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2.16 Fabricated or Induced Illness

SCOPE OF THIS CHAPTER

This procedure has been written with reference to ‘Safeguarding Children in Whom Illness is Fabricated or Induced’ (DSCF, 2008).

The Royal College of Paediatricians and Child Health's report 'Fabricated or Induced Illness by Carers' (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.

For more information about local health processes see Guidance for Health Professionals who work with children where Fabricated or Induced Illness (FII) is suspected, within Leicester, Leicestershire and Rutland

AMENDMENT

This chapter was updated in September 2018.


Contents

  1. Introduction
  2. Recognition
  3. Response
  4. Consultation
  5. Medical Evaluation
  6. Referral
  7. Immediate Protection
  8. Strategy Discussion / Meeting
  9. Section 47 Enquiry
  10. Barriers to Assessment of FII, and in particular, Assessment of the Medical History
  11. Engagement with Parents
  12. Police Investigation
  13. Outcome of Section 47 Enquiry
  14. Initial Child Protection Conference
  15. Covert Video Surveillance
  16. Assessment and Treatment of Carers
  17. Concerns about Professionals
  18. Problem Resolution

    Flowchart: Fabricated and Induced Illness (FII)


1. Introduction

Fabricated or Induced Illness is a condition whereby a child suffers harm through the deliberate action of her/his main carer and which is attributed by the adult to another cause.

It is becoming increasingly recognised and is a potentially lethal form of abuse.

There are three main ways of the parent fabricating (making up or lying about) or inducing illness in a child:

  • Fabrication of signs and symptoms, including fabrication of past medical history;
  • Fabrication of signs and symptoms and falsification of hospital charts, records, letters and documents and specimens of bodily fluid;
  • Induction of illness by a variety of means.

The above three methods are not mutually exclusive. Existing diagnosed illness in a child does not exclude the possibility of induced illnesses. The very presence of an illness can act as a stimulus to the abnormal behaviour and also provide the parent with opportunities for inducing symptoms.

Concerns will be raised when it is considered that the health or development of a child is likely to be significantly impaired or further impaired by the actions or inactions of a carer or carers having fabricated or induced illness.

It is important that the initial and continuing focus is on the outcomes or impact on the child's health and development and not focussed on attempts to diagnose the parent or carer.

The range of symptoms and body systems involved in the spectrum of fabricated or induced illness are extremely wide, as can be the medical services in which children present, spanning primary, secondary and tertiary care. In some cases, the parent may also avoid or neglect to seek medical care or attention

Where a Paediatric Consultant is involved they are the Lead Health Professional (termed the Responsible Paediatric Consultant) and therefore have lead responsibility for all medical decisions.

Where a child has no Paediatrician and the concerns have been investigated by a consultant and discharged the GP should take lead responsibility with support from the Designated Doctor. In exceptional circumstances a paediatric referral should be made.

It is essential that there is clarity about who is taking on this responsibility. Where more than one Paediatric Consultant is involved formal discussion and agreement should be reached between all parties and other professionals notified of the decision as to who will take Paediatric Lead Responsibility.


2. Recognition

All professionals who come into contact with children and their families, or adults who are parents, may come into contact with a child or parent where there are suspicions of fabricated or induced illness. These suspicions are likely to centre on discrepancies between what a parent says and what the professional observes.

Fabricated or induced illness is most commonly identified in younger children (77% under five years old) - [McClure et al (1996) study]. The average length of time to identification was greater than six months in a third of cases and more than a year in a fifth of the cases - [Schreier and Libow (1993)]

In identifying and recognising fabricated or induced illness, professionals need to concentrate on the interaction of three variables:

  • The state of health of the child, which may vary from being entirely healthy to being sick;
  • The parental view which at one end is neglectful, and at the other end causes excessive intervention either directly or indirectly;
  • The medical view, which is equally on a spectrum from being dismissive at one end to performing excessive intervention or treatment at the other.

This consideration may give rise to concerns of the child possibly suffering significant harm as a result of having illness fabricated or induced by their carer.

