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1.3.30 Perplexing Presentations (including Fabricated or Induced Illness)


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Definition
Risks
Indicators
Protection and Action to be Taken
Agency Roles and FII Protocol
Issues
Further Information
Amendments to this Chapter


Definition

Fabricated or Induced Illness is a condition whereby a child‘s clinical presentation is not adequately explained by any confirmed genuine illness, and the situation is impacting upon the child’s health and social wellbeing. This may be called ‘perplexing presentations’ or ‘Medically Unexplained Symptoms’. The rarer ‘true’ FII involves the child suffering harm through the deliberate action to falsify specimens or investigations, or induction of actual illness in the child, or deception of medical services by her/his main carer.

For many children and young people who present with ‘perplexing presentations’ or ‘medically unexplained symptoms’ paediatricians will be able to work with the family to make a decision that further investigation or specialist opinion is not required and could be detrimental to the child or young person’s best interests. This will follow assessment of the presenting issues and exploration of possible causes.

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

It is a relatively rare but potentially lethal form of abuse.

It is important that the focus is on the outcomes or impact on the child's health and development and not initially 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.

Investigation of Fabricated and Induced Illness and assessment of harm to a child falls under statutory framework provided by Working Together 2015 and Safeguarding Children in whom illness is fabricated or induced (Supplementary guidance to Working Together to Safeguard Children). HM Government 2008.


Risks

There are four main ways of the carer fabricating 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 medical information, records, letters and documents and specimens of bodily fluids;
  • Exaggeration of symptoms/real problems. This may lead to unnecessary investigations, treatment and/or special equipment being provided;
  • Induction of illness by a variety of means.

The above four methods are not mutually exclusive.

Harm to the child may be caused by them experiencing one or more of the following:

  • A disordered perception of illness and health, leading to anxiety about health and abnormal illness behaviour;
  • (Inadvertent) iatrogenic harm including admission to hospital, exposure to hospital acquired infection, blood tests or X-rays;
  • A greater degree of invasive medical attention than is truly justified. In extreme cases this may include surgical procedures, insertion of venous lines, artificial feeding, anaesthesia or more prolonged hospital admissions;
  • Interference with normal life, including school attendance, social activities, relationships or educational achievement;
  • Older children may support their parents/carer in the perplexing presentation, even to the point of being complicit with active deceit;
  • Child victims of FII may be subject to prolonged legal proceedings and are at risk of further abuse and on-going morbidity due to abuse.

Indicators

These may include:

  • Reported symptoms and signs found on examination are not explained by any medical condition from which the child may be suffering;
  • A carer reporting symptoms and observed signs that are not explained by any known medical condition;
  • Physical examination and results of investigations do not explain the symptoms or signs reported by the carer;
  • The child has an inexplicably poor response to prescribed medication or other treatment, or intolerance of treatment;
  • Acute symptoms and signs are exclusively observed by/in the presence of one carer;
  • On resolution of the child’s presenting problems, the carer reports new symptoms or reports symptoms in different children in sequence;
  • The child’s daily life and activities are limited beyond what is expected due to any disorder from which the child is known to suffer, for example partial or no school attendance and the use of seemingly unnecessary special aids;
  • The carer seeks multiple opinions inappropriately.

Concerns may also be raised by other professionals who are working with the child and/or parents/carers who may notice discrepancies between reported and observed medical conditions, such as the incidence of fits.


Protection and Action to be Taken

Practitioners 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.

Where there is a suspicion of FII, practitioners should consider this guidance carefully when fulfilling their role in assessing and investigating their concerns effectively.

Agencies and practitioners need to be mindful that where a child has suffered, or is likely to suffer, significant harm it is essential to make an immediate referral to Children’s Social Care in accordance with the Referrals Procedure

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

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

  • Be alert to potential indicators of illness being fabricated or induced in a child including an up to date chronology;
  • 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;
  • Proportionality between monitoring and intervention;
  • 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.

