Fabricated or Induced Illness/Perplexing Presentation

1. Introduction

Fabricated or Induced Illness is a clinical situation where a child is, or is very likely to be, harmed due to parents'/carers' behaviour and action, carried out in order to convince doctors that the child's state of physical and/or mental health or neurodevelopment is impaired (or more impaired than is actually the case).

The term 'Fabricated or Induced Illness by Carers' was first introduced by the Royal College of Paediatrics and Child Health (RCPCH) in 2002.

As there is on-going debate about terminology, it is prudent to define the terms of Medically Unexplained Symptoms (MUS), Perplexing Presentation (PP) and Fabricated or Induced Illness (FII) for the sake of this policy.

1. Medically Unexplained Symptoms - the child complains of symptoms which are not explained by any known pathology but there are likely underlying (usually psychosocial) factors in the child. This may include observations of symptoms if the child is pre- or non- verbal;
2. Perplexing Presentations – the actual state of the child's physical/mental health is not clear yet but there are alerting signs of possible FII. There is no perceived risk of immediate serious risk to the child's physical health or life;
3. Fabricated or Induced Illness – this is a form of child maltreatment in which a child is, or is very likely to be, harmed due to caregivers behaviour and actions which are carried out in order to convince health professionals that the child's health is impaired (or more impaired than is actually the case).

In Working Together to Safeguard Children, FII is included under Physical Abuse [1]. Evidence will be required regarding the caregiver's motivation for harming the child.

A review of 796 cases [2] showed that nearly all abusers were female (97.6%) and the child's mother (95.6%). Mean age of the caregiver at the time of the child's presentation was 27.6 years of age. Perpetrators were frequently reported to be in healthcare related professions (46%), to have had obstetric complications (24%) or to have a history of child maltreatment (30%). The most common psychiatric diagnoses recorded were factitious disorder imposed on self (31%), personality disorder (19%) and depression (14%).

Another review of 451 published accounts noted a fatal outcome in 6% of cases and prolonged or permanent disability in 7%.[3]

[1] HM Government (2018) Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. Crown Copyright: July 2018
[2] Yates, G and Bass, C 'The perpetrators of medical child abuse (Munchausen syndrome by proxy) – a systematic review of 796 cases', Child Abuse & Neglect, 72(2017), pp.45-53
[3] Sheridan, MS 'The deceit continues: an updated literature review of Munchausen syndrome by proxy', Child Abuse & Neglect, (2003) 27(4), pp.431-451

2. Features of Perplexing Presentation and FII

As mentioned previously, the mother is nearly always involved or the instigator of FII; the involvement of fathers is variable (they may be unaware, suspicious or actively involved but rarely solely involved).

FII is based on the caregiver's underlying need for their child to be recognised and treated as ill or more unwell than the child actually is. It may involve physical and/or mental health. Motivations are:

1. The carer experiences a gain from the recognition and treatment of their child as unwell – they are using the child to fulfil their needs and ignore the effects on the child. Gains may be psychosocial (sympathetic attention from others and the continued physical closeness of their child) or material (financial support for the care of the child, improved housing, holidays, assisted mobility and disabled parking);
2. The carer's mistaken beliefs, concerns and anxiety about their child's health. This can include:
   • A belief that their child needs extra support at school and an Education Healthcare Plan (EHCP);
   • Misinterpreting aspects of their child's presentation;
   • Misuse of the internet to develop a belief about what is wrong with their child,

Rarely carers can develop psychotic delusional beliefs about their child whilst occasionally a carer with Autism Spectrum Disorder (ASD) may have fixed ideas about their child's health.

In FII, caregivers' needs are primarily met by health professionals. The caregivers' behaviour and actions intend to convince health professionals about the child's health although it is not usually ill intentioned towards their child per se but they may cause harm in order to have their assertions believed. Caregivers may engage professionals thus:

1. Most often by presenting and erroneously reporting the child's symptoms, history, results of investigations, medical opinions and diagnoses. There may be exaggeration, distortion, invention or deception (although on occasion the caregiver's may not be intending to deceive should they hold incorrect beliefs);
2. Less commonly, caregivers may undertake physical actions such as falsifying documents, interfering with investigations (such as putting sugar or blood in the child's urine samples, interfering with intravenous lines, withholding food or medication and at the extreme end, inducing illness). This is to convince the health professional about the child's poor health.

Whilst many support groups and advocates for patients and their carers are very good, some exist for conditions about which there is a divided medical opinion. Some groups post inaccurate information, discuss diagnoses and how to obtain them.

Mental illness may also be present in the carer:

• A personality disorder is most likely to be found in caregivers who derive a clear gain from having their child as being regarded as (more) ill;
• An anxiety disorder may lead the caregiver to have unfounded anxieties about their child's health;
• Rarely a psychotic disorder or ASD may underpin fixed beliefs about a child's health;
• Some caregivers may have hypochondriasis (illness anxiety about themselves), somatic symptom disorder (in which they genuinely feel the pain or other symptoms due to underlying emotional difficulties) or factitious disorder (in which they purposefully deceive others by appearing to be ill, purposely getting sick or by self injury).

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. The presence of alerting signs where the actual state of the child's physical/mental health is not yet clear but there is no perceived risk of immediate serious harm to the child's physical health or life may be evidence of a 'Perplexing Presentation'.

Perplexing presentations indicate possible harm due to fabricated or induced illness which can only be resolved by establishing the actual state of health of the child. Not every perplexing presentation is an early warning sign of fabricated illness, but professionals need to be aware of the presence of discrepancies between reported signs and symptoms of illness and implausible descriptions of illnesses and the presentation of the child and independent observations of the child.

3. Harm to the Child

This may occur due to the caregiver's actions or healthcare professional actions (harm being inadvertently caused by investigations or medication).

Consider:

1. Child's health – the child undergoes repeated examinations, investigations, procedures and treatments whilst genuine illness may be overlooked by healthcare professional due to repeated presentations;
2. Effect on child's development and daily life – the child may have interrupted school attendance and education, normal life activities may be limited, the child is potentially socially isolated and may assume a sick role (e.g. use of an unnecessary wheelchair);
3. Child's psychological wellbeing – the child may be anxious about their health, be silently trapped in falsification of illness or later develop a psychiatric disorder. Some older children may embrace the sick role and become the main driver of false beliefs about their own sickness.

It is important to remember that children may also present with FII whom may also have confirmed diagnosis for one or more medical conditions. FII does not just present in otherwise fit and well children

4. Siblings

It may be that only one child in a family is subject to FII or has a PP. Siblings not subject to FII or PP may be distressed and concerned by the apparent ill health of their affected sibling. They may also feel or be neglected. It is important that their needs are also considered. Some perpetrators may also go on to fabricate symptoms or illness in siblings.

5. Other Victims

As with other forms of perpetrators on occasion, FII perpetrators have abused spouses or animals. There may need to be consideration of referral to Adult Safeguarding, RSPCA or initiation Domestic Abuse risk assessment processes. as appropriate.

6. Alerting Signs to Possible FII

Alerting signs are indicators of possible FII rather than definitive proof of FII. They vary depending on who recognises them e.g. GPs, HVs, education and so on. In essence there is discrepancy between what is reported and how the child presents. Alerting signs may be seen in the child or caregiver.

