It can be very difficult to confirm a suspected case of fabricated or induced illness (FII).
Healthcare professionals will naturally assume that a parent or carer will always act in the best interests of a child in their care, unless there's strong evidence to suggest otherwise. They will also want to make sure they do not miss any genuine health conditions.
If FII is suspected
If a healthcare professional notices signs of FII, they'll usually refer the case to a community paediatrician.
A senior paediatrician will examine the medical evidence to determine whether there's a clinical explanation for the child's symptoms. They may also seek further specialist advice and arrange further testing. They will consider whether the child should be admitted to hospital so that nurses can observe them directly.
If the senior paediatrician also suspects FII, they'll put together a detailed record of all the available information related to the child's treatment and involvement with health services. They'll explore how the family is functioning, the parents' views, and the child's views if they're old enough.
They'll record their concerns in the child's health records, so that any other clinicians who see the child are aware of the concerns.
Healthcare professionals will meet to discuss the concerns and agree on whether the signs can be explained by a diagnosed health condition, or whether it appears to be a case of FII. The parents will usually be told the outcome of the meeting, and future plans will be discussed with them.
If there's thought to be a risk of harm to the child, healthcare professionals will also refer the case to children's social care.
Health and education rehabilitation plan
Whether or not the child is referred to children's social care, healthcare professionals will create a health and education rehabilitation plan for the child.
The plan will cover the actions needed to resolve the situation and help the child recover, such as:
- stopping any unnecessary medicines or treatment
- getting the child back to school
- psychological support for the child and the family
Doctors will usually lead on creating the plan, and education and social care professionals may also be involved. The child's parents or carers will be asked to support the plan.
A lead professional (usually a paediatrician or other health professional, or sometimes a social worker) will review the plan regularly with the family, until the child is healthy and there are no longer any concerns.
If the parents or carers will not agree to a plan, or do not support it, the child will be referred to children's social care who will take any steps needed to prevent harm.
Referral to children's social care
If the child may be at risk of harm, for example if there's evidence that the parent or carer may be making the child ill, healthcare professionals will refer the case to the local authority children's social care team and the police.
They will decide whether to tell the parents or carers about the referral.
Children's social care teams consist of a number of different professionals. They're employed by local authorities responsible for protecting children from abuse and neglect.
Other agencies involved with the child's welfare, such as their school or social services, may be contacted in case they have information that's relevant, such as the child being absent from school.
The children's social care team will usually ask the healthcare professionals to provide a detailed record of the past events in the child's medical history.
Once complete, the information will be presented to the children's social care team and the police. The social care, police and medical staff will meet to discuss the best way to proceed with the case.
Child protection plan
If the child is thought to be at immediate risk of physical harm, children's social care will remove them from the care of the parent or carer. The child may be placed in the care of another relative or in foster care.
In many cases of suspected FII, the child is already in hospital. They'll be moved to a safe place inside the hospital so that their medical assessment can continue. Alternatively, the parent or carer may be banned from the child's ward.
As the child is commonly at risk of significant physical or mental harm, a child protection plan is drawn up. This plan takes into account the child's health and safety needs, as well as their educational or social needs. For example, the child may have been deprived of regular education because their parent or carer kept them away from school.
As part of the child protection plan, the parent or carer may be asked to have a psychiatric assessment or family therapy. If they refuse to comply with the child protection plan, the child may be removed from their care.
Police investigation
If the police decide there's enough evidence to bring criminal charges, they'll investigate the case.
In rare cases, covert (secret) video surveillance may be used to collect evidence that can help to confirm a suspected case of FII.
Only the police have the legal authority to do this, and it's only done if there's no other way of getting information needed to explain the child's symptoms.
Further information
The Royal College of Paediatrics and Child Health (RCPCH) has published information and guidance about the protection of children in cases of FII: