Fabricated or Induced Illness and Perplexing Presentations Guidance

MULTI-AGENCY GUIDANCE FOR THE MANAGEMENT OF

PERPLEXING PRESENTATIONS, OR, SUSPECTED FABRICATED OR INDUCED ILLNESS

1. Introduction

This guidance is written to support multi-agency frontline practitioners to make appropriate decisions on how to safeguard children who present with perplexing presentations (PP) and Fabricated or Induced Illness (FII), additionally advise practitioners on how to recognise these issues, how to assess risk and how to manage these types of presentations in order to obtain better outcomes for children.

This guidance is based on the Royal College of Paediatrics and Child Health (RCPCH) 2021 guidance Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in children – guidance – RCPCH Child Protection Portal as well as learning from Serious Case Reviews, and aims to put the RCPCH 2021 document in context for practitioners working in Lewisham.

Whilst mainly applicable to health practitioners, this multiagency guidance is applicable to all frontline staff working with children, young people, and their families.

The term ‘children' or ‘child’ applies to all children and young people who have not yet reached their 18th birthday as per the Children Act 1989. The fact that a child has reached 16 years of age; is living independently or is in further education; is a member of the armed forces; is in hospital; in prison or in a young offender's institution, does not change his or her status or entitlement to services or protection under the Children Act 1989.

2. Purpose

The purpose of this policy is to:

Provide Lewisham frontline practitioners with a single consistent approach in the management of PP, or suspected FII.
Advise safeguarding partnerships of a single consistent approach across local providers and staff in the management of PP, or suspected FII.
Provide staff with the information and guidance they need to fulfill their statutory duties to safeguard and protect children and young people when there is suspected PP or FII.
Clearly define roles and responsibilities so that the process is transparent, and staff understand the complexities involved and have realistic expectations about the timeframes within which any given case can be managed.

3. Descriptions

Medically Unexplained Symptoms (MUS)

The symptoms which the child complains, and which are presumed to be genuinely experienced are not fully explained by any known pathology. These may be psychosocial and may be part of PP or FII.

Perplexing presentations (PP)

The term Perplexing Presentations (PP) has been introduced to describe the commonly encountered situation when there are alerting signs of possible FII not yet amounting to likely or actual significant harm, when the actual state of the child’s physical, mental health and neurodevelopment is not yet clear, but there is no perceived risk of immediate serious harm to the child’s physical health or life. The essence of alerting signs is the presence of discrepancies between reports, presentations of the child and independent observations of the child, implausible descriptions and unexplained findings or parental behaviour.

4. Considerations if there are Alerting signs

Examples of Alerting Signs may include:

Symptoms only witnessed by parent or carer
The reporting of multiple unrelated sets of symptoms, often alarming in nature
Parent/carer frequently speaks for the child or refuses for the child to be seen alone
A history of changing GPs or visiting different hospitals for treatment
The child has limited / interrupted school attendance and education;
The child’s normal daily life activities are limited (not able to join in PE for example);
The child assumes a sick role (e.g., with the use of unnecessary aids, such as wheelchairs);
Physical examination and results of medical investigations do not explain reported symptoms and signs;
There is an inexplicably poor response to prescribed medication and other treatment;
New symptoms are reported on resolution of previous ones.
Excessive use of any medical websites, jargons, or alternative opinions.
Parents may object to communication between professionals and may make frequent complaints about professionals

Fabricated and Induced Illness (FII)

FII is a clinical situation in which a child is, or is very likely to be, harmed due to parent(s) behaviour and action, carried out to convince doctors that the child’s state of physical and/or mental health and neurodevelopment is impaired (or more impaired than is the case). FII results in physical and emotional abuse and neglect, because of parental actions, behaviours, or beliefs and from doctors’ responses to these. The parent does not necessarily intend to deceive, and their motivations may not be initially evident.

It is important to distinguish the relationship between FII and physical abuse / non-accidental injury (NAI). In practice, illness induction is a form of physical abuse (and in Working Together to Safeguard Children, fabrication of symptoms or deliberate induction of illness in a child is included under Physical Abuse). For this physical abuse to be considered under FII, evidence will be required that the parent’s motivation for harming the child is to convince doctors about the purported illness in the child and whether there are recurrent presentations to health and other professionals. This particularly applies in cases such as suffocation or poisoning.