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

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.

Practitioner challenge of presentations by clinicians without labelling the situation as Fabricated and Induced Illness is vital and should feed into the holistic assessment of families.

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 paediatrician will tell the parent(s) that they do not have an explanation for the signs and symptoms.

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.

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 (see Referrals Procedure) should be made to Children’s Social Care or the Police:

  • Lead responsibility for the coordination of action to safeguard and promote the child’s welfare lies with Children’s Social Care;
  • 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 practitioner 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.


Agency Roles and FII Protocol

Children’s Social Care Role

There are some features of FII investigation that mean there will be variance to usual safeguarding procedure which are legitimate in these circumstances (e.g. non-disclosure to parents, timescales for Assessments etc.). Where this variance occurs it is important to document the decisions taken alongside the rationale. Where procedure is not followed senior managers should be consulted and asked to authorise this variance as being in the interest of the child’s welfare.

Involvement of Social Care

Social Care will be the lead agency in any investigation of harm to a child caused by FII. There are a two ways in which Social Care may be involved:

  • Social Care will already be involved with the family when issues of FII are suspected;
  • Another agency identifies the possibility of FII and makes a referral.

Information Shared with Children’s Social Care

This practice guide sets out the process by which agencies will make Children’s Social Care aware that they have concerns that FII may be affecting a child’s welfare.

The first step in the process is to have a Professionals Meeting for all those involved in the care of the child to clarify the concerns and the evidence for possible FII. No concerns should be raised with the family at this stage and they must not be aware of the meeting. To ensure quoracy a Designated Safeguarding professional and the child’s GP must be present.

The meeting will consider whether they feel they have sufficient evidence to make a Safeguarding referral either for FII or Child Protection. The meetings can be complex and where there is doubt about a presentation, agencies may choose to gather more evidence to support decision making. At this point chronologies should be compiled and merged using the Serious Case Reviews chronology template.

A second meeting should be convened to review the merged chronologies. A social worker should be invited to attend this meeting and a decision should be taken at the meeting as to whether or not a referral to Social Care should be made. Again the family must not be made aware of the concerns nor the actions taken at this stage.

If the decision is made to refer on the basis of FII, the Designated Safeguarding professional will provide an analysis of the chronologies and level of risk using the agreed template (to be attached).

The Children’s Social Care Duty Service will record the information shared by the other agency and this will go through the usual 24 hour decision-making process to decide whether this information is being treated as a contact or a referral.

Where the information is taken as a contact and it is agreed that the referring agency is going to undertake some further exploration of the issues to gather evidence, it may be appropriate for Children’s Social Care to offer some advice about the best way in which to gather this information. If chronologies have not already been prepared they should be compiled at this stage allowing four weeks for this work to be completed Chronologies, when combined, should provide a detailed history of the case, including the medical, psychiatric and social histories of the child. Subsequently it may be agreed to add in details of these histories for parents/carers and siblings.

It is essential that the referring agency agrees to communicate the outcome of this further exploration. In these cases Social Care will send written confirmation of the decision which will include this expectation.

Where a referral is taken by Social Care and FII is to be investigated, a strategy meeting will be convened.

Children’s Social Care strategy meeting

The strategy meeting is convened by Children’s Social Care. In the case of strategy meetings convened to consider FII it is essential that they are face to face meetings and that minutes are taken to ensure there is an accurate record of the discussion.

(In each case negotiation between agencies involved will be needed to see who can undertake the administration functions of the meeting).

The meeting will include the referrer, a lead paediatric consultant, police, health and social care as a minimum. Other agencies and partners that may have information to share will be invited to attend. In rare instances when the paediatric consultant cannot attend, the hospital named doctor or designated doctor for safeguarding children (who are also consultant paediatricians) should be invited. The designated nurse / named nurse will also attend.

Social Care will need to make and record a decision at this point about whether they are going to undertake an Assessment with the family or to work with other agencies in an undisclosed way for a period.

