View Working Together View Working Together

4.7 Fabricated or Induced Illness

SCOPE OF THIS CHAPTER

This chapter has been reviewed to take account of the DSCF 2008 document 'Safeguarding Children in Whom Illness is Fabricated or Induced

The main changes as a result of the 2008 government guidance are:

  • The emphasis on medical evaluation of the concerns;
  • The requirement to report any concerns to the child's GP who will refer the child to a paediatric consultant at an early stage;
  • The paediatric consultant is the lead health professional and therefore has lead responsibility for all decisions pertaining to the child's health care;
  • Any decision to use Covert Video Surveillance to be a multi agency decision at a Strategy Discussion/Meeting.

It should also be read in conjunction with Home Office and Department of Health Guidance 2002, Complex Child Abuse, Investigations, Inter Agency Issues.

The Royal College of Paediatricians and Child Health's report 'Fabricated or Induced Illness by Carers' (2002) 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

This chapter was amended in February 2015, as the contact details for the police officers seeking advice about covert surveillance has changed.


Contents

  1. Introduction
  2. Definition
  3. Identifying Concerns of Fabricated or Induced Illness
  4. Consultation and Confidentiality
  5. Medical Evaluation
  6. Referral to Children's Social Work Services
  7. Immediate Protection
  8. Strategy Discussions/Meetings
  9. Record Keeping
  10. Section 47 Enquiry and Social Work Assessment
  11. Police Investigation
  12. Outcome of Section 47 Enquiry and Social Work Assessment
  13. Social Work Assessment and the Child Protection Plan
  14. The Child Protection Plan
  15. Chronology
  16. The Initial Child Protection Conference


1. Introduction

1.1 Fabricated or Induced Illness is a relatively rare but potentially lethal form of abuse.
1.2 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.
1.3 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.
1.4 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.


2. Definition

2.1 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.

There are three 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 hospital charts, records, letters and documents and specimens of bodily fluids;
  • Induction of illness by a variety of means.
2.2 The above three methods are not mutually exclusive.
2.3

The following is a list of behaviours exhibited by carers which may be associated with fabricating or inducing illness in a child. The list is not exhaustive and should be interpreted in the context of the individual parents’/carers’ cultural behaviours and practices, their understanding of, and attitude towards, the child’s illness, their management of this and their views about the child’s best interests:

  • Deliberately inducing symptoms in a child by administering medical or other substances, by intentional suffocation, or by interfering with the child’s body as to cause physical signs;
  • Interfering with treatments by overdosing, not administering them or interfering with medical equipment such as infusion lines;
  • Claiming that the child has symptoms which are unverifiable unless observed directly, such as pain, frequency of passing urine, vomiting and fits; these claims result in unnecessary investigations and treatments which may cause secondary physical problems;
  • Exaggerating symptoms, causing professionals to undertake unnecessary investigations and treatments; these may be invasive, harmful and possibly dangerous;
  • Repeated presentation to a variety of doctors in different settings;
  • Obtaining specialist treatments or equipment for children who do not require them;
2.4 Harm to the child may 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.


3. Identifying Concerns of Fabricated or Induced Illness

3.1 Concerns that a child is suffering or likely to suffer significant harm as a result of illness fabricated or induced by a carer may be raised by a number of different types of professionals or, more rarely, by family members or members of the public.
3.2 These concerns may arise when:
  • Reported symptoms and signs found on examination are not explained by any medical condition from which the child may be suffering; or
  • Physical examination and results of medical investigations do not explain reported symptoms and signs; or
  • There is an inexplicably poor response to prescribed medication and other treatment; or
  • New symptoms are reported on resolution of previous ones; or
  • Reported symptoms and found signs are not observed in the absence of the carer; or
  • Over time the child is repeatedly presented with a range of symptoms to different professionals in a variety of settings; or
  • 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.
3.3 There may be a number of explanations for these circumstances and each requires careful consideration and review.
3.4 Concerns may be raised by 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.
3.5 Professionals who have identified concerns about a child's health must discuss these with the child's GP or consultant paediatrician responsible for the child's care.
3.6 If any professional considers their concerns about fabricated or induced illness are not taken seriously or responded to appropriately, these should be discussed with their Named Doctor or Named Nurse.


4. Consultation and Confidentiality

4.1 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.
4.2 Consultation with colleagues in the same and 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.
4.3 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.
4.4 Where concerns exist about fabricated or induced illness, it requires professionals to work together, evaluating all the available evidence, in order to rule out a medical cause and reach an understanding of the reasons for the child’s signs and symptoms of illness. The management of these cases requires a careful medical evaluation which considers a range of possible diagnoses. At all times professionals need to keep an open mind to ensure that they have not missed a vital piece of information.


5. Medical Evaluation

5.1 Where there are concerns about possible fabricated or induced illness, the signs and symptoms require careful medical evaluation by a paediatrician.
5.2 Unless a paediatrician is already involved, the child's GP should make a referral to a paediatrician. The Paediatrician is responsible for determining the nature and extent of medical testing needed to formulate a decision regarding Fabricated Illness. Evaluation will be made of the potential impact of further medical investigation on the child.  It is the responsibility of the Paediatrician to liaise with the Designated Doctor when considering the formulation of a diagnosis of Fabricated Illness.
5.3 Where, following a set of medical tests being completed, a reason cannot be found for the reported or observed signs and symptoms of illness and there is a consideration of Fabricated Illness, the Paediatrician may limit further investigation on order to prevent further harm to the child.
5.4 In the normal course of events the Paediatrician will discuss with parents the outcome of medical investigations and whether further investigations are required. If there is a concern about likely further Significant Harm of the child, the Paediatrician will determine the point at which further medical disclosure to parents may be ceased.


6. Referral to Children's Social Work Services

6.1 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 the Children's Social Work Services in accordance with the Making Referrals to Children's Social Care Procedure.
6.2 Whilst professionals should in general, discuss any concerns with the family and, where possible, seek agreement to making referrals to Children's Social Work Services, this should only be done where such discussion and agreement seeking will not place a child at increased risk of significant harm - see Information Sharing and Confidentiality Procedure.
6.3 Children's Social Work Services should decide within one working day how to respond and what actions should be taken in accordance with the Referrals Procedure. Decisions should be agreed between the referrer and the recipient of the referral about what the parents will be told, by whom and when.
6.4 From the point of the referral, all professionals involved with the child should work together in the following way:
  • Lead responsibility for action to safeguard and promote the child's welfare lies with Children's Social Work 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;
  • All agencies involved with the child must continue to share information following the referral as before.
6.5 All decisions about what information is shared with parents, when and by whom, should be taken jointly.
6.6

The Parent/Carer of Concern

Fabricated or induced illness is most often carried out by the child’s mother, but other persons, male and female, have been responsible in some cases, particularly when they have significant responsibility for the child’s daily care. Carers exhibit a range of behaviours when they wish to convince others that their child is ill. It is important to distinguish between an anxious parent responding to a very sick child and those who exhibit abnormal behaviour.

The Non-Abusing Parent

It is important to consider that the non abusing parent may have been innocently convinced by the other parent/carer that the child is seriously ill and therefore may be unwittingly involved in perpetuating the illness and in undertaking actions of concern, e.g. giving medication or supporting a limitation on the child’s activity. It is therefore essential that any genuine concern held by this non abusing parent for the child’s illness are acknowledged and addressed providing a history of evidence where possible.

Attention must also be paid to the possibility of active or passive collusion with the abuse by each parent: the assessment process must consider the role of each parent in the particular family system and ensure each parent has the opportunity to be seen alone.

Abuse by Professional Carers

(Persons in a Position of trust)

Children can be subjected to fabricated and induced illness in a variety of settings. Any concerns about the behaviour of professional staff must be taken seriously. Concerns may be raised by an unexpected pattern of incidents which seems to relate to patterns of caring and, when identified, should be discussed with the relevant named or designated professional for child protection (concerns about persons in a position of trust).


7. Immediate Protection

7.1 The first priority is to ensure the safety of the child.
7.2 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, child protection powers should be used to act secure the immediate safety of the child.


8. Strategy Discussions/Meetings

8.1 If, at the referral stage or at any time during the Assessment, it is confirmed that the child is at risk of Significant Harm, then an assessment under Section 47 of the Children Act 1989 must be initiated.
8.2 Liaison between Police and Children’s Services must take place within 24 hours to agree any immediate steps for the protection of the child.  In any event such liaison should be held within a timescale which reflects the urgency of need but in any case within three working days.
8.3 If there is reason to suspect fabricated or induced illness, it is vital that all available information is carefully evaluated and its accuracy verified where possible. Given the complexity of this type of abuse, it is likely that a face to face meeting will be the most effective way to carry out a Strategy Discussion. (See also Strategy Discussions Procedure) Such meetings should be chaired by a Children’s Social Work Manager.
8.4 More than one Strategy Meeting may be required where the child’s circumstances are very complex.
8.5 Prior to the Strategy Meeting, Children’s Social Work Services will initiate a lateral check to determine whether or not the alleged perpetrator is known to the mental health trust via their safeguarding team. If known, Children’s Social Work Services will be given the name and contact details of the Care Co-ordinator or Team in contact with the perpetrator.
8.6 Prior to the Strategy Meeting taking place, a Chronology will be prepared by all agencies to inform the Strategy Discussion. The medical chronology will incorporate relevant health information relating to the child and will be informed by the hospital Safeguarding Team.
8.7

