Fabricated and Induced Illness

This is a post by Sarah Phillimore. I was recently alerted to a Radio 5 Live Investigation into ‘Fabricated and Induced Illness’ [FII] in May 2019. I think this is a useful opportunity to explore FII in more detail for readers of this site. 

The history of Fabricated and Induced Illness [FII]

Concerns that parents may exaggerate or even cause their children’s symptoms of illness have been around for a long time. It used to come with the flowery title ‘Munchausens Syndrome by Proxy’, from the fictional character Baron Munchausen who told outrageous lies about his non existent achievements.

Obviously, this description was confusing to many parents and professionals, as well as wrongly giving the impression that it was a psychiatric condition in its own right. As Kate Grieve commented in 2015, the case of R v LM [2004] QCA 192 at para. 67 (4 June 2004)  in the Supreme Court of Queensland, Australia, held that “the term factitious disorder (Munchausen’s Syndrome) by proxy is merely descriptive of a behaviour, not a psychiatrically identifiable illness or condition”. She further comments:

FII is not a mental illness as can be diagnosed. Perpetrators will have various psychological, psychiatric, and environmental features leading to the behaviour of fabricating or inducing illness in a child. FII is a form of child abuse where the perpetrator uses medical professionals as tools to subject the child to harm.

Therefore, now we use the more sober descriptor ‘Fabricated and Induced Illness’  [FII] but obviously the problem remains the same.

The NHS describe it in this way.

FII covers a wide range of symptoms and behaviours involving parents seeking healthcare for a child. This ranges from extreme neglect (failing to seek medical care) to induced illness.

Behaviours in FII include a mother or other carer who:

  • persuades healthcare professionals that their child is ill when they’re perfectly healthy
  • exaggerates or lies about their child’s symptoms
  • manipulates test results to suggest the presence of illness – for example, by putting glucose in urine samples to suggest the child has diabetes
  • deliberately induces symptoms of illness – for example, by poisoning her child with unnecessary medication or other substances

How widespread is FII?

FII It is undoubtedly a ‘real thing’ and can cause serious harm to children as well as a massive drain on NHS resources. But it is also a rare thing – it is difficult to estimate with certainty how many cases arise each year, but some estimate about 50. The NHS refer to one study which published in 2000 which estimated 89 cases of FII in a population of 100,000 over a two-year period. However, they believe this figure is a likely under-estimate of the actual number of cases.

Taking a figure of 50 per year, is on a par with statistics around children who are murdered; 330 children were killed between 2009 to 2015  i.e. about 47 per year. Compare this with road traffic accidents  – in 2011, 2,412 children aged 0-15 years were killed or seriously injured on Britain’s roads. So about 7 children a day will die or be badly hurt on the roads as opposed to less than 1 a week being victim to FII.

Fiightback told Radio 5 Live that they had about 600 people seeking their support and 70% had been ‘cleared’. They had attempted FOI requests from LA to be told that no data was held about numbers of FII cases.

Concerns that cases of FII are rising

The group “Fiightback” was set up “to support those accused of FII, to fight for an unbaised criteria, a fair investigation and a pathway to rebuild the lives of those wrongly accused”. It shared with the BBC their worries about a ‘wave of false allegations’ of FII.

It now wants a review into the number of FII child protection investigations like Amy’s, as well as the FII guidelines for medical and social work staff.

It also wants national and local policy on responses to accusations of FII to be looked at, and new standards set.

Carol Monaghan MP – who has led calls in Parliament to raise awareness of FII – said she would support an inquiry.

She added: “Disturbingly, diagnoses can be made by health professionals who have not met or examined the child, and child protection procedures can then be instigated as a result of a remote diagnosis.”

I can’t comment on the statistics that inform that comment about ‘wave of false allegations’ because I don’t know them. I can’t find any references on the Fiightback website. All I can say that in my practice spanning 20 years I have only been instructed to act in a handful of FII cases. I have not encountered in the past few years any noticeable increase. And I would be very troubled if diagnosis of any medical condition was attempted by any doctor who had not actually met the child – unless this was a court authorised review of medical records collected by other doctors for e.g.

