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Definition

Fabricated or Induced Illness (FII) is a condition whereby a child suffers harm through the deliberate action of their main carer and which is attributed by the carer to another cause. Such behaviour can be present in one or both carers and can involve the passive compliance of the child. It may constitute maltreatment of the child under Section 31 of the Children Act 1989 and the child may suffer Significant Harm as a result.

It is a relatively rare but 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's health and development and not initially on attempts to diagnose the parent or carer.

The range of symptoms and body systems involved in the spectrum of fabricated or induced illness are extremely wide.

Investigation of Fabricated and Induced Illness and assessment of significant harm to a child falls under statutory framework provided by Working Together to Safeguard Children 2015 and Safeguarding Children in whom Illness is Fabricated or Induced (Supplementary Guidance to Working Together to Safeguard Children), HM Government 2008.


Risks

Whilst cases of fabricated or induced illness are relatively rare, the term encompasses a spectrum of behaviour which ranges from a genuine belief that the child is ill through to deliberately inducing symptoms by administering drugs or other substances. At the extreme end it is fatal, or has life changing consequences for the child.

Contrary to normal professional relationships with parents / carers, being challenging about suspicions from the start may scare off a parent or carer thus making it more difficult to gain evidence. There may be an unintended consequence in increasing the harmful behaviour in an attempt to be convincing.

Parents / carers who harm their children this way may appear to be plausible, convincing and have developed a friendly relationship with practitioners before suspicions arise. They may also demonstrate a seemingly advanced and sophisticated medical knowledge which can make them difficult to challenge. Practitioners should demonstrate professional curiosity and challenge in an appropriate way and with coordination between the agencies.


Carer’s Behaviour

There are a number of ways of the carer fabricating or inducing illness in a child. These include:

  • Fabrication of signs and symptoms, including fabrication of past medical history and psychological illness;
  • Fabrication of signs and symptoms and falsification of hospital charts, records, letters and documents and specimens of bodily fluids;
  • Exaggeration of symptoms/real problems. This may lead to unnecessary investigations, treatment and/or special equipment being provided;
  • Induction of illness by a variety of means, including by administering medication or other substances, by means of intentional obstruction of the airway or by interfering with the child’s body in order to cause physical signs; and / or
  • Obtaining specialist treatments or equipment for children who do not require them.

The above 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.


Indicators

  • Reported symptoms and signs found on examination are not explained by any medical condition from which the child may be suffering; or
  • Physical examination and results of medical investigations do not explain reported symptoms and signs; or
  • There is an inexplicably poor response to prescribed medication and other treatment; or
  • New symptoms are reported on resolution of previous ones; or
  • Reported symptoms and found signs are not observed in the absence of the carer; or
  • Over time the child is repeatedly presented with a range of symptoms to different professionals in a variety of settings; or
  • The child’s normal, daily life activities, such as attending school, are being curtailed beyond that which might be expected from any known medical disorder from which the child is known to suffer;
  • Excessive use of any medical website or alternative opinions.

There may be a number of explanations for these circumstances and each requires careful consideration and review.

Concerns may also be raised by health professionals to whom a child is presented or they come into contact with. However other professionals, such as Teachers, Nursery Staff or Social Workers, who are working with the child and/or parents/carers may have cause for concern or notice discrepancies between reported and observed medical conditions, such as the incidence of fits.


Protection and Action to be Taken

Where there is a suspicion of FII, practitioners should consider this guidance carefully when fulfilling their role in assessing and investigating their concerns effectively.

The dawning of concerns is a crucial time. This critical threshold is a matter of individual professional judgement; a preliminary consultation with your safeguarding children Lead/ Named or Designated professional/ manager should be undertaken. If concern that FII is a possibility persists, there should be a discussion with Children’s Social Care. Reasonable suspicion of FII warrants the early and active involvement of statutory agencies.

Agencies and practitioners need to be mindful that where a child has suffered, or is likely to suffer, significant harm, it is essential to make a referral to Children’s social care in accordance with the Contacts and Referrals with Children’s Social Care Procedure.

Children who have had illness fabricated or induced require coordinated help from a range of agencies.

Joint working is essential, and all agencies and professionals should:

  • Be alert to potential indicators of illness being fabricated or induced in a child;
  • Be alert to the risk of harm which individual abusers may pose to children in whom illness is being fabricated or induced;
  • Share and help to analyse information so that an informed assessment can be made of children’s needs and circumstances including an up to date Chronology;
  • Contribute to whatever actions and services are required to safeguard and promote the child’s welfare;
  • Assist in providing relevant evidence in any criminal or civil proceedings.