These concerns may arise when:

  • Reported symptoms and signs found on examination are not explained by any medical condition;
  • Physical examination and results of medical investigations do not explain reported symptoms and signs; There is an inexplicably poor response to prescribed medication and other treatment which does not produce the expected effects;
  • New symptoms are reported on resolution of previously identified symptoms and problems;
  • Reported symptoms and identified signs are not observed in the absence of the carer;
  • Over time the child is repeatedly presented with a range of symptoms and problems potentially to different health professionals and in a variety of settings;
  • The child’s normal, daily life activities are being curtailed beyond that which might be expected from any known medical disorder from which the child is known to suffer;
  • Other considerations include:
    • The child denies the parental reports of symptoms and shows no sign of illness;
    • Specific problems occur that are not linked to any known illness or problem suffered by the child (e.g. apnoea, fits, choking or collapse);
    • There is a history of unexplained illnesses or deaths or multiple surgery in parents or siblings of the family;
    • There is a past history in the parent of child abuse, self-harm or somatising, or false allegations of physical or sexual assault.

There may be a number of explanations for these circumstances and each requires careful consideration and review.

See Local Contacts.


3. Response

All professionals who have concerns about a child's health should discuss these with their line manager, their agency's designated safeguarding children adviser and the GP or paediatrician responsible for the child's health. If the child is receiving services from LA children's social care, the concerns should also be discussed with them. Professionals, other carers or another parent may notice discrepancies between reported and observed medical conditions (eg the incidence of fits).

Professionals who have identified concerns about a child’s health should discuss these with the child’s GP or consultant paediatrician responsible for the child’s care. Schools and nurseries should liaise with the Public Health Nurse (School Nurse or Health Visitor) to facilitate this enquiry. The public health nurse will check health records and liaise with GP or Consultant to establish factual diagnoses and discuss concerns. Where the concern is upheld the School or Nursery should be informed to make referral to children’s social care.

If any professional has concerns about a situation being indicative of fabricated or induced illness, then these should be discussed with the agency’s Designated Professional who should consult the Named Health Professional (e.g. Named Nurse/Named Doctor within the organisation where the child is under consultant care) If professionals are encountering barriers to information sharing they should contact the Named Nurse/Named Doctor within the organisation where the child is under consultant care, within Leicestershire Partnership Trust (LPT) this may be delegated to Senior Safeguarding Practitioners.


4. Consultation

Children who have had illness fabricated or induced require coordinated help from a range of agencies.

Joint working is essential, and all agencies and professionals should:

  • Be alert to potential indicators of illness being fabricated or induced in a child;
  • Be alert to the risk of harm which individual 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 children’s needs and circumstances;
  • Contribute to whatever actions and services are required to safeguard and promote the child’s welfare;
  • Assist in providing relevant evidence in any criminal or civil proceedings.

Consultation with peers or colleagues in other agencies is an important part of the process of making sense of the underlying reasons for these signs and symptoms. The characteristics of fabricated or induced illness are that there is a lack of the usual corroboration of findings with signs or symptoms or, in circumstances of diagnosed illness, lack of the usual response to effective treatment. It is this puzzling discrepancy which alerts the medical staff to possible harm being caused to the child.

Harm to the child may also be caused through unnecessary or invasive medical treatment, which may be harmful and possibly dangerous, based on symptoms that are falsely described or deliberately manufactured by the carer, and lack independent corroboration.

The signs and symptoms require careful medical evaluation for a range of possible diagnoses. This is likely to include health professionals working closely with professionals in other agencies who have day-to-day contact with the child (e.g. day care providers or schools).

Where a reason cannot be found for the signs and symptoms, a second medical opinion should be considered and specialist advice and tests may be required.

If a paediatrician has suspicions that a child is being abused s/he should both seek a second medical opinion and make a referral in line with Referral and Assessment to LA children's social care - promptly, rather than waiting to be sure. Failure to alert the LA children's social care and / or the Police early enough is likely, in proven cases, to lead to greater suffering by the child. - [Fabricated or Induced Illness by Carers (Royal College of Paediatricians and Child Health, 2009)]

See also Referrals to Children’s Social Care Procedure, which provides guidance on the difference in LA children's social care between s47 and an assessment.