But if such concerns are raised, then it is right that they are properly investigated and we have clear evidence to either support or deny them. A suggestion was made in 2018 that such cases are on the rise because local authorities want to avoid paying for services – that is an extremely serious situation, if true. Andy Bilson commented to Radio 5 Live that the definition of FII appeared to be widening in some areas to include parents who ‘genuinely’ believed their child was ill – thus bringing into the net of suspicion those parents seeking services for their children.

Efficient and speedy investigation is needed.

FII brings the ‘perfect storm’ for a family justice system, already prone to risk averse decision making. FII represents something that doesn’t happen often, but when it does the consequences for child could be catastrophic. Little wonder then that many professionals may act defensively.

And of course, professionals are fallible. A decision made hastily to separate parents and child may turn out, after proper investigation to have been the wrong decision, based on imperfect understanding of the medical evidence as it initially presented. The Websters for example, whose child’s broken bones were caused by scurvy, rather than deliberate infliction of force. Sally Clark, who was convicted of murder on the failure of Professor Sir Roy Meadows to understand and apply statistics correctly.

We need a clear idea about how many cases there are and how many do not result in any findings against the parent – as the impact of such cases can be devastating if no findings are made. Amy, the mother interviewed by BBC Five Live commented :

I felt like my character was assassinated, my family was ripped apart and my child was stolen

So how do we manage these cases?

Few would disagree that if a competent medical practitioner raises a concern that a child is being hurt by a parent, that this needs to be investigated and the child kept safe while the investigation is carried out. The problem of course is that this investigation can often take many months or even years and throughout that time the child is likely to be living separately from his parents, although hopefully still having regular contact.

The key therefore must be to make sure investigations are carried out as efficiently and quickly as possible.  The NHS guidance for medical professions highlights the necessary steps.

  • Its important to have a senior paediatrician to carry out an overview of the case and to seek further specialist advice or testing if needed.
  • A detailed chronology must be written of all the available information related to the child’s medical history. 
  • Doctors must contact the relevant child protection team of the local authority’s children’s services to inform them of the concerns.
  • Other agencies involved with the child’s welfare, may be contacted in case they have information that’s relevant such as the child being absent from school.
  • The police will also need to be informed and all professionals must meet to discuss the best way to proceed with the case.
  • Covert (secret) video surveillance may be used to collect evidence that can help to confirm a suspected case of FII but this will require proper authorisation and is rare in practice as usually the parent will not be allowed unsupervised access to a child once concerns about FII are raised.  For a discussion about surveillance of families by social workers, see this post from Pink Tape. 

The LA will usually start care proceedings immediately and seek separation of child and parent, unless there are other family members who can help to provide constant supervision.  There may well be parallel police and care proceedings – while care proceedings should never ‘wait’ for criminal proceedings to get started or conclude, it is clear that if a live police investigation is also on going, this has the potential to cause delay.

As ever the focus must be on the evidence – what is needed, who is best person to provide it, and how should it be tested. This are not easy cases and will require more than most continuity of Judge and lawyers.

Further Reading

Re X, Y and Z (Children) [2010] EWHC – Application by local authority to withdraw from proceedings, under FPR r 4.5, for interim care of three children. Local authority ordered to contribute to the costs of the parents.

Concerns over Fake Illness Cases in Troubled GOSH department – April 2018 Melanie Newman

Safeguarding children in whom illness is fabricated or induced – 2008 Statutory guidance from Department of Education, on protecting children where carers or parents make a child ill or pretend a child is ill.

Regional Child Protection procedures for West Midlands – guidance on FII 2017

Achieving Best Evidence in Children Act cases. 

 

23 thoughts on “Fabricated and Induced Illness

  1. ELS

    It seems to me that an allegation of factitious disorder made in a family court setting should be treated in the same way that sparring parents counter accuse of mental health disorders promulgating social worker’s without medical degrees o to supporting investigation of such amateur accusations.

    I was accused of having MBP and taken to *another* emergency court hearing to defend allegations that I was telling my child they would get diabetes and their legs would fall off. Rather than ask me about such a ludicrous allegation I had to attend court again explaining that the endocrinological condition for which my child has received treatment under a medical consultant for six years had diabetogenic effects if the drug dose was too high. My degree is in medical biochemistry and I work in the pharmaceutical industry so that makes me more confident and savvy with medical terminology and treatment than some. It doesn’t mean that I have MBP.

