C110A - Application for a care or supervision order and other orders under Part 4 of the Children Act 1989 or
an Emergency Protection Order under section 44 of the Children Act 1989 (04.14) © Crown copyright 2014
C110A
To be completed by the court
The family court sitting at
Case number Date issued
Child(ren)’s name(s)
Fee charged
Application for a care or supervision
order and other orders under Part
4 of the Children Act 1989 or an
Emergency Protection Order under
section 44 of the Children Act 1989
Name of applicant
Full name of respondent(s)
Nature of application
Care and supervision or other Part 4
Care
Supervision
Interim care order
Interim supervision order
Other (please specify)
Is the Local Authority considering adoption?
Yes No
If Yes, please complete Section 7b
Emergency Protection Order
information on the whereabouts of the child[ren]
(Section 48(1) Children Act 1989).
authorisation for entry of premises
(Section 48(3) Children Act 1989).
authorisation to search for another child on the
premises (Section 48(4) Children Act 1989).
Other (please specify)
Is an urgent hearing required?
Yes No
If Yes, complete Section 1
Is a without notice hearing required?
Yes No
If Yes, complete Section 2
Are there previous or ongoing proceedings for the child(ren)?
Yes No
If Yes, complete Section 3
Are there factors aecting litigation capacity?
Yes No
If Yes, complete Section 4
Is this a case with an international element?
Yes No
If Yes, complete Section 5
Additional information required
What order(s) are you applying for? (tick all which apply)
Reset form
Print form
Reset form
Print form
Hall Town County Council
Carole Smith
Jacob Donahue
2
Child 1 - Full name of child Date of birth
Order(s) applied for
(including interim orders)
D D
/
M M
/
Y Y Y Y
Is the child accommodated?
Yes No
If Yes, from what date?
D D
/
M M
/
Y Y Y Y
Name of mother Name of father Parental Responsibility
Yes No
Summary of
childrens details
Child 2 - Full name of child Date of birth
Order(s) applied for
(including interim orders)
D D
/
M M
/
Y Y Y Y
Is the child accommodated?
Yes No
If Yes, from what date?
D D
/
M M
/
Y Y Y Y
Name of mother Name of father Parental Responsibility
Yes No
Child 3 - Full name of child Date of birth
Order(s) applied for
(including interim orders)
D D
/
M M
/
Y Y Y Y
Is the child accommodated?
Yes No
If Yes, from what date?
D D
/
M M
/
Y Y Y Y
Name of mother Name of father Parental Responsibility
Yes No
Child 4 - Full name of child Date of birth
Order(s) applied for
(including interim orders)
D D
/
M M
/
Y Y Y Y
Is the child accommodated?
Yes No
If Yes, from what date?
D D
/
M M
/
Y Y Y Y
Name of mother Name of father Parental Responsibility
Yes No
0 8
0 2
2 0 1 0
Alice Elaine Smith
1 6
0 1
2 0 1 4
Carole Smith
Jacob Donahue
3
1. Is the application for urgent consideration?
Complete this section if you have ticked the relevant box on the front of
the form
Proposed timetable
The application should be considered within hours/days
If consideration is sought within 48 hours, you must complete the section
below
What eorts have been made to put
each respondent on notice of the
application?
Is the urgent hearing for:
(tick as required)
Contested ICO
EPO
urgent preliminary Case Management Hearing
Set out the order(s)/directions sought
Set out the reasons for urgency
Part A - All applications
4
B – The grounds are
Any applicant
that there is reasonable cause to believe that [this] [these] child[ren] [is]
[are] likely to suer signicant harm if
or
the child[ren] [is] [are] not removed to accommodation
provided by or on behalf of this applicant
or
the child[ren] [does] [do] not remain in the place where
[the child] [they] [is] [are] currently being accommodated.
Local authority applicants
that enquiries are being made about the welfare of the child[ren] under
Section 47(1)(b) of Children Act 1989 and those enquiries are being
frustrated by access to the child[ren] being unreasonably refused to
someone who is authorised to seek access and there is reasonable cause to
believe that access to the child[ren] is required as a matter of urgency.
