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4.20 Fabricated or Induced Illness

RELATED GUIDANCE

For additional information please see:

DCSF, Safeguarding Children in whom illness is fabricated or induced - Supplementary guidance to Working Together to Safeguard Children (2008).

The Royal College of Paediatricians and Child Health's report Fabricated or Induced Illness by Carers (FII): A Practical Guide for Paediatricians (2009) provides more in-depth information for professionals, particularly those in health, describing the role of paediatricians and other healthcare professionals recommending how they should work with professionals from other agencies.

AMENDMENT

In March 2016, this chapter was significantly updated by fully revising Section 3, Considerations for Health Professionals, updating the flowchart and should be re-read.


Contents

  1. Introduction
  2. Recognition
  3. Considerations for Health Professionals
  4. Medical Evaluation
  5. Referrals
  6. Immediate Protection
  7. Action Following a Referral
  8. Initial Strategy Meeting
  9. Further Strategy Meetings
  10. Social Work Assessment of Needs and Strengths
  11. Use of Covert Video Surveillance (CVS)
  12. Child Protection Conference

    Appendix 1:Considerations for the Police

    Appendix 2: Considerations for Schools


1. Introduction

Fabricated or Induced Illness (F.I.I.) by definition is a condition whereby the child, usually, but not always, under the age of five years, suffers harm through the deliberate action of the main carer, in most cases the mother, but which is manipulated and attributed by her to another cause. For example, suffocation or deliberate poisoning of the child may be presented as cot death or an accidental overdose. Harm to a child may also be caused through unnecessary or invasive medical treatment based on symptoms that are falsely described or deliberately manufactured by the carer, and lack independent corroboration.

FII is a condition in which illness is fabricated or induced in a child by a parent or carer (who is in the position of a parent). If as a result of a carer's behaviour there is concern that the child is or is likely to suffer Significant Harm this guidance should be followed. The key aim is to assess the impact of Fabricated or Induced Illness on the child's health or development and to consider how best to safeguard the child's welfare. This requires a clear and sound multi-agency approach with Children's Specialist Services as lead agency ensuring that all other agencies, in particular health professionals with a thorough knowledge of child health and development, are involved.

There are three main ways of the carer fabricating or inducing illness in a child. These are not mutually exclusive and include:

  • Fabrication of signs and symptoms. This may include fabrication of past medical history;
  • Fabrication of signs and symptoms and falsification of hospital charts and records, and specimens of bodily fluids. This may also include falsification of letters and documents;
  • Induction of illness by a variety of means.

The most important principles in dealing with issues of suspected fabricated or induced illness in children are:

  • The necessity of multi-agency co-operation in information gathering and planning; and
  • Extreme care should be taken with confidentiality. This includes limiting attendance at Strategy Meetings to people invited on a strict 'need to know' basis and careful management of the recording of information and decisions on case notes and medical records to avoid premature disclosure to the parent/carer.  Careful consideration should be given to what the parents should be told, when and by whom, taking account of the child's welfare. Concerns should not be raised with a parent if it is judged that this action will jeopardise the child's safety. See Information Sharing and Confidentiality Procedure for further detailed guidance.


2. Recognition

Concerns that a child may be suffering or likely to suffer Significant Harm as a result of Fabricated or Induced Illnesses, may be raised by a variety of professionals, family members (including a partner of the person possibly fabricating or inducing the illness) or members of the public. These concerns may arise when:

  • Reported signs and symptoms are not observed on a regular day to day basis independently of parent or carer;
  • The child's daily life activities are being curtailed beyond that which might be expected of any known medical disorder from which the child is known to suffer;
  • Reported signs and symptoms that are found on examination are not explained by any medical condition from which the child may be suffering;
  • The child may be encouraged or required to appear disabled in order to obtain unnecessary specialist treatment or equipment;
  • Physical examination results or investigations do not explain reported signs and symptoms found on examination;
  • There is an inexplicably poor response to prescribed medication and other treatments;
  • New signs and symptoms are reported on resolution of previous ones;
  • It may also include signs and symptoms such as: poor or erratic attendance at early years establishment or school, even when medical explanations for absence are provided;
  • Failure to thrive (sometimes through deliberate withholding of food);
  • Fabrication of medical symptoms, especially where there is no independent witness (claiming to have medical symptoms);
  • Unexplained bleeding (especially anal or genital or bleeding from the ears);
  • Frequent unsubstantiated allegations of Sexual Abuse, especially when accompanied by demands for medical examinations;
  • Frequent accidental overdose (especially in very young children);  
  • Failure of a child to respond to treatment which should assist their recovery (carer may be obstructing drips or tampering with medication);
  • Non- attendance at school, even when medical explanations for absence are provided.

This is not an exhaustive list.

Resourceful parents/carers can mimic almost any disease/illness. Lists are only of use when a concern of fabricated or induced illness has been raised as a possibility.

Child protection cases that feature Fabricated or Induced Illnesses are especially complex and disturbing for practitioners. One worker should never undertake investigations in isolation. Multi-agency working, the identification of a key worker to co-ordinate the investigation, consultation with other experts in this area and good supervision of those most involved, are essential.

  • Practice guidance;
  • Be prepared for the carer to present as very plausible and well informed as to the nature of the child's medical problems;
  • Information received directly from the family, especially the suspected parent/carer should be subject to the independent verification to ensure its validity;
  • Avoid early confrontation with the suspected parent/carer until adequate evidence is obtained and a protection plan for the child is constructed;
  • Keep focused on the impact of the carer's behaviour on the child when assessing levels of risk. Many parents/carers who are suspected of fabricated or induction of illness in children behave in bizarre ways themselves. It is important always to keep in mind the question of how his/her behaviour influences the safety and functioning of the child;
  • Children under the age of five, especially preverbal children and children with an existing diagnosed illness, disability and/or communication difficulties are at greatest risk because of their inherent vulnerability;
  • If the child is in hospital his/her intake of food, drink and medication should be controlled as much as possible by hospital staff;
  • Before placing children with other members of either extended family, ensure that thorough assessment of them has taken place. It is not uncommon for fabricated or induced illness to be a feature of the family behaviour in previous generations. Any alternative carer should demonstrate an ability to believe that the suspected abuser may have posed a risk to the child. This may be hard to ascertain if the carer is a relative;
  • Whilst undertaking the assessment, ensure that the child is spoken to and asked how they feel, how they believe they became ill, although this will depend on the child's age and level of understanding. In some cases, it has been known that the child has known all along what the parent/carer has been doing, but has not been able to say. This has to be carefully undertaken as not to raise the suspicions of the suspected parent/carer;
  • All practitioners involved in possible Fabricated or Induced Illness cases must ensure that their record keeping is accurate, including clear documentation of all decision-making processes.


3. Considerations for Health Professionals

Introduction

There are three main ways in which a carer may fabricate or induce illness in a child. They are not mutually exclusive and include:

  • Fabrication of signs and symptoms. This may include fabrication of past medical history;
  • Fabrication of signs and symptoms and falsification of hospital charts and records, and specimens of bodily fluids. This may also include falsification of letters and documents;
  • Induction of illness by a variety of means.

All health professionals should:

  • Be alert to potential indicators of illness being fabricated or induced in a child;
  • Be alert to the risk of harm which individuals, or potential abusers may pose to children in whom illness is being fabricated or induced;
  • Share, and help to analyse information so that an informed assessment can be made of the child’s needs and circumstances;
  • Contribute to whatever actions (including the cessation of unnecessary medical tests and treatments) and services are required to safeguard and promote the child’s welfare; and
    • Regularly review the outcomes for the child against specific planned outcomes;
    • Work co-operatively with parents unless to do so would place the child at increased risk of harm.
  • Assist in providing relevant evidence in any criminal or civil proceedings, should this course of action be deemed necessary;
  • Such cases can pose conflicts of loyalty for health professionals for whom the child and the parents may also be patients. Such professionals have a duty to safeguard and promote the welfare of the child.

