Key takeaways
Recognising signs of fabricated or induced illness
Healthcare professionals must stay alert to unusual or inconsistent symptoms
Multi-agency collaboration is essential for safeguarding
Early communication between clinicians and social services reduces risk
Documentation and transparency protect vulnerable patients
Accurate records and clear reporting help prevent harm and legal issues
The case of Re N raised concerns regarding perplexing presentation/ fabricated or induced illness. At the conclusion of a 36-day fact finding exercise within care proceedings, findings were made by the High Court against the mother of two children, including that she had syphoned blood, provided medication (including morphine) without medical reason, falsified symptoms and played medical professionals off against each other.
The Court’s findings highlight:
The importance of practitioners being aware of the updated Royal College guidance on fabricated illness (updated in 2021 from the 2009 version) which can be found here: Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in children – guidance - RCPCH Child Protection Portal
The importance of the following list of reminders for safeguarding aimed at assisting in early identification of safeguarding issues:
All paediatricians must have a practical and detailed working knowledge of the guidance of the Royal College of Paediatrics and Child Health entitled “Perplexing Presentation (PP/Fabricated or Induced Illness (GII) in Children – guidance” (2021) and any amendments thereto. This is particularly important for the Consultant Paediatricians who often are called upon to exercise an overview of the children’s presenting compliant, diagnosis and treatment and are tasked with coordinating the same.
The child’s Consultant Paediatrician plays a pivotal role in the coordination and facility of investigations. The Consultant Paediatrician, must ensure that there are:
regular multidisciplinary meetings to which all relevant practitioners are invited, including nursing staff and specialist tertiary practitioners,
SPOC [Single Point of Contact] - clearly identified individual(s), may be the Consultant Paediatrician, who acts as a single point of contact and coordinate the opinion of different treating clinicians.
established clear lines of communication between all relevant practitioners that must include nursing staff, specialist tertiary practitioners and safeguarding leads.
established collaborative boundaries within which all practitioners regardless of their seniority or position are encouraged to contribute to the discussions,
Perplexing presentation raises FII as a point for consideration, even if it is to be considered and dismissed.
Where FII has been discounted, it should remain under consideration until it can be properly dismissed.
Clinical notes, notes of meetings and notes of conversations should be as contemporaneous and as clear as possible.
Safeguarding concerns should be clearly recorded in writing that must include an accurate record of any referrals that follow and the outcome.
Avoid ambiguous terms such as ‘working diagnosis’ unless this is agreed by all at a multidisciplinary meeting and the reasoning for doing so is clearly communicated to the parents/carers.
Correspondence and notes should be consistent and accurate. The history should be accurately reported.
The parents/carers should be kept fully informed about the clinical thinking and treatment decisions. Over medicalised conversations should be avoided and kept simple and to the point. The conversations should be clearly noted and the reasoning for clinical decisions should also be communicated in writing to the parents and copied to all relevant clinicians including specialist tertiary clinicians.
Step back and take an objective view of whether a referral to a tertiary centre should be made. Record the reasoning for the decision accurately.
Save for emergencies and unforeseen circumstances, do not step outside any specialist advice until this has been discussed and agreed with the relevant specialist and communicated to all relevant clinicians.
Where a second opinion is sought, record the reasoning for this carefully.
Everybody involved in treating and caring for the children is likely to make important contributions to the professional discussions. It is essential that those who work in less senior roles feel valued and are able to freely contribute to the discussions. These individuals can have a greater insight in the day to day life of the family and the patient.
At all times establish and maintain professional boundaries with the patients and their family. To do otherwise would be a disservice to the patient and their family at a time when they are likely to need the professional around them most.
Always keep an open mind.
The case is a salient reminder to those involved in safeguarding to ensure they are aware of the guidance and its contents to assist in identifying and then managing safeguarding concerns.