This meeting requires the involvement of key senior professionals responsible for the child's welfare and must include Children's Social Work Services, the Police and the Paediatric Consultant responsible for the child's health. Additionally the following may be invited as appropriate:

  • A senior ward nurse if the child is an inpatient;
  • A member of medical staff nominated by the Paediatrician and Designated Doctor as considered appropriate;
  • GP, Health Visitor/School Nurse;
  • Staff from education settings if appropriate;
  • Local authority's legal adviser.
8.8 Decisions about undertaking covert video surveillance and keeping records should be made at a Strategy Discussion/Meeting. Any such decision should be clearly recorded, with reasons given why it is necessary.
8.9

The Strategy Meeting should:

  • Agree the plan the timing of any criminal investigation;

    Plan how the section 47 investigation should be undertaken including the need for medical treatment, who will carry out what actions, when and for what purpose;
  • Agree any immediate action required to safeguard and promote the welfare of the child.  If the child is in hospital decisions should also be made about how to secure the safe discharge of the child;
  • Determine whether or what information should be shared with the family and whether such information sharing may place a child at increased risk of suffering Significant Harm.
8.10 At the conclusion of the Strategy Discussion a list of action points, timescales, agreed roles and responsibilities and an agreed mechanism for reviewing completion of action points must be recorded by the Chairperson using the ICS examplars and circulated to all parties within one working day.


9. Record Keeping

All records should be kept securely to prevent unauthorised access and ensure that they cannot be interfered with. In certain circumstances, where a child’s safety is at risk, it may be necessary to create a health supplementary record and hold it separately from the child’s main records. This should not extend to keeping full duplicate records except in exceptional circumstances. A decision to keep supplementary records should be made at the Strategy Discussion.

All staff should take careful and detailed notes, recording any unusual events and distinguished between events recorded by the carer and those actually witnessed by staff from the onset. Notes should be timed dated and signed legibly, and must be kept in a secure place so that they cannot be accessed by unauthorised persons.


10. Section 47 Enquiry and Social Work Assessment

When fabricated or induced illness by a carer is suspected, Children’s Social Work Services will conduct the  Assessment in conjunction with the doctor who has lead responsibility for the child’s healthcare (usually a consultant paediatrician) and other relevant agencies.

10.1

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:

  • What further information is required about the child and family and how it should be obtained and recorded;
  • Whether it is necessary for records to be kept in a secure manner and how this will be ensured;
  • Who will carry out what actions, by when and for what purpose, in particular planning further paediatric assessment(s);
  • Whether the child requires constant professional observation and if so, whether or when carer(s) should be present;
  • 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;
  • The nature and timing of any police investigations, including analysis of samples and covert video surveillance.


11. Police Investigation

11.1 All relevant information gathered by the Police should be available to other relevant professionals, to inform discussions about the child's welfare and contribute to the Section 47 Enquiry and Social Work Assessment.
11.2 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 challenging the suspect.
11.3 The use of covert video surveillance (CVS) is governed by the Regulation of Investigatory Powers Act 2000.
11.4 The primary aim of CVS 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.
11.5 After a decision has been made 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.
11.6 Any use of covert surveillance by the Police should be carried out in accordance with good practice advice available from the National Crime and Operation Faculty, the National Police Chief’s Council Manual of Surveillance Standards and the National Police Chief’s Council Policy for Covert Monitoring Posts, both of which are held by the National Specialist Law Enforcement Centre (NSLEC).
11.7 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.gov.uk.
11.8 CVS should be used if there is no alternative way of obtaining information which will explain the child's signs and symptoms, and the Strategy Discussion considers that its use is justified on the medical information available.
11.9 A contingency plan should be agreed between Children’s Social Work Services, the Police and health services which can be implemented immediately if CVS provides evidence of the child suffering Significant Harm.