Authorised person applicants
that there is reasonable cause to suspect that the child[ren] [is] [are]
suering, or [is] [are] likely to suer, signicant harm and enquiries
are being made with respect to the welfare of the child[ren] and
those enquiries are being frustrated by access to the child[ren] being
unreasonably refused to someone who is authorised to seek access and
there is reasonable cause to believe that access to the child[ren] is required
as a matter of urgency.
C – The additional
order(s) applied for
information on the whereabouts of the child[ren]
(Section 48(1) Children Act 1989).
authorisation for entry of premises (Section 48(3) Children Act 1989).
authorisation to search for another child on the premises
(Section 48(4) Children Act 1989).
D – The direction(s) sought
contact with any named person (Section 44(6)(a) Children Act 1989).
a medical or psychiatric examination or other assessment of the child[ren]
(Section 44(6)(b) Children Act 1989).
to be accompanied by a registered medical practitioner, registered nurse
or registered midwife (Section 45(12) Children Act 1989).
an exclusion requirement (Section 44A(1) Children Act 1989).
If the application is for an Emergency Protection Order only,
please complete B, C and D as appropriate
5
Complete this section if you have ticked the relevant box on the front of
the form
Set out the order/directions
sought
Set out the reasons for the
application to be considered
without notice. (This information
is a requirement, a without notice
hearing will not be directed
without reason)
Do you require a without notice
hearing because it is not possible
to give notice including abridged
or informal notice?
Yes No
If Yes, please set out reasons below
Do you require a without notice
hearing because notice to a
respondent will frustrate the
order that is being applied for?
Yes No
If Yes, please set out reasons below
Other (please specify)
2. Is the application for a without notice hearing?
6
Complete this section if you have ticked the relevant box on the front of
this form.
Please give details (include
name of child(ren), case no.,
date(s) of application, dates
proceedings concluded, order
made)
Please also provide the name of
any children’s guardian who has
been involved in any previous
or ongoing proceedings
involving a child of one or both
respondents
Is continuity of the childrens
guardian required?
Yes No
If No, why not?
3. Previous or ongoing proceedings
1.EPO application re Sam Smith dob 01.04.06, 17.01.2009
2. Care & Placement Order made re Sam Smith dob 01.04.06,
case number PLO9C1012345- case concluded 16.10.09
3. Adoption Order re Sam Smith made 03.01.10
Note: Above child is full sibling of Alice Elaine Smith subject of this
application.
Verity Caring
Ms Caring was the CG for Sam Smith
7
4. Factors aecting ability to participate in proceedings
Complete this section if you have ticked the relevant box on the front of
this form.
Please give details of any factors
aecting litigation capacity
Provide details of any referral to or
assessment by the Adult Learning
Disability team, and/or any adult
health service, where known,
together with the outcome
Are you aware of any other factors
which may aect the ability of the
person concerned to take part in
the proceedings?
None
None
Birth father is in prison. Production Order may be required.
8
5. Cases with an international element
Complete this section if you have ticked the relevant box on the front of
this form.
Do you have any reason to
believe that any child, parent or
potentially signicant adult in
the child’s life may be habitually
resident in another state?
Yes No
If Yes, please give details
Do you have any reason to
believe that there may be an
issue as to jurisdiction in
this case (for example under
Brussels 2 revised)?
Yes No
If Yes, please give details
Has a request been made or
should a request be made to
a Central Authority or other
competent authority in a foreign
state or a consular authority in
England and Wales?
Yes No
If Yes, please give details
9
Set out in not more than the two
following pages the threshold
criteria relied upon
6. Grounds for the application
The grounds for the application
are that the child(ren) is suering
or is likely to suer, signicant
harm and the harm or likelihood
of harm is because the child is:
not receiving care that would be reasonably expected from a parent
beyond parental control
The Local Authority submits that the statutory threshold criteria as set out in Section 31(2) and Section 38(2)
of the Children Act, 1989 are met in respect of the child, Alice Elaine Smith (born on 8th February 2010).
At the time that protective measures were taken, that date being 16th January 2014, there are reasonable
grounds for believing that the child was suffering, or was likely to suffer, significant harm, in the form of
physical and emotional neglect, and that the harm, or likelihood of harm, is attributable to the care given to
the child, or likely to be given to her if the order were not made, not being what it would be reasonable to
expect a parent to give her.
1. The Local Authority refers to proceedings numbered PL09C012345, wherein findings were made that S
(full sibling to Alice) suffered bruising to his face and that the injuries sustained by S were found to have
been inflicted by Mr Jacob Donahue (father to S and Alice) and the mother, Carole Smith, failed to protect S,
partly as a result of her Heroin dependence. S adopted.
2. Mr Donahue has a previous conviction for assaulting a child. Mr Donahue is currently serving a four year
prison sentence at HMP Dartmoor for assaulting his partner. Miss Smith’s relationship with Mr Donahue
ended in approximately October 2010.
3. On 8th February 2010 Alice was born showing signs of drug withdrawal.
4. In August 2011 Miss Smith formed a new relationship with Mr Treadwell and they began to cohabit.
Maternal grandparents reported that Mr Treadwell and Miss Smith were misusing illegal substances and Mr
Treadwell was violent towards Miss Smith. Family well known to the Police because of concerns about drug
dealing and domestic abuse.
5. In January 2012 Mr Treadwell was convicted of assault occasioning actual bodily harm to a neighbour and
possession of Heroin with intent to supply. Sentenced to 3 years in prison.
6. On 30th April 2013 initial Child Protection Conference. Police report that Alice (aged 3) was playing
unsupervised in a park near her home on two occasions after 7pm without shoes on. Alice said she was
hungry and appeared reluctant to return home. When returned home by the Police, Mr Treadwell commented
that ‘the little bugger was always running off’.
7. Mr Treadwell refused to co-operate with family support services offered (May/June 2013); verbally abusive
the family support worker (appointment terminated) and encouraged Miss Smith not to co-operate. Alice was
observed by the family support worker to seek little attention from her parents; keen to kiss and cuddle the
worker; often in her pyjamas with dirty feet and overgrown toenails. No toys seen.
8. 29th June 2013 Child Protection review. Health Visitor assessment indicates that Alice’s speech and
language is delayed by about 12 months.
9. 1st July 2013. Alice missed an appointment for corrective eye surgery for her squint. If this operation is not
carried out within the next 18 months, the condition will not be correctable. In October 2013 Alice failed to
attend a re-arranged appointment.
10. August 2013. Miss Smith confides in play scheme worker that Mr Treadwell assaulted her the previous
evening in front of Alice.
10
Continued from overleaf – Set out
the threshold criteria relied upon
11. On 12th August 2013 Mr Treadwell was arrested for possession of Cannabis and Heroin with intent to
supply. Police report that Alice at home and appeared ‘blank’ during Police raid; drug paraphernalia on low
table; large quantities of Cannabis found in kitchen cupboard and three men in the house all known to the
Police as local drug dealers.
12. On 11th November 2013, police informed that Alice was in the street at 6.45pm. It was a cold evening
and Alice was not wearing any shoes or a coat.
13. On 12th November 2013 staff from Alice’s nursery report; ongoing missed sessions and lateness; Alice
sometimes falling asleep in the play corner; other children avoid Alice because of her odour and that Alice is
very needy of adult attention. Social worker observed Alice at nursery – she appeared tired, her hair was
matted, she smelt of urine, wanted to cuddle to Social worker and asked: “can I come and live at your
house?”
14. On 20th December 2013, Police attend the home because of complaints relating to drug use, shouting
and loud music. Mr Treadwell overheard calling Alice - ‘a squinty eyed little bitch’. Police observed dirty
clothes, stale food, cigarette ends and dirty nappies strewn across the living room floor. Toilet smeared with
faeces. Unknown male asleep in Alice’s bed. At 2pm Alice dressed in pyjamas with dirty feet and matted hair.
15. On 16th January, 2014 police protection was taken in relation to Alice, Miss Smith later agreed to Alice
being accomodated persuant to section 20, CA,1989.