Health professionals are well placed to recognise the early signs and symptoms of fabricated or induced illness in a child through their monitoring of pregnancies and child health promotion. They may have unique knowledge of uncorroborated, odd or unusual presentations, which may present in acute, primary or secondary care.

Children who are having illness fabricated or induced may present with common problems, e.g. repeated nose bleeds, or un-witnessed seizure - like episodes, or reports of claims which are unusual and not possible to test for, such as particular allergies.

Stages of Action

(see Merseyside Child Protection Advisors Group: Fabricated or Induced Illness Guidelines flowchart for further details).

NB – cases will only progress to the next stage if clinically indicated.

Stage 1

The Health Professional may observe unusual behaviour or unexplained incidents which may lead or give rise to a concern of a possible FII.

In these circumstances any health professional with a concern should not share this information with the parents/carers as it may place the child at extreme risk.

You must inform and discuss the concern with the following professionals (as appropriate for the service/organisation) before taking any action:

  • Named Doctor/Nurse for Safeguarding Children and/or member of the Safeguarding Children Team;
  • Named midwife.

The named professionals will review the information from the referrer. They will check that there has been challenge to the family where it has been safe to do so, and that this has been clearly documented. The named professional will then progress to Stage 2 if indicated.

NB The concerns may also originate from other professionals such as education staff who may be given information from a parent/carer which appears to be exaggerated in relation to the child’s presentation in school. School staff may also be concerned about the excessive number of hospital / GP appointments a child is reported to require. School staff may share this information with the School Nurse who should then seek advice from the key health professionals noted above.

If concerns about possible FII are raised by any professional at a multi-agency meeting or during any assessment by Children’s Social Care, the relevant health professional must be contacted and this process instigated without delay.

Stage 2

The health professional and the Named Doctor / Nurse (or member of the Safeguarding Children Team) must gather all the Trust’s records (both paper and electronic) and meet to review the information. Liaison must take place between all health providers.

At this stage there needs to be a consideration as to whether F.I.I. concerns exist or whether, on review of the health information, these have been allayed. In the latter case, an action plan to manage the case should be prepared, led by the named professional from the organisation in which the concern was raised.

If at any stage of this process there is any difference of professional opinion the case must be escalated to the relevant Designated Doctor without delay.

Stage 3

If there are ongoing concerns, these must be reported to the Designated Doctor who may allocate the case to a Consultant Community Paediatrician.

The Designated Doctor or the Consultant Community Paediatrician who has been allocated the case will co-ordinate and chair the Health Professional’s FII meeting.

Prior to the meeting the Designated Doctor or the Consultant Community Paediatrician who has been allocated the case is responsible for seeking information from the Police, Social Care and Education to inform and assist the decision making.

The representative from each health organisation attending the meeting will be required to complete the health chronology template appended to this guidance document. The chronology will detail the involvement of all health professionals involved with the family from the organisation and a copy of this must be provided for the Chair of the meeting.

Key professionals who should attend the Health Professionals meeting are:

  • Designated Doctor and/or Consultant Community Paediatrician;
  • Named Safeguarding Children professionals for Primary and Acute Trusts;
  • GP;
  • Attending Doctor / Nurse / Midwife;
  • Health Visitor or School Nurse.

Other relevant professionals involved with the health care e.g.:

  • Dietician;
  • Therapist.

This list is not exhaustive, relevant professionals should be identified by the review of the records in all Trusts.

At the end of the Health Professionals meeting a decision needs to be made as to whether there is:

  • Likelihood of significant harm and meets threshold for referral to social care;
  • Concerns, but doesn’t meet threshold for referral to Social Care;
  • No evidence of Significant Harm.

