Fabricated or Induced Illness

This document is only valid 72 hours after printing. For the latest version please visit

Fabricated or Induced Illness

AMENDMENT

In November 2020, minor amendments were made regarding terminology to reflect the language used in County Durham.

Introduction
Fabricated and Induced Illness
Sharing Health Information when Concerns re Fabricated or Induced Illness
Referral to Children's Services
Response by Children's Services and Strategy Meeting
Disclosure of Concerns to the Child's Carers
Child Protection Conference
Work with Carers who have Fabricated or Induced Illness
Working with Children
Emergency Action
Covert Video Surveillance
Risk from a Member of Staff
Further Information and Guidance
Appendix 1: Template: Possible warning signs of fabricated or induced illness
Appendix 2: Chronology for Fabricated or Induced Illness

1. Introduction

These procedures should be followed if:

There are concerns that illness may be being fabricated or induced in a child; or
There are concerns that the child's parent or carer may be fabricating or inducing illness in themselves and that this may cause harm to the child. Such concerns may also apply to unborn children.

Any assessment of the potential impact of these risks upon the child should be considered in the context of the age/vulnerability of the child concerned.

Health professionals should also refer to their own Trust's NHS Safeguarding Procedures.

2. Fabricated and Induced Illness

There are three main ways, not mutually exclusive, in which a parent/carer may fabricate or induce illness in a child:

Fabrication of signs and symptoms, for example, fabrication of past medical history;
Falsification of hospital charts, records, letters, documents and specimens of bodily fluids;
Induction of illness by a variety of means.

2.1 Behaviours Associated with Fabricated/Induced Illness

Behaviours include:

Deliberately inducing symptoms in children by administering medication or other substances, or by means of intentional suffocation;
Interfering with treatments by over dosing, not administering them or interfering with medical equipment such as infusion lines;
Claiming the child has symptoms which are unverifiable unless observed directly, such as pain, frequency of passing urine, vomiting, or fits;
Exaggerating symptoms, thereby causing professionals to undertake investigations and treatments which may be invasive, are unnecessary and therefore are harmful and possibly dangerous;
Obtaining specialist treatments or equipment for children who do not require them;
Alleging psychological illness in a child;
Persistently requesting assessments for conditions such as autistic spectrum condition.

2.2 Recognition

Where illness is being fabricated or induced, extensive, unnecessary medical investigations may be carried out in order to establish the underlying causes for the reported signs and symptoms. The child may also have treatments prescribed or operations which are unnecessary. These investigations can result in children spending long periods of time in hospital and some, by their nature, may also place the child at risk of suffering harm or even death.

Carers exhibit a range of behaviours when they believe that their child is ill. A key professional task is to distinguish between the over anxious carer who may be responding in a reasonable way to a very sick child and those who exhibit abnormal behaviour. Such abnormal behaviour can be present in one or both parents/carers and often involves the passive compliance of the child.

Many incidents of concern can be warning signs of fabricated or induced illness and practitioners should note the 'Possible Warning Signs of Fabricated or Induced Illness Template'.

3. Sharing Health Information when Concerns re Fabricated or Induced Illness

Practitioners remain the first point of contact for most health problems in children. Practitioners should share information even if they have emerging concerns. A risk might only become apparent when a number of people with emerging concerns share them.

In all cases the overriding consideration in making decisions about information- sharing must be the child's safety and wellbeing.

In situations of possible induced or fabricated illness practitioners should not discuss their concerns with the parents/carers. This is because such discussion may increase the risk of significant harm to the child. Decisions about what discussions are to take place with the parents/carers are to be made on an inter-agency basis, following referral to First Contact.

3.1 Discussion with Named or Designated Doctor for Child Protection

In any case in which a paediatrician suspects FII they should discuss the case with the Named Nurse or Doctor for Child Protection. In some cases it may be appropriate first to have a health professionals meeting to enable all health information about the child to be shared. At this meeting a decision should be made as to whether the child may be at risk of significant harm and if so a referral should be made to First Contact.

3.2 Chronologies

In all cases of suspected FII a chronology should be prepared. The preparation of the chronology should not delay intervention if this would put the child at increased risk of harm. It is the responsibility of the Paediatric Consultant to ensure that this chronology is compiled. However it may be compiled by other health colleagues.

3.3 Consent

When health professionals are collecting health information from other health professionals or sharing information they should first consider seeking consent from the parent or the competent young person to do so. Information on a carer's health may also be of great value. Consent should be considered following a discussion with named professionals for the sharing of such information.