While the child's signs and symptoms are being evaluated and before concerns are confirmed, the Lead medical professional should retain the lead role, and the priority of Police officers (and LA children's social care) should be to assist the paediatrician with identification of the reason for the child's symptoms. The balance will change when it becomes clear that a crime appears to have been committed.

Normally, lead medical professional would tell the parent/s that s/he has not found the explanation for the signs and symptoms and record the parental response.

Parents should be kept informed of further medical assessments / investigations/tests required and of the findings but at no time should concerns about the reasons for the child’s signs and symptoms be shared with parents if this information would jeopardise the child’s safety and compromise the child protection process and/or any criminal investigation.


5. Medical Evaluation

Where there are concerns about possible fabricated or induced illness, the signs and symptoms require careful medical evaluation for a range of possible diagnoses by a paediatrician.

If no paediatrician is already involved, the child's GP should make a referral to a paediatrician where there are new concerns. Where a child has been discharged following investigation the GP should review the case and seek advice from the Named Doctor Safeguarding within the CCG.

Following completion of any relevant investigations, further specialist advice and tests may be required.

The Lead medical professional will tell the parent(s) that they do not have an explanation for the signs and symptoms they have investigated.

Parents should be kept informed of further medical assessments/ investigations/tests required and of the findings but at no time should concerns about the reasons for the child's signs and symptoms be shared with parents if this information would jeopardise the child's safety and compromise the child protection process and/or any criminal investigation (see Engagement with Parents).


6. Referral

When there is concern that probable 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 Social Care Services or the Police in accordance with the Referrals to Children’s Social Care Procedure.

Children’s Social Care 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.

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 Social Care 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 or GP is the lead health professional and therefore has lead responsibility for all decisions pertaining to the child’s health care. The lead health professional should seek support from the Named/Designated Doctor.

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.


7. 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.


8. Strategy Discussion / Meeting

If there is reasonable cause to suspect that the child is suffering, or likely to suffer significant harm, the Children’s Social Care Services should convene a Strategy Discussion/Meeting involving all the key professionals. See Strategy Discussions Procedure

Unless there is an emergency, this should be a Strategy Meeting, chaired by a manager from the Children’s Social Care Services.

If emergency action is the required response, for example, if a child’s life is in danger through poisoning or toxic substances being introduced into the child’s blood stream, an immediate Strategy Discussion should take place.

The Strategy Discussion/Meeting requires the involvement of key senior professionals responsible for the child’s welfare. At a minimum, this must include Children’s Social Care Services, the Police and the responsible Paediatric Consultant or GP responsible for the child’s health.

Additionally the following should be invited to Strategy Meetings as appropriate:

  • A hospital safeguarding lead if the child is an in-patient;
  • A medical professional with expertise in the relevant branch of medicine;
  • GP, Public Health Nurse (Health visitor or School Nurse);
  • Staff from education settings if appropriate;
  • Local authority’s Legal adviser;
  • Local authority adult social care;
  • Named or Designated Nurse or Doctor;
  • Mental health Practitioner (if appropriate either from CAMHS or Adult Services);
  • Any other involved health professional e.g. therapists, mental health practitioners, additional paediatricians;
  • Relevant specialist services including voluntary organisations.

Where the Strategy Discussion/Meeting decides that a Section 47 Enquiry should be initiated, see Section 9, Section 47 Enquiry

Decisions about undertaking covert video surveillance and keeping records should be made at a Strategy Discussion/Meeting (see Section 15, Covert Video Surveillance). Any such consideration should be clearly recorded, with reasons given why it is necessary. 

It may be necessary to have more than one Strategy Discussion/Meeting.

This is likely where the child’s circumstances are very complex and a number of discussions are required to consider whether and, if relevant, when to initiate a Section 47 Enquiry.

For some children it may be necessary to institute legal proceedings either immediately or soon after the Child Protection Conference has ended.