1. The child:
   • Reported physical, psychological or behavioural symptoms and signs not observed independently by others;
   • Reported or observed signs and symptoms not explained by any medical condition in the child;
   • Results of examinations and investigation do not explain the reported symptoms or signs;
   • Unusual investigation results;
   • Inexplicable poor response to treatment;
   • Unexplained impairment of child's daily life e.g. school attendance, social isolation;
   • Reported signs and symptoms from the caregiver are not corroborated by the child's presentation or what is reported by the child.
2. Caregiver:
   • Repeated reporting of new symptoms;
   • Repeated presentation to healthcare settings;
   • Seeking multiple medical opinions including out of area and private consultations;
   • Repeated "Was Not Brought" to appointments, including cancellations by parents;
   • Not accepting reassurance and insisting on further unwarranted investigations and treatments (may be based on internet searches);
   • Object to discussion between professionals;
   • Frequent complaints;
   • Not letting the child be seen on their own or give their own account;
   • Repeated unexplained changes of school, early years setting, GP or other health professional. Repeated house moves should also be considered.

If one alerting sign is present, look for others. Always consider any associated harm to the child. If alerting signs are found, a paediatrician must become involved. The course of action will depend on whether there is an immediate serious risk to the child's health or life.

There may be times when a member of staff is responsible for the explained or inexplicable signs and symptoms in a child. Any such concerns about a member of staff should be discussed with the organisations safeguarding lead and consideration given for a referral to the local authority designate officer (LADO [5]) See Managing Allegations of Abuse Made Against Persons who Work with Children and Young People Procedure.

[5] HM Government (2006) Safeguarding Children in whom illness is fabricated or induced

7. Information Sharing

The child's best interests are the overriding consideration in deciding what information should be shared. Any information shared should be relevant and proportionate; for example, only relevant health and social care information about parents, carers and siblings should be shared in order to protect the subject child(ren).

Any practitioner working with a child can share relevant sensitive personal information lawfully, including without consent, if it is necessary for the exercise of functions imposed by legislation such as:

• Safeguarding or promoting welfare;
• In order to keep a child safe from harm;
• To protect their physical, mental and emotional wellbeing.

The General Data Protection Regulation (GDPR) and the Data Protection Act 2018 do not prevent or limit the sharing of information by those with safeguarding or welfare duties towards children for the purposes of keeping children safe.

Practitioners are reminded that if they are concerned about a safeguarding data sharing matter, they are advised to seek advice from legal representatives where appropriate, from Safeguarding Leads or information governance leads.

Strong caregiver objections could indicate a referral to Children's Social Care on grounds of medical neglect.

While professionals should usually seek to discuss any referral with the family and seek their agreement to action, this should only be done where such discussion and agreement-seeking will not place a child at increased risk of significant harm. In cases of possible or confirmed FII, informing the parents may increase the risks for the child(ren). Informing parent / carers of concerns of fabricated illness should not be disclosed until a multi-professional strategy meeting has taken place and agreement made about what information is to be shared with the caregiver, when it is going to be shared and by whom. Any decision on whether to share information or not should be clearly documented.

See Protocol on Sharing Information in Order to Safeguard and Promote the Welfare of Children Procedure.

8. What Different Practitioners / Agencies Should do Prior to a Potential Referral to Children's Social Care

Professionals not from a Health setting including Education/Early years/Early Help/Children's Social Care

Professionals may have concerns because parents are describing a child's illness or health needs which are not witnessed by the professionals.

In such situations professionals should consider the alerting signs mentioned above if they remain concerned or have heightened concerns they should discuss the child with the safeguarding lead within their organisation. If concerns remain, then the child should be discussed with relevant health professionals (e.g. GP, paediatrician, HV or Children and Young Peoples Nurse (if involved) and mental health services for adults and children). It is the responsibility of the safeguarding lead for that agency to coordinate the approach to relevant health professionals after consultation with children's services so they are aware the concerns exist and can be monitored. Consent from the parents to do this should be sought on the grounds that that this is usual practice where a child has an illness which is impacting on their health or development. At this stage the concern about possible FII should not be disclosed to the parent/carer. If parents refuse consent for a discussion with health professionals then this should be discussed with the safeguarding lead to consider whether refusal increases the level of concern. When a parent/carer reports restrictions/limitations for normal school activities due to reported 'health' issues, it is important this is verified.

Professionals should keep careful and secure records of absences and reasons given by parents for absences so that these can be corroborated. The professionals should listen to the child and document what they are saying.

