13.13 Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in children

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Contents

• 1. Introduction(Jump to)
• 2. Definitions(Jump to)
• 3. Harm to the child(Jump to)
• 4. Alerting Signs/Recognition(Jump to)
• 5. Response(Jump to)
• 6. Referral(Jump to)
• 7. Initial Consideration of Referral(Jump to)
• 8. Strategy Meetings and S47(Jump to)
• 9. Pre-birth Consideration(Jump to)
• Appendices(Jump to)

1. Introduction

Since the publication of the Royal College of Paediatrics and Child Health (RCPCH) guidance on Fabricated or Induced Illness by Carers (FII) in 2009, there have been significant developments in the field. The RCPCH Child Protection Companion 2013 extended the definition of FII in 2013 by introducing the term Perplexing Presentations (PP) with new suggestions for management.

This new RCPCH guidance here provides procedures for safeguarding children who present with perplexing presentations and FII and offers practical advice for paediatricians on when and how to recognise it, how to assess risk and how to manage these types of presentations in order to obtain better outcomes for children.

What is covered in this guidance?

• Updated terminology and definitions for PP, FII and Medically Unexplained Symptoms (MUS)
• Features of PP and FII including the relationships between parent, doctor and child, and alerting signs of possible FII
• Response to alerting signs
• Developing and implementing a Health and Education Rehabilitation Plan
• When to refer to children’s social care and how to escalate concerns.

These SSCP procedures are derived from the RCPCH (Royal College of Paediatrics and Child Health) guidance published in March 2021. The full guidance can be accessed here

2. Definitions

See Appendix A

3. Harm to the child

Harm to the child from FII/ PP takes several forms. Some of these are caused directly by the parent, intentionally or unintentionally, but may be supported by the doctor; others are brought about by the doctor’s actions, the harm being caused inadvertently.

The following three aspects need to be considered when assessing potential harm to the child. As FII is not a category of maltreatment in itself, these forms of harm may be expressed as emotional abuse, medical or other neglect, or physical abuse. There is also often a confirmed co-existing physical or mental health condition with the child.

A. Child’s health and experience of healthcare

• The child undergoes repeated (unnecessary) medical appointments, examinations, investigations, procedures and treatments that may be experienced as physically and psychologically uncomfortable or distressing.
• Genuine illness may be overlooked due to repeated presentations.
• Illness may be induced by the carer (e.g., poisoning, suffocation, withholding food or medication and potentially threatening the child’s health or life).

 B. Effect on the child’s development and daily life

• The child’s education is limited or interrupted.
• The child’s normal daily life activities are limited.
• The child assumes a sick role – e.g., with the use of unnecessary aids such as wheelchairs.
• The child is socially isolated.

 C. Child’s psychological and health-related wellbeing

• The child may be confused or anxious about their state of health.
• The child may develop a false self-view of being sick and vulnerable.
• Adolescents may embrace this and may then become the main driver of the behaviour. Social media may encourage this.
• There may be active collusion with the carer’s behaviour.
• The child may be silently trapped in the falsification.
• The child may later develop a psychiatric disorder or psychosocial difficulties.

4. Alerting Signs/Recognition

Alerting signs of FII are not evidence of FII. However, they are indicators or possible FII (not yet amounting to likely or significant harm) and if associated with possible harm to the child, they amount to general safeguarding concerns. 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 behaviours.

Professionals may be concerned at the possibility of a child suffering Significant Harm as a result of having illness fabricated or induced by their carer.

Alerting signs to possible FII are:

A. In the child

• Reported physical, psychological or behavioural symptoms and signs not observed independently in their reported context by any professional.
• 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.

 B. Parent/ Carer 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 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.
• Not letting the child be seen on their own.
• Talking for the child / child repeatedly referring or deferring to the parent
• Repeated or unexplained changes of school (including to home schooling), or GP or of paediatrician / health team.
• Factual discrepancies in statements that the parent makes to professionals or others about their child’s illness.
• Parents pressing for irreversible or drastic treatment options where the clinical need for this is in doubt or based solely on parental reporting.

5. Response

Concerns about a child’s health should be discussed with a health professional who is involved with the child such as the school nurse, GP or paediatrician. If alerting signs are present, they should be discussed with the Named Doctor, Named Nurse or Health safeguarding team. Alerting signs do not amount to fabrication but require further investigations to see if the child has an underlying illness.

If any professional considers their concerns are not taken seriously or responded to appropriately, these should be discussed with the Designated Doctor or Designated Nurse (see also Surrey Health Service Contacts). The Surrey FaST process (FAST escalation policy) should also be referred to.