9. Section 47 Enquiry

When it is decided that there are grounds to initiate a Section 47 Enquiry, decisions should be made at the Strategy Discussion about how the Section 47 enquiry will be carried out including:

  • Whether it is necessary for records to be kept in a secure manner and how this will be ensured;
  • Whether the child requires constant professional observation and if so, whether or when carer(s) should be present;
  • Who will carry out what actions, by when and for what purpose, in particular planning further paediatric assessment(s) and any mental health assessments (CAMHS) to limit and contain further assessments & interventions;
  • Arrangements for the medical records of all family members, including children who may have died or no longer live with the family, to be collated by the consultant paediatrician or other suitable medical clinician;
  • The nature and timing of any Police investigations, including analysis of samples and covert surveillance (this will be Police led and co-ordinated, with advice available from the National Crime Faculty);
  • The need for extreme care over confidentiality, including careful security regarding supplementary records;
  • The need for expert consultation;
  • Any particular factors, such as the child and family’s culture, religion, ethnicity and language which should be taken into account;
  • The needs of siblings and other children with whom the alleged abuser has contact;
  • The needs of parents or carers (see Section 16, Assessment and Treatment of Carers);
  • The nature and timing of any Police investigations, including analysis of samples and covert video surveillance (see Section 15, Covert Video Surveillance);
  • How information will be shared with parents and at what stage;
  • Obtaining legal advice over evaluation of the available information (where a legal adviser is not present at meeting);
  • To agree process for medical peer review (see Section 10, Barriers to Assessment of FII, and in Particular, Assessment of the Medical History).


10. Barriers to Assessment of FII, and in particular, Assessment of the Medical History

Perpetrators of FII are likely to be manipulative, divisive and/or deliberately deceptive. A feature of FII is therefore that parents/carers may misrepresent what has been said by those professionally involved with their child to other professional staff. This may be either to support their own fabrications, or to foster division amongst those involved with them, which in turn prevents concerns being taken seriously.

Parents/carers may therefore present themselves very differently to different people and, in particular, may flatter and impress newly involved agencies/clinicians. They may also be both knowledgeable about the supposed illness and extremely persistent in their demands 'on behalf of' the child.

These presentations are likely to lead to conflicting opinions amongst professionals involved with a family.

FII concerns tend to emerge after significant medical input. Often a number of practitioners from different medical disciplines have acted, in good faith, on reported symptoms. When FII is then raised as a potential diagnosis, this will require review of previous diagnoses and interventions. Managing the review of medical intervention appropriately is vital in order to:

  • Avoid inappropriate criticism of previous intervention which may now appear to have been unnecessary;
  • Address conflicting medical opinion;
  • Disentangle actual illness from fabricated or exaggerated presentations.

Agreed Chronologies are particularly important in complex cases, or those which have involved expressions of concern over an extended period. Both medical and social chronologies are needed.

This is important to support professional analysis and provide clarity as to the nature of concerns. If practitioners require support in regard to reaching judgements or where clarity is required, they should seek supervision within their own agency e.g. within Health, with a Named Nurse/Doctor. Following supervision a plan of action should be agreed with clear timescales.

The designated doctor for child protection should facilitate a peer review of previous medical interventions. Where doubt is raised about a previous diagnosis/intervention, applied by a different medical practitioner, it is vital that that person is invited to review their findings informed by the current concerns.

The process needed in individual cases should be detailed in the strategy meeting(s), and close liaison maintained between the designated doctor/other medical expert and the investigating social worker/Police officer. This is, in particular, to identify and take account of disagreements over medical diagnoses/interpretation of previous events.

The production of full medical chronologies for siblings is equally important.


11. Engagement with Parents

No family member should be informed that a concern has been raised about possible FII abuse until this has been explicitly agreed by the Police and Children's Social Care. This would not normally be prior to the first strategy meeting. The strategy meeting should reach an explicit decision about what and when to tell family members of the suspicions and by whom. Where it is agreed that initial enquiries will not be shared with family members, the subsequent strategy meetings must explicitly review this decision.