The meeting will follow the process set out for all strategy discussion/ meetings.

The Strategy Meeting Template is an appropriate tool to record the discussion and decision making of this meeting, with reference to the minutes.

The purpose of a strategy meeting is to assess whether the threshold for s47 enquiry has been met and to plan an approach to any further gathering of evidence / information. Other forms of harm must be considered as well as physical harm, which may be the obvious issue.

It is likely in investigations of FII that a number of strategy discussions/ meeting will be held before a decision about s47 can be taken. A designated Safeguarding Health Professional should attend each strategy meeting and there must be decisions taken about:

  • The assessed risk to the child and whether s47 threshold is met;
  • Any immediate steps necessary to reduce the risk of harm (for example, cancelling unnecessary medical procedures or instituting closer observation of the child);
  • Timescales for further actions / meetings (subsequent strategy discussions/ meetings should be planned for no more than one months’ time. This is important to prevent drift and loss of focus);
  • The plan for further investigation and information gathering;
  • Communication with carers and confidentiality (including how, when, and by whom they should be informed of any child protection concerns);
  • How the child can be given an opportunity to tell their story – this requires careful consideration and planning;
  • Any outstanding investigations, further information gathering, and opinions that would be helpful;
  • Responsibility for the Assessment;
  • The security of medical records;
  • The level of practitioner observation required;
  • Whether the carers should be allowed on the ward if the child is an inpatient– if this is deemed to be unsafe then an emergency order may be required which will need to be instituted by either the police or the local authority;
  • Any potential implications for other patients or their carers who are on the ward at that time;
  • The planning of further medical and nursing assessment;
  • The need for forensic sampling, special observation or Covert video surveillance;
  • The needs of siblings and other children in the family;
  • The needs of carers, particularly after disclosure of concerns;
  • The development of an integrated health chronology (and agreement on who should do this);
  • Clarification of who will be the responsible paediatric consultant for the child (if not already explicit);
  • Any further opinions needed (including specialist child protection opinion or to address a specific clinical issue);
  • What is known about the carers’ past behaviour, medical history, current health state and any treatment, equipment, aids or benefits being received either for themselves or the child.

Where there are a number of strategy meetings it is important that colleagues are given an understanding of whether it is essential or useful for them to attend. The Chair of the strategy meeting will help guide the colleagues, where possible, about their attendance. There may be an arrangement that colleagues who do not attend are available by phone in case unanticipated significant information is shared and decisions are needed involving them.

If the strategy meeting/s do not agree to progress to s47, a child in need plan may be appropriate to address needs identified for the child.

S47 enquiries

If the strategy meeting decides that s47 threshold is met, then plans to inform and involve the parent in the s47 enquiries must be agreed, where they are not already aware.

An Initial Child Protection Conference will be convened within 15 working days of this decision to commence s47 enquiries, in line with Working Together 2015 where the outcome of the s47 enquiries identifies that concerns are substantiated and the child is judged to be continuing to, or be likely to suffer significant harm.

Planning for the Child’s welfare

The child’s welfare must remain paramount in any investigation of FII and all of those involved have a responsibility to consider the best way in which to protect and promote his/her well-being. 

The Role of Health Services

For the purpose of the Bournemouth, Dorset & Poole Fabricated and Induced illness guidance, health services include: Health services commissioned by Dorset Health Care University NHS Foundation Trust,  (GP  primary care services and hospital and community provider services and Foundation Trusts) South Western Ambulance NHS Trust (including Urgent Care Service (UCS) (GP Out of Hours service)).

Nationally, NHS 111 provide a service which may be accessed by parents where FII is present.

All health practitioners need to be aware of the factors that indicate fabricated and induced illness and that are within this guidance and listed references. The RCPCH 2009 is useful guidance to assist health practitioners further.