All discussions, including those with parents/carers, must be documented and kept in a secure record.

In situations where the child may be at immediate risk of serious harm through an induced illness an immediate referral to the police and children's social care should be made in accordance with the Safeguarding Referrals Procedure. A Strategy Meeting should be requested and convened to include any relevant Health professionals. This will allow health information to be shared formally.

Children's Health (HV or CYPN) Practitioners: If practitioners have concerns that a parent/carer is impairing a child's health, development or functioning by fabricated or induced illness, they should meet with parents/carers to discuss the child's illness, parental concerns and ascertain which other health professionals are involved. Any concerns the practitioner has regarding fabricated or induced illness should not be disclosed to the parent/carer at this time

After discussion it may be that some parents have misunderstood information, are anxious about their child or have concerns that their child's needs are not being met. This may lead to health-seeking behaviours or exaggeration of symptoms. The practitioner should seek parents/carers consent to discuss the child with any professionals involved including the consultant.

Where the practitioner has on-going concerns about FII and the child is already known to other health professionals, then information should be sought from those health professionals regarding the medical illness/diagnosis, and advice or an appropriate care plan should be provided. Concerns about possible FII must be shared with the other health professionals (including GPs). The HV or CYPN should discuss their concerns with their line manager or safeguarding lead.

Midwives: Midwives may be alerted to possible FII by the mothers own health-seeking behaviour, history of unusual/unexplained illness, unusual complications of pregnancy, and unexplained deaths of previous children. If concerns are raised then previous pregnancy notes should be obtained and the midwife must discuss concerns with the Trust Safeguarding Team/ Named Midwife.

Child and Adolescent Mental Health & Emotional Wellbeing Services/ Community Paediatricians: Staff within CYPMHS, emotional wellbeing services and /or community paediatrics may also be alerted to concerns about possible FII in the process of evaluating children for emotional wellbeing, mental health and/or behavioural difficulties.

Repeated requests for a diagnosis of conditions such as Attention Deficit Hyperactivity Disorder (ADHD) or Autism Spectrum Disorder (ASD), especially when assessments have ruled out these conditions, should raise the index of suspicion for FII. However, it should be noted that it is not uncommon for parents to request second opinions, and consideration should be made to the fact that there are a number of children who do get a diagnosis of ADHD/ASD when reassessed. A repeat parental request for another medical/CYPMHS opinion should not automatically trigger an investigation for FII, as this might be inappropriate.

In CYPMHS cases of FII there have usually been very many requests for assessments for mental health diagnoses with repeated requests for second/third/fourth opinions until a diagnosis acceptable to the parent/carer is made.

CYPMHS and emotional wellbeing practitioners should seek advice from the Trust's safeguarding children's lead / team. Initial concerns about a child's presentation will also be shared with the Paediatrician and/or GP that referred the patient and other relevant health professionals.

General Practitioners (GPs): In cases of suspected FII, the GP is likely to have had a higher level of involvement and knowledge of the child and family than other health professionals. GP's involvement and contribution to the management of FII concerns is essential to ensure that all key information with regard to the child is shared. GPs will also be aware about parental health issues – including both physical and mental health – and these should be taken into consideration as part of any assessment and information sharing.

If there are concerns about the welfare of a child and FII is a consideration, the child's needs are paramount and the GP has a duty to share any relevant and proportionate information that may impact on the welfare of a child. This includes sharing relevant information about parents and carers as well as the child. As the primary record keeper of all health records, GPs can play a key role in recognising patterns of worrying behaviour from multiple presentations at different settings.

If there are concerns about FII and the child is not known to a consultant they should be referred to a Paediatrician, Consultant Child Psychiatrist or Consultant Clinical Psychologist (dependent upon the presenting issues) with expertise in symptoms and signs that are being presented.

