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4.3.3 Fabrication or Induction of Illness by Parent or Carer

SCOPE OF THIS CHAPTER

This chapter seeks to determine the nature of this very rare and complex form of abuse, together with the procedures that need to be progressed. Note (unlike other assessments) the carer should not be advised of the concern until following a multi-agency meeting agreeing this will not put the child further at risk.

RELATED CHAPTERS

Greater Manchester Safeguarding Procedures fabricated or Induced Illness

Safeguarding Children in Whom Illness is Fabricated or Induced, Department for Children, Schools and Families (2008)

AMENDMENT

This chapter was updated in March 2017 to reflect current process and procedures. A new link has been added to NHS Choices, (2016) Fabricated or Induced illness, (see Further Reading).


Fabricated or Inducted Illness (previously known as Munchausen Syndrome by Proxy) is a rare and potentially devastating condition in which the child's carer fabricates symptoms in their child or induces them by a variety of means. Research has shown that the way in which a case of Fabricated Illness is managed can have a major impact on the outcome for the child. The key issues are to assess the impact of Fabricated Illness on the child's health and development and to consider how best to safeguard that child. This requires a clear and sound multi-agency approach with Children's Services as lead agency, ensuring that all appropriate professionals are involved.

Fabricated Illness can be broken down into three main behaviours, though more than one may co-exist at any one time:-

  • Fabrication of signs and symptoms;
  • Falsification of hospital charts, reports, letters or specimens of bodily fluids;
  • Induction of illness by a variety of means.

Concerns may be raised by any person in contact with the child when:-

  • Reported signs and symptoms cannot be explained by any known medical condition;
  • Reported signs and symptoms are not observed independently of the carer;
  • Multiple investigations fail to reveal any organic disease and trials of treatment fail to effect improvement;
  • Over time the child is repeatedly presented with a range of signs and symptoms;
  • New symptoms are reported on resolution of previous ones;
  • The child's normal life activities are being curtailed beyond that which might be expected for any medical disorder from which the child is known to suffer.

Careful medical evaluation is necessary. This may include further opinions from other specialists and sub-specialists and may necessitate specialist investigations, the results of which should be carefully recorded in the medical notes, along with the information given to the family and the reactions this provokes.

Behaviours exhibited by parents or carers who fabricate or induce illness in their child may include one or more of the following:-

  • Deliberately inducing symptoms 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 pumps;
  • Claiming the child has symptoms which are unverifiable unless observed directly, such as pain, urinary frequency, vomiting or fits. These claims may result in multiple investigations and treatments that in turn can cause harm to the child;
  • Exaggerating symptoms, causing professionals to undertake investigations and treatments which may be invasive, are unnecessary and possibly harmful;
  • Obtaining specialist treatments or equipment for children who do not require them;
  • Alleging psychological illness in a child.

Many children in whom illness is fabricated or induced will be well-known to health professionals. Some may have been admitted or investigated in different hospitals. It is imperative that all of the child's past medical history is explored and information from other hospitals is acquired.

When, after careful consideration of all available information, (including medical investigation results) and liaison with other relevant health professionals, a diagnosis of Fabricated Illness is suspected, a referral should be made to the Duty Social Worker in the Multi-Agency Screening Safeguarding Service, Children's Services, or the Emergency Duty Team, by telephone. This referral should be followed up in writing within 48 hours. The referral should be acknowledged by the appropriate Children's Services Team within one working day of receipt. If an acknowledgement is not received within 3 working days, it is the duty of the referrer to follow this up.

The carer should not be informed of the professionals' concerns over Fabricated Illness nor of the referral until there is multi-agency agreement that to do so would not place the child at greater risk. This is strikingly different to the way we would normally work.

Following referral, Children's Services will undertake an Assessment (see Children and Families – Single Assessment Protocol and Guidance Procedure) together with all relevant agencies. The pace of this assessment will be dictated by the level of risk the child is deemed to be exposed to and will be in line with the Framework for the Assessment of Children in Need and their Families.

If concerns are confirmed by initial investigation, a Strategy Meeting convened and chaired by the Head of Service Child Protection or a team manager within the Child Protection Unit should take place at the earliest opportunity and ideally within 24 hours of the decision being made. This meeting should involve as a minimum: Children's Services, the Police, the lead Paediatrician, the lead Ward Nurse (if the child is an in-patient) and a Local Authority legal representative. It may also involve other relevant professionals e.g. Health Visitor, School Nurse, etc.

The Strategy Meeting will be used to undertake the tasks set out in Flow Chart 4 - Working Together 2015.

If a Section 47 Enquiry is initiated decisions should be made about:-

  • How the s47 enquiry as part of the Core Assessment will be carried out - what further information is required about the child and how it should be obtained;
  • Whether it is necessary for supplementary records to be kept in a secure place in order to safeguard the child;
  • Whether the child requires constant professional observation and if so whether or when the carer should be present;
  • Who will carry out what actions, by when and for what purpose, in particular the planning of further paediatric assessment;
  • Any particular factors of race or ethnicity that should be taken into account;
  • The needs of siblings and other children with whom the alleged abuser has contact;
  • The nature and timing of any police investigation including whether covert video surveillance should be considered, a task for which the police should have responsibility;
  • The needs of the parents or carers.

There are three possible outcomes following a s47 enquiry:-

  • Concerns not substantiated. Full feedback to all involved;
  • Concerns substantiated, but the child not judged to be at continuing risk of suffering Significant Harm. It may be agreed that a plan for safeguarding the child can be developed and implemented without a Child Protection Conference. This is a decision that should be taken with extreme care and full agreement of relevant professionals;
  • Concerns substantiated and child judged to be at continuing risk of suffering significant harm. A Child Protection Conference should be convened.

Advice and support is available to all professionals from:

Consultant Paediatrician, RBH – Named Doctor 01204 390658
Consultant Psychiatrist, CAMHS, RBH 01204 390659
Consultant Paediatrician, Bolton Primary Care Trust – Designated Doctor 01204 362333
Head of Service Child Protection and Leaving Care 01204 337470

Urgent advice outside of working hours can be obtained from the On-duty Consultant Paediatrician who can be contacted at the Royal Bolton Hospital – 01204 390390.


Further Reading

Safeguarding Children in Whom Illness is Fabricated or Induced, Department for Children, Schools and Families (2008)

Framework for the Assessment of Children in Need and their Families, Department of Health (2000)

Working Together to Safeguard Children, Department for Children, Schools and Families (2015)

NHS Choices (2016), Fabricated or Induced illness

Munchausen Syndrome by Proxy Abuse, Eminson and Postlethwaite 2000


Supplementary Guidance for Individual Practitioners

Remember: Multi-agency working is essential in cases of suspected Fabricated Illness.

Confrontation with the child's carer is to be avoided.


For Health Visitors/School Nurses:

A referral to/discussion with the child's General Practitioner or a Consultant Paediatrician at the Royal Bolton Hospital should be arranged with full documentation of all concerns.


For General Practitioners:

A referral to/discussion with a Consultant Paediatrician at the Royal Bolton Hospital should be arranged with full documentation of all concerns.


For Hospital Practitioners:

A referral to/discussion with a Consultant Paediatrician at the Royal Bolton Hospital should be arranged with full documentation of all concerns.


For Consultant Paediatricians:

if, following medical evaluation (+/- further investigation) and information-gathering from all relevant professionals (for example Health visitor, School Nurse, etc) there remains concern regarding the possibility of Fabricated Illness – a referral to Children's Services Multi Agency Screening Safeguarding Service should be made. This referral should be followed up in writing within 48 hours.

End