3.4 Sharing Health Information without Consent

The key factors in deciding whether or not to share confidential information without consent are necessity and proportionality, i.e. whether the proposed sharing is likely to make an effective contribution to preventing the risk and whether the public interest in sharing information overrides the interest in maintaining confidentiality.

In making the decision the practitioner must weigh up what might happen if the information is shared against what might happen if it is not and make a decision based on professional judgement. The nature of the information to be shared is a factor in this decision- making, particularly if it is sensitive information where the implications of sharing may be especially significant for the individual or for their relationship with the practitioner and the service.

The reasons for the decision to share or not to share information should be clearly documented.

Where there is a clear risk of significant harm to a child, the public interest test will almost certainly be satisfied. There will be some cases where the Practitioner will be justified in sharing limited confidential information in order to make decisions on sharing further information or taking action the information shared should be necessary for the purpose and be proportionate.

Information can be shared without consent if it can be justified under section 47 of the Children Act as prevention of Significant Harm or under a police investigation. The Children Act does not require information to be shared in breach of confidence but a practitioner should not refuse a request for information without considering the relative risks of sharing information, if necessary without consent, against the potential risk to the child if information is not shared.

In any case of doubt, advice should be sought from the safeguarding leads.

4. Referral to Children's Services

5. Response by Children's Services and Strategy Meeting

Upon receipt of a referral, Children's Services should gather information and convene an inter-agency Strategy Meeting. A series of Strategy Meetings may be required before a conclusion is reached on the need for a S47 assessment. It may be helpful for the first Strategy Meeting to scope the nature of the concerns, agree what further information is needed, how this will be gathered, and also whether immediate action is required. All agencies/professionals involved should be asked to consider the need for a completed chronology for this or subsequent Strategy Meetings. The chronology format should be the same for all agencies to complete to ensure ease of collation.

This meeting should be chaired by a Team Manager.

Staff attending the Strategy Meetings should be sufficiently senior to be able to contribute to the discussion of often complex information and to make decisions on behalf of their agencies.

5.1 Attendance at Strategy Meetings

The meeting should be organised to ensure that the following professionals can attend:

Children's Social Care;
Sergeant from Police Safeguarding Unit;
Responsible Paediatric Consultant;
Obstetrician in the case of an unborn child;
Named Doctor for Child Protection;
Named Nurse for Safeguarding Children;
Named Nurse from acute hospital if appropriate;
GP;
Midwife, Health Visitor or School Nurse dependent on the age of the child;
School or Nursery dependent on the age of the child;
The legal advisor to the Local Authority if appropriate.

In all cases, legal advice should be sought.

5.2 Decision Making

All agencies should provide a chronology for Strategy Meetings if time allows.

The Strategy Meeting should decide whether to initiate a formal enquiry under Section 47. For complex cases, more than one Strategy Discussion may be required.

The discussion should include:

5.2.1 Assessment of risk and safety planning

The level of harm the child has already suffered;
The risk of future harm and any complicating factors;
Current safety arrangements already in place;
Whether an immediate safety plan is needed to reduce the risk of harm e.g.:
- Cancelling unnecessary medical procedures;
- Instituting closer observation of the child;
- 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;
Consideration of the child's safety network and how it may be used to provide immediate safety;
Consideration of how all involved health professionals can work together to ensure a coordinated, informed response to any health problems.

5.2.2 Information Gathering

Any outstanding investigations, further information gathering, and opinions that would be helpful;
The planning of further medical and nursing assessment;
The need for forensic sampling, special observation or Covert Video Surveillance;
The development of an integrated health chronology (and agreement on who should do this);
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 them or the child;
Strengths within the family.

5.2.3 Action Planning

Plan for communication with carers 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;
Responsibility for the Child & Family Assessment;
The security of medical records;
The level of professional observation required;
Addressing the needs of siblings and other children in the family;
Addressing the needs of carers, particularly after disclosure of concerns;
Clarification of who will be the Responsible Paediatric Consultant for the child (if not already explicit).

5.2.4 Possible outcomes of the Strategy Meeting(s):

No further action by Children's Social Care;
Provision of Services by one or more agencies;
Continued monitoring by identified professionals of specific concerns;
Child & Family Assessment;
Section 47 Assessment;
The police start a criminal investigation;
Immediate Action to protect the child(ren);
A further Strategy Meeting or series of meetings, and/or an Initial Child Protection Conference once the Section 47 investigation is completed;
Depending on the circumstances of the case, consideration should be given to the possibility of the use of Covert Video Surveillance (see Section 11, Covert Video Surveillance).

