Significant harm to a 9-year-old boy over a number of years due to alleged fabricated or induced illness (FII). These concerns became heightened when Child R was placed in foster care where he was seen to flourish, including being fully mobile and eating without medical intervention. Learning includes: agencies, particularly health professionals, may benefit from systems that help recognise FII; when a child is under the care of multiple teams and the diagnosis is unclear, there is a need for a multi-disciplinary team meeting between health professionals; a need for continuing professional curiosity rather than relying on parental response; loss of focus on the harm to the child can occur when concentration on proving FII becomes a distraction; need for a move away from the inability to appropriately challenge parents because of concern about FII; multi-agency representation in strategy discussions is essential so that a full picture of the child's life can be formulated.
      
 Title:  Child safeguarding practice review (CSPR) – Child R 2020. LSCB: Leicestershire and Rutland Safeguarding Children Partnership Author: Margaret Crawford Date of publication: 2022  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                             1    Title: Child Safeguarding Practice Review  (CSPR) - Child R 2020  Safeguarding Children Partnership: Leicestershire and Rutland  Safeguarding Children Partnership  Author: Doctor Margaret Crawford      2  Child Safeguarding Practice Review (CSPR) Child R  Introduction This Child Safeguarding Practice Review (CSPR) relates to a case of potential Fabricated or Induced Illness (FII) and concerns a young child known as Child R. Most of the agencies or organisations providing services to him or otherwise involved in this case were from Leicestershire. The review also involves a hospital from another county as Child R also spent some time being treated by this hospital.  The purpose of a CSPR is to understand what happened and why, so that learning can be identified to support future improvements to safeguard and promote the welfare of children, and this includes the identification of good practice. The overall aim is to learn from what happened to prevent or reduce the risk of similar incidents. It is not undertaken to hold individuals or organisations to account. This CSPR considered any updates to procedures and training that may be required to support practice in relation to FII.  The independent report author of this CSPR, Doctor Margaret Crawford, is a Consultant Paediatrician who has taken a special interest in safeguarding children.  The Terms of Reference meeting for this CSPR identified several strands of work that would be undertaken in order to better understand what had happened in relation to this case and identify how to improve procedures and processes in the future: • Strand 1: An examination of the Health records of Child R. Interviews with key professionals, as necessary, in order to identify any learning relating to this case in relation to FII and the wider Health agencies’ interaction with Child R and his family. This will include identifying any learning in respect of collation and analysis of Health information in future cases to support timely identification of triggers to consider FII or other safeguarding procedures. • Strand 2: An examination of the role of the Police, Children’s Social Care and Health when FII is identified as a potential factor and how planning processes, such as Strategy Discussions, can explore and plan best practice in gathering evidence and pursuing timely single and joint assessment and investigations. • Strand 3: An audit of cases, by identifying a small number of cases that have been referred to Leicestershire Children’s Social Care (CSC) on the basis of concern regarding FII.  The audit focused on: o Evidence of compliance with the updated procedure for FII, introduced in December 2019 o Evidence of good multi-agency information sharing at all points of process applied    3  o Quality of decision making by CSC manager and oversight to process o Action has been taken appropriately to support and protect the child without delay. • Strand 4: All agencies to test the knowledge and confidence of frontline practitioners in responding to cases where FII may be indicated.  Summary of the Case Over a number of years, Child R suffered significant harm because of alleged fabrication or exaggeration of illness. Child R presented with a number of medical issues from soon after birth. These required numerous health interventions with increasing complexity, including being subjected to invasive treatment, therapy and surgery. His care involved many specialisms: Gastroenterology, Paediatric Surgery, Paediatric neurology, allergy, Audiology and Ophthalmology. He received input and treatment from Dieticians, Speech and Language Therapists, Physiotherapists, Occupational Therapists and Community Nurses.  Child R suffered growth failure due to poor nutrition (that included apparent dependence on artificial forms of feeding, moving from naso-gastric feeding to gastrostomy feeds and for long periods of time, intravenous feeding). He experienced limitations with mobility partly due to lack of nutrition but with no underlying medical cause otherwise. These concerns became heightened when Child R was nearly 9 years old when, because of a multi-agency review of his circumstances, he became subject to legal intervention and was placed in foster care where he was seen to flourish, including being fully mobile and eating normally without further medical intervention.  