    The sad reality is bitter custody battles churn up and out all sorts of bitter allegations that an already overwhelmed system can’t deal with without some guess work at play — and that will always be manipulated by the party prepared to shout the loudest and most ridiculous allegations.

    In my humble opinion. (Article 10 …)

    Reply
    1. Sarah Phillimore Post author

      I have certainly seen a very quick ‘hardening’ of attitudes towards parents in the few cases I have been involved in, which I suppose is inevitable once doctors feel there is sufficient evidence to fear that a parent is hurting a child and lying about it. And I think the only thing that can possibly work to deal with this is get on with a full hearing ASAP. Cases that drag on for months and years are really damaging to everyone involved.

      Reply
  2. Angelo Granda

    But where is the inhumanity?
    The inhumanity is in separating the Mum from the child when such a medical condition is suspected.
    Mum and the child should be hospitalised, detained,supported,controlled or imprisoned TOGETHER!
    Then, if necessary, Mum and child should be rehabilitated and/or reformed TOGETHER.

    That is my view of humanity and human rights.

    Reply
    1. Sarah Phillimore Post author

      Really? If the mother – as has happened in cases in which I have been involved – tried to drown the child? Tried to suffocate the child? How safe do you think that child would be?

      Reply
      1. Angelo Granda

        I am concerned that too often lawyers really,really have little idea of what ordinary citizens mean by humanity and human rights.
        They have become too accustomed to stripping them away from us hastily. Due to their own anxieties and fears of imminent harm,they feel they are somehow rescuing children by taking them from loving parents into a cold,heartless care-system where the risk of institutional abuse and exploitation are ten times worse.
        Doctors and SW’s indeed make factitious assessments and judgments . When they talk of parents trying to drown children or suffocate them, both of those are criminal allegations to be treated with great caution. You should never remove children from parents summarily on the basis of opinion and hearsay. These stories and narratives may sound right to you because they come from SW’s but they are usually factitious when one gets down to the bones of the matter ( as portrayed by ELS above).
        The precise solution is to limit the powers of the family courts to interfere with family life.Bring in proportionality and enable proportionate sanctions . KEEP FAMILIES TOGETHER under a close supervision order of some kind even if it has to be in some sort of mother and child hostel .
        Unfortunately,lawyers seem not to have much idea of human rights, proportionality and fairness. I suppose it has come about over the years ; they have become affected by too much power.

        Reply
  3. Amy

    One important aspect, at least to me, in this case, is that the information that was used to prove the accusation false was available, to the accuser, at the outset.

    It was stated by independent medical experts that the information shared by the accusing person was incomplete, misleading and contained erroneous information.

    Setting the sat nav early in an investigation is probably difficult not to do given human nature but it does makes things more difficult, because an entrenched position is that much harder to come out from.

    I am too close to this for impartial discussion, but I do want to say, that I agree an accusation of FII, is very serious and it should not be made or taken lightly. There was never any dispute about the importance of an investigation from me. If this had been true, the consequences would be deadly. A child’s safety is paramount. My child’s safety and wellbeing was far more important to me than my feelings.

    However, the investigation is not harmless either.

    I am confident all parties involved would tell you there was open and ready cooperation by parents.

    Though, I feel that I should be allowed to acknowledge now at this distance, it was a really painful experience. It took a long time.

    It would be nice if there was greater obligation for consistent cooperation by all parties with the legal process. When professionals make unnecessary delays, it causes a more protracted process.

    It would be good to have a review as I think there are ways that the process of investigation could be improved and the screening for when an investigation is needed could be better refined.

    Reply
    1. Sarah Phillimore Post author

      Thanks for commenting Amy. Family Law have asked me to write a piece on practical advice for professionals dealing with these cases – at the moment I am thinking that the most important things to do are gather the information asap, have a proper chronology and push for earliest possible finding of fact with judicial continuity. What else do you think could have helped make a more positive difference in your proceedings?

      When you say ‘greater obligation for consistent co-operation’ do you think there is a role for mediation between hospital staff and parents? I know that was suggested around Charlie Gard/Alfie Evans cases but I can see those involve rather different issues.