If any concerns relate to a member of staff, these should be discussed with the relevant Named or Designated Professional and the SSCP Allegations Against Staff, Carers and Volunteers Procedure should be followed.

If alerting signs are found in primary care or by education or allied health professionals in the community, it is appropriate that a referral is made by the GP to a paediatrician/CAMHS professional, as the resolution lies in ascertaining the actual state of the child’s health.

One of two courses of action need to be followed depending on whether there is or is not an immediate serious risk to the child’s health/life.

5.1 Immediate serious risk to child’s health / life

The child may be at immediate risk of serious harm, particularly by illness induction. This is most likely to occur when there is evidence of frank deception, interfering with specimens, unexplained results of investigations suggesting contamination or poisoning or actual illness induction, or concerns that an open discussion with the parent might lead them to harm the child. In this situation:

An urgent referral must be made to the police and children’s social care as a case of likely significant harm due to suspected or actual FII, and this should lead to a strategy discussion that includes health representatives as per SSCP guidance.

The safety of siblings also needs to be considered.

Securing any potential evidence (e.g. feed bottles or giving sets, nappies, blood/urine/ vomit samples, clothing or bedding if they have suspicious material on them).  This should be done in consultation with the police.  

Documenting concerns in the child’s health records (e.g. ‘this unusual constellation of symptoms, reported but not independently observed, is worrying to the extent that, in my opinion, there is potential for serious harm to the child’). This is important in case the child is seen by other clinicians who are not aware of the concerns.

Considering whether the child is in need of immediate protection and measures taken to reduce immediate risk.

All practitioners should be mindful of situations where to inform the parents of the referral would place a child at increased risk of harm.  In this situation, carers would not be informed of the referral before a multiagency discussion has taken place. This would usually be in the form of a formal strategy discussion. Information sharing: advice for practitioners (publishing.service.gov.uk); Surrey Multi-Agency Information Sharing Protocol

Urgent protection of the child would require contacting Police on 999 who can then use their police protection powers. In addition, a referral to Children’s services should be made.

 5.2 Alerting signs with no immediate serious risk to the child’s health / life – Perplexing Presentations (PP).

Paediatricians should refer to the relevant section the RCPCH Child Protection Companion and RCPCH. The procedures are derived from the RCPCH guidance published in March 2021. The full guidance can be accessed here

The term Perplexing Presentations (PP) denotes the presence of alerting signs to possible FII, in the absence of the likelihood of immediate serious risk to the child’s physical health or life. Perplexing Presentations nevertheless indicate possible harm to the child which can only be resolved by establishing the actual state of health of the child. They therefore call for a carefully planned response. This will be led by the responsible clinician (Responsible Paediatric Consultant or Child Psychiatrist) with advice from the Named Doctor.

The essence of the response is to establish the current state of health and functioning of the child and resolve the unexplained and potentially harmful situation for the child. The term Perplexing Presentations and management approach can and should be explained to the parents and the child, if the child is at an appropriate developmental stage. Reflecting with parents about the differing perceptions that they and the health team have of the child’s presenting problems and possible harm to the child may be very helpful in some cases, particularly if it is done at an early stage.

If the initial concerns arise directly from school as opposed to health, it is recommended that school explain to the parents that information is required from health to understand the concerns e.g., poor school attendance. It is then appropriate for either the parents or education to contact health (either GP, consultant paediatrician or child psychiatrist) with their query about the actual health of the child. If the parents do not agree to a health assessment and the sharing of information about the child, we recommend that schools then follow their internal safeguarding policies. Professionals should refrain from using FII terminology, as the state of the child’s health has not yet been assessed.

If primary healthcare is the only contact for the child, then the GP should refer to a paediatrician for further assessment of the child’s health. If concerns arise within General Practice, we recommend that there should be consultation with the Named GP for Safeguarding Children.

If the response from health is felt to be inadequate, then the SSCP escalation process should be followed. 7.2 The Surrey FaST Resolution Process

If at any stage new information should come to light to suggest the child is currently suffering significant harm, then a referral to Children’s Services (and Police if immediate protection is required) must be made.

Response to Perplexing presentations:

A responsible Paediatric Consultant or Child Consultant Psychiatrist should be identified with advice from the Named Doctor and the health safeguarding team (who do not have clinical responsibility for the child).

Responding to PP requires a multidisciplinary approach, although the Responsible Consultant continues to have overall clinical responsibility for the child and that the background safeguarding processes are supported by the Named Doctor and the health safeguarding team. The Designated Doctor may need to provide appropriate support in these challenging cases.