Analysis and Findings The CSPR Panel considered three periods of time: Child R’s birth to Age 2 years 6 months; 2 years 6 months to 5 years old (during this time an initial referral to Social Care was made and a series of Strategy Discussions took place) and 6 to 9 years old, following which the 2nd referral to Children’s Social Care was made. In each of these time periods, the Panel considered reported symptoms and presentations and resulting medical investigations and hospital admissions. Also considered was any parental resistance to advice from health professionals, complaints about health professionals, safeguarding concerns and the voice of Child R. It was acknowledged that fabricated illness is complex and subtle in presentation and may be difficult to identify and presents challenges in planning responses. The findings cover the following learning themes: training, communication (between agencies and between Health professionals, as well as discussion of concerns with carers and experienced practitioners), medical concerns, complaints and schooling: • All agencies, but particularly Health professionals, need support and may benefit from systems that aid the recognition of fabricated illness. The absolute basis of this is that, if any professional is concerned that a   4  presentation may include fabrication, there should be easy access to someone with experience and expertise in planning responses. Within Health, this may be named safeguarding professionals via a senior colleague. • Under new guidelines now in place, when there are alerting signs with no immediate risk to the child’s health (perplexing presentations), the responsible Clinician with appropriate advice may be able to work with the parents/carers to produce a plan that does not lead to continuing over-investigation and possible harm.  • When a child is under the care of multiple teams, there is a need for a Multi-Disciplinary Team (MDT) meeting between Health professionals when the diagnosis is unclear. The MDT should aim to triangulate concerns, opinions and especially reasons for second opinions. While it is noted that this should be easier now that remote meetings are common, there is often great difficulty in getting attendance from essential individuals when more than one centre is involved.1 • There needs to be a flow of information between Health organisations to maintain a focus on accumulative concerns relating to FII.   • There is a need for continuous professional curiosity and professionals need to check in with each other and not just rely on carers passing on information. With all children with complex needs, there needs to be good communication between the professionals involved with their care, not just relying on parental response. • Recognition and confidence in managing FII requires well-coordinated responses both internally within health but also across any other agencies who may know the child. To support this there should be: o Clear guidance relating to managing FII o A clear pathway to FII expertise for advice for practitioners in any organisation when they are concerned about fabricated illness o Regular updating of FII recognition and response in mandatory training o Training of all professionals involved with children.2 • A naso-gastric tube should be regarded as a medical device and treated as such. Responsibility should be with the Practitioner that prescribed it. • When naso-gastric tube feeding commences, there should be a plan and timeline for returning to normal feeding when there is no clear underlying condition requiring continuation.  1 “Perplexing Presentations (PP) / Fabricated or Induced Illness (FII) in Children RCPCH guidance”, Royal College of Paediatrics and Child Health (RCPCH), March 2021, available at https://childprotection.rcpch.ac.uk/resources/perplexing-presentations-and-fii/ Section 5.3 2 Section 10.1 in relation to Health professionals, “Perplexing Presentations (PP) / Fabricated or Induced Illness (FII) in Children RCPCH guidance”.   5  • When a child is under the care of two different Trusts, and it is known that safeguarding supervision is separate, then there is a case for supervision being common to both organisations. • It is easy to lose focus on the harms occurring to the child when considering FII. Concentration on proving FII can be a distraction from placing the needs and welfare of the child at the centre of professional concern and may hinder conversations with parents and lead to delay making referrals for support and safeguarding.  • A Strategy Discussion provides an opportunity for multi-agency information sharing and planning. When a Strategy Discussion is held because of concern about FII, it is important to focus on the harm to the child that is evidenced, rather than identifying or confirming the evidence for FII.  • Good multi-agency representation in Strategy Discussions, including Health professionals involved with the child, the GP, Social Care, Education and Police, is essential when considering FII so that a full picture of the child’s life can be formulated. • Consensus about a child’s state of health needs to be reached between all Health professionals involved with the child and family, including GPs, Consultants, private doctors and other significant professionals who have observation about the child.3 This should include Therapists, Nurses and others together with the views of Education and Children’s Social Care if they have already been involved.   • A health Chronology is an important part of a complex case where FII may be considered. There should be recognition of these as time consuming and that the professionals doing chronologies need the release of a lot of time to do them. This should be emphasised and supported by organisations.4  • There has been an anxiety about the impact of discussing professional concerns relating to FII with parents in the past which was evident at certain periods of the child’s life. There should be a move away from the inability to appropriately challenge the parents because of concern about FII except where challenging will put the child at immediate risk of harm. This is the approach now recommended by the updated guidance on FII. • It is important that those in Education and Social Care, as well as in Health, have appropriate support and expertise available to support frontline practitioners. This will be particularly important when considering multi-agency referrals and responses.   