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 diagnosed 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.


Health Professionals

Children with fabricated or induced illness may be presented to a range of medical specialists, most commonly to universal services, the GP, Health Visitor or School Nurse or a hospital Emergency Department (A&E) or to a general Paediatrician following referral from a GP. Children may also be presented to a specialist Paediatrician, Paediatric, Orthopaedic and specialist Surgeons, allied health professionals such as Pharmacists and professionals involved in mental health services and obstetric care. Frontline ambulance staff may become aware of repeated calls to an address involving a child which may involve calls where a child is not conveyed to hospital. Concerns may also follow an evaluation of the child’s signs and symptoms whilst a hospital in-patient.

Actions:

  • Where a child is thought to be in immediate danger an urgent referral must be made to the Police or Children’s Social Care;
  • Concerns should be discussed with the Named Nurse/ Doctor or Designated Nurse/ Doctor; the manager should be informed;
  • Where a child is in hospital it is important to secure appropriately and to date relevant equipment e.g. syringes, feeding equipment and food/drink samples etc for police investigation;
  • In conjunction with the Named Nurse/ Doctor, checks should be made as to which agencies and professionals are involved with the child/ family;
  • Information should be collated from the GP, Health Visiting/ School Nursing records, Emergency Department (A&E) attendances, hospital records and any other health records;
  • Where concerns of fabricated or induced illness or risk of harm are allayed, this decision and action plan should be recorded. Consideration should be given to the appropriateness of following the Targeted Early Help process and of further discussion through the supervision process;
  • Where concerns about fabricated or induced illness remain, Children’s Social Care must be informed and further work undertaken to gather relevant information. An initial health professionals meeting should be called by the Named Nurse/Doctor and should include as a minimum, the referrer, a Consultant Paediatrician, the child’s GP, School Nurse or Health Visitor and any other health professionals involved with the child and parents/carers. The purpose of the meeting is to share information, commence a chronology of significant events and form a consensus of opinion. Detailed chronologies of health/medical involvement should be compiled for all relevant family members, the information analysed and the outcome reported back to Children’s Social Care;
  • Guidance from a Consultant Child Psychiatrist should be sought at an early stage;
  • Where there is a likelihood that is suffering Significant Harm or impairment of health or development attributable to fabricated or induced illness, a referral to Children’s Social Care must be made;
  • Health professionals should consider seeking advice from their organisation’s legal department as threats of litigation are common in cases of fabricated or induced illness. This consideration should not prevent health professionals from taking action which they believe to be in the child’s best interests.

Role of the Paediatrician

Cases of fabricated or induced illness are exceptionally complex and there is no place for working in isolation. A Consultant Paediatrician should be appointed to assess cases. Two Consultant Paediatricians may need to share the management of a case to provide mutual support and to cover absence.

Specialist Paediatric opinion and investigation (possibly involving a tertiary centre) may be required. It is essential that in their referral the Paediatrician makes clear their concerns about possible fabricated or induced illness in order to prevent unnecessary invasive investigation and to ensure staff exercise appropriate vigilance. Referrals must be carried out on a controlled, planned basis.

Pressure from parents/ carers for a change of Consultant should be resisted. At no time should the overall management of the case be allowed to drift from one Consultant to another, nor should decisions be left to junior medical staff.

The Consultant Paediatrician should check all medical records of the child and siblings.


Police

Any suspected case of fabricated or induced illness may involve the commission of a crime and therefore, the Police should be involved. The Police should be alerted to suspected cases of fabricated or induced illness as early as possible Before suspicions are confirmed, the responsible Consultant for the child’s health should retain the lead role for the child’s health and the priority of Police officers should be to assist the Paediatrician, where relevant and appropriate in reaching an understanding of the child’s health status. The balance may change when it becomes clear whether or that a crime appears to have been committed. In such circumstances, the Police will need to ensure the rights of the suspect are upheld and that evidence is gathered in a fair and appropriate way. The Police should work within a multi-agency framework and information held by professionals should be shared.

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.

Police Officers planning surveillance in cases of suspected fabricated or induced illness may seek advice from the National Crime Agency, Telephone 0370 496 7622, communication@nca.x.gov.uk.


Support and Supervision

Working with children and families where it is suspected or confirmed that illness is being fabricated or induced in a child requires sound professional judgements to be made. It is demanding work that can be stressful and distressing. All practitioners involved in such work should have access to advice and support. Suspected cases should be discussed during safeguarding supervision which should be recorded.


End.