Health staff who are concerned that a child may be suffering or may suffer significant harm due to the fabrication or induced illness by their parent/carer will:

  1. Seek advice from the Safeguarding children Team in their own organisation, in the first instance, before embarking on any course of action;
  2. Check with other health practitioners involved, their records and assessment of the child’s circumstances. This should include a check with NHS 111 (see below);
  3. Raise general concerns, for example frequent attendance at GP surgery with no substantive cause, with parents and record responses according to record keeping guidance;
  4. Document early concerns in the child’s case notes so that other clinicians will have access to that information. Carers’ access to records may need to be restricted;
  5. Do not discuss with parents/carer you suspect FII. You can inform parents that you are concerned for the welfare of the child due to….. (your assessment) and are referring to Children’s Social Care, if there is no additional risk to the child;
  6. If concerns remain, discuss with the safeguarding advisor for your organisation who will advise on next course of action. Information sharing is important at this stage;
  7. Safeguarding advisor to inform Named Nurse for Safeguarding Children of organisation of a potential FII, who will inform the Designated Nurse;
  8. A professionals meeting should be convened as outlined above and may result in a referral to Social Care being made;
  9. Health Services will nominate one person from each health organisation (who are involved with the case) to coordinate health responses for the case;
  10. The meeting to be recorded in the child’s record as a multi- agency meeting with regard to  (reason for meeting e.g.  absence from school due to ill health);
  11. There is emotional impact on staff working with these cases and they should seek the support of their manager and supervision as per organisational policy.

Accessing information from NHS 111

Requests for information should be made to NHS 111 SWAST Safeguarding Team on: safeguarding@swast.nhs.uk 01392 261575.

Give as much information as possible regarding names, dates of birth, current and past addresses, post codes and telephone numbers. A time frame for the searches should be provided as only information within the specified time frame will be provided.

The Paediatrician’s Role

The RCPCH 2009 (reference in appendix 2) is useful guidance to assist health practitioners further.

A lead paediatric consultant will be identified as early as possible to be responsible for coordinating all decisions about the child’s healthcare (whether the child is or is not known to paediatric services).

The paediatrician should begin by assessing the safety of the child, particularly in the case of suspected non-accidental poisoning and suffocation. Clear patterns of constant and careful observation of the child should be instituted. The essential questions for the paediatrician are:

  • Does the child actually suffer from an illness?
  • If so, does the recognised illness explain all of the child’s reported symptoms and observed signs and symptoms or their severity?
  • If not, what is the likely cause of the child’s reported symptoms and observed signs?
  • Is the child suffering or at risk of harm?

Practice Points:

Approach to diagnosis

  • When FII is included in the differential diagnosis [1], put equal effort into confirming or excluding the diagnosis of FII and the exploration for genuine disease;
  • FII is not a ‘diagnosis of exclusion’ and continued investigations for other less probable physical diagnoses may cause the child further harm;
  • Proceed in a timely manner to the investigation which is most likely to confirm a diagnosis either of FII or an organic condition;
  • Consider the differential diagnosis set out in Table 1 (RCPCH 2009) – is this child’s ‘illness’ likely to fall into another category?

[1] Differential diagnosis is the process of distinguishing of a disease or condition from others presenting similar symptoms.