The essence of management is establishing, as quickly as possible, the child’s actual current state of physical and psychological health and functioning, and the family context. The Responsible Consultant will need to explain to the parents and the child (if old enough) the current uncertainty regarding the child’s state of health, the proposed assessment process and the fact that it will include obtaining information about the child from other caregivers, health providers, education and social care if already involved with the family, as well as likely professionals meetings. Wherever possible this should be though working collaboratively with the parents. If they do not give agree for this to happen, the parents’ concerns about this process should be explored and can often be dispelled. However, under the NHS’ interpretation of General Data Protection Regulations (GDPR) for the UK information sharing can take place without consent if: there are safeguarding concerns, it is in the best interests of the child, is necessary and proportionate and is done in a manner according to the Art 34, GDPR. Strong parental objections could indicate a referral to children’s social care on the grounds of medical neglect; that the doctors are unable to establish the state of health and medical needs of the child.  When paediatricians become concerned about a perplexing presentation, an opinion from a tertiary specialist may be necessary. Parents themselves may request another opinion and it is their right to do so. However, this opinion given should be supplied with all the background information to help in informing the opinion and to avoid the repetition of investigations unnecessarily. The seeking of multiple alternative opinions, particularly when there has already been a reasonable diagnostic formulation, is almost always harmful to the child and may well increase concern about FII. There may need to be one or more professionals’ meetings to gather information, and these can be virtual meetings. Where possible, families should be informed about these meetings and the outcome of discussions as long as doing so would not place the child at additional risk. Care should be given to ensure that notes from meetings are factual and agreed by all parties present. Notes from meetings may be made available to parents, on a case-by-case basis and are likely to be released to them anyway should there be a Subject Access Request for the health records according to the agencies Information Governance Policies and in line with guidance on sharing 3^rd party information.

For some cases the key to differentiating between erroneous and true reports of symptoms and signs is a period of close or constant observation of the child. This can be overt observation by a nurse or other professional (e.g. teacher), not covert surveillance. For all cases but especially out-patient cases, as many sources of information as possible should be gathered, in particular the child’s functioning at school.

If careful medical assessment suggests that the child does not have any medical condition or a medical condition is exaggerated or appears misunderstood then the symptoms are ‘medically unexplained’ this can be presented to the child’s family as ‘good news’, with reassurance that most children either spontaneously improve over time with or without a clear medical (and educational plan if necessary) plan for support/rehabilitation and that no further investigations or treatments will be initiated unless the situation objectively changes.

A plan for rehabilitation of the child to normal activities, stopping any current unnecessary medical treatment and ongoing medical monitoring will be needed.

Involvement of MindWorks Surrey Mindworks may be helpful; in particular the family may need to be helped to think through how their lives will be different if the child is no longer ‘ill’ and be helped to construct a credible narrative about the child’s ‘recovery’.

After attempting a reassuring, non-invasive approach to the perplexing symptoms and reported signs or the parents do not support the Health and Education rehabilitation plan (HERP),  if the carers reject the doctor’s hypothesis and insist on further intervention or further opinions, or if they ‘sack/dismiss’ the doctor concerned and demand a change of doctor, or if the child develops new and unexplained physical symptoms or signs (e.g. faltering growth) or reported non-physical symptoms, e.g. anxiety, autism etc. then a judgment will need to be made as to whether a child safeguarding referral needs to be made. The views of the child should be ascertained if possible, ideally without the parents/carers present.

If a further medical opinion is sought it is important that the person giving the opinion is fully aware of the background and concerns. Clinicians should never allow themselves to be dictated into arranging tests or treatments that are not clinically indicated.

It is important that the situation for the child is resolved and that they are able to return to a more normal lifestyle. If that does not happen, despite attempts by the treating team to help, or if contact is broken so that no information is available, a safeguarding referral is indicated.

In a minority of cases, there may be clear evidence that the carer is an unreliable historian. If, for example, aspects of the history have been convincingly proven not to be true, mutually exclusive accounts have been given, the history is medically implausible and cannot be attributed to parental anxiety, limited ability or disordered health beliefs, then that is a significant risk factor that requires referral under safeguarding procedures.