12. Outcome of Section 47 Enquiry and Social Work Assessment

12.1 Concerns not Substantiated

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

In these circumstances, it may be that no protective action is required, but the family should be provided with the opportunity to discuss what further help it may require and the Assessment may be completed.

12.2 Concerns Substantiated but no Continuing Risk of Significant Harm

Concerns may be substantiated, but it is agreed between the agencies involved with the child and family that a plan for ensuring the child's future safety and welfare can be developed and implemented without the need for a Child Protection Conference or a Child Protection Plan

In this case, the decision not to proceed to an Initial Child Protection Conference must be endorsed by the Head of Service within Children's Social Work Services and recorded on the child's electronic record.

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

In all circumstances the assessments may demonstrate that services should be provided to the child and family to support them and promote the child's welfare as a Child in Need.

12.3 Concerns Substantiated and Continuing Risk of Significant Harm

Where concerns are substantiated and the child is judged to be suffering or at risk of suffering Significant Harm, an Initial Child Protection Conference must be convened. 


13. Social Work Assessment and the Child Protection Plan

In cases of fabricated or induced illness, the Social Work Assessment should particularly address:

  • The cause of any presenting symptoms, illness or developmental delay, i.e. what may be organic in origin and what is likely to be related to abuse;
  • The drivers for the actions of the abusing parent and where relevant their own mental health needs;
  • The capacity of the abusing parent to recognise the damage they have done to their child’s heath and emotional welfare and their ability to change; it may be helpful for a psychiatrist with expertise in this area to inform this part of the assessment;
  • Whether there is a need for psychological expertise to assess cognitive functioning and personality traits of the abusive parent;
  • The capacity of each potential caregiver in the family to understand the abuse and their ability to believe that the child has been abused by another member of the family;
  • The capacity of the non abusing parent to acknowledge the abusive actions and level of risk presented by the abusing parents and their ability to act to protect the child;
  • The nature of the child’s relationship with each family member and how he/she is perceived in the family and the local community;
  • How the child’s siblings perceive her/his health;
  • The overall plan for therapeutic work with the child and family.


14. The Child Protection Plan

In drawing up the outline Child Protection Plan, particular attention should be given to the nature of contact between the child and the parents/carers to ensure it does not offer another opportunity to repeat the abuse. This may mean that contact has to be closely supervised.

  • Where a family member is expected to provide this supervision it is vital that they are assessed as capable of undertaking this task and that they are continually support in this task with a 24 hour contact number for support and advice as required;
  • Where the risk of harm is assessed as high, supervision will be best provided by a professional whose level of knowledge enables them to be alert to the precursors of further abusive behaviour.


15. Chronology

When there are concerns about possible fabricated or induced illness, children’s social care will collate the relevant information into a detailed Chronology. This should include the medical, psychiatric and social histories of the child, parents, siblings and other significant family members. The chronology should allow a reader to track

  • The relevant history of the child and family which led to any statutory intervention;
  • The nature of these interventions, including planned outcomes;
  • The means by which change is to be achieved; and
  • The progress which is being made in achieving these outcomes.

The Chronology should enable patterns of presentation for medical treatment to be recognised not only for the child but also across generational boundaries. It will also inform decisions about how best to provide services necessary to safeguard the child’s welfare and achieve change in the family.


16. The Initial Child Protection Conference

See also Initial Child Protection Conferences Procedure.

16.1 The extent and manner of involvement of family members in the conference should be carefully considered. An abusing carer may not feel able to acknowledge their behaviour to their partner or within the conference forum. A non-abusing carer may not wish to discuss the level of their awareness in front of the other parent. The conference chair must ensure that the conference provides both the abusing and non-abusing parent with the best opportunity to present their views and wishes to the conference in order that the decision and any child protection planning is informed by this information.
16.2

Attendance at this conference should be as for other initial conferences - with the additional experts invited as appropriate:

  • A professional with expertise in working with children and families where a care giver has fabricated or induced illness in a child (ideally this person should have involvement/knowledge of the case being discussed at conference);
  • A paediatric consultant with expertise in the relevant area of medicine as that giving concern (ideally this person should have involvement/knowledge of the case being discussed at conference).
16.3 The health history of any siblings should also be considered based on information provided by agencies at the conference.
16.4

The conference should decide whether the child is at continuing risk of 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. For some children it may be necessary to institute legal proceedings either immediately or soon after the conference has ended. In some cases legal proceedings may have been initiated prior to the conference.

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

End