurred?”

Paediatrician: “I don’t know but I don’t think she was standing up. They’re localised burns. With a shower you’d expect splash marks … there’s a very clear demarcation on these burns.”

The paediatrician reported that the nursing staff had expressed concerns to her regarding the interaction between A and her mother. When asked by the judge to clarify this, the paediatrician said the nurses noted that the degree of comfort from the mother was less than expected; that the mother had seemed detached and was not tearful despite the child’s treatment having been medically severe.

Lawyer for the CFA asked the paediatrician if she had any additional concerns to which she replied that A also had facial bruising of each side of her face for which there was no specific explanation. She also reported her further concerns that when a skeletal survey was done on A, a healing rib fracture, which was about three weeks old, was found on the child’s left-hand side. She explained that this injury in a child was unusual, except following a road traffic accident, but that she obtained no explanation for the injury from the mother.

The paediatrician told the court that some types of injuries are of more concern than others and that an unexplained rib-fracture in a child is internationally looked on as a sign of possible child abuse.  She told the CFA lawyer that this type of injury in a child would have been very painful, but that A’s mother said she was unaware of the injury. The paediatrician reported that the combination of A’s rib fracture and significant burns injury when taken together with the nursing staff’s observations and the difficulty of matching the injuries with the mother’s explanations gave rise to a suspicion of neglect and possible non-accidental injury to A.

Paediatrician: “It leads one to question how the burn happened.”

The paediatrician told the judge that the full medical assessment of A would take some days. The judge asked to see the photographs of A’s injuries and she studied them.

Judge: “If the child was sitting in the bath, the feet would be injured?”

Paediatrician: “Yes, unless she was kicking her feet which is unlikely.”

The mother’s lawyer asked the paediatrician about the timeline of events on the night of A’s injury. The paediatrician said that the child should really have been sent by ambulance from the local hospital to the regional hospital as the child’s mother had informed the staff she did not drive and had asked for the services of an ambulance. The judge said she was shocked that a small child in such pain should be required to travel by car and the paediatrician agreed that Child A should have been transferred by ambulance.

The social worker told the court that she had only become aware of this family in the previous month. The mother had three children of pre-school age, all with different fathers. The social worker reported that Gardaí had been called to the children’s home following a domestic dispute which had been anonymously reported. An eviction notice was served by the local housing authority on the family but this notice was not proceeded with. A file on the family had been opened by the CFA due to the lack of supervision of the very young children and also due to the dangerous state of disrepair of the house. There were no bannisters on the stairs and no glass in some of the windows.

A referral to the CFA was made by the local hospital as a result of the burns injury to A. The older bruising to A’s face was noted by staff at the local hospital. The mother had told staff at the local hospital that the grandmother had been present during the burning incident but the mother subsequently gave a different version of events to the staff at the regional hospital. The social worker reported that the mother had told staff at the regional hospital that Child B had turned on the hot tap in the bath. The mother told staff at the regional hospital that the facial bruising to A had been caused by a fall from a swing.

The social worker said a consultation with the plastic surgeon’s department raised concerns about the timeline of the burns injury and a skeletal survey for all the children was ordered as a result. The hospital staff was concerned that the burn injury was, at best, due to neglect but the inconsistency in the explanations given was a further cause of concern. The social worker said the child’s mother remained by her side all the time throughout the treatment she received. She said she had a meeting with A’s mother to highlight the concerns regarding the injuries; the burn injury, the healing rib fracture and the two facial bruises which were independent of each other. Taken together this series of injuries posed a “red flag” for the professionals regarding the possibility of abuse of Child A.

The social worker said a safety plan had then been put in place for the children. The plan dictated that until such time that a full child protection assessment was carried out, the children would need CFA supervision and that it would not be possible for the CFA to “rule out anyone who was in contact with [A] at the time of the event”. The social worker said that this assessment would take five weeks. A Garda investigation would also be carried out regarding A’s injury as a notification had been made to Gardaí.

The judge asked what weight should be given to the evidence provided by staff at the local hospital where initial treatment had taken place, given that they subsequently sent the child to travel to the regional hospital with the mother by car. The lawyer for the CFA asked the social worker if future orders in excess of 29 days would be sought, to which the social worker replied that she believed a full care order would be sought later and that a “rushed assessment is counter-productive”. The social worker said she had checked with A’s GP who said that the child had been to see her for a bump on the head but not for either the rib fracture or the facial bruises.

The mother’s lawyer asked the social worker about the account of the incident given to her in the regional hospital by A’s mother. The social worker told the court that the mother seemed fatigued and that she was conscious of not exacerbating the situation as the mother had been asked the details on numerous occasions. The social worker agreed that the mother had done all that was expected of her and had engaged with the CFA since the incident.

The mother’s lawyer asked her what the future plan for A would entail. The social worker said the mother was fully informed about the procedure for the social work assessment and that [the mother] would be a part of that plan. She said the mother had a challenging job in parenting very children under four years of age on her own for the most part.