Frontline Response to Alerting signs

Alerting signs are not evidence of FII. However, they are indicators of possible FII (if not amounting to likely or actual significant harm). There may be several explanations for these circumstances, and each requires careful consideration and review.

At the point of alerting signs being identified, the concerns need to be escalated. The response is dependent on setting. At this stage, professionals should refrain from using FII terminology, as the state of the child’s health has not yet been assessed

Community settings

If the initial concerns arise from non-health community settings such as school, social services, or police, they should explain to parents the need to involve health. It is then appropriate for either the parents or education to contact health (GP, Consultant Paediatrician or Consultant Child Psychiatrist depending on who is already involved.)

If the parents do not agree to a health assessment and the sharing of information about the child, the setting will need to escalate to safeguarding leads within their own organisations to decide what action they should take following their safeguarding guidance.

Health Settings

If the initial concerns arise in or have been escalated to health settings, the doctor for the specified team is termed the ‘Responsible Clinician’. This could be the GP, Consultant Child Psychiatrist, Consultant Paediatrician, or any specialty in which the child is being seen.

Health response to Alerting signs should be escalation to the Named Doctor for their organisation. This is usually the Named GP for Safeguarding Children in Primary Care or the Named Doctor for the hospital trust.

If the child is not known to any secondary services, primary care clinicians should refer to a Consultant Paediatrician or Psychiatrist (depending on the presentation of the child) following initial discussions with Named GP for Safeguarding Children in Primary Care. The Consultant Paediatrician or Consultant Child Psychiatrist will be the ‘Responsible Clinician’.

5. Imminent Risk to Life / Health (FII)

Frontline response when there is an imminent risk to life/health

If there is immediate risk of serious harm identified, the professional should escalate to their line manager and the Safeguarding Leads of their organization. They should be supported to make urgent referrals to the police and MASH. This should lead to a strategy discussion and ensuring the child is in a place of safety. The safety of siblings should also be considered.
Examples of immediate risk may include evidence of illness induction, evidence of frank deception such as interfering with specimens, contamination of feed bottles or poisoning.
Concerns regarding the possibility of FII must not be shared with parents/carers as this may increase the risk to the child and this should be reiterated as part of the discussion.
In accordance with London Safeguarding Children Procedures, the strategy meeting should take place within one working day. All involved health professionals, the safeguarding team, children social services, police and education should be represented. The strategy meeting should be prioritised by all professionals. If they are not able to attend, they should send a fully briefed substitute. It is important for the substitute to be able to make decisions on behalf of the professional. All professionals are expected to attend the meeting fully prepared and able to discuss their concerns and understand that concerns should not be shared with the parents at this stage. There should be multi-agency agreement about the safeguarding response, and when and who should inform the parents.
In very rare cases, covert video surveillance may be used as part of multi-agency decision-making and is led by the police.
If at any time any practitioner considers their concerns are not being taken seriously or responded to appropriately; s/he should discuss this with the Named safeguarding Doctor of their organization , or the Designated Safeguarding Children professionals within the ICB. Concerns should be escalated in accordance with the Lewisham LSCP Escalation Policy: lscp_escalation_policy_-_21.04.2020.pdf (safeguardinglewisham.org.uk)
The Responsible Clinician, with the support of the Safeguarding leads within their organisation, should prepare a chronology (see appendix 3).
All practitioners involved with the child should continue to record their concerns and observations accurately and objectively in the child's health record so that other clinicians have access to the information. In such cases parent/carers access to the record will need to be restricted, with a clear note to reflect this, if there would be risk to the child.
The Responsible Clinician should arrange a follow up Professionals’ Meeting with the Named Safeguarding doctor of the organisation and all other involved healthcare professionals for feedback of the outcome and any further action required. Professionals meeting should be within six weeks to allow time to gather any further information if needed and prior to discharge from CSC oversight. See Flow Chart in Appendix 1.

