“a child’s symptoms, of which the child complains and which are presumed to be genuinely experienced, are not fully explained by any known pathology. The symptoms are likely based on underlying factors in the child (usually of a psychosocial nature). MUS can also be described as ‘functional disorders’ and are abnormal bodily sensations which cause pain and disability by affecting the normal functioning of the body.” b. Perplexing Presentations (PP): “the commonly encountered situation when there are alerting signs of possible FII (not yet amounting to likely or actual significant harm) when the actual state of the child’s physical, mental health and neurodevelopment is not yet clear, but there is no perceived risk of immediate serious harm to the child’s physical health or life. The essence of alerting signs is the presence of discrepancies between reports, presentations of the child and independent observations of the child, implausible descriptions and unexplained findings or parental behaviour.” c. Fabricated or Induced Illness (FII): “a clinical situation in which a child is, or is very likely to be, harmed due to parent(s’) behaviour and action, carried out in order to convince doctors that the child’s state of physical and/or mental health or neurodevelopment is impaired (or more impaired than is actually the case). FII results in emotional and physical abuse and neglect including iatrogenic harm.”
“In the child • Reported physical, psychological or behavioural symptoms and signs not observed independently in their reported context • Unusual results of investigations (e.g. biochemical findings, unusual infective organisms) • Inexplicably poor response to prescribed treatment • Some characteristics of the child’s illness may be physiologically impossible e.g. persistent negative fluid balance, large blood loss without drop in haemoglobin • Unexplained impairment of child’s daily life, including school attendance, aids, social isolation. Parent behaviour • Parents’ insistence on continued investigations instead of focusing on symptom alleviation when reported symptoms and signs not explained by any known medical condition in the child • Parents’ insistence on continued investigations instead of focusing on symptom alleviation when results of examination and investigations have already not explained the reported symptoms or signs • Repeated reporting of new symptoms • Repeated presentations to and attendance at medical settings including Emergency Departments • Inappropriately seeking multiple medical opinions • Providing reports by doctors from abroad which are in conflict with UK medical practice • Child repeatedly not brought to some appointments, often due to cancellations • Not able to accept reassurance or recommended management, and insistence on more, clinically unwarranted, investigations, referrals, continuation of, or new treatments (sometimes based on internet searches) • Objection to communication between professionals • Frequent vexatious complaints about professionals.”
“… there has to be factored into every case which concerns a discrete aetiology giving rise to significant harm a consideration as to whether the cause is unknown. That affects neither the burden nor the standard of proof. It is simply a factor to be taken into account in deciding whether the causation advanced by the one shouldering the burden of proof is established on the balance of probabilities.”
"how often have I said to you that, when you have eliminated the impossible, whatever remains, however improbable, must be the truth?"
"Propensity - the correct question/what requires to be proved? 39. A distinction must be recognised between, on the one hand, proof of a propensity and, on the other, the individual underlying facts said to establish that a propensity exists. In a case where there are several incidents which are relied on by the prosecution to show a propensity on the part of the defendant, is it necessary to prove beyond reasonable doubt that each incident happened in precisely the way that it is alleged to have occurred? Must the facts of each individual incident be considered by the jury in isolation from each other? In my view, the answer to both these questions is "
“Incident occurred why: multiple line infections and displacements. Why did this happen? Inherent increased risk of central line infections amongst patients who have complex gastrointestinal problems and also receiving parental [sic] nutrition. Audit of practice and observation of staff performing care did not reveal any issues. Extensive literature review of practice and discussion with colleagues in other centres did not reveal a single causative factor. Lack of documentation detailing care and management of central lines in several areas of the Trust. This did not allow staff to ensure the guideline was adhered to. Changes in practice and evidence base necessitated the Trust policy requiring updating. Patient Factors: The two patients examined both had complex gastrointestinal medical needs requiring long term PN. It is well documented that central line infections in this population of patients is high … HS developed behavioural issues involving chewing and tugging his line .. it is also of note BR had her PN line found to be disconnected twice and leaking on a separate occasion due to a cracked bung once. Parafilm was used to try to prevent this which has limited evidence of its use. Individual staff factors: All staff involved … had received training and been deemed competent in the care and management of central venous access lines. This was demonstrated in a snapshot audit… PN practice had changed prior to these incidents and although all staff had received training it was reportedly causing staff stress… Team factors: a major contributory factor is that there is no unified approach to central line management. This starts with the surgical team …. There is no consistency or clear guidance with regards to infected lines being removed and appropriate time for new ones being inserted. This fragmented care pathway leads to confusion and a lack of evidence based care. Root Causes: It has not been possible to identify a root cause for the apparent increased incidence of central line infections in the two patients investigated.”
“ Follow RCPCH guidance for perplexing illness, including aim to introduce feeds and remove lines if possible as part of health rehabilitation plan (Gastro team – led by Drs SAN, SB and SAA). If further episodes of vomiting / diarrhoea or other symptoms investigate with toxicology etc. and professional curiosity as to possible FII cause rather than organic cause (Gastro team – led by Drs SAN, SB and SAA, supported by Dr SAC and safeguarding team). Gather chronologies for 2 cases HS and LW (led by Dr SB and Dr SAN) . Move HS and LW to separate wards tomorrow. MDT discussion with HS’s mother to discuss perplexing illness openly and ward relocation – suggested to be held with Dr SB/SW/nursing prior to ward move. MDT discussion with LW’s mother to discuss perplexing illness openly and ward relocation – suggested to be held with Dr SAN/nursing prior to ward move. Dr SW to also assist with this conversation or another professional – wasn’t clarified. Meet again next week to update (Dr SI will organise)” Meet again next week to update (Dr SI will organise)”
“agreement that LW’s case was complex given his history” and “agreement that mother was right not to pursue bowel transplant” but those do not appear to me to be factors that weigh in favour of a finding of FII. Dr Ward also raised the presence of ibuprofen but noted that it was “difficult to distinguish in this case” between genuine problems and associated anxiety, and FII. i. As for “factors pointing away from FII” the agreed response of the experts was, “All agree that the evidence supports FII”
“It is very unusual for a parent actively to seek palliation as a route for their child and I have never seen this in my career to date. Throughout my relationship [with MT] an apparent lack of emotion was evident and I found her manner very cold and clinical.”
“unanimous agreement between professionals that bowel transplant wouldn’t be in his best interests as success rate is low with high chances of morbidity pre and post transplant.”
“The likelihood of the mother removing the line could not be ignored .. The only way of removing the mother, as the legal guardian, from HS’s room was to make a formal report to Social Services and The Police. This I did ….”
“strong adhesive dressing was used which nurses would have to use alcohol wipes to life the adhesive in stages … There was no possibility, in my view, that HS would be able to remove the dressing… [after the line detachment] the strong adhesive dressing had been peeled back … I believed that HS was physically unable to remove the dressing and the central line ….”
“IO: How has it been having a child in the hospital for so long? MT: It’s been bloody hard.”