6. Disclosure of Concerns to the Child's Carers

If the Strategy Meeting agrees that there are concerns about FII and that other agencies need to be involved, the possibility of FII will need to be discussed with the carers. Professionals should be supported through the process of disclosure and the approach should be agreed and carefully planned beforehand dependent on the circumstances of the case and risk.

A detailed note of the discussion should be made in the child's case notes.

7. Child Protection Conference

If the case proceeds to a child protection conference it is essential that the conference is organised so that key professionals including the Responsible Paediatric Consultant can attend. See Child Protection Conference Procedure.

8. Work with Carers who have Fabricated or Induced Illness

To gauge the prognosis for positive change in carers who have fabricated or induced illness it is essential to gain an understanding of:

Their capacity to understand and acknowledge the harm which has been caused to the child;
The underlying motivations which led them to fabricate or induce illness;
The perpetuating factors which supported the continuation of the abuse and the extent to which these could be removed.

It is important to explore what life will be like now that the child has been found to be well or better than previously thought. Carers will require help with constructing an accurate narrative of the past which they can share with significant others in their life, including the family.

9. Working with Children

Professionals will need to decide when and how to involve the child in the decision-making and planning processes.

Children of sufficient age and understanding often have a clear perception of what needs to be done to ensure their safety and wellbeing.

In cases involving older children it is important to ascertain the child's perceptions, beliefs, and feelings about their state of health, particularly their anxieties and beliefs about their future wellbeing. It is also important to elicit the child's view of their experiences of medical care.

10. Emergency Action

Sometimes it may be apparent at the point of referral to First Contact that emergency action is necessary, for example, when a child's life is in danger, possibly through poisoning or toxic substances being introduced into the child's blood stream. Emergency action should normally be preceded by an immediate Strategy Discussion between the Police, Children's Social Care, Health and other agencies as appropriate.

11. Covert Video Surveillance

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

Covert video surveillance should be used if there is no alternative way of obtaining information which will explain the child's signs and symptoms, and the multi-agency strategy discussion meeting considers that its use is justified based on the medical information.

12. Risk from a Member of Staff

There may be times when a member of staff is responsible for the unexplained or inexplicable signs and symptoms in a child. This should be borne in mind when considering how to manage the child's care. Any such concerns about a member of staff should be discussed with the relevant safeguarding, Senior Nominated Officer and the Local Authority Designated Officer.

13. Further Information and Guidance

For further information and guidance see:

Appendix 1: Template: Possible warning signs of fabricated or induced illness

The order of numbering in the template does not indicate the relative importance of each category.

'Symptoms' are subjective experiences reported by the carer or the patient. 'Signs' are observable events reported by the carer or observed or elicited by professionals. Set out below are some examples of behaviour to look out for.

Professionals should bear in mind the limits of the template, which is to give an indication of whether fabricated or induced illness is a possibility.