Initial management

  • Agree who will assume role of ‘lead paediatric consultant’;
  • Use this guidance in conjunction with RCPCH and government publications;
  • Document early concerns in the child’s case notes so that other clinicians will have access to that information. Carers’ access to records may need to be restricted;
  • Discuss concerns with Named and / or Designated Health Practitioners and other relevant colleagues, including nursing staff involved with the child;
  • Conduct and document an immediate assessment of the risk of harm based on available information: Is the child in need of immediate protection?
  • If the child is not currently in hospital, consider whether a planned admission with careful observation and / or specific investigations would help to elucidate the clinical diagnosis;
  • Consider whether any immediate investigations or further opinions (e.g. from appropriate tertiary specialists for the child's symptoms / signs / condition) are likely to assist in the diagnosis. This should be balanced by the potential to cause harm to the child;
  • Consider constant supervision of the child or other measures to reduce the risk of immediate harm;
  • Stop any harmful treatments or invasive procedures unless they are clearly indicated. It is unacceptable to cause the child further iatrogenic harm whilst the diagnosis of FII is being considered;
  • Consider whether there is concern that the child may be at risk of significant harm – if that concern cannot be resolved quickly and simply then a referral should be made;
  • Consider whether referral should be made to Children’s Social Care (the diagnosis does not need to have been confirmed). This is likely to be indicated if there is a risk of harm to the child through illness induction, or harm through the carer’s disagreement with the need for further observation or with paediatric consensus about the child’s state of health. (See Flowcharts). If the assessment suggests there is reasonable cause to suspect the child is suffering or is likely to suffer significant harm, Children’s Social Care should convene a multi-agency strategy discussion/ meeting;
  • Where concerns are not so high & the threshold for significant harm is not reached it may be appropriate to manage the case primarily by reassurance (as in example 1, RCPCH Table 1) or to discuss the case with the named or designated practitioner for safeguarding children (as in example 2, RCPCH Table 1);
  • Prepare a chronology (the named / designated practitioner will give guidance on the format. The template used is that used for serious case reviews).

At this stage concerns about FII should not be discussed with the family as the child may be put at risk.

Further medical management

  • Ensure that the lead paediatric consultant maintains continuity and control of the case, irrespective of the involvement of other practitioners;
  • Resist requests for a change of clinical team or hospital as this may place the child at risk of harm;
  • A clinical report should be prepared for the multi-agency strategy discussion/ meeting outlining the medical concerns;
  • If the child is not at immediate risk of harm, consider whether further investigations or opinions are likely to assist. Are special forensic tests likely to help? If so, discuss these in the strategy discussion/ meeting;
  • Keep detailed and meticulous medical and nursing records, recording all investigations, observations and consent;
  • Corroborate all information obtained with other agencies. This may need to be repeated should new events be reported;
  • Clinical and child protection plans must be shared with ‘on call’ staff in handover meetings;
  • Consider whether the case may require the use of Covert Video Surveillance (CVS). If so, discuss this in the Strategy Discussion/ Meeting. CVS must be managed & performed by the Police (under the Regulation of Investigatory Powers Act 2000 – RIPA).

Ensure that any decisions to undertake CVS is recorded in the child’s record held by each agency involved in the decision, and that this is signed by a senior manager. The Chief Executive of the Trust must be informed about the use of CVS.

Identification of genuine illness

  • If a genuine cause for the child’s symptoms and signs is found and the possibility of FII is excluded, communicate this immediately and clearly to the clinical team, including primary and secondary care, and to Children’s Social Care;
  • Always remember that genuine disease and FII may co-exist;
  • If the carers were already aware that FII was being considered, ensure that a full explanation is provided, and an apology offered for any distress caused.

Police Role

Police have a lead role in any investigation into criminal activity in FII cases. Any suspected case of FII may also involve the commission of a crime. Whilst there is no specific FII legislation, cases of intentional smothering /poisoning are criminal assaults whilst more subtle forms of FII, for example tampering with feeding tubes, withholding food and drink or causing unnecessary medical interventions are possible offences of criminal neglect (Section 1 Children and Young Persons Act 1933). The police will gather evidence of suspected criminal offences in FII cases. Medical evidence will also be sought from medical practitioners treating the child. If sufficient evidence is available the police will present the case to the CPS for their consideration and decision to charge.

The Police will work with other agencies and attend strategy meetings. Any evidence gathered within a police investigation will ordinarily be shared to assist in the analysis of risk and decision making about appropriate actions to take.

The police use technical means to gather evidence in many types of criminal investigation and it may be appropriate to consider their use in an FII case. If it is agreed at a strategy meeting that such an approach is indicated the police will take responsibility for its implementation and management.