The judge recalled the paediatrician and said there was not a huge discrepancy in the mother’s versions of events. The mother had consented also to the remaining children undergoing medical examinations and those results had been normal. The judge enquired what additional tests were necessary in the care of A and the paediatrician said that a bone chemistry analysis was necessary, the results of which were likely to take a number of weeks. The judge asked what the bone chemistry analysis would indicate and the paediatrician told the court it was part of the overall assessment.

Judge: “Is it your view that the mother was not forthcoming in her account?”

Paediatrician: “Mum was very defensive about what happened … This is not usual … it’s usually free-flowing.”

The paediatrician said the nursing staff was concerned about the mother’s ability to care for the burns. This would require regular bathing and application of cream with frequent nappy changes to reduce inflammation and pain. The mother’s lawyer told the judge that A had been brought to her family GP regularly and said she could not understand the staff’s concerns regarding the mother’s ability to provide the ongoing care needed.

The mother told the judge that [A’s] father is currently in jail and that he had initially insisted on a DNA test to prove that he was in fact the father of Child A. The mother’s lawyer asked her to describe the night of the incident. The mother said they were all going out to an event and that she had bathed two children and put them in swing chairs downstairs while she bathed A upstairs.

When she returned after checking the children downstairs, A was in the bath and the shower was turned on. She realised A had received a burn but did not think it was too bad and phoned her mother. She advised her to put ice on the burn and a nappy. When the mother checked the skin after this, she noticed a red rash. She rang the out-of-hours doctor but said it was closed.

She phoned her mother again and then her brother came and drove all the family to the local hospital. They waited about 15 minutes in the emergency department after which time a staff member looked at the burns and gave Calpol to A and gave her a bed on the corridor. After two hours the mother said a doctor examined A and took pictures of the injury to check with colleagues. The mother was told to bring the child to the regional hospital which would mean a two-hour journey. The mother was advised to find her own transport and was sent home.

The mother told the court that she went home overnight and found a drive to the regional hospital early on the following morning. Staff at the regional hospital advised the mother that A would need to be admitted for a possible skin-graft. The mother said there seemed to be confusion in the hospital about whether the child’s grandmother had been present at the time the burn happened but the mother said the grandmother was never there at that time but had come to the house afterwards.

The mother’s lawyer asked her if she had attended the family GP many times with Child A to which she replied that she went there “lots of times … there is always something”. The mother described an admission of A to the local hospital which had happened a year earlier due to the child not eating or drinking. Tests had been carried out on the child and the problem was sorted.

The mother’s lawyer asked her if she ever had any indication that her child had suffered a broken rib. The mother said she never had an indication of that injury but that A had cried a lot in her grandmother’s home. She told the court that her brothers and others would were often in the grandmother’s home. The mother also said that Child A sometimes banged her head or bit her siblings when she was angry.

Mother’s lawyer: “Have you ever caused hurt, upset or distress to your kids?”

Mother: “Never … I wouldn’t have gone to the hospital and shown it to the public.”

The mother explained that she had requested the council to come and fix the bannisters on the stairs in the house but that they had only fixed it recently after months of waiting. The CFA lawyer asked the mother about the status of her relationship with the father of her youngest child, C. The mother told the court that the relationship had ended and that C’s father was actually packing his stuff to leave on the day of the burning incident to A. The mother told the CFA lawyer that this man had left the house about an hour before the incident which had resulted in A’s burn injury.

The CFA lawyer asked the mother to describe how the burn injury happened. She said A was in the bath with some tepid water in it when she left to check on the baby who was crying downstairs as he sounded very uncomfortable. She lifted the baby from his swing seat and placed him in his cot. She went back upstairs to see lots of steam and the hot tap in the on position.

CFA lawyer: “You went a long way about bathing the children … These were horrific burns. You need to give as much information as you can. The CFA must get to the bottom of [Child A’s] issues.”

The judge asked the lawyers if there was anything else they needed to add. The mother’s lawyer told the judge that the mother was providing all the aftercare she needed in the hospital every day and was capable of looking after her recuperation.

The judge said she had heard all of the evidence and that she was very concerned about the handover of A from the local to the regional hospital and that this had in turn led to some ambiguity.

Judge: “I would think the mother was flooded with so much in her life … it was chaotic”.

The judge said this was a case where a very young child suffered a very serious injury, which was largely unexplained. The lack of explanation for the historic injury was very concerning when coupled with the burn injury. The judge said she had decided to make an interim care order with directions for very particular aftercare.  Releasing A into the care of her mother in her own home following discharge would be a cause of trauma to the child as going back into the same bath where the injury happened would be traumatic.

Judge: “It is the court’s view that the child should remain on in hospital to receive the aftercare… The mum has many children under four years of age and it’s extraordinary what is on her plate. The CFA can do its assessment in the meantime.”

CFA lawyer: “The HSE will not keep the child in hospital except maybe for a period.”

Judge: “I am not prepared to make an open-ended order … This court is focused on this little girl.”