      Thanks for taking the time to comment; I listened to the Radio 5 Live piece and you clearly had an extremely difficult year.

      Reply
  4. Angelo Granda

    Amy, Your comment , to me, is wise and incisive and I can’t thank you enough for it.
    The facts were freely available to the accuser/s had the case been conducted correctly and the investigative process been followed with scrupulous attention to legal guidelines and safeguards.
    In my view, too often CP professionals seem to deliberately avoid freely available facts. The Family Court process appears chaotic. Haste seems to be more important than truth and accuracy. Much of the process is conducted by firms of solicitors whose staff are not always fully qualified. Matters are considered in a rush before court by a Children’s panel and fact-finding hearings take place without any real steps having been taken to seek out real evidence and facts.
    Sarah, i suggest qualified barristers should become involved at a much earlier stage. Family Courts should be more strict on procedure in proportion to the serious decisions to be taken. Why not pay a few visits to the Crown Court and study how process is conducted with much more respect from the very first directions hearing. The barristers appear to know what they are doing . In the Family Court ,too many mistakes are made at the earliest stages .
    If you watch the lawyers at work in the Crown Court , you will see less chaos and more attention to detail.
    It will give you ideas for your paper to Family Law.

    Reply
  5. Amy

    Thank you, Sarah.

    I agree with your proposals.

    First, I think mediation between hospital staff and parents would be a great asset. When both sides are scared, and communication breaks down, nothing positive is achieved.

    Second, gathering information and holding a fact finding asap would be the single biggest achievement.

    When I say ‘greater obligation for consistent co-operation with the court’ what I am referring to is our difficulties in gathering information, such that we could proceed with a fact finding.

    We applied for medical records by SAR, and then court order. It was argued in court that we should not have the medical records as it would put our child in danger and would breach her human rights. Thankfully, the court disagreed and acknowledged that these were important to the case and made the order. That order was not complied with, a court appointed commissioner had to be sent in. Still this was not properly complied with and we returned to court… It took 9 months to get her complete medical records.

    In addition, it took six months from the date that the consultant made an FII accusation/ child protection referal to the date that the consultant submitted a report. This meant that my daughter was away from home, first in hospital, then in foster care for six months before we knew the official accusation and why.

    If there was some kind of rule that once an FII accusation has been used to achieve an order, and a child is in a place of safety, a clock starts ticking, and now, there is a duty to ensure all medical records are lodged to court and the report in a timely manner… I think that would be helpful.

    I am not arguing the investigation shouldn’t happen or be done differently. That’s not my area of expertise. But if you remove a child from their family, please don’t dally with the records.

    If the consultant and the hospital had released the report and her medical records in a timely manner, I feel, rightly or wrongly, that it could have halved the time this case took to reach a resolution. If not more.

    Positives. I do try to look for the positives.

    After the initial stage of the social work/police investigation, it was concluded that my other children were not at risk, and they remained safe in my care through out. They were never placed on the at risk register and never subject to an order. I am incredibly thankful for this individual and considerate approach.

    Another positive was independent advocacy. When you are accused of being a monster, there is a tendency for people to start treating you like one. Having an independent advocate helped me through many meeting and tough patches. I would encourage local authorities to encourage advocacy because it is a positive step to better communication and helps parents engage better through the process.

    Last but certainly not least, is our legal team. Whom we owe our whole world. I don’t think lawyers hear often enough how vital, valuable and significant their work is. To me, our legal team remains my real life heros. They stood up for me when I had crumpled. They remained steadfast and diligent. I am truly thankful for the work they have done.

    Reply
    1. Sarah Phillimore Post author

      Thank you for that comment – it certainly chimes with what I think is most important. We need to find a way to get the necessary information as quickly as possible so Judge can resolve the dispute, one way or another. Would you be ok if I quote some of this in the article?