Referrals regarding possible FII cases should be forwarded to the Police Safeguarding Referral Unit on telephone 01305 222777 or by e-mail on sru@dorset.pnn.police.uk

Record Keeping

  • Ensure strict adherence to current best practice in record keeping;
  • Always document concerns about possible FII – failure to do so will prevent important information from being shared, thereby increasing the risk of harm to the child;
  • Carefully manage the carer's access to medical records;
  • Ensure the records clearly identify the responsible paediatric consultant;
  • Keep multi-disciplinary case records;
  • Provide an appropriate summary of the case if records do not follow the patient between Trusts or clinical teams;
  • Document all decisions made and all information that influenced these;
  • Record the source of all information and, if appropriate, document verbatim comments;
  • Ensure the child’s record differentiates between what is observation, fact and opinion;
  • Ensure records are stored securely and that the responsible consultant and Trust are informed of this location and have access to the records.

The Role of Education / Early Years Settings

For the purpose of this guidance education refers to and includes: Schools, Education Social Worker Service / Education Welfare Service, Educational Psychologists, Early Years (including pre-schools, nurseries and childminders) and LA Special Educational Needs Department, Learning Support Services, EMTAS, Youth Services and other LA staff working with children and young people.

Staff need to be aware of factors that could indicate fabricated or induced illness, including:

  • Frequent and unexplained absences from school/ setting;
  • Regular absences to attend medical appointments;
  • Repeated claims by parent/carers that a child requires medical attention for symptoms that are not verifiable unless observed e.g. fainting, vomiting and temperatures;
  • Failure to provide medical information or refusing consent to refer to Health practitioners e.g. school nurse, community paediatrician, educational psychologist etc.
  • The parent/carer presenting as having a detailed knowledge and understanding of medical procedures, signs and symptoms;
  • The child informing a member of staff that they are receiving multiple medical appointments, treatments, etc without understanding why;
  • Conflicting or false stories about health issues, or deaths in the family given by the child or parent/carers;
  • A parent/carer could target a particular member of staff who they perceive to be sympathetic and understanding of the difficulties which they may face – staff need to be aware that they could inadvertently collude with the parent/carer.

Action to be taken in School /Setting:

The member of staff who has concerns needs to ensure that they have a detailed written record of their concerns. This should include any discussions with the parent/carers and any information/evidence which substantiates their concerns. It will also include attendance summaries which detail the dates of absences and patterns of absence for medical appointments, illness where appropriate, observed illness of the child or reported illness in the child reported by parents/carers or the child.

If there are immediate safeguarding concerns then these need to be discussed with the Designated Child Protection Lead for the school /setting or the member of staff’s Line Manager and a referral made to Children’s Social Care (CSC) as appropriate. 

If there are no immediate concerns then the following action needs to be undertaken:

  • The Lead Agency must decide what information is to be sought, what information is to be shared and who the information is to be shared with in the agency;
    • Who needs to know;
    • What information is needed;
    • Period of monitoring and reporting;
    • How should information be recorded;
    • Consider undertaking a CAF in order to ensure a holistic approach is taken.
  • The Lead Agency should have an informal discussion with the Education Social Work Service / Education Welfare Service / Safeguarding Officer / Lead for Early Years about their concerns and the child’s attendance and to ascertain if there are other siblings in the family that they are not aware of;
  • The Lead Practitioner should discuss their concerns about the number of absences, frequent medical appointments, etc with the parent/carer to obtain further information. Consent should be sought to make a referral to the link Community Paediatrician / Paediatrician [2]. If consent is given, the Lead Practitioner will to make a referral to the Community Paediatrician / Paediatrician, highlighting their concerns and detailing patterns of absence, attendance at medical appointments, information provided by parent / carer and child. If no consent is given then the Lead Practitioner must discuss with the designated child protection person/Line Manager to agree the next action;
  • A single agency practitioners meeting should be convened with all educational staff involved to be invited, (including LA SEN, Educational Psychologists, Early Years etc) and Legal Services if there are concerns that FII may be evident, but individuals do not have a significant level of concern to refer to Children’s Social Care. The meeting will decide the appropriate course of action.  All education agencies must provide a chronology of significant concerns / events for the meeting and a named person collates these to inform the meeting;
  • The outcome from the referral to the Community Paediatrician / Paediatrician must be obtained and fed back to those who form part of the practitioners meeting;
  • If sufficient evidence – a referral will be made to Children’s Social Care;
  • If there is insufficient evidence to support FII the group must decide how to continue to monitor and support the child.  Seek the view of and support of the named LA Safeguarding Leads.