The CFA lawyer told the judge that ordering the hospital to keep the little girl following the discharge date would lead to an “overlap in the separation of powers”. However, the judge insisted that the court would first of all need to be satisfied that everything in the child’s life was alright.

Judge: “Somehow this little girl broke her rib and nobody knows why … something went badly wrong.”

The judge made an interim care order for 29 days. She made directions that the necessary assessments for A be done in the interim. The judge recommended that A remain in the hospital until the next court date.

Day two: Rural town district court: Child B and Child C

Lawyers for the CFA had already secured five-day interim orders for Child B and Child C in a rural district court. The case came before the same district judge as had heard the initial application in a neighbouring local district court two days later where the CFA were seeking interim orders for 29 days for B and C.

The lawyer for the mother told the court she was not objecting to the application. Child C’s father was present in the court and his lawyer said he was not objecting.

The CFA lawyer said that the judge had already heard the paediatrician’s evidence regarding the injuries to A on the previous court date and asked that he would rely on the same evidence.

A’s social worker outlined a summary of the injuries. There were second degree burns on six per cent of Child A’s body. There were bruises to the child’s face and further tests had revealed an untreated broken rib, which would have been a cause of significant pain to A. The social worker said this was a rare type of case based on unknowns but where there was a reasonable risk that non-accidental injury had taken place. This had led to a decision to seek the initial interim orders for B and C.

The social worker told the judge that there were 13 adults involved in the day-to-day care of the children and that no adult could be discounted, although it was not possible to completely discount that the injuries could have been accidental. The social worker said that a multi-disciplinary meeting between CFA and medical staff considered the timeline of events and the possibility that the rib fracture was suggestive of abuse.

The judge said that A’s burns could have happened accidentally but the problem was “inconsistent explanations for a very serious injury”. He said the injuries as presented were, at best, caused by neglect and at worst caused by physical assault to A. These injuries must have taken place while the child was in the care of adults. Thus there was concern for the care of A’s younger siblings while in the same care.

The social worker told the court that A was still in the care of the regional hospital as she required further assessments to rule out any additional older fractures. She reported that a Garda investigation was going on and that the social work assessment would be “Garda-led at this time.” She told the judge that the CFA was seeking care orders for both B and C for 29 days.

The mother’s lawyer pointed out that the mother had engaged well with the CFA and had taken all steps to take the child to the local hospital. The local hospital had, after assessing A’s injury, released the child to the care of her mother and had refused to transport the child to the regional hospital. The mother’s lawyer enquired about proposals for access to the child by her mother. The social worker replied that access would be facilitated on weekly basis.

Social worker: “Mam has been very attentive towards her daughter.”

The social worker reported that A’s foster parents had already visited her in the hospital where they had been shown how to correctly dress the child’s wounds.

The judge said there was no allegation regarding the care of B or C. However, given the seriousness of the injuries which have occurred to A, a totally unexplained fracture which was deemed by medical staff to be “very suggestive of abuse” and serious burns for which there were inconsistent explanations, there was now a serious cause for concern for the two younger siblings. The judge decided that the threshold for the 29-day interim care orders had been reached and he granted the orders in respect of B and C.

Day three: Provincial city district court: Child A

The CFA lawyer told the judge that A was ready to be discharged from the regional hospital. The judge said she was very concerned about the child’s placement. The CFA provided a detailed report to the judge regarding her placement. The social worker told the judge there was no medical reason for A to remain at the regional hospital.

The CFA lawyer asked the social worker if the foster parents had visited the child in hospital. The social worker told the court that the foster parents had already made frequent visits to the hospital so that the child could become acquainted with them. She also reported that she [the social worker] had visited the foster parents’ home, which she found to be spacious and welcoming. A would have her own bedroom there with an additional single bed for use by the foster mother during the transitional period. The social worker answered questions from the CFA lawyer saying that these foster parents have ten years’ experience and that the foster mother had taken some time off from her part-time work in order to care for A.

The judge enquired if the additional medical assessments on A had now been completed by the regional hospital. The social worker replied that the survey had been repeated and that no additional fractures had been found. No continuing special treatment was now needed for the care of her burns apart from the application of anti-bacterial cream. The judge enquired about arrangements for access for A with her family and siblings and the social worker said her colleague was dealing with the matter of access.

The judge said that she had no information about A’s placement on the previous date this matter was before her.

Judge: “I wanted to be sure that the foster parents would be able to deal with it.”

The CFA lawyer said that A’s mother was now in a new relationship and that consequently there were lots of assessments needing to be done.

Judge: “Is the father aware?”

CFA lawyer: “Yes, he is in prison but is aware.”

Judge: “This is a sad and troubling case … The placement of [Child A] was today’s priority.”

The judge said she was aware that A’s mother had been at her side providing care while she was in the regional hospital and that the transition to foster care would thus be traumatic.

The judge ordered that access to the Child A’s mother was to “accommodated in a full and frequent manner”. Now that the child was being released from the regional hospital to foster parents, the judge said she was transferring the matter to the local district court. The judge described the matter as being very difficult and said that she wished all parties well.