Stage 4

  1. Likelihood of significant harm and meets threshold for referral to Social Care

    If there is evidence of, or risk of, significant harm, the Designated Doctor or the Consultant Community Paediatrician who has been allocated the case will:
    • Liaise with the Local Authority Safeguarding Children Unit with notification that a referral for a possible case of FII is going to be made;
    • Make a referral to the Local Authority Safeguarding Children Services in accordance with local procedures;
    • If there is a difference of opinion between agencies, the Multi-Agency Escalation Procedure should be activated.
    From the point of referral, all professionals involved with the child should work together as follows:
    • Lead responsibility for action to safeguard and promote the child’s welfare lies with Children’s Social Care;
    • Any suspected case of FII may involve the commission of a crime and therefore the police should always be involved;
    • The paediatric consultant is the lead health professional and therefore has lead responsibility for all decisions pertaining to the child’s healthcare.
  2. Concerns - but doesn’t meet threshold for referral to Social Care

    An action plan will be put in place, which should/may include a containment strategy:
    • A lead paediatrician to coordinate care and health information;
    • Primary care to ensure the child sees the same GP where possible who can liaise with the lead paediatrician if concerns arise;
    • Local AED department to be informed of containment strategy if indicated, gathering more information from a wider professionals meeting and/or challenging the carer if safe to do so.
    A date for a review meeting will be agreed. It might be helpful to:
    • Challenge the carer if safe to do so;
    • Continue to observe child and family – are patterns emerging?
    • Continue to keep detailed records being specific about the evidence base/source of information;
    • Continue to reassess the situation in the light of new information;
    • Arrange a date for a review meeting if appropriate.
  3. No evidence of significant harm

    If there is no evidence of significant harm and sufficient objective evidence of organic disease to account for the presentation, the concerns and decisions should be documented and typed copies of the minutes sent to all members of the Health Professionals Group and contributing agencies. The family GP or identified Acute Trust health professional should take responsibility for the on-going monitoring of the case.

    The outcome of stage 4 will be communicated by the chair to the designated nurse and to the designated doctor (if not the chair).

Stage 5

Children’s social care is the lead agency following a referral. Local Authority Safeguarding Children Services will arrange and chair a multi agency strategy meeting. The designated doctor will inform the Local Authority of health professionals who should be invited.

Record Keeping

Good record keeping is an important part of the accountability of professionals to those who use their services. Records should use clear, straightforward language, should be concise, and should be accurate not only in fact, but also in differentiating between opinion, judgements and hypotheses. It should be clearly documented which information has been obtained directly from carers.

Where it is considered that illness may be fabricated or induced, the records relating to the child’s symptoms, illnesses, diagnosis and treatments should always include the name (and agency) of the person who gave or reported the information, and be dated ad signed legibly. All telephone conversations should be recorded fully.

The recording and retention of information, including information about covert video surveillance, should be made in accordance with the Data Protection Act 1998.

All records should be kept securely to prevent unauthorised access and ensure they cannot be interfered with.

Requests for access to the child’s records should be actioned in accordance with each agency’s Access to Records policy and procedures. Where there is any doubt about the retention or disclosure of information, legal advice should be sought.

For further information see the HM Government/DCSF “Safeguarding Children in whom Illness is Fabricated or Induced” (2008).

See also Merseyside Child Protection Advisors Group: Fabricated or Induced Illness Guidelines flowchart.


4. Medical Evaluation

Where there are concerns about possible Fabricated or Induced Illness, the signs and symptoms require careful medical evaluation by a paediatrician(s). For children who are not already under the care of a paediatrician, the child's GP should make a referral to a paediatrician, preferably one with expertise in the specialism which seems most appropriate to the reported signs and symptoms.

Tests and their results should be fully and accurately recorded, including those with negative results. It is important to ensure these records are not tampered with or results altered in the child's notes: also, that the name of the person reporting any observations about the child is recorded clearly in the child's notes and dated.