16.The threshold document is relied upon to satisfy the threshold criteria on an interim basis.
The Local Authority reserves the right to amend, enlarge, vary or replace the facts relied upon hereto to
satisfy the threshold criteria in anticipation of any final hearing, until such time as these are agreed.
11
7. Plans for the child(ren)
7a. Please give a brief summary of
the plans for the child(ren).
The summary must include any
contact arrangements that are in
place or are proposed.
What is the local authoritys
proposal including placement and
support services and are there
any requirements which the local
authority wish the court to impose
under Part 1 of Schedule 3 Children
Act 1989?
It is not sucient just to refer to or repeat the Care Plan.
7b. Having regard to s. 22
Adoption and Children Act 2002
is the local authority considering
adoption?
Yes No
Does the application for a
placement order(s) accompany
this application?
Yes No
If not, why not and when will it
be submitted?
Have you notied the relevant
Central Authority or the
competent authority in the
foreign state in cases to which
section 5 of this form applies?
Yes No
The immediate plan is for Alice to remain in her current foster
placement. Alice has assessed and supported contact twice a week for
one and a half hours in the contact centre. There is no planned contact
with any other family members.
The maternal grandparents have played an important role in Alice's life.
They are not able to offer Alice an alternative family placement. The
appropriate level and frequency of contact between the maternal
grandparents and Alice will be assessed over the next few weeks.
Also within the next few weeks, the Social Worker intends to visit Jacob
Donahue in prison to ascertain his up to date views. He has not played
an active part in Alice's life. Mr Donahue has a criminal conviction against
him for assaulting a non-related child. There was also a Finding of Fact
(Oct 2009) wherein, Mr Donahue was found to be the perpetrator of an
injury to the first child of Mr Donahue and Miss Smith, namely Sam
(1.4.06) who is now adopted.
In the medium term the Local Authority will assess the value to Alice of
the maternal grandparents' contact and ascertain the views of Mr
Donahue.
The Local Authority are of the view that Alice needs to achieve
permanence outside of the family. Neither of the parents are capable of
meeting Alice's needs. No one within the family is putting themselves
forward as alternative permanent carers with the exception of the
paternal Aunt, Ms Morgan and her partner Mr Stevens. An initial viability
assessment of them was not positive (Annexe document).
Alice needs to achieve permanence either through long term fostering or
adoption.
The Local Authority have not yet formulated a final plan. A permanency
planning meeting will be held in line with statutory timeframe. After which
the Local Authority will be in a position, if adoption is the plan, to apply for
a Placement Order.
12
8. Timetable for the child(ren)
The timetable for the child will be set by the court to take account of dates of
the signicant steps in the child’s life that are likely to take place during the
proceedings. Those steps include not only legal steps, but also social, care,
health, education and developmental steps and any timetable for a case with
an international element.
Please give any relevant dates/events
in relation to the child(ren)
• it may be necessary to give
dierent dates for each child.
Are you aware of any signicant
event in the timetable, before
which the case should be
concluded?
Yes No
If Yes, please give a date
D D
/
M M
/
Y Y Y Y
and give your reasons
By what date should the child(ren)
be placed on a permanent basis?
Name of child
D D
/
M M
/
Y Y Y Y
Name of child
D D
/
M M
/
Y Y Y Y
Name of child
D D
/
M M
/
Y Y Y Y
Name of child
D D
/
M M
/
Y Y Y Y
Please give your reasons
Medical appointment to arrange Alice's corrective eye surgery which is
now urgent. Permanency planning meeting to be arranged.
In September 2014, Alice is due to start primary school.
2 0 1 4
0 9
0 1
Ideal is for Alice to start primary school within the catchment area of her
permanent placement. Alice is due to start school in September 2014.
Alice Elaine Smith
0 1
0 9
2 0 1 4
Alice is due to start school in September 2014
13
9. Attending the court
If an interpreter will be required, you must tell the court now so that one
can be arranged.
If Yes, please specify the language and dialect:
Are you aware of whether an
interpreter will be required?
Yes No
If attending the court, do any of the
parties involved have a disability for
which special assistance or special
facilities would be required?