      Reply
  6. Angelo Granda

    I talk from my own experience and that of many others when I say that when a referral is made to the LA by a hospital doctor ,GP or school perhaps, the Children Act lays down a process already ; it is designed to ensure mediation between hospital professionals,parents and SW’s. The whole idea of strategy meetings,child-protection conferences etc. is to gather information and establish facts .Often no conferences or mediation take place because the LA does not follow correct process.
    Children are removed into care before facts are known because the professionals allow their fears ,often factitious, to run away with them. Then,of course ,they launch a child-protection investigation and proceedings belatedly.Once that starts, hospital staff are commanded by the LA’s not to communicate at all with parents or give out information or medical reports of the children on any account,except to the LA. All information and data is controlled by the LA.

    I would add that were children not taken away unlawfully but families made subject to an interim supervision order or something similar, there would not be so much urgency and hasty judgments less likely.
    As Amy has commented gathering information and holding a fact finding asap would be the single biggest achievement. Professionals should work towards new habits and change front line practices. The guidelines and safeguards are there for them .Their jobs would be much simpler were they to conform to them and the system much less likely to fail children.

    Reply
  7. Emma

    In my case I was actually unsurprised although still disappointed as this was yet another allegation and expected given that my daughter does have an endocrinological condition (ironically an inherited one from the accuser!).

    Practically it was somewhat helpful in having a rapid hearing and fact finding expedited — which was necessary because the consultant had overseen the care foraix years from his original diagnosis. I was able to construct a response statement which included the patient information leaflet from the medicine and paraphrase from that. It became obvious within minutes of the hearing that this was a(nother) vexatious allegation calmly and factually defended. It was actually referred to in the final hearing as a reason for the contact order in that in the face of such allegations I had remained focussed on the needs f the children and not gone for counterattack. As with most things the facts and the truth are the answers and I was confident the medical data would make the idiocy apparent. It did. The judge even asked the SW if they wanted to stop th hearing having had a chance to read my response statement and being fully furnished with the facts.

    Which is where my specific criticism lies; the disappointment was that after 18months of hearings by this point and being fully aware of the condition, treatment and awareness that the accuser had not attended routine follow up appointments — the SW still chose to call an emergency hearing rather than ask me directly about the allegations.

    I do wonder — a few years on — if that was her only way to stop the constant accusations, perhaps knowing I would successfully and calmly defend myself. Perhaps …

    Reply
    1. Sarah Phillimore Post author

      Thanks Emma, an interesting comment about the perspective re what makes an emergency and the shadow that can cast.

      Reply
  8. Emma

    I do think there are other societal forces at play here. I have been a medical writer since 1996 and there has been a substantial increase in health anxiety and lobbying as a result of the role of the internet in sharing both great and dire information pertaining to health and medicine.

    The rise of ‘Dr Google’, anti-vaxers and indeed health activism in the cases of Charlie Gard and Alfie Evans demonstrate the double edged sword that accompanied greater access to health information. The saying we have in medical communications is better informed doesn’t necessarily mean better understood. The level of health literacy is dire; which compounded with the emotional demands of dealing with a child who is ill or you believe is ill means there is a notable rise in cyberchondria/health anxiety disorder.

    Social media public health campaigns are necessary and brilliant. But there is also the risk of scaremongering and ‘overprotectivess’; coupled with media distortion and frenzy it is easy to see how a parent could appear to be a candidate for Factitious Disorder. It is quite rare and quite easily diagnosed or dismissed. The overlap into family court likely requires better training. But realistically can we expect SWs to be medical experts on top of every other expectation?

    No.
    As always, if someone makes a malicious allegation then it can be successfully defended. If someone raises a genuine concern then expeditious and expert responses are the answer.

    Reply
    1. Sarah Phillimore Post author

      Thanks Emma, sorry didn’t notice this comment had got stuck behind filter. But that’s the key point isn’t it – that SW are not and cannot be expected to be medical experts. So these cases will stand and fall upon the speed with which the correct specialists can be identified and can report.

      Reply
    1. Sarah Phillimore Post author

      Thanks – I shall send you a draft of my article? Family Law want some ‘Top tips’ for lawyers dealing with these cases, so some insight from parents would be very helpful.

