7 Point Briefing: Theo - suspected fabricated and induced illness
Background
Theo is a 7-year-old boy, of white British background. Theo was an in-patient in hospital when a referral was made to the local authority raising concerns due to suspected fabricated and induced illness. Theo has a diagnosis of autism, and a history of complex health needs. Theo has an education, health and care plan (EHCP) and attended a special school due to his needs. Theo has missed a lot of education due to hospital admissions.
Since infancy, Theo has reportedly experienced significant health difficulties which have resulted in extensive investigations and invasive treatments. Although no medical cause had been found for Theo’s reported symptoms, he had experienced tube feeding, intravenous feeding, and a wide range clinically unexplained symptoms, and medical symptoms remaining unresolved with usual treatment. Theo has been described as ‘failing to thrive’ due to persistent weight loss/inadequate weight gain. Theo’s mother is reported to have sought surgical treatment and multiple opinions from a wide range of hospitals, there were concerns that Theo’s feeding tubes were being interfered with, and there was an unexpected positive toxicology finding that was not thought to be attributable to prescribed medication.
A strategy meeting was convened, and due to the significant harm suspected, a notification was made to the National Panel by the Local Authority. The City of York Safeguarding Children Partnership instigated the Rapid Review Process.
Following the making of an Interim Care Order, Theo’s time with his mother was limited and supervised. Following this change, Theo made a swift and significant recovery from all symptoms, and within a few days was eating and drinking normally. Theo was placed in foster care where he continues to thrive.
Areas of good practice highlighted
The school advocated effectively for Theo’s expressed wish to being school and achieved an expediated transition to full time education when Theo was first allocated a place.
Education colleagues were diligent in recording Theo’s presentation, comments and wishes, and in sharing these with health and social care colleagues. The social worker worked to understand Theo’s lived experience through conversation, observation, inference and mentalization (imagining things from his perspective).
Early identification of need and support through early help.
A social work assessment undertaken during a previous period of involvement was thorough and robust. The social worker demonstrated professional curiosity in understanding why Theo was underweight and failing to thrive. The social worker sought medical advice to understand more about Theo’s needs.
The referral from the Consultant Paediatrician was detailed which enabled partners to come together quickly. A child protection medical report was undertaken swiftly.
Police and social care worked closely together to facilitate family time.
All agencies referred to the North Yorkshire and City of York Safeguarding Children’s Partnership Guidance ‘Perplexing presentations, fabricated and/or induced illness in children’.
Key Learning Points
The following multi-agency learning points were identified as part of the Rapid Review Process:
Learning Point 1 - Child Voice
Where concern are identified in relation to perplexing presentation or fabricated and induced illness, agencies should work collaboratively and strategically to understand the child’s lived experience. This may be achieved through specific consideration of the child’s voice in any reviews/ meetings, including any barriers associated with ascertaining this, and how these may be overcome, and the identification of actions related specifically to understanding the child’s lived experience from their perspective e.g. via direct work.
Learning Point 2 - Engaging Fathers
Little was known about Theo’s paternal family. There could have been more exploration in assessments about the role of Theo’s father, and the impact on Theo’s wellbeing and sense of identity.
Learning Point 3 - Networks
There could have been greater exploration of the family’s support network, their sense of belonging within their community and Theo’s mother’s experiences, beliefs and narratives related to parenting and health.
Learning Point 4 - Practice Guidance
Regular review meetings with health practitioners involved such as lead consultant and , including education, GP and children’s social care colleagues (where there is prior involvement) may have assisted with the collation of information about what was happening for Theo earlier. While clear effort was made to apply the guidance, it was agreed that timescale expectations and review ( within 3 months ), clearer ownership of the process and actions, might have created more opportunities for multi-agency re-evaluation of concerns. A clearer process with distinct evaluation points may have provided a more robust opportunity to draw on the partnership’s collective expertise.
Learning Point 5 - Information sharing
Information about concerns related to perplexing presentations was not shared with Theo’s GP. Some information was not shared with Theo’s school which impacted their understanding of safeguarding concerns related to his care.
It is essential that minutes from meetings and health chronologies are shared with Primary Care.
Learning Point 6 - Triangulation
Information gathered for assessments should always triangulate the accounts of parents with other professionals working with the family (as well as others in the network) irrespective of how plausible the information appears to be.
Learning Point 7 - Professional Challenge
Agencies reflected on the importance of professional curiosity and of professionals at all levels being able to give and receive respectful challenge. This is important to create opportunity to explore competing and alternative hypotheses, and to minimise the potential for perceptions of hierarchy, power and expertise to be a barrier to expressing challenge.
Next Steps
A multi-agency action plan has been produced and monitored by the Case Review Subgroup.
Useful resources and further reading
Perplexing Presentations and Fabricated and/or Induced Illness in Children.