Yes No
If Yes, please specify what the needs are:
Please state whether the court
needs to make any special
arrangements for the parties
attending court (e.g. providing a
separate waiting room or other
security requirements).
Court sta may get in contact with you about the requirements
Yes No
If Yes, please give details
Are you aware of whether an
intermediary will be required?
The possibility of a Production Order in relation to Mr Donahue (father)
currently in prison.
Court may consider the use of video link.
14
10. Allocation proposal
Judicial continuity
Please give the following details of
other proceedings:
Case number
Name of Judge
Date of last relevant order
Are proceedings nished or
outstanding?
Finished Outstanding
Applicant’s allocation proposal
Lay justices
District Judge level
Circuit Judge level
DFJ/Section 9 sitting as a Judge of the High Court
High Court Judge level
Set out the applicable
paragraphs of the schedule to
the Presidents Guidance on the
distribution of business
Part 2 (To be completed by the Court)
Allocation decision in
accordance with the Allocation
Rules and the Presidents
Guidance on the distribution of
business
Lay justices
District Judge level
Circuit Judge level
High Court Judge level
Listed for
Case Management Hearing
Time Date
D D
/
M M
/
Y Y Y Y
Part 1 (To be completed by the
applicant Local Authority on issue)
PLO9CO12345
DJ Fuller
AO made 03.01.10
Rule 20 of the Family Court (Composition and Distribution of Business)
Rules 2014. A hearing before lay justices will facilitate a prompt hearing;
avoid delay; the issues are not complex and none of the matters set out in
the schedule to the President's Guidance apply in this case.
15
Location
of court
or
Name of Judge
District Judge
Legal Adviser
Date
D D
/
M M
/
Y Y Y Y
Allocated by
11. Signature
Print full name
Your role/position held
The facts in this application are true to the best of my knowledge and belief
and the opinions set out are my own.
Signed
Applicant
Date
D D
/
M M
/
Y Y Y Y
Andrew Coppen
Senior Solicitor, Childcare Team, Hall Town County Council
2 8
0 1
2 0 1 4
16
Solicitors name
Address
Telephone number
Mobile telephone number
Fax number
Email
DX number
Solicitors Reference
The applicant
Name of applicant
(local authority or authorised person)
Name of contact
Job title
Address
Contact telephone number
Mobile telephone number
Fax number
Email
DX number
Solicitor’s details
Postcode
Postcode
Details of parties – please complete this section in full
Hall Town County Council
Megan Jenkins
Senior Social Worker
Civic Centre
Hall Town
H T 3
0 N B
03312 123456
07745 674390
N/A
megan.jenkins@halltown.gov.uk
DX 23 56 78
Andrew Coppen
Civic centre
Hall Town
H T 3
0 N B
03312 356892
07756 689 456
N/A
andrew.coppen@halltown.gov.uk
DX 4590 38
AC/PLOAliceSmith
17
The respondents
If there are more than two respondents please continue on a separate sheet.
Respondent’s full name
Date of birth
D D
/
M M
/
Y Y Y Y
Gender Male Female
Place of birth
(town/county/country, if known)
Current address
Telephone number
Relationship to the child(ren)
Name of child(ren) Relationship Parental Responsibility
Yes No
Yes No
Yes No
Yes No
Respondent 1
Postcode
Respondent’s full name
Date of birth
D D
/
M M
/
Y Y Y Y
Gender Male Female
Place of birth
(town/county/country, if known)
Current address
Telephone number
Relationship to the child(ren)
Name of child(ren) Relationship Parental Responsibility
Yes No
Yes No
Yes No
Yes No
Respondent 2
Postcode
Carole Smith
1 6
0 4
1 9 8 7
British
62 Mainstone Road
Hall Town
Alice Elaine Smith
Mother
Jacob Donahue
2 4
1 1
1 9 8 6
British
HMP Dartmoor
c/o Prison Governor HMP Dartmoor
C O 9
4 d m
09345 763289
Alice Elaine Smith
Father
18
The child(ren)
Please give details of the child(ren) and the order(s) you are applying for.
If there are more than four children please continue on a separate sheet.
Child 1
Child’s full name
Date of birth
D D
/
M M
/
Y Y Y Y
Gender Male Female
Name of social worker and
telephone number
If the child is not
accommodated, who does the
child live with?
At which address does
the child live?
Postcode
Child 2
Child’s full name
Date of birth
D D
/
M M
/
Y Y Y Y
Gender Male Female
Name of social worker and
telephone number
If the child is not
accommodated, who does the
child live with?
At which address does
the child live?
Postcode
Alice Elaine Smith
0 8
0 2
2 0 1 0
Megan Jenkins
Accommodated since 16th January 2014
LA Foster Carer
Address withheld
19
Child 3
Child’s full name
Date of birth
D D
/
M M
/
Y Y Y Y
Gender Male Female
Name of social worker and
telephone number
If the child is not
accommodated, who does the
child live with?
At which address does
the child live?
Postcode
Child 4
Child’s full name
Date of birth
D D
/
M M
/
Y Y Y Y
Gender Male Female
Name of social worker and
telephone number
If the child is not
accommodated, who does the
child live with?
At which address does
the child live?
Postcode
If more than four children, continue on a separate sheet.
20
Others who should be given notice
Persons full name
Date of birth
D D
/
M M
/
Y Y Y Y
Gender Male Female
Address
Relationship to the child(ren)
Name of child Relationship Parental Responsibility
Yes No
Yes No
Yes No
Yes No
Relationship to the respondents
Name of respondent Relationship
Person 1
Postcode
Persons full name
Date of birth
D D
/
M M
/
Y Y Y Y
Gender Male Female
Address
Relationship to the child(ren)
Name of child Relationship Parental Responsibility
Yes No
Yes No
Yes No
Yes No
Relationship to the respondents
Name of respondent Relationship
Person 2
Postcode
Bill Treadwell
62 Mainstone Road
Hall Town
Alice Elaine Smith
Mother'spartner
Carole Smith
Partner
21
Annex Documents
1. Social Work Chronology attached to follow
(A succinct summary)
If to follow please give reasons why not included and the date when the
document will be sent to the court.
2. Social Work Statement and
genogram
attached to follow
If to follow please give reasons why not included and the date when the
document will be sent to the court.
3. The current assessment
relating to the child and/or
the family and friends of the
child to which the Social Work
Statement refers and on which
the local authority relies
attached to follow
If to follow please give reasons why not included and the date when the
document will be sent to the court.
4. Care plan attached to follow
If to follow please give reasons why not included and the date when the
document will be sent to the court.
5. Index of checklist documents attached to follow
If to follow please give reasons why not included and the date when the
document will be sent to the court.
This annex must be completed by the applicant with any application for a care, supervision or other Part 4 order.
The documents specied in this annex must be led with the application if available.
If any relevant document is not led with the application, the reason and any expected date of ling must be stated.
All documents led with the application must be clearly marked with their title and numbered consecutively.
Included in SW evidence template of Megan Jenkins.
Included in SW evidence template of Megan Jenkins
Initial viability assessment of Ms Morgan and her partner attached.
Section 31A care plan within the SW evidence template
LAC care plan to follow
22
What to do once you have completed this form
Ensure that you have:
attached copies of any annex documents.
signed the form at Section 11.
provided a copy of the application and attached documents for each of the respondents, and for
Cafcass or CAFCASS CYMRU.
given details of the additional children if there are more than four.
given details of the additional respondents if there are more than two.
the correct fee.
It is good practice to inform Cafcass or CAFCASS CYMRU that you are making this application. The court will
expect the local authority to have informed Cafcass or CAFCASS CYMRU that proceedings are being issued.
Have you notied Cafcass - Children and Family Court Advisory and Support Service (for England)
or
CAFCASS CYMRU - Children and Family Court Advisory and Support Service Wales.
Yes No
If Yes, please give the date of notication
D D
/
M M
/
Y Y Y Y
Now take or send your application with the correct fee and four copies to the court.
Please refer to the Family Proceedings Fees Order for the correct fee in respect of your application.
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