[2] In the West of Dorset County there are no ‘link community paediatricians’.

AT NO STAGE IN THE PROCESS SHOULD THE CONCERNS BE RAISED WITH PARENT/CARERS.

Any decision to discuss FII with a family must be taken at a multi-agency strategy meeting. It may be appropriate to discuss specific concerns e.g. frequent absences but guidance should be sought fro the safeguarding lead as to how best to approach this and the family’s response should be documented.

If Social Care agree that the case meets the FII process a Strategy meeting will be convened by them and the meeting will agree the action to be taken by all agencies. Support can be offered by the LA Safeguarding Lead. 

It is important to recognise the emotional impact on staff working with FII; support should be made available by their manager for any member of staff who needs to discuss their own feelings about the situation.

Ambulance Service Role

Individual ambulance or Urgent Care Service (UCS) clinicians are unlikely to identify FII, as they do not receive a previous medical history prior to patient contact and an individual clinician is unlikely to see a child more than once. Practitioners may however raise concerns if following an emergency call, the child is found to be well. An example of this may be a child who is reported to have had a ‘fit’ but is found after an 8 minute response to not be exhibiting signs of being postictal or unwell.

Concerns may also be raised if the emergency ambulance or UCS system is repeatedly used as a first port of contact for an episode of illness, rather than for worsening symptoms.

South Western Ambulance Trust (SWAST) has a robust process for monitoring frequent callers. Definitions:

Emergency Ambulance: An address that calls more than three times per month

Urgent Care Service (UCS): An individual who calls more than five times per month.

This information is collated monthly and shared widely with partners including the Police and Clinical Commissioning Group (CCG) colleagues. This information should be scrutinised as part of the information gathering exercise. SWAST should also be asked to search their systems to provide information for every investigation as calling patterns may reveal a pattern of using multiple services to gain attention and/or medication or medical equipment.

UCS clinicians should closely question any requests for a new prescription of medications other than common drugs, or equipment such as a supply of oxygen during the out of hours period, and seek advice from the duty paediatrician.

All OOHs contacts are shared with the patients’ own GP, and these contacts should be seen in the wider context of contacts with the extended health services.

SWAST point of contact for information to support investigations: safeguarding@swast.nhs.uk 01392 261575.

Communication with the family about the suspected diagnosis of FII:

The family should usually be spoken to by the consultant paediatrician together with a social worker.

  • Ensure that the medical diagnosis is explained in a non-judgemental, dispassionate, truthful and honest way, and without causing unnecessary distress;
  • Follow the principles involved in the disclosure of any other serious medical diagnosis, bearing in mind that an abusive carer will presumably be well aware of the cause of the child’s illness but other family members may be totally unaware;
  • Consider how to support the perpetrator, family members, and staff after the disclosure meeting as this will be a very stressful event;
  • Include the following in the agenda:
    • The reasons why the identification of FII seems likely / has been considered;
    • Any other possible causes for the child’s signs and symptoms;
    • Any further investigations and their likely impact on the decision regarding FII;
    • The plan in terms of any ongoing management of the child’s medical condition and monitoring arrangements, with likely timescales where possible;
    • The prognosis for the child;
    • Supportive services available for a carer who is suspected of abuse and for a non-abusing carer.