3 Section 5.3, “Perplexing Presentations (PP) / Fabricated or Induced Illness (FII) in Children RCPCH guidance”. 4 Section 7, “Perplexing Presentations (PP) / Fabricated or Induced Illness (FII) in Children RCPCH guidance”.   6  • When a carefully constructed Clinical Management Plan is met with difficulties, and there is parental refusal to cooperate, FII is a consideration. • When safeguarding issues are being raised by one Health professional, it may be time to have a multi-professional meeting to discuss those concerns with joint safeguarding supervision so that all professionals are aware of the individual concerns. • It should be recognised that GPs are the repository of all health information, including private medical opinions which may have been sought, and interrogation of those records and involvement of GPs may provide information not available in any other forum. • With complaints, when there are safeguarding concerns, good liaison between the Complaints Team and Safeguarding Team can lead to a well thought out response without an unsuitable apology.5 • When a complaint is made about an individual professional in any agency, the cause of that complaint may be that there has been a challenge made to the carer with the response aimed to get a less challenging professional. • Change of professionals is a feature of FII. Recording each complaint, minor or major, if achievable would be helpful in recognising the problem and supporting the diagnosis. • There should be a clear pathway for schools to access health professionals when they have concerns and the carer is resistant to allowing that communication. In this situation, where home schooling was happening, there could still have been communication with the education authorities. Actions related to learning and changes in practice The recently updated Royal College of Paediatrics and Child Health (RCPCH) FII Guidance was published during the course of the CSPR. The overarching themes identified by the CSPR Panel were mapped against the new guidance and it was agreed that any changes to local procedures would reflect both the national guidance and the findings of the CSPR. The updated Leicester, Leicestershire & Rutland (LLR) SCP procedure on “Multi-agency management of Medically Unexplained Symptoms, Perplexing Presentations and Fabricated or Induced Illness (FII)” reflects the national RCPCH guidance in: • emphasising the harms that are occurring to the child rather than the need to confirm evidence for FII, with the welfare of the child being at the centre of any discussion  5 Section 10.3, “Perplexing Presentations (PP) / Fabricated or Induced Illness (FII) in Children RCPCH guidance”.   7  • the need for more open discussion with carers (previously in the national guidance, there was emphasis on not sharing concerns about fabrication with parents) • the need for a consensus about a child’s state of health between all Health professionals involved with the child and family, including GPs, Consultants, Private Doctors and other significant professionals who have observations about the child (including those from other agencies if they have already been involved) • the need for responsibility to be taken by a senior medical practitioner regarding the use of a medical device and a plan to stop its use when the reason for the need is not clear – e.g., use of a naso-gastric tube for feeding • dealing with the issue of complaints, which with perplexing presentation/FII are often frequent and vexatious, and the need to support staff when such complaints are made, recognising the emotional trauma that this can cause • the need for good agency representation at meetings of Health professionals and any multi-agency Strategy Discussion  • the need to involve schools in meetings, as appropriate, and the need for a clear flow of information from schools where they have concerns about a child • the need for chronologies when a case reaches the threshold for FII, noting they are extremely time consuming and, in accordance with the new RCPCH guidelines, they are not essential immediately to enable a referral to Social Care. The updated LLR procedure also provides a detailed flowchart to ensure that staff in all agencies, both in the Health sector and other statutory and voluntary agencies, have clear routes to discuss concerns in relation to both perplexing presentations and where there are immediate concerns for child safeguarding from suspicions of FII. Awareness training for relevant staff in all agencies regarding the updated procedure will be directed at a wide range of staff in agencies who both have a potential role in managing cases of FII and perplexing presentations and have staff who may need to have an awareness of this. Conclusions Child R was given excellent medical care with appropriate investigations and management based on the symptoms that were presented. New guidance may aid in earlier action being able to be taken. Changes had already occurred between the first and second referrals to Social Care regarding Child R, with many areas of good practice seen. Between the time of the first referral at nearly 4 years of age and the second referral at age 9 years, there had already been a change of emphasis and procedures that led to good multi-agency management of the situation and the institution of legal proceedings when this became necessary. The case of Child R is extremely complex. As is usual in complicated cases of FII, it has led to a number of findings. These have been managed by an action plan. The issues raised by the findings have been dealt with in the local sub-region by the   8  introduction of the new “Multi-agency management of Medically Unexplained Symptoms, Perplexing Presentations and Fabricated or Induced Illness” procedures.    