The GP should make it clear about their concerns re possible FII in the referral letter. This letter should not be copied to parent/carers. Timeliness of the referral will depend on presentation. For example if there are signs or symptoms of induced illness such as suffocation or poisoning then same day referral is needed with a concurrent urgent referral to Children's Social Care (CSC).

GPs should also discuss concerns with the practice safeguarding lead and/or Designated Health Professionals for Safeguarding Children. When recording concerns about FII, GPs should ensure that these concerns are recorded within the child's clinical record but that the entry is not visible on online access, as parental awareness of the concern may escalate the risk to the child.

Adult Mental Health Services: Adult mental health staff may become concerned about the welfare of a child in relation to possible FII. These concerns may be increased if a patient who is a parent is known to fabricate or induce illness in themselves, although this can exist within the parent's presentation and not the child's. If an adult mental health worker has any concerns of this nature about a child's welfare they should be discussed with the Trust Safeguarding Team.

Allied Health Professionals: If staff have concerns about FII in children they are providing therapy and care for they should discuss with their line manager and/or Trust Safeguarding Team and GP or the practitioner who referred to their service. They should also discuss with their clinical manager.

Consultant Paediatricians, Consultant Child Psychiatrist or Consultant Clinical Psychologist: All cases of suspected FII should be led by a Consultant Paediatrician, Consultant Child Psychiatrist or Consultant Clinical Psychologist. A Consultant Child Psychiatrist or Consultant Clinical Psychologist should only be the Lead Consultant when the child presents with symptoms suggestive of mental illness or psychological issues – they cannot be the lead for a child presenting with symptoms of a physical illness. This Consultant should take a lead role in this process.

During the thorough medical evaluation, the Lead Consultant should obtain information from the GP and other Consultants who have been involved in the child's care. This may include relevant information about the parent's health and the siblings.

Medical records of any siblings under 18 years of age should also be reviewed (see section on information sharing). The Consultant should discuss any cases with the Trusts Safeguarding Team and Named Doctor for Safeguarding/Child Protection.

In order to avoid unnecessary investigations and harm by further consultation, testing or treatment, a management plan for when the child presents to hospital or primary care should be decided in the early stages of the investigation. This should be clearly documented in the records and shared with the GP and other health professionals so that records can be appropriately flagged. It should not be shared with parents at this stage. It is important that all discussions with parents/carers and other healthcare professionals are carefully recorded in the notes, which should be stored securely.

Other Consultant Specialists: If another Consultant, other than a Paediatricians or CYPMHS Consultant, has a concern about FII in a child in their care they should refer to a general or community Paediatrician as appropriate. The case should also be discussed with the Named Doctor for Safeguarding in the Trust and the Safeguarding Team. If there are immediate concerns for the child's safety an urgent referral should be made to Children's Social Care. If there are immediate concerns then it may be appropriate to ring 999.

9. Health Professionals Meeting

A health professionals meeting could be convened by the Lead Consultant in conjunction with the Trust(s) Safeguarding Team(s) when concerns are emerging from within health agencies but it is unclear whether a referral to CSC is indicated. Any health professional could request a meeting of this nature via their Safeguarding Team. Each health professional should ensure their information and knowledge of involvement with the family is collated in preparation for this meeting. Use of a chronology may be helpful at this time but is not a pre-requisite as this should not delay convening the meeting. Information sharing is an approved and appropriate process within health for the purpose of gathering information to support referral and acting in the child's best interest where concerns of fabricated or induced illness are being considered/present.

The purpose of the meeting is to:

• Gather and share all relevant information (including previous investigations, results, current treatment, any known relevant information regarding parents/carers and siblings, etc.);
• Obtain clarity about the impact of presentations on the child's health, development and functioning;
• Distinguish between presentations which could be attributable to any pre-existing confirmed medical conditions and those for which there is no confirmed diagnosis;
• Discuss the concerns;
• Consider other possible reasons for child and parents behaviour;
• Discuss the possibility of whether any early direct intervention, if any, should take place and what that should be;
• Reach a consensus regarding further actions and management.

