Fabricated or Induced Illness is a rare, potentially lethal form of abuse.
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 important that the focus is on the outcomes or impact on the child and not initially on attempts to diagnose the parent or carer.
These procedures are based on the DoH 2002 document Safeguarding Children in Whom Illness is Fabricated or Induced which provides further essential guidance and The Royal College of Paediatricians and Child Health 2001 guidance Fabricated or Induced Illness by Carers which provides further guidance for medical clinicians.
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:
The above three methods are not mutually exclusive.
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.
Doctors/paediatricians may be concerned at the possibility of a child suffering Significant Harm as a result of having illness fabricated or induced by their carer.
These concerns may arise when:
Concerns about a child’s health should be discussed with a health professional who is involved with the child such as the school nurse, GP or paediatrician.
If any professional considers their concerns are not taken seriously or responded to appropriately, these should be discussed with the Designated Doctor or Designated Nurse.
There may be a number of explanations for these circumstances and each requires careful consideration and review.
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 proven organic 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.
The signs and symptoms require careful medical evaluation for a range of possible diagnoses.
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.
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 should be made to Children’s Social Care Services or the Police in accordance with the Referrals Procedure.
Whilst professionals should in general, discuss any concerns with the family and, where possible, seek agreement to making referrals to Children’s Social Care 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.
In accordance with the Referrals Procedure, the Children’s Social Care Services team should decide within one working day how to respond and what actions should be taken.
Whilst the Children’s Social Care Services have lead responsibility for action to safeguard and promote the child’s welfare, the decision should be taken in consultation with the Consultant Paediatrician responsible for the child’s health care and the Police as any suspected case of fabricated or induced illness may also involve the commission of a crime.
All decisions about what information is shared with parents should be taken jointly, bearing in mind the safety of the child.
If there is reasonable cause to suspect that the child is suffering, or likely to suffer Significant Harm, Children’s Social Care Services should convene a Strategy Discussion/Meeting involving all the key professionals.
If emergency action is the required response, that is, if a child’s life is in danger through poisoning or toxic substances being introduced into the child’s blood stream, an immediate Strategy Discussion should take place, i.e. on the same day as the receipt of the Referral.
The Strategy Discussion ,however, should usually take the form of a Strategy Meeting, chaired by a manager from Children’s Social Care Services, when considering this complex form of abuse.
This 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 as appropriate:
Where the Strategy Discussion/Meeting decides that a Section 47 Enquiry should be initiated, see Section 7, Section 47 Enquiry and Core Assessment.
It may be necessary to have more than one Strategy Discussion/Meeting. This is likely where the child’s circumstances are very complex and a number of discussions are required to consider whether and, if relevant, when to initiate a Section 47 Enquiry.
For example, there may be circumstances where concerns have not been substantiated but doubts remain as to the reasons for a child’s presentation and fabricated or induced illness remains as a possibility. In these circumstances it may be appropriate for the Strategy Discussion/Meeting to agree further assessment or monitoring as necessary to establish an adequate explanation and then re-convene. These further assessments may be of a single or multi-agency nature. Care must be taken to keep monitoring timescales so that concerns are not allowed to drift over long periods of time.
When it is decided that there are grounds to initiate a Section 47 Enquiry as part of a Core Assessment, decisions should be made at the Strategy Discussion/Meeting about how the Section 47 Enquiry will be carried out including:
Any evidence gathered by the Police should be available to other relevant professionals, to inform discussions about safeguarding and promoting the child’s welfare and contribute to the Section 47 Enquiry and Core Assessment.
In cases where a criminal offence is suspected and a prosecution is contemplated, it is important that the suspects rights are protected by adherence to the Police and Criminal Evidence Act 1984, which would normally rule out any agency other than the police confronting the suspect.
See Section 11, Covert Video Surveillance.
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.
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. In these circumstances, the Core Assessment will be completed.
Where concerns are substantiated and the child is considered to be at continuing risk of Significant Harm, an Initial Child Protection Conference must be held – see Section 10, Initial Child Protection Conference.
Concerns may be substantiated, but an assessment made that the child is not judged to be at continuing risk of harm. In this case, the decision not to proceed to an Initial Child Protection Conference must be endorsed by the relevant manager within the Children’s Social Care Services and recorded on the relevant records and database. A multi–agency meeting under the Child Concern Model may be considered as an appropriate forum to consider how best to meet the needs of the child and promote his/her welfare.
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 under the Child Concern Model as part of a Child's Plan and/or as a Child in Need.
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. All evidence must be documented by this stage and an interim Child Protection Plan for the child must already be in place – see Section 11, Section 47 Enquiries and Core Assessments Procedure.
The conference should be held within 15 working days of the last Strategy Discussion/Meeting.
Attendance at this conference should be as for other initial conferences although specific decisions about the participation of the parents/carers will need to be discussed with the Conference Chair - see Section 6, Initial Child Protection Conferences Procedure
The following experts should be invited as appropriate:
Each agency should contribute a written report to the conference, which sets out a chronology of their involvement with the child and the family. This is particularly important for health professionals. All available medical notes (including GP, health visitor and all local hospital notes) should be reviewed before the conference and a detailed chronology of the medical history of the child and any siblings drawn up.
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.
The lead responsibility for covert video surveillance is carried by the Police.
All decisions to undertake covert video surveillance should be taken at the highest level within West Midlands Police on the recommendation of a Strategy Discussion/Meeting and should be clearly recorded, with reasons given why it is necessary.
Where there is any doubt about the use of covert video surveillance, legal advice should be sought.
The decision should be notified to the Director of Children’s Services and the Chief Executive of the relevant NHS Trust.
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.
The necessary action to implement the decision will be the responsibility of the Police, who should obtain the necessary authorisation under the Regulation of Investigatory Powers Act 2000. If that authority is granted, the Police have sole responsibility for implementing and undertaking any such surveillance, including the supply and installation of any equipment and the security and archiving of the video tapes.
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).
Officers planning surveillance in cases of suspected fabricated or induced illness should seek advice from the National Centre for Policing Excellence (NCPE) Operations Helpdesk and consult the confidential document, ‘Suggested Good Practice for the use of covert surveillance equipment in a hospital’, which can be obtained from the Helpdesk.
All personnel including nursing staff who will be involved in its use should have received specialist training.
Children’s Social Care Services should have a contingency plan in place, which can be implemented immediately if covert video surveillance provides evidence of the child suffering Significant Harm.
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