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4.1.9 Children in whom illness is Fabricated or Induced

Contents

  1. Introduction
  2. Incidence and Impact
  3. Management of Cases
  4. Management of Suspected Cases
  5. Children Residing outside Coventry
  6. Referral to Children's Social Care
  7. Strategy Meeting
  8. Attendance at Strategy Meeting
  9. The Strategy Meeting
  10. Plan for Further Assessments
  11. Section 47 Enquiries
  12. The Criminal Investigation
  13. Outcome of Section 47 Enquiries
  14. Child Protection Conference
  15. Covert Video Surveillance (CVS)


1. Introduction

  1. In 2008 the Department for Education published supplementary guidance to Working Together to Safeguard Children. (HM Government 2006). The aim of this guideline was to provide a national framework within which agencies and professionals at local level draw up and agree upon their own more detailed ways of working together where illness may be being fabricated or induced in a child. This guidance states, "It is intended that LSCBs local safeguarding children procedures should incorporate this guidance and its references to Covert Video Surveillance, rather than having separate guidance on fabricated or induced illness in children. Within local procedures, the section on covert video surveillance should make reference to the good practice advice for police officers, which is available to them from the National Crime Faculty."
  2. The aim of this local procedure is simply to clarify and formalise the way in which Coventry agencies should work together when faced with this complex and difficult form of abuse. It should be read alongside the National Guidance.
  3. This guideline refers to the 'fabrication or induction of illness in a child' rather than using any particular term. If as a result of a carer's behaviour, there is concern that the child is or is likely to suffer Significant Harm, this guidance should be followed.
  4. There are three main ways in which a carer may fabricate or induce illness. These are on a continuum of abnormal behaviour and are not mutually exclusive.
    • Fabrication of signs and symptoms: this may include fabrication of past medical history;
    • Fabrication of signs and symptoms and falsification of hospital charts and records and specimens of bodily fluids; this may also include falsification of letters and documents;
    • Induction of illness by a variety of means
  5. Carers with this form of abnormal behaviour can be distinguished from the anxious carer who requires reassurance that their child is well or carers who present to the Children's Emergency Department for minor ailments rather than more appropriately seeking advice from their General Practitioner.


2. Incidence and Impact

Figures collected by the British Paediatric Surveillance Unit over a 2 year period (September 1992- August 1994) suggest that in a region with 1 million inhabitants, the expected incidence would be approximately one child per year therefore the expected incidence in Coventry (with a population of around 306.000 would be 1 child every 3 years.

The same UK Research found that 6% of the victims of Fabricated or Induced Illness died and 35% suffered major physical illness.


3. Management of Cases

Key issues to consider in the management of Fabricated or Induced Illness.

3.1

Fabricated or Induced Illness is a complex form of abuse. Any potential case should be managed from the outset by senior professionals from each of the agencies involved. In Coventry this would be

  • Health -The Consultant Paediatrician responsible for the case;
  • Police -The Detective Inspector from the Police Child Abuse Protection Team
  • Children's Social Care -A team manager from the Referral and Assessment Service or Neighbourhood Service if the family is already known to Social Care
  • Child Protection leads in other agencies involved
3.2 There should be an emphasis on shared responsibility particularly in discussions on the case management and in decisions on if and when to share information with carers.  A Strategy Meeting (see Section 7, Strategy Meeting) is the appropriate forum at which to reach a consensus on this issue.
3.3 In general when there are concerns that illness in a child is being fabricated or induced, the decision to refer to Children's Social Care and the receipt of a referral SHOULD NOT be discussed with carers
3.4 There is the potential (although rare) need for the use of Covert Video Surveillance (CVS) (see Section 15, Covert Video Surveillance (CVS)).


4. Management of Suspected Cases

4.1

Concerns arising in a General Practice

The majority of cases of Fabricated or Induced Illness come to light in the hospital setting. However, early concerns may be raised by the child's General Practitioner. In this situation, the GP should refer the child directly to a Consultant Paediatrician and not via the 'choose and book system'. This referral should be initiated by a phone call and confidential letter outlining the reasons for concerns and specifying that the GP is following the Fabricated or Induced Illness procedure. The referral should be made to a Consultant with an interest in the particular area suggested by the reported signs and symptoms.

The Consultant should ensure that they see the child personally. They should discuss the case with the Named or Designated Doctor for Child Protection.


4.2


Inpatients

Where concerns arise about a child who is an in-patient, advice should be sought from the Named Doctor or Named Nurse for child protection at the University Hospital Coventry and Warwickshire (UHCW) NHS Trust or the designated professionals within the PCT. The child's Consultant Paediatrician must take lead responsibility for decisions about the child's health care. This responsibility should not be delegated to junior medical staff.

4.3 Concerns may arise in other medical settings for example adult or child psychiatry or in a child seen by 'adult physicians'. In such circumstances, the child should be discussed with and referred to a Consultant Paediatrician with advice sought from the named and or designated health professionals.
4.4 In all cases, professionals must keep an open mind as to the potential causes of the child's symptoms and signs, which should be thoroughly and appropriately investigated. Medical records must be kept securely; this may entail locking the notes trolley in a secure room on the ward. Nursing and medical records should be written in continuity. Observations made routinely by nursing staff should be signed. Carers should be kept informed of the findings of any investigations. Concerns about Fabricated or Induced Illness should not be shared if this would jeopardise the child's safety.
4.5 Every effort should be made to talk to the child (if age appropriate) without the carers present.


4.6


Concerns arising in Education
  There are many reasons why a child or parent may falsely report illness to schools. It is not uncommon for children, about whom there are concerns around neglect to be kept away from school with illness used as an "excuse" This in general raises further issues of neglect rather than fabricated illness and should be discussed with the child protection lead, the education social worker and Children's Social Care. The school nurse may be able to give advice around management of specific illnesses and can liaise with a Consultant Paediatrician if one is involved.
4.7

More significant concerns around Fabricated or Induced Illness may arise in school. In general children who are the victims of induced illness will come to the attention of Paediatricians; it is those children in whom parents are falsely reporting illness, but not inducing it who may come to the attention of staff in education first.

Examples include children reported to have frequent seizures who never have a fit at school; or a child reported to have a serious medical condition such as a malignancy, who appear well and don't attend any appointments. Suspicions should be higher in younger children.
4.8 Any serious concerns around Fabricated or Induced Illness should be discussed with the Child Protection lead and if necessary referral made to Children's Social Care for further investigation. The referrer must make it clear that their concerns are around Fabricated or Induced Illness. The case should be discussed with a Paediatrician. If there is not one already involved, the Designated or Named Paediatrician for the PCT or UHCW should be contacted for advice.


5. Children Residing outside Coventry

Children may be referred or admitted to University Hospital Coventry and Warwickshire NHS Trust from areas outside Coventry, typically North and South Warwickshire, Northampton and Birmingham. Concerns about Fabricated or Induced Illness should initially be referred to Coventry Children's Social Care, who will have responsibility for liaising with the local authority in which the child normally resides. Senior professionals from the area in which the child resides should be represented at any Strategy Discussion/Meeting and should participate in any Section 47 Enquiry.


6. Referral to Children's Social Care

6.1 In these complex cases, the Consultant Paediatrician may seek advice from a senior social worker. This discussion should be clearly documented.
6.2 If the Consultant Paediatrician or other senior medical practitioner has concerns that the child has been or is likely to be significantly harmed as a result of Fabricated or Induced Illness then they must make a referral to Children's Social Care. They should not wait until they have proof of illness being fabricated or induced.
6.3 This referral must first be made verbally to the manager of the Referral and Assessment Service (RAS). This initial discussion with RAS may reveal the family as being already known to Children's Social Care i.e. in Neighbourhood or Specialist Services) and the manager of that service should then be contacted. The verbal referral should be followed by a written referral faxed to the same manager within 24 hours. The receiving officer would then fax back confirmation of receipt of referral & action to be taken.


7. Strategy Meeting

7.1 The National Guidance describes situations in which a Strategy Meeting would not be required on receipt of a referral. Locally if the guidelines on discussion with Named or Designated Doctors are followed it is anticipated that there be an assumption that a Strategy Discussion would be held in all cases unless it is agreed jointly between a senior paediatrician and team manager from Children's Social Care.
7.2 Following receipt of a referral with concerns about Fabricated or Induced Illness from a senior practitioner a face to face Strategy Meeting should be convened (within the timescales set out in 'Working Together'). This Strategy Meeting should be chaired by a Social Care manager or senior practitioner in the event of the non-availability of a manager.
7.3 Given the complexity of these cases it is not unusual to need more than one Strategy Meeting to discuss all the issues arising and information which becomes available as a result of further enquiries.


8. Attendance at Strategy Meeting

8.1

The Strategy Meeting should be attended by:

  • The referring Paediatrician
  • If the child is an inpatient, a senior ward nurse.
  • The GP, Health Visitor, school nurse or other medical personnel as appropriate
  • The DI or Sergeant of the Police Child Abuse Protection Team
  • The manager and a case worker from Children's Social Care
  • A legal representative from Children's Social Care
  • If the child is in education, the child protection lead for the school concerned.
8.2 The police must be invited since any suspected case of Fabricated or Induced Illness may involve the commission of a crime.


9. The Strategy Meeting

9.1

As detailed in the National Guidance the Strategy Meeting should consider:

  • The child's medical history and factors giving rise to the concerns about Fabricated or Induced Illness
  • The need to keep the medical and other records secure and method of doing this
  • The need for Covert Video Surveillance
  • What further information is required?
  • Supervision of carers
  • How further assessment will be undertaken
  • Factors in the family
  • Needs of siblings or other children
  • The nature and timing of any police investigations
  • The needs of parents or carers

In addition a decision on whether or not to discuss concerns about Fabricated or Induced Illness with the carers should be taken jointly at the Strategy Meeting.
9.3 A clear decision must be recorded in respect of whether a Section 47 Enquiry is to be initiated & clear timescales for actions by identified parties.
9.4 A copy of the minutes must be distributed to all parties whether present or not.


10. Plan for Further Assessments

10.1 The child may need to be referred to a Tertiary Centre for further medical assessment. For children in Coventry this is likely to done either at Leicester Royal Infirmary or Birmingham Children's Hospital. The Child's Paediatric Consultant should take responsibility for making this referral and for informing their Consultant colleagues of the concerns about Fabricated or Induced Illness. Likewise if the child is to be an inpatient, senior nursing staff should liaise with colleagues in the Tertiary Centre. Consideration should also be given to requesting a review of the medical notes by a paediatrician not previously involved in the case.


11. Section 47 Enquiries

Section 47 Enquiries as part of the Core Assessment involve a systematic gathering of information and usually a specialist assessment initiated as described above.


12. The Criminal Investigation

The police are the lead investigative agency although the nature and timing of any investigation will depend on medical evidence. If there is evidence that a crime has been committed the suspect's rights must be protected by adherence to the Police and Criminal Evidence Act 1984. This states that a suspect should not be confronted with evidence by anyone from any agency except the police.


13. Outcome of Section 47 Enquiries

There are 4 possible outcomes:

  1. Concerns not substantiated

    Medical tests identify a medical condition
  2. Concerns remain, but no evidence of Fabricated or Induced Illness and child not felt to be at risk of harm

    The child's health and wellbeing needs to be monitored. A joint decision on how this is to be achieved should be agreed during a Strategy Discussion. (This could lead to a Strategy Meeting recommending the convening of a Child Protection Conference)
  3. Concerns substantiated, but child not judged to be at continuing risk of Significant Harm

     The child needs ongoing monitoring by a Consultant Paediatrician or other senior medical staff, with early referral to Children's Social Care and further Strategy Discussion/Meeting if the situation changes.
  4. The Child has suffered Significant Harm as a result of Fabricated or Induced Illness

    Children's Social Care must proceed to a Child Protection Conference so that ongoing risks to the child can be jointly discussed.


14. Child Protection Conference

14.1

Timing

within 15 working days of the last Strategy Meeting


14.2


Attendance

  1. Professionals

    As with the Strategy Meeting. Each professional should provide a written report. A detailed medical chronology should be drawn up by the lead Consultant Paediatrician. Information must be provided by the child's General Practitioner, either in person or by liaising with the Consultant Paediatrician and providing a written report.

    In addition any professionals who have given a second opinion on the child should submit a report. If no such second opinion has been sought a consultant with expertise in the branch of paediatric medicine suggested by the symptoms of illness process caused by the suspected abuse should be invited to attend.

    Consideration should be given to inviting a professional with expertise in working with children and families with a history of Fabricated or Induced Illness. Such individuals are scarce. In the absence of an expert being available, a Consultant Paediatrician who is independent of the case should be invited.
  2. The child

    If appropriate.
  3. Family Members

    It may be necessary to exclude one or more family members from all or part of the conference. This needs to be discussed jointly at the final Strategy Meeting before the conference and legal advice sought.
14.3 The decisions to be made at the conference are the same as with any other Child Protection Conference. The key issue to be considered is whether the needs of the child can be responded to within their family context within a timescale appropriate for the child.
14.4 Therapeutic work with the child is likely to be needed irrespective of where they are placed to address the physical and emotional consequences of Fabricated or Induced illness 


15. Covert Video Surveillance (CVS)

15.1

The use of covert video surveillance

(CVS) is governed by the Regulation of Investigatory Powers Act 2000.

15.2

CVS is undertaken by the police.

They will only be able to carry out CVS if they obtain the necessary authorisation under the 2000 Act. To do this they will have to demonstrate:

  1. That the use of CVS is necessary to detect or prevent crime, or serious crime

    And
  2. That the evidence cannot be gathered by other less intrusive means.
15.3

The decision to undertake CVS should be made at a multi-agency Strategy Meeting. It should only be used if there is no alternative way of obtaining information which will explain the child's signs and symptoms and those at the Strategy Meeting consider its use justified based on the medical information available. The surveillance manager at Little Park Street Police Station should be invited to the Strategy Meeting to advise on the logistics of setting up CVS and to initiate a feasibility study based on the particular case. In these circumstances authorisation to carry out CVS must come from the Chief Constable of West Midlands Police. The Chief Executive of UHCW NHS Trust must be informed of the plan to undertake this investigation.

Police officers should carry out any necessary monitoring. All police involved in its use should have received specialist training in this area.

The safety of the child is the over-riding factor in the planning and carrying out of CVS. Police and health staff will ensure that the surveillance monitoring is live and that contingencies are in place should immediate intervention be required to safeguard the child. The primary aim is to ascertain whether the child is having illness induced. Of secondary importance is the obtaining of criminal evidence.

Children's Social Care should have a contingency plan in place, which can be implemented immediately if CVS provides evidence that the child is being harmed.

It is recognised that the logistics of setting up CVS on the Paediatric wards at UHCW would be extremely challenging.

CVS would only be used in exceptional circumstances, but it may be necessary and therefore a decision has been made to retain the above advice and leave open the option to use it providing the strict criteria for its authorisation and safety are met.

End