      Reply
      1. Angelo Granda

        Sarah, I look forward to your article .If I might make a further comment.
        Emma is a medical writer and Amy is a professional too. It seems to me that both of them are able to use language which not only obtained respect in Court but here on the CPR , they have also made you sit up and listen.
        I know you are going to use them for your paper.
        It is very important that process and investigations are conducted correctly from the earliest possible stage and that freely available facts and background are sought.The key point is that it must be done speedily,as you say.
        Yet, usually, families subjected to these types of allegations are vulnerable ones. They are not professionals. Ordinary Mums and Dads have been making the same general point for years to no avail.
        Sw’s just take data and information which happens to lie on their computers, often do not even bother seeing the parents to ask their views, by-pass the need for a child-protection conference attended by GP’s and other medicals,advocates etc. and simply say to parents ‘See you in Court’.
        If the Court finds the LA’s have acted incorrectly, it will make little difference. It has a very wide discretion and will not hold the authorities to account.
        Amy makes the point about her legal team being everything. I agree with her.She had a good one. I imagine she had a barrister.
        Legal representation is vital to vulnerable families and no matter what else you put in the paper,don’t forget to mention it. Adequate legal funding is essential to fair hearings.

        Reply
        1. Amy

          You raise such an important point, Angelo. Would you be surprised to hear my husband is a lawyer? Undoubtedly not.

          We had the advantage of educational and career backgrounds which set us up to engage in this process. Albeit, clumsily in the beginning.

          I support other families now, and for far too many the ability to write a constructive letter is a big hurdle.

          This only causes further communication difficulties and a greater widening of the gap between these parents and professionals.

          I don’t know what can be done specifically, but I feel that a parents ability to spell and their capacity to utilize language constructively should not be an additional check in the box that confirms they have hurt their child.

          I do see how this makes it harder for successful two way engagement. Independent parent support or independent advocacy, or active independent mitigation would be beneficial to help parents participate when they have unfortunately come through life without these skills.

          And I whole heartedly and enthusiastically agree, we need proper fully funded legal aid! That is vital. If the state is going to intervene in family life they must fully fund a families ability to join the conversation on equal footing, defend their rights and ensure justice is upheld.

          Reply
  9. Michelle

    I need some help finding a specialist solicitor that can help me. I can’t afford to pay for it myself and I am not eligible for Legal Aid.

    Some Background:
    I was accused of MSBP at the back end of the 1990s.
    My case got put on hold whilst my eldest daughter had been placed into temporary care (to if her behaviour and amount of seizures would be the same without me) whilst the Test Cases for Sally Clark and Angela Cannings was tested.
    I broke down as I was told by the child Psychiatrist interviewing me for court said that my daughter would no longer remember me because he thought that she would only have a memory span of 2 weeks given the brain damage that happens when she has seizures. He said that I would cause her more upset by having her back with me as she now only knew the new carers.

    There were other things said in court by solicitors, Social Services and medical professionals that caused me to break, I tried to take my own life and indeed up being sectioned for a brief time, the staff on the ward tried to explain that I was too unwell to carry on with any proceedings, but Social Services would not allow any delays. When back in court for an update hearing I was the coerced into ending proceeding by writing a declaration stating I caused my daughter to be the way she was. I should have spotted at the time that they all knew they were wrong because what I wrote was so watery my own solicitor was convinced they wouldn’t accept it. They took a second to say they accepted it. They can’t even have had time to read it.

    I’ve always thought that I would eventually fight back for my daughter, but have struggled with Chronic Migraines, anxiety and PTSD ever since so not been well enough. I just keep getting hurdles put in my way that prevent me getting anywhere.

    There is so much more to my story obviously, but I’m trying to keep this brief. Could anyone offer me some advice/support going forward?

    Reply
    1. Sarah Phillimore Post author

      I am sorry Michelle, this sounds very complicated and difficult. I read that you ‘confessed’ to hurting your daughter but now say you were forced into confessing? This is going to be very difficult to challenge unless you have some clear evidence about that. And even if you did have clear evidence, and you did get your ‘confession’ thrown out, the point made about your daughter still stands – if she has been with other carers for a long time, it may not be possible to get the courts to agree to move her. I am really sorry but this sounds like a massive up hill struggle and you would certainly need specialist advice.
      There may be someone on this list who can help. I am sorry I can’t be more helpful.
      https://childprotectionresource.online/legal-advice/

      Reply

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