If after the health professionals meeting or discussion concerns persist about FII and cannot be addressed within healthcare services independently then a referral to Children's Social Care should be made requesting that a strategy meeting is held due to concerns of FII. Notes of meetings and discussions should be made and action plans should be documented.

If FII is not thought to be an on-going concern at this time but child health needs have been identified and a co-ordinated healthcare response is required Follow up health meetings could be arranged

10. Referral

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 and there are concerns of significant harm to the child, a referral should be made to Children's Social Care Services or the Police in accordance with Lincolnshire Safeguarding Children Partnership Referrals Procedure. See Safeguarding Referrals Procedure.

Children's Social Care should decide within one working day how to respond and what actions should be taken. Decisions should be agreed between the referrer and the recipient of the referral about what the parents will be told, by whom and when.

From the point of the referral, all professionals involved with the child should work together as follows:

• Lead responsibility for action to safeguard and promote the child's welfare lies with Children's Social Care;
• Any suspected case of fabricated or induced illness may involve the commission of a crime and therefore the police should always be involved;
• The paediatric consultant, CYPMHS consultant or consultant psychologist is the lead health professional and therefore has lead responsibility for all decisions pertaining to the child's health care.

If there is immediate risk of serious harm:

• An urgent referral must be made to Children's Social Care as a case of likely significant harm, leading to a strategy discussion involving the police;
• Secure any potential evidence e.g. feed bottles, nappies, blood/urine/vomit samples, clothing or bedding if indicated);
• Document concerns in the child's records (so that other professionals are aware);
• Consider if immediate protection of the child is needed (this is best obtained by the police using their police protection powers; it may take several hours for Social Care to obtain an emergency protection order);
• Rarely, covert video surveillance may be used but this must be led by the police.

Do not inform the carers or seek their consent as this may increase the risk to the child

11. Strategy Discussion / Meeting

If there is reasonable cause to suspect that the child is suffering, or likely to suffer significant harm, then Children's Social Care should convene a Strategy Discussion/Meeting see, Strategy Discussions Procedure and Section 47 Enquiries and Social Work Assessments Procedure involving all the key professionals. Each professional should ensure their information and knowledge of involvement with the family is collated in preparation for this meeting. Use of a chronology may be helpful at this time.

Unless there is an emergency or immediate risk of harm, this should be a Strategy Meeting, chaired by a manager from Children's Social Care.

If emergency action is the required response, for example, if a child's life is in danger through poisoning, an immediate Strategy Discussion should take place.

The Strategy Discussion/Meeting requires the involvement of key senior professionals responsible for the child's welfare. At a minimum, this must include Children's Social Care, the Police and a representative from Health, such as the Paediatric Consultant responsible for the child's health.

Additionally the following should, where possible, be invited to Strategy Meetings as appropriate:

• Team manager or practice supervisor CSC;
• Social worker;
• Named/Designated Doctor;
• Specialist/Named Nurse Safeguarding from relevant organisation(s);
• Lead Paediatric Consultant/CYPMHS Consultant (as applicable);
• Senior Police Officer from Lincolnshire Police;
• The referrer;
• Other allied health professionals involved in the child's care;
• Other Consultants involved in the child's care;
• Adult or child emotional wellbeing or Mental Health Practitioner/ Consultant (if involved with a parent or child's care);
• General Practitioner;
• School or early years setting representative;
• Legal advisor to local authority if appropriate;
• LADO if appropriate.

Where the Strategy Discussion/Meeting decides that a Section 47 Enquiry should be initiated, see Section 47 Enquiries and Social Work Assessments Procedure.

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.

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 to agree further assessment, monitoring or compilation of a combined health/ agency chronology 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.

Once consensus has been achieved, a meeting should be held with the caregivers, social worker and/or the responsible paediatric consultant. The meeting will explain to the caregivers that a diagnosis may or may not have implications for the child's functioning, and that genuine symptoms may have no diagnosis. It is preferable to acknowledge the child's symptoms rather than use descriptive 'diagnoses'.