This reversal of the presumption of openness which underpins most work with parents/carers, reflects the physical risks to the child which are present in confirmed cases of FII. Confronting parents with the suspicion of FII in an unplanned way can increase the risk of direct harm to the child, particularly where the concern is that the parent/carer may have already directly harmed the child. Historically it has been noted that where a perpetrator is informed that professionals are doubting that their child is genuinely ill this can prompt an increase in their attempts to show that the child is, indeed, sick.

Where a criminal offence may have been committed, it is important that any communication with the parents does not interfere with the criminal investigation.

Consideration should also be given to an assessment of the parent / carer by adult mental health services, and referral to therapeutic services as appropriate. The Police and Crown Prosecution Service should be informed about such action, if there is a criminal investigation / prosecution of the parent / carer.

At the same time, it is important not to maintain secrecy any longer than necessary to safeguard the child, in order to:

  • Maximise the prospects of subsequent working relationships with the family;
  • Be able to test out and gain a fuller view of suspicions;
  • Capitalise on the strengths in the family as well as assessing the concerns.


12. Police Investigation

Any evidence gathered by the Police must be available to other relevant professionals, to inform discussions about the child’s welfare and contribute to the Section 47 Enquiry and the Assessment.

In cases where a criminal offence is suspected 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, which would normally rule out any agency other than the Police confronting the suspect.

See Section 15, Covert Video Surveillance in relation to Covert Video Surveillance.


13. Outcome of Section 47 Enquiry

13.1 Concerns Not Substantiated

As with all Section 47 Enquiries, the outcome may be that concerns are not substantiated - e.g. investigations may identify a medical condition, which explains the signs and symptoms.

It may be that no protective action is required, but the assessment concludes that services should be provided to the child and family to support them and promote the child’s welfare as a Child in Need. In these circumstances, the assessment should be completed and a planning meeting held to discuss the conclusions, and plan any future support services with the family.

13.2 Concerns Substantiated but No Continuing Risk of Significant Harm

Where concerns are substantiated, but the assessment concludes that the child is not judged to be at continuing risk of harm, the decision not to proceed to an Initial Child Protection Conference must be endorsed by the relevant Manager within Children’s Social Care Services and recorded on the relevant records and database. However, any request for, a planning meeting to consider future action may be considered as an appropriate format to meet the needs of the child and promote his/her welfare.

Any request by a senior manager, or a named or designated professional in an involved agency that a strategy meeting be convened should be agreed.

13.3 Concerns Substantiated and Continuing Risk of Significant Harm

Where concerns are substantiated and the child judged to be suffering or at risk of suffering Significant Harm, an Initial Child Protection Conference must be convened. All evidence must be documented by this stage and a safety plan /risk assessment for the child must already be in place - see Outcome of the Section 47 Enquiry of Section 47 Enquiries Procedure.

The conference should be held within 15 working days from the last Strategy Discussion.


14. Initial Child Protection Conference

Attendance at this conference should be as for other initial conferences - see Initial Child Protection Conferences Procedure - although specific decisions about the participation of the parents/carers will need to be discussed with the Conference Chair and the following experts invited as appropriate:

  • Designated Doctor or Lead Paediatrician / GP;
  • A professional with expertise in working with children and families where a care giver has fabricated or induced in a child;
  • The responsible paediatric consultant with expertise in the branch of paediatric medicine caused by the suspected abuse.

Each agency should attend and/or contribute a written report to the conference - see Initial Child Protection Conferences Procedure - which sets out the nature of its involvement with the child and the family. This information should be precise and factual.

The child may have been seen by a number of professionals over a period of time: Children’s Social Care Services have responsibility for ensuring that, as far as is possible, this chronology (with special emphasis on the child’s medical history) has been systematically brought together for the conference. Where the medical history is complex, this should be done in close collaboration with the paediatric consultant responsible for the child’s health care. The health history of any siblings should also be considered. The Conference Chair has responsibility for ensuring that additional or contradictory information is presented, discussed and recorded at the conference whilst being mindful of the guidance set out in Section 10, Barriers to Assessment of FII, and in Particular, Assessment of the Medical History

Careful consideration should be given to when agency reports will be shared with the child’s parents. This decision will be made by the Conference Chair, in consultation with the professional responsible for each report.

If the family has recently moved or received services in another area, contact should be made and information obtained from the paediatric services in the area where the family previously lived. 

The conference should decide whether the child is suffering or likely to suffer Significant Harm, and therefore in need of a Child Protection Plan. If this is the case, an outline Child Protection Plan should be developed stating clearly what action will be taken to safeguard the child immediately after the conference, as well as in the longer term.

A Child in Need plan may be the outcome and actions developed within the multi -agency forum.

The conference should also consider what action if any is required to protect siblings in the family.


15. Covert Video Surveillance

The use of covert video surveillance (CVS) is governed by the Regulation of Investigatory Powers Act (RIPA) 2000.

After consideration at a Strategy Discussion to use CVS in a case of suspected fabricated or induced illness, the surveillance should be undertaken by the Police. The operation should be controlled by the Police and accountability for it held by a Police manager. The Police should supply and install any equipment, and be responsible for the security of and archiving of video tapes.

The decision will only be made if there is no alternative way of obtaining information to explain the child’s signs and symptoms and its use is justified on the medical information available.

The primary aim of the surveillance is to identify whether a child is having an illness induced; and the obtaining of criminal evidence is of secondary importance. The safety of the child is the overriding factor. 

Any use of covert surveillance by the Police should be carried out in accordance with good practice advice available from the ACPO (2004) Manual of Surveillance Standards and the ACPO (2004) Policy for Covert Monitoring Posts, both of which are held by the National Specialist Law Enforcement Centre (NSLEC).

Police Officers planning surveillance in cases of suspected fabricated or induced illness may seek advice from the National Crime Agency:

All personnel including nursing staff who will be involved in its use should have received specialist training.

Children’s Social Care Services should have a contingency plan in place, which can be implemented immediately if covert video surveillance provides evidence of the child suffering Significant Harm.


16. Assessment and Treatment of Carers

Where the existence of FII is established, as well as ensuring the welfare of the child, attention should be given to ensuring that assessment and treatment of any illness is offered to the carer with this behaviour.

An adult mental health assessment must be considered.

The named doctor for child protection at the Mental Health Trust should be formally contacted to nominate an appropriate colleague to carry out an assessment. This request should be recorded.

The assessing adult psychiatrist should be involved after the medical process considering FII has been completed.

If the assessing psychiatrist is being asked to comment about treatment, then this question should distinguish between treatment for the carer's psychological needs and the treatment for risk improvement. These aims are not necessarily the same. It should also be emphasised that currently the evidence base does not allow professionals to make clear statements about the risk assessment in the long term or even in the short term.


17. Concerns about Professionals

Most cases of FII involve parents/carers. However, the possibility that such behaviour could be found in professionals or volunteers acting in a caring capacity should be borne in mind. Such concerns should be raised discreetly and directly with the Designated or Named Doctor or Nurse for Safeguarding in the relevant organisation. It is vital that an individual does not discuss their concerns with other colleagues as this may inadvertently alert the perpetrator who could then take steps to cover up their actions or, worse still, escalate their behaviours. The process set out in this procedure must be followed, bearing in mind the additional factors set out in Allegations Persons who work with children Procedure, which set out arrangements for managing allegations of abuse made against professionals and volunteers.


18. Problem Resolution

FII and its management raises considerable ethical dilemmas for practitioners and has high potential for conflict between agencies and practitioners. It is particularly important that these are aired between agencies openly, in order that the focus of concern remains the child. Please refer to Resolving Practitioner Disagreements and Escalation of Concerns Procedure.

Where FII cases have raised particular concerns about the practice of individuals/agencies or the policies of agencies within this procedure, consideration should be given to debriefing meetings.


Flowchart: Fabricated and Induced Illness (FII)

Click here to view Flowchart: Fabricated and Induced Illness (FII).

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