Where, following a set of medical tests being completed, a reason cannot be found for the reported or observed signs and symptoms of illness, further specialist advice and tests may be required. Normally, the consultant responsible for the child's care will tell the parent(s) that they do not have an explanation for the signs and symptoms. The parental response to this information should be recorded. The consultant would then set out the next steps, including what further assessments/investigations/tests (perhaps in a more specialist setting) are required to tease out the possible explanations. Parents should be kept informed of findings from these medical investigations but at no time should concerns about reasons for child's signs and symptoms be shared with the parents if this information would jeopardise the child's safety. The child should continue to receive appropriate health care and support should continue to be provided to the child's carers by health professionals.


5. Referrals

When a possible explanation for the signs and symptoms is that they may have been fabricated or induced by a carer and as a consequence the child's health or development is or is likely to be impaired, a Referral should be made to Children's Specialist Services or the Police in accordance with the Contacts and Referrals Procedure.

All professionals should seek guidance from the Designated Health Professional before discussing any concerns with the family. Whilst as a general principle the family's agreement, wherever possible, should be sought before making a Referral to Children's Specialist Services, this should not be done in suspected FII cases if there may be suspicion that the parent(s) are causing harm to the child. In these cases informing the parent(s) may place the child at increased risk of Significant Harm.

Concerns that a child’s illness may be fabricated or induced are most likely to come from a health professional however any agency in contact with the child may become concerned e.g. education staff where a child is frequently absent from school on questionable health grounds, or nursery staff may not observe fits of a child who is described by a parent as having frequent fits. It is essential that paediatrician is involved in the assessment of F.I.I. However the paediatrician will almost always need the help of social care and other agencies in gathering information needed to confirm or refute the diagnosis. The paediatrician will play a key role in the collation and interpretation of heath information / evidence for non-health professionals.

Children's Specialist Services should decide within one working day how to respond and what actions should be taken. Decisions should be agreed between the referrer and the recipient of the Referral about what the parents will be told, by whom and when.

Where there are suspicions of F.I.I. in a child, a referral must be made to Children’s Social Care in accordance with the making referrals procedure. From the point of the Referral, all professionals involved with the child should work together as follows:

  • Lead responsibility for action to safeguard and promote the child's welfare lies with Children's Specialist Services;
  • Any suspected case of Fabricated or Induced Illness may involve the commission of a crime and therefore the police should always be involved;
  • The paediatric consultant is the lead health professional and therefore has lead responsibility for all decisions pertaining to the child's health care.

In cases where the police obtain evidence that a criminal offence has been committed by the parent or carer, and a prosecution is contemplated, it is important that the suspect's rights are protected by adherence to the Police and Criminal Evidence Act 1984.


6. Immediate Protection

If at any point there is medical evidence to indicate the child's life is at risk or there is a likelihood of serious immediate harm, an application for an Emergency Protection Order or Police Protection powers should be used to secure the immediate safety of the child.


7. Action Following a Referral

Referrals to Children's Specialist Services in relation to Fabricated or Induced Illness should be managed in accordance with the Managing Individual Cases Procedure

Once any professional/agency has identified that there is a suspicion of fabricated or induced illness an initial Strategy Meeting must be held.

The aim should be for the initial Strategy Meeting to take place within fifteen working days, and no later than twenty working days from the Referral, unless the situation requires an earlier meeting.


8. Initial Strategy Meeting

All Strategy Meetings will be co-ordinated and chaired by an officer from the Safeguarding Unit. The initial Strategy Meeting will include professionals from each relevant agency, including:

  • Child Protection Coordinator/Independent Reviewing Officer;
  • Team manager;
  • Designated Doctor or Designated Nurse for child protection;
  • Any relevant health professional involved with the family;
  • Senior Investigating Police Officer;
  • Local Authority legal adviser;
  • General Practitioner;
  • Education.

The Purpose of the initial Strategy Meeting is to:

  • Share information and plan and produce a detailed chronology of all the issues, with clear recognition of confirmed signs and symptoms
  • Decide whether Section 47 Enquiries should be initiated;
  • Confirm the key professional involved in any planned investigation;
  • Clarify and limit the number of health professionals seeing the child;
  • Consider the need to access the families' medical records;
  • Consider if covert surveillance is appropriate;
  • Consider if an Initial Child Protection Conference should be convened.


9. Further Strategy Meetings

It may be that certain information may not be available for the Strategy Meeting. The initial Strategy Meeting should still be held and clearly identify what further information is required and why, and set a timescale for a second Strategy Meeting so that information can be considered, and plans reviewed and adjusted accordingly. Further Strategy Meetings should be held as required. At the conclusion of the investigation, a Strategy Meeting should be held to review any decision regarding Child Protection Conference and future plans.

All Strategy Meetings have the same purpose as the initial Strategy Meeting.


10. Social Work Assessment of Needs and Strengths

If the outcome of the initial Strategy Meeting is that Section 47 Enquiries should be initiated a Social Work Assessment of Needs and Strengths (single assessment) must commence.

The timescale for completing the Social Work Assessment of Needs and Strengths is 35 working days, however it is recognised that some specialist assessments may not be able to be completed within this timescale.


11. Use of Covert Video Surveillance (CVS)

The decision to use CVS in a case of fabricated or induced illness should be made at a multi-agency Strategy Discussion or Meeting (see Section 8, Initial Strategy Meeting above). The CVS should be undertaken by the police. CVS should only be used if there is no alternative way of obtaining information which will explain the signs and symptoms and the multi-agency Strategy Meeting considers that its use is justified based on the medical information available. The Chief Executive of NHS Trust should be kept informed of any decision to apply for the use of CVS in his/her Trust.

Police Officers planning surveillance in cases of suspected fabricated or induced illness may seek advice from the National Crime Agency, Telephone 0370 496 7622, communication@nca.x.gsi.gov.uk.


12. Child Protection Conference

The decision to convene a Child Protection Conference should be informed by the need to have all the evidence thoroughly documented, and protection of the children already in place. It may necessitate conferences being called outside of recommended time scales. (Given that there may be a number of Strategy Meetings any Conference should be held within fifteen working days of the final one).


Appendix 1: Considerations for the Police

  • Any suspected case of Fabricated or Induced Illness may also involve the commission of a crime and therefore the police should always be involved at an early stage in accordance with Working Together 2015;
  • Such complex cases must be led by an experienced detective supervisor who as part of the inter-agency management team should, if possible, consider an arrest strategy well in advance of it being carried out, in particular where such enquiries are conducted on hospital wards;
  • All investigative avenues must be considered, including the use of covert surveillance, ensuring that the very highest standards of professional integrity are maintained.


Appendix 2: Considerations for Schools

Schools have an important role to play in the identification and management of suspected cases of Fabricated or Induced Illness. Through their day to day contact with children, teachers and other school staff are particularly well placed to notice outward signs of a child may be suffering or likely to suffer Significant Harm.

Similarly, staff members from CYPD school support services, such as Education Welfare Services and Educational Psychologists, are in a position to raise concerns.

There are a number of factors that teachers and other school staff should be aware of that can indicate that a pupil may be the subject of Fabricated or Induced Illness:

  • Frequent and often unexplained absences from school;
  • Regular absences to keep hospital or doctors' appointments;
  • Repeated claims by a parent/carer that a child is frequently unwell and that she/he requires medical attention for symptoms or illness that have not been observed by staff;
  • Conflicting or patently untrue stories about illnesses, accidents or deaths in the family.

Schools should be aware of significant changes to a child's physical or emotional state, unexplained injuries, changes in behaviour and a failure to thrive.

End