In cases where the caregiver is believed to have a mental illness, there should be consideration of psychological or psychiatric review being undertaken by a mental health specialist.

The current consensus opinion is offered to the caregivers with the acknowledgment that this may well differ or depart from what they have previously been told. A plan is then made about what to explain to the child and rehabilitation is offered. It is premature, and important not to discharge the child from paediatric care even if there is no current verified illness.

The RCPCH have developed guidance for paediatricians and health professionals on how best to achieve consensus with caregivers, particularly on the prevention, recognition and management of conflict in paediatric practice [6].

[6] www.rcpch.ac.uk/resources/achieving-consensus

12. Chronology

The chronology consists of a list of significant events that have occurred by date and time if relevant.

Health chronologies must be compiled by multi-professional health teams and should include an experienced health professional who can interpret significant events (usually a consultant paediatrician or CYPMHS consultant). It should be decided who is responsible for having oversight of the chronology. This may be the lead paediatrician (should the child already be under the care of one) or the Designated Doctor. Should the Designated Doctor not be a paediatrician, the Named Doctor of ULHT or associated Health Trust should be available to lend expertise.

A summary and overall analysis should be compiled to include:

• Proven diagnoses;
• Important comments by caregivers and child;
• Information about caregivers and child's perception of illness;
• Discrepancies between reported and observed health information and behaviours/presentations;
• Commentary on whether the overall situation is likely to meet the significant harm threshold.

The need for a chronology should not delay any other processes (including strategy meetings).

Chronologies are complex and time consuming. The paediatrician, Designated Doctor and health safeguarding team should all be supported and have protected time for this process.

13. Section 47 Enquiry

When it is decided that there are grounds to initiate a Section 47 Enquiry as part of a Social Work Assessment, decisions should be made at the Strategy Discussion/meeting about how the Section 47 enquiry will be carried out including:

• What further information is required about the child and family and how it should be obtained and recorded;
• Whether it is necessary for records to be kept in a secure manner and how this will be ensured;
• Whether the child requires constant professional observation and if so, whether or when carer(s) should be present;
• Who will carry out what actions, by when and for what purpose, in particular planning further paediatric assessment(s);
• Any particular factors, such as the child and family's culture, religion, ethnicity and language which should be taken into account;
• The needs of siblings and other children with whom the alleged abuser has contact;
• The needs of parents or carers; including any relevant medical history;
• The nature and timing of any police investigations, including analysis of samples and covert video surveillance;
• How information will be shared with parents and at what stage.

14. Outcome of Section 47 Enquiry

Concerns Not Substantiated

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 assessment concludes that services should be provided to the child and family to support them and promote the child's welfare as a Child in Need or Team Around the Child (TAC). In these circumstances, the Social Work Assessment should be completed and a planning meeting held to discuss the conclusions, and plan any future support services with the family.

Concerns Substantiated but No Continuing Risk of Significant Harm

Concerns may be substantiated, but it is agreed between the agencies involved with the child and family that a plan for ensuring the child's future safety and welfare can be developed and implemented without the need for a Child Protection Conference or a Child Protection Plan

In these circumstances, the decision not to proceed to an Initial Child Protection Conference must be endorsed by the relevant Manager within Children's Social Care and recorded on the relevant records and database. Again, a planning meeting to consider future action may be considered as an appropriate format to meet the needs of the child and promote his/her welfare.

Should there be a request by a senior manager, or a named or designated professional in an involved agency that a Child Protection Conference be convened this should be discussed between the named/ designate professional and senior manager in children's services.

Concerns Substantiated and Continuing Risk of Significant Harm

Where concerns are substantiated and the child 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 a child and family progress plan initiated, See Section 47 Enquiries and Social Work Assessments Procedure.

The Child Protection Case Conference should be held within 15 working days from the last Strategy Discussion/Meeting i.e. the point at which the decision to initiate the Section 47 Enquiry was made.