Cases where neither organic disease nor FII is confirmed:

  • These children come under the broad umbrella of ‘non-organic’ symptoms;
  • Consider whether the child (if older) could be fabricating their own illness;
  • Explain the differential diagnosis and likely diagnosis to the carers;
  • Explain that medicine may not have the answer and some children have to ‘live with’ their symptoms but can be helped to learn to manage them;
  • Avoid the use of unscientific terminology;
  • Avoid further investigations to look for the highly improbable which might risk causing iatrogenic harm;
  • Draw up a plan for rehabilitating the child. Ensure that parents / carers are aware of their responsibilities in this respect and the likely consequences of non-concordance;
  • Consider making a CAMHS referral;
  • If the carers request further investigations and there are concerns about the risk of significant harm, a referral should be made to Children’s Social Care.

Ongoing paediatric monitoring

  • Monitor features of genuine disease, consequences of abuse or emotional and Behavioural difficulties;
  • Communicate with the child protection team, including Children’s Social Care, and other clinicians involved;
  • Provide update reports, witness statements, and attend child protection conferences or court when appropriate.

Specific Responsibilities of a LSCB

Safeguarding Children in whom illness is fabricated or induced (Supplementary guidance to Working Together to Safeguard Children). HM Government 2008 states that:

The specific responsibilities of an LSCB in relation to cases involving fabricated or induced illness are:

  • To ensure that the LSCB safeguarding children procedures reflect this guidance;
  • To ensure that there is a level of agreement and understanding across agencies about operational definitions and thresholds for referral and intervention, and to communicate clearly to individual services and practitioner groups their shared responsibility for protecting children within the framework of this national guidance;
  • To encourage and help develop effective working relationships between different services and practitioner groups, based on trust and mutual understanding;
  • To audit and evaluate how well local services work together to safeguard children, to improve joint working in the light of knowledge gained through national and local experience and research, and to make sure that any lessons learned are shared, understood, and acted upon;
  • To identify the number of children in need who are at risk of significant harm as a result of fabricated or induced illness, or who have suffered significant harm, and to identify resource gaps (in terms of funding and/or the contribution of different agencies);
  • To help improve the quality of work to safeguard and promote the welfare of children who have illness induced or fabricated by specifying the training needs of practitioners and managers, and to ensuring that this training is delivered; and to raise awareness within the wider community of the need to safeguard children who may be at risk of this type of abuse and promote their welfare, and to explain how the wider community can contribute to these objectives.

Where the LSCB has a planned programme of work on fabricated or induced illness, this should be agreed and endorsed by all the Board members within the framework of the Children’s and Young People’s plan, and should be set out in its own plan. The LSCB may find it useful to set up a working group or sub-group, on a short-term or a standing basis, to carry out specific tasks and/or to provide specialist advice in relation to this guidance.


Issues

Whilst cases of fabricated or induced illness are relatively rare, the term encompasses a spectrum of behaviour which ranges from a genuine belief that the child is ill through to deliberately inducing symptoms by administering drugs or other substances. At the extreme end it is fatal, or has life changing consequences for the child.

Contrary to normal practitioner relationships with parents, being challenging about suspicions from the start may scare off a parent thus making it more difficult to gain evidence. However, the nature of the suspicion being related to fabricated and induced illness should not prevent practitioners from intervening and making the relevant referrals.

Practitioners should demonstrate practitioner curiosity and challenge in an appropriate way

Parents who harm their children in this way may appear to be plausible, convincing and have developed a friendly relationship with practitioners before suspicions arise. They may also demonstrate a seemingly advanced and sophisticated medical knowledge which can make them difficult to challenge.



Amendments to this Chapter

This chapter was reviewed and updated in February 2017 to offer greater clarity about the processes to follow when there are concerns about FII, the need to positively recognise FII rather than seeing it as a diagnosis of exclusion and the importance of focusing on outcomes for the child. The chapter should be read in its entirety.

End.