6. Perplexing Presentations and Management

Secondary Care Management of Probable FII without Immediate Risks

The essence of management is establishing, as quickly as possible, the child’s actual current state of physical and psychological health and functioning, and the family context.
If the child is not known to any secondary services, primary care clinicians should refer to a Consultant Paediatrician or Consultant Child Psychiatrist (depending on the presentation of the child) following initial discussions with Named GP for Safeguarding Children in Primary Care.
This referral should reiterate the need not to alert the parents/carer to the possibility of FII at this stage.

The Consultant Paediatrician or Consultant Child Psychiatrist will be the ‘Responsible Clinician’

The Responsible Clinician will arrange for a medical evaluation to take place as appropriate. Identification of probably FII can be a difficult and protracted task and may require a multi-agency approach and expertise. It can involve relatively long periods of observation.
Information gathering is usually needed to understand if this is Probable FII, Perplexing presentations or Medically Unexplained Symptoms as the management is very different.
Following information gathering and review of the child, If concerns persist about probable FII, but it is still unclear whether this meets the threshold for referral to children’s social care, the Responsible Clinician should arrange a Professional’s Meeting. This meeting should take place within 10 working days, or earlier if required. All professionals involved in the care of the child, including health, education, and social care should be invited to the meeting.
The professionals meeting should explore the facts, hear from all professionals involved and come to a consensus agreement regarding whether:
1. If this is ‘Probable FII’ with immediate serious risk to the child’s health or life (see flowchart below), or
2. It should be managed as a perplexing presentation.
3. In addition, the meeting should also consider if there are any other safeguarding risks to the child or siblings.
A detailed chronology should be completed by all involved practitioners regarding their own involvement with the child (see appendix 3) within 10 working days (or sooner if necessary) and returned to the Responsible Clinician for the case for collation within health in conjunction with the Named Doctor and Nurse for Safeguarding children for the organisation. The composite chronology will be shared with the Named Safeguarding professionals for the organisation.
The Responsible Clinician will chair the meeting. Clear terms of reference and records of the meeting must be made available at the time, the arrangement of these made by the Chair.
Whilst professionals should in general, discuss any concerns with the family and, where possible, seek agreement to making referrals to Children's Social Care, this should only be done where such discussion and agreement-seeking will not place a child at increased risk of significant harm, and for probable FII should only be shared after agreement at the multiagency strategy discussion.
At this stage any referral to social care and police as appropriate should lead to a strategy discussion with key professionals involved with the child.
If there is no obvious deception, illness induction and no serious immediate risk, in which case the clinical management should be managed as for PP as below.

Secondary Care Management of Perplexing Presentations

Alerting signs are present and escalated from the community as described above or identified in secondary care.
Responsible Clinician will arrange for a medical evaluation to take place as appropriate.
The responsible clinician should obtain a history and observations from caregivers, explore parental views, family functioning and support and any need for/previous early help or social care involvement. (A chronology will be helpful, see chronology template in appendix 3)
The child’s view should be explored alone, to find out their views and beliefs as well as worries, mood and wishes. Consideration will need to be given if the child is non-verbal, has special education needs, and or disabled. The Three Houses tool https://www.mefirst.org.uk/ is useful to explore their views, or RCPCH tools referenced in the 2021 guidance.
There needs to be an assessment of immediate risk. If there is no immediate risk, then the responsible clinician along with a colleague will involve parents in the assessment plan.
There may be safeguarding, or welfare needs that are unmet, and these must be considered separately to the clinical picture.
The Responsible Clinician’s role is to maintain clinical oversight, collate information and make medical decisions in relation to the child’s care.
The Named doctor for Safeguarding Children in the same organization should maintain safeguarding oversight. Safeguarding and Clinical care roles should be kept separate by two different clinicians.
Following information gathering and evaluation of concerns, a professionals meeting should be arranged as described in Section 6. The panel should come to a consensus agreement, discuss management plans, and review the needs of the whole family.
The Responsible Clinician should meet with the parents to share the consensus and plan which should be negotiated with the young person if possible
To enable return to education, the Responsible clinician should call a Team around the Child (TAC) meeting with the school, GP and any other professionals needed to facilitate a smooth return.
Referral to the Police and MASH may be
The child’s GP should always be kept informed as it is important to recognize the needs of the whole family.
Parents and young people should be informed of the outcomes of professional meetings if it is safe to do so.

7. Considerations for Medical Evaluation

All signs and symptoms must be subject to careful medical evaluation for a range of possible diagnoses.
All tests and their results should be fully and accurately recorded, including those with a negative result. It is important that the child's records are not tampered with, or test results altered in the child's notes.
If the child is not currently in hospital, consider whether a planned admission with careful observation would help to elucidate the clinical diagnosis.
Carefully consider whether any immediate investigations or further opinions are likely to assist in the diagnosis.
Stop any harmful treatments or invasive procedures unless they are clearly indicated. It is unacceptable to cause a child further harm from medical actions, whilst the diagnosis of FII is being considered.

If there is risk of immediate harm, do not wait to confirm the diagnosis before referring to children's social care as a delay may be detrimental to the child.
Chronology of health involvement from ALL agencies should be prepared to provide an overall picture and comprehensive information for submission to Children’s Social Care.

8. Considerations for MASH on receipt of referral

Imminent or probable risk to a child’s health/ life from FII or another cause should involve an urgent strategy discussion. All involved health clinicians, education and safeguarding professionals should be invited. No information should be shared with the parents.
MASH will notify the responsible clinician of referral outcome within 3 working days of referral receipt.
In accordance with Lewisham LSCP Escalation Policy, escalation should occur if there are concerns regarding the MASH referral decision. lscp_escalation_policy_-_21.04.2020.pdf (safeguardinglewisham.org.uk)
In the event of likely / experienced harm, at any stage, a referral can be made by the involved professional and will be managed through the usual MASH process.

9. Record Keeping

Medical records should be kept in accordance with the Data Protection Act 1998. Practitioners should also follow the principles of record keeping set out in guidance documents supplied by their Professional bodies.
Detailed, accurate and informative medical records are pivotal to the management of a suspected FII case. If a child moves between clinical teams or between organisations, it is best practice for the notes to follow the child. This may not always be possible and so a clinical summary must accompany the child.
It is essential that the records include a health chronology of the child's medical presentation, including aspects which may indicate FII. It is crucial to record the source of information, e.g., whether a symptom or sign was independently observed by staff or reported by a parent / carer.
If FII is suspected, requests by a child's parent / carer to access their records under the Data Protection Act 1998 may be refused if:
1. The disclosure would be likely to cause serious harm to the physical or mental health or condition of the child
2. The child has provided the information in the expectation that it would not be disclosed to the parent / carer
3. The data was obtained because of an examination or investigation to which the child consented in the expectation that the information would not be so disclosed
4. The child has expressly indicated that the information should not be so disclosed.

10. Training and Supervision Requirements

All staff who have contact with children or their families should have appropriate safeguarding training and an understanding of PP and FII. Those specialising in the care of children or families need additional training to ensure a higher level of awareness and understanding of PP and FII.
Staff will need support and supervision in dealing with cases of PP or suspected FII. Staff support should be an integral part of a health professional's contract. It is important that line management and professional supervision and mentorship arrangements are explicit so that staff know how to access additional support when it is needed. The facilitation of debriefing sessions can be helpful in providing support for all members of the team.
Staff to be aware that children with disabilities/ special needs are equally at risk this must be considered when there are concerns of PP or suspected FII.

11. Monitoring

This guidance and application will be reviewed annually by the Designated Safeguarding Children Professionals in collaboration with the Named Safeguarding Children professionals in health provider organisations.

12. Equality and diversity statement

NHS Southeast London ICB is committed to equality of opportunity for its employees and members and does not unlawfully discriminate based on their “protected characteristics” as defined in the Equality Act 2010 - age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation. An Equality Impact Assessment has been completed for this policy.

If members or employees have any concerns or issues with the contents of this policy or have difficulty understanding how this policy relates their role, they are advised to contact the Chief Operating Officer.

13. Links to other Policies/Documents and Guidance

This guidance is to be used in conjunction with: