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5.13 Fabricated and Induced Illness

RELEVANT GUIDANCE

For additional information, please see:

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

The Royal College of Paediatricians and Child Health's report 'Fabricated or Induced Illness by Carers' (2002). Royal College of Paediatrics and Child Health website 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. The report is currently being updated to take account of Working Together to Safeguard Children and recent clinical developments.

AMENDMENT

In December 2011, references to the National Centre for Policing Excellence Operations Helpdesk were replaced with references to the Specialist Operations Centre, Covert Advice Team in Section 8, Covert Video Surveillance.


Contents

  1. Introduction
  2. Identifying the Problem
  3. If Fabricated or Induced Illness is Suspected by any Professional
  4. Medical Evaluation
  5. Roles and Responsibilities following a Referral
  6. Strategy Discussion / Meeting
  7. Initial Child Protection Conference
  8. Covert Video Surveillance


1. Introduction

These procedures should be followed in conjunction with the more detailed RLC NHS Trust Guidelines re Fabricated and Induced Illness and the Liverpool and South Sefton Clinical Commissioning Group's Primary Care Guidelines re Fabricated and Induced Illness.

There are three main ways of fabricating or inducing illness in a child:

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


2. Identifying the Problem

Behaviours exhibited by carers when fabricating or inducing illness in a child can include the following:

  • Deliberately inducing symptoms in children by administering medication or other substances, or by means of suffocation;
  • Interfering with treatments by overdosing, not administering them or interfering with medical equipment such as infusion lines;
  • Obtaining specialist treatments or equipment for children who do not require them;
  • Exaggerating symptoms, causing professionals to undertake investigations and treatments which may be invasive, are unnecessary and therefore are harmful and possibly dangerous;
  • Claiming that the child has symptoms which are unverifiable, unless observed directly, such as pain, frequency of passing urine, vomiting, or fits. These claims result in unnecessary investigations and treatments which may cause secondary physical problems;
  • Alleging psychological illness in a child.

Concerns about possible fabricated or induced illness may arise when:

  • Reported symptoms and signs found on examination are not explained by any medical condition from which the child may be suffering;
  • 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;
  • New symptoms are reported on resolution of previous ones;
  • Reported symptoms and found signs are not seen to begin in the presence of the care giver;
  • Over time the child repeatedly presents with a range of symptoms;
  • The child's normal activities are being curtailed beyond that which might be expected for any medical disorder from which the child is known to suffer.


3. If Fabricated or Induced Illness is Suspected by any Professional

Any professional or member of staff working in a Primary Care setting who is concerned about the possibility of illness being fabricated or induced in a child should initially discuss these concerns with their line manager and/or the appropriate child protection/safeguarding advisor for the service.

Any professional or member of staff working within the RLC NHS Trust who is concerned about the possibility of illness being fabricated or induced in a child should initially discuss these concerns with their line manger and the child's consultant.

The Primary Care and RLC NHS Trust Guidelines indicate the appropriate lines of consultation in such circumstances.

Where any other practitioner have a concern about possible fabricated or induced illness, they must consult immediately with a Named Professional for child protection within their own organisation. The Named Professional must decide whether to make an immediate referral to Children's Social Care. If the concern exists but does not warrant an immediate referral, the Named Professional along with the involved practitioner/s must determine which other information is required in order to determine what action is necessary.

Should a social worker in the course of involvement with a family suspect any element of fabricated or induced illness, or should another non-health professional refer such concern to Children's Social Care, advice should be sought from the Safeguarding Children Specialist Nurse or the Named Nurse in an acute setting.


4. Medical Evaluation

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

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

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

The paediatrician should gather information by reviewing the child's notes, including the results of any tests, and liaising with all relevant health professionals and also Children's Social Care and the police.

He/she should convene a multi-agency meeting of the relevant health professionals to collate the available health information on the child, siblings and parents, construct a chronology and review the available evidence.

The meeting is for professionals only and parents/carers are not involved or notified at this point. The safety of the child is paramount whilst fabricated or induced illness is being considered. If an alleged perpetrator attempts to remove the child from hospital before a meeting has taken place and there is risk to life or likelihood of serious and immediate Significant Harm to the child, then the professional must seek urgent assistance from the Police who will consider using emergency powers of Police Protection.

If the meeting of health professionals finds that there is sufficient objective organic evidence to account for the child's presentation, the concerns and decisions made should be documented and copies circulated to the relevant health professionals including the child's GP, for ongoing monitoring.

If the meeting of health professionals does not find that there is sufficient objective organic evidence to account for the child's presentation, a referral should be made to Children's Social Care using the Referral, Investigation and Assessment Procedure.

All practitioners involved in possible fabricated or induced illness cases must ensure that their record keeping is accurate, including clear documentation of all decision-making processes.


5. Roles and Responsibilities following a Referral

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
  • Any suspected case of fabricated or induced illness may involve the commission of a crime and therefore the police should always be involved
  • The paediatric consultant is the lead health professional and therefore has lead responsibility for all decisions pertaining to the child's health care

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

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, for example, if a child's life is in danger through poisoning or toxic substances being introduced into the child's blood stream, an application for an Emergency Protection Order or Police Protection powers should be used to secure the immediate safety of the child.

At this stage careful consideration should be given to what the parents should be told, when and by whom, taking account of the child's welfare. Concerns should not be raised with a parent if it is judged that this action will jeopardise the child's safety. See Information Sharing Procedure for further detailed guidance.


6. Strategy Discussion / Meeting

Children's Social Care will convene a Strategy Meeting within two working days of the referral except where emergency action is the required response, in which case an immediate Strategy Discussion should take place.

The Strategy 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 Paediatric Consultant responsible for the child's health.

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

  • A senior ward nurse if the child is an in - patient,
  • A medical professional with expertise in the relevant branch of medicine
  • GP, Health visitor and School Nurse
  • Staff from education settings if appropriate
  • Local authority's Legal adviser
  • Designated Nurse/Named Nurse

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

As well as those matters listed in the Strategy Discussion / Child Protection Referrals – Safeguarding (s.47) Referrals Procedure the Strategy Meeting will also consider the following:

  • Arrangements for the immediate protection and care of the child, including whether the child requires constant professional observation and if so, whether or when the carers should be present;
  • Whether it is necessary for records to be kept in a secure manner and how this will be ensured
  • The planning and purpose of further paediatric assessments;
  • The nature and timing of any police investigations including the analysis of samples. This will be particularly pertinent if covert video surveillance is being considered, as this will be a task for which the police should have responsibility
  • Whether covert video surveillance is appropriate
  • When and how information about the concerns should be shared with the parents
  • Obtaining legal advice over evaluation of the available information (where a legal adviser is not present at meeting)


7. 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:

  • A professional with expertise in working with children and families where a care giver has fabricated or induced in a child
  • A paediatric consultant with expertise in the branch of paediatric medicine caused by the suspected abuse

Each agency should contribute a written report to the conference which sets out the nature of its involvement with the child and the family. This information should be precise and where possible validated at its source.

The child may have been seen by a number of professionals over a period of time: Children's Social Care has 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.

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 the each report.

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


8. Covert Video Surveillance

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

After a decision has been made at a Strategy Meeting 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 National Crime and Operation Faculty, 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 Specialist Operations Centre, Covert Advice Team, Telephone 0845 000 5463, soc@npia.pnn.police.uk.

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

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

End