Category	Possible warning signs Please note categories 8 and 10 relate explicitly to parent/carer or siblings of the child concerned
1.	Reported signs and symptoms found on examination are not explained by any medical condition from which the child may be suffering. Here the doctor is attempting to put all the information together to make a diagnosis but the signs and symptoms do not correlate with any recognised disease or where there is a disease known to be present. A very simple example would be a skin rash which did not correlate with any known skin disease. An experienced doctor must be on their guard if something described is outside their previous experience;
2.	Physical examination and results of medical investigations do not explain reported symptoms and signs. Physical examination and appropriate investigations do not confirm the reported clinical story. For example, it is reported a child turns yellow (has jaundice) but no jaundice is confirmed when the child is examined and a test for jaundice, if appropriate, is negative. A child with frequent convulsions every day has no abnormalities on a 24-hour video-telemetry (continuous video and EEG recording) even during a so-called 'convulsion';
3.	There is an inexplicably poor response to prescribed medication and other treatment. The practitioner should be alerted when treatment for the agreed condition does not produce the expected effect. This can result in escalating drugs with no apparent response, using multiple medications to control a routine problem and multiple changes in medication due to either poor response or frequent reports of side effects. On investigation, toxic drug levels commonly occur but may be interspersed with low drug levels suggesting extremely variable administration of medication fluctuating from over- medication to withdrawal of medication. Another feature may be the welcoming of intrusive investigations and treatments by the parent;
4.	New symptoms are reported on resolution of previous ones. New symptoms often bear no likely relationship to the previous set of symptoms. For example, in a child where the focus has been on diarrhoea and vomiting, when appropriate assessments fail to confirm this, the story changes to one of convulsions. Sometimes this is manifest by the parents transferring consultation behaviour to another child in the family;
5.	Reported symptoms and found signs are not seen to begin in the absence of the carer, i.e. the perpetrator is the only witness of the signs and symptoms. For example, reported symptoms and signs are not observed at school or during admission to hospital. This should particularly raise anxiety of FII where the severity and/or frequency of symptoms reported are such that the lack of independent observation is remarkable. Caution should be exercised when accepting statements from non-medically qualified people that symptoms have been observed. For example, in one case there was evidence that the school described episodes as 'fits' because they were told that was the appropriate description of the behaviour they were seeing;
6.	The child's normal, daily life activities are being curtailed beyond that which might be expected for any medical disorder from which the child is known to suffer. The carer limits the child's activities to an unreasonable degree and often either without knowledge of medical professionals or against their advice. For example, confining a child to a wheelchair when there is no reason for this, insisting on restrictions of physical activity when not necessary, adherence to extremely strict diets when there is no medical reason for this, restricting child's school attendance;
7.	Over time the child is repeatedly presented with a range of signs and symptoms. At its most extreme this has been referred to as 'doctor shopping'. The extent and extraordinary nature of the additional consultations is orders of magnitude greater than any concerned parent would explore. Often consultations about the same or different problems are concealed in different medical facilities. Thus the patient might be being investigated in one hospital with one set of problems and the parent will initiate assessments elsewhere for a completely different set of problems (or even the same) without informing these various medical professionals about the other consultations;
8.	History of unexplained illnesses or deaths or multiple surgeries in parent/carer or siblings of the family. The emphasis here is on the unexplained. Illness and deaths in parents or siblings can frequently be a clue to further investigation and hence a diagnosis in naturally occurring illness. In FII abuse, perpetrators frequently have had multiple unexplained medical problems themselves, ranging from frequent consultations with the general practitioner through to the extreme of Munchausen's syndrome where there are multiple presentations with fabricated or induced illness resulting in multiple (unnecessary) operations. Self-harm, often multiple, and eating disorders are further common features in perpetrators. Additionally, other children either concurrently or sequentially might have been subject to FII abuse and their medical history should also be examined;
9.	Once the perpetrator's access to the child is restricted, signs and symptoms fade and eventually disappear (similar to category 5 above). This is a planned separation of perpetrator and child which it has been agreed will have a high likelihood of proving (or disproving) FII abuse. It can be difficult in practice, and appear heartless, to separate perpetrator and child. The perpetrator frequently insists on remaining at the child's bedside, is unusually close to the medical team and thrives in a hospital environment;
10.	Exaggerated catastrophes or fabricated bereavements and other extended family problems are reported. This is an extension of category 8. On exploring reported illnesses or deaths in other family members (often very dramatic stories) no evidence is found to confirm these stories. They were largely or wholly fictitious;
11.	Incongruity between the seriousness of the story and the actions of the parents. Given a concerning story, parents by and large will cooperate with medical efforts to resolve the problem. They will attend outpatients, attend for investigations and bring the child for review urgently when requested. Perpetrators of FII abuse, apparently paradoxically, can be extremely creative at avoiding contacts which would resolve the problem. There is incongruity between their expressed concerns and the actions they take. They repeatedly fail to attend for crucial investigations. They go to hospitals that do not have the background information. They repeatedly produce the flimsiest of excuses for failing to attend for crucial assessments (somebody else's birthday, thought the hospital was closed, went to outpatients at one o'clock in the morning, etc.). We have used a term, 'piloting care', for this behaviour;
12.	Erroneous or misleading information provided by parent. These perpetrators are adept at spinning a web of misinformation which perpetuates and amplifies the illness story, increases access to interventions in the widest sense (more treatment, more investigations, more restrictions on the child or help, etc.). An extreme example of this is spreading the idea that the child is going to die when in fact no one in the medical profession has ever suggested this. Changing or inconsistent stories should be recognised and challenged.

Appendix 2: Chronology for Fabricated or Induced Illness

Click here to view Appendix 2: Chronology for Fabricated or Induced Illness - to follow.

DurhamSafeguarding Children Partnership Procedures Manual