15. Initial Child Protection Conference

Attendance at this Conference should be as for other initial Conferences, (see Social Care Assessments Procedure) although specific decisions about the participation of the parents/carers will need to be discussed with the Conference Chair and the following experts invited as appropriate:

• A professional with expertise in working with children and families where a care giver has fabricated or induced illness in a child;
• A paediatric consultant with expertise in the branch of paediatric medicine caused by the suspected abuse.

Each agency should contribute a written report to the Conference which sets out their involvement with the child and the family. This information should be precise and where possible validated at its source.

The health history of any siblings should also be considered.

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 Conference should decide whether the child is at continuing risk of suffering Significant Harm, and therefore in need of a Child Protection Plan. If this is the case, an outline Child Protection Plan should be developed stating clearly what action will be taken to safeguard the child immediately after the Conference, as well as in the longer term. For some children it may be necessary to institute legal proceedings either immediately or soon after the Conference has ended.

The Conference should also consider what action if any is required to protect siblings in the family.

If there is a paediatric consultant involved with the child then it is their responsibility to be the responsible paediatrician. If several consultants are involved, the lead would be the professional who raised the concern. If the concern was raised by another agency (e.g. school) then the responsible paediatrician would be the consultant with the largest degree of involvement.

If the responsible paediatric consultant is also the Named Doctor, another paediatrician in the trust should take over the role of lead paediatrician. This means safeguarding decisions can be made free from threats and complaints whilst the responsible paediatrician will also have suitable support.

All consultant paediatricians should share in acting as the responsible paediatrician for PP and FII cases on their caseload – they should not all be the responsibility of one individual.

In cases of perplexing presentation or FII, the aim is to quickly establish the child's current physical and psychological health, and the family context. The paediatrician should explain the uncertainty about the child's state of health and the need for professional meetings.

It is important that information shared within the Initial Child Protection Conference provides information and clarity on the following points:

• History and observations from all caregivers including parents, grandparents, child minders;
• If a significant antenatal, perinatal or postnatal history is give, this should be verified with the relevant clinician;
• Explore the caregiver's views;
• Explore family life, financial support and effects of the child's difficulties;
• Explore sources of support which are being received;
• Ascertain whether there is, or has been, involvement of Children's Social Care;
• Ascertain siblings' health and wellbeing;
• School attendance.

Child's Health

The responsible paediatrician should:

• Collate all current medical/health involvement;
• Ascertain who has made diagnoses and whether these have been based on parental reports or professional observations and investigations;
• Consider inpatient admissions for direct observations of the child;
• Consider if further investigations are needed;
• Obtain information about the child's current functioning including, behaviour, emotional state, peer relationships, mobility and use of aids;
• Caregiver's view.

Child's View

The responsible paediatric consultant should:

• Explore the child's views (if able to) with the child alone, to include the child's own view of their symptoms, their beliefs about their illness, their mood and wishes;
• Observe verbal and non-verbal communication from the child, both when alone and with a caregiver present;

The child's views may be influenced by the caregiver, as well as the child feeling loyalty to their caregiver, impacting on their ability to express their own views.

16. Cross Border Issues

It is not unusual for a Lincolnshire child to be receiving medical care from hospitals or specialists outside of county. In cases of FII, the carer may often seek multiple medical opinions from specialists practicing in geographical locations out of county.

Should safeguarding concerns arise, the local authority where the child is living on either temporary or permanent basis is responsible for S47 enquiries.

There is an expectation that irrespective of their geographical location, all of those involved in the child's care are similarly involved within all social care meetings. This may be via attendance in person, teleconferencing or videoconferencing (where available). Where the lead paediatrician is from an out of county hospital this should not negate their duty to act as the lead paediatrician 'Boundary arguments' must not get in the way of keeping a child safe.

Appendix 1: Fabricated and Induced Illness Pathway

Click here to view Appendix 1: Fabricated and Induced Illness Pathway.