Kate Grieve highlights the key guidance and forensic considerations in cases of Fictitious or Induced Illness.
In cases of Fictitious or Induced Illness (FII) a carer, usually the mother, intentionally causes or fabricates illness in a child in her care. Carers may simply exaggerate or fabricate their child’s symptoms by falsifying medical history or tampering with tests in order to make the child appear ill, or they may deliberately induce symptoms through various methods including poisoning, starvation, or suffocation.
Where illness is being induced or fabricated, unnecessary and invasive medical investigations may be carried out causing the child to spend periods in hospital and attend unnecessary medical appointments. This places the child at risk of both significant physical and emotional harm including harm as a result of an abnormal relationship with their carer and disturbed relationships with other family members. The child may also suffer a loss of their personal identity through the adoption of the ‘sick role’.
A paediatrician who suspects FII should have regard to The Royal College of Paediatrics and Child Health (RCPCH) guidance Fabricated or Induced Illness by Carers (FII): a Practical Guide for Paediatricians  (reviewed in 2012) . This Guidance sets out a non-exhaustive spectrum of cases where FII concerns arise. The range includes simple anxiety; misperceived symptoms with genuine belief about the perceived illness; exaggeration or non-treatment of real problems, fabrication, or induction of illness; delusional disorders on behalf of the carer; and unrecognised genuine medical conditions.
The Guidance also sets out indicators which should alert professionals to the possibility of FII, the risks to child, and steps to be taken by the treating professionals including the designation of a responsible paediatric consultant who is responsible for the child’s health and is the key clinical lead for the case providing an overview of treatment.
In 2008 the Department for Children Schools and Families published supplementary guidance to Working Together to Safeguard Children called Safeguarding Children in whom illness is fabricated or induced . Child Protection professionals must have regard to this guidance. In Coventry City Council v X, Y and Z (Care Proceedings: Costs)  1 FLR 1045  1 FLR 1045 the judge was critical of the local authority for failing to follow the procedures recommended in the Guidance.
The National Institute for Health and Care (“NICE”) includes the alerting features of FII in its own guidelines When to suspect child maltreatment: NICE guidelines  published in March 2013. Those alerting features are divided into two, according to the level of concern, with recommendations either to 'consider' or 'suspect' maltreatment: ‘consider’ means that maltreatment is one possible explanation for the alerting feature or is included in the differential diagnosis; to ‘suspect’ means there is a serious level of concern about the possibility of child maltreatment but there is not proof of it.
Practitioners are advised to suspect fabricated or induced illness if a child's history, physical or psychological presentations or findings of assessments, examinations or investigations leads to a discrepancy with a recognised clinical picture and one or more of the following is present: reported symptoms and signs only appear or reappear when the carer is present or are only observed by the carer; an inexplicably poor response to prescribed medication or other treatment; new symptoms are reported as soon as previous ones have resolved; there is a history of events that is biologically unlikely; despite a definitive clinical opinion being reached, multiple opinions from both primary and secondary care are sought and disputed by the carer and the child continues to be presented for investigation and treatment with a range of signs and symptoms; the child's normal daily activities, such as school attendance, are being compromised, or the child is using aids to daily living more than would be expected for any medical condition that the child has.
The RCPCH, Working Together, and NICE Guidance are essential reading for legal practitioners.
FII cases can include very large amounts of medical evidence from a large number of medical institutions. Once in proceedings, obtaining a paediatric overview from an independent expert consultant paediatrician for the purposes of a fact finding hearing can distil this evidence.
The RCPCH Guidance emphasises that ‘the key tool in diagnoses is the [medical] chronology… however the preparation of the chronology should not delay intervention if this would put the child at increased risk of harm’, accepting that the preparation of a chronology is a complex and time consuming task. As such, a chronology may not be available. The court may find a chronology drafted by the legal practitioners helpful when marshalling large amounts of medical and other evidence.
In A County Council v A Mother, A Father, and X.Y, & Z (By their Guardian)  2 FLR 129 at para 44, Mr Justice Ryder held that findings of fact must be based on all available materials, not just on medical materials, no matter how cogent they may seem to be in isolation. Investigations of fact should have regard to the wider context of social, emotional, ethical, and moral factors.
The judge went on to state  that, ‘I have been careful to separate out from the opinion of various professionals: medical, healthcare, and social care, evidence that is no more than opinion or propensity and which has not assisted me to resolve the factual issues, including the diagnoses that are central to this hearing. The assessment of adult credibility as to the responsibility for harming a child remains the function of the court….
‘I venture to suggest that if a court considers the broader context of expert evidence, that is the social, educational, and healthcare history, with the rigour described above, there must be surely be less likelihood of inappropriate reliance on what may transpire to be insufficiently cogent and sometimes frankly incorrect expert evidence even where it is un-ovcontradicted…Paper overviews can artificially limit the contextual material upon which opinion and in particular diagnostic opinion is given and can reduce the quality or cogency of the forensic expert’s opinion by his or her reliance upon multiple hearsay.’
Professor Tim David, in his article Avoidable pitfalls when writing medical reports for court proceedings in cases of suspected child abuse  cited and approved by Ryder J in the above X, Y & Z case, made clear his view that forensic medical practice should mirror clinical medical practice unless there is a good reason not to. This includes the assessor seeing the child and the carer and taking a medical history himself. He makes clear that the assessor should rely upon primary data wherever possible.
However, the reality is that funding constrains work by the consultant paediatrician undertaking a forensic assessment in a case of suspected FII, who, potentially, will approach the task without the assistance of a medical chronology.
The alternative course is for the legal representatives to abandon the paediatric overview and instead focus on a limited number of incidents or a single medical issue and to use that as a ‘decider’. However, this is not without its difficulties as case law makes clear that in cases of suspected fabricate or induced illness the ‘welfare of the child cannot be deduced from any one sole professional perspective….it is a multi-faceted concept’ .
 To see the Royal College's guidance, click here.
 To see the supplementary guidance, click here.
 To see the NICE guidelines, click here.
 At paras 47-49
 www.archdischild.com  799-804
 per Ryder J ibid para 182