5.3 Medical Evaluation

5.3.1 The role of the Paediatrician:

• Obtain history from parents or care givers or and or other significant adults who have a good understanding of the child’s life or can represent the voice of child
• Verify any significant pregnancy, birth and postnatal history from records
• Explore parent’s views of their child’s health difficulties and the impact of this on the family and family functioning
• Explore the parent’s support network including social media and support groups.
• Determine whether there is current early help, social work involvement or other professional involvement. If yes, then involve them in a discussion about emerging health concerns. If no, consider whether a referral into these avenues of support would be appropriate.
• Ascertain the health and wellbeing of any siblings.
• Explore with the child alone (if of an appropriate developmental level) their own view of their symptoms, their beliefs about the nature of their illness, any worries or anxieties, mood and wishes
• Observe contrast in verbal/non-verbal communication when alone in appointments compared to the parent being present (where possible

For further details please see The RCPCH guidance here.

5.3.2. The responsible Paediatrician should (with the support of the health safeguarding team as appropriate.)

1. Review the Childs Health and wellbeing:

• Collate all current medical/health involvement in the child’s investigations and treatment, including from GPs and private doctors, with a request for clarification of what has been reported and what observed. This is not usually a request for a full chronology, which would need to include all past details of health involvement and which is often not relevant at this point. This should be supported by the Safeguarding Teams.
• Ascertain who has given reported diagnoses and the basis on which they have been made
• Consider inpatient admission for direct observations of the child
• Consider whether further definitive investigations or referrals for specialist opinions are warranted or required.
• Obtain information about the child’s current functioning, including; school attendance, attainments, emotional and behavioural state, peer relationships, mobility, and any use of aids. It is appropriate to explain to the parents the need for this. If the child is being home schooled and there is therefore no independent information about important aspects of the child’s daily functioning, it may be necessary to find an alternative setting for the child to be observed (e.g. hospital admission).
• Any child who is home educated should be confirmed with the Surrey Education Service to ensure this is the approved option for the child - General information about educating your child at home - Surrey County Council (surreycc.gov.uk)

This should include obtaining medical information from all private providers (if relevant). All doctors whether practicing privately or in the NHS have a duty to ensure they maintain their competencies as regards to safeguarding children and adults and all are bound by GMC standards.

       2. Parents’ views

The responsible paediatric consultant should (with the support of the health Safeguarding team):

• Obtain history and observations from all caregivers, including mothers and fathers; and others if acting as significant caregivers.
• Verify any significant pregnancy, birth and postnatal history from records
• Explore the parents’ views, including their explanations, fears and hopes for their child’s health difficulties.
• Explore family functioning including effects of the child’s difficulties on the family
• Explore the parent’s support network including social media and support groups.
• Ascertain whether there has been, or is currently, involvement of early help services or children’s social care. If so, these professionals need to be involved in discussion about emerging health concerns.
• Ascertain the health and wellbeing of any siblings.
• Explore a need for Early Help support and refer to children’s social care on a Child in Need basis, where appropriate depending on the nature and type of concerns, with consent from parents.

       3. Child’s view

• The responsible paediatric consultant should try to explore the child’s view alone (if of an appropriate developmental level and age) to ascertain: - the child’s own view of their symptoms; the child’s beliefs about the nature of their illness; worries and anxieties; mood; wishes.
• Observe contrast in verbal/non-verbal communication when alone in appointments compared to the parent being present (where possible)

5.4 Reaching a consensus

The aim of the full medical and psychosocial view is to again clarity about any verified illnesses and remaining perplexing presentations.

• A multi professionals meeting should be chaired by the Named Doctor to determine the consensus. If the Named Doctor is the child’s main Paediatrician then another clinician experienced in safeguarding should chair the meeting. Parents should be aware of the meeting and should receive the consensus conclusions.
• The decision should be either:

The perplexing presentation can be explained by verified conditions or medically unexplained symptoms emanating from the child, there are perplexing elements, but the child will not come to harm as a result OR

There is a concern that the child is coming to harm by fabrication of symptoms by their parent or by their fixed erroneous beliefs about the child’s health

The meeting should agree:

• Whether further investigations or further medical opinion is sought
• How to support the family and child function using a Health and Education Rehabilitation Plan (Appendix A). The parents should be given the opportunity to contribute to the proposed plan.
• The health needs of siblings.
• Requesting an acute Consultant Paediatrician if not already involved.
• Next steps in the eventuality that parents disengage or request a change of paediatrician in response to the communication meeting with the Responsible Paediatric Consultant about the consensus reached and the proposed Health and Education Rehabilitation Plan.
• All records of key discussions and safeguarding supervision should be kept in each organisation’s records. If there is more than one health record a flagging system should be in place.

5.5 Escalation:

If disagreements remain between Health professionals, then the Named or Designated Doctor should convene a Health Professionals meeting to agree on the health issues. The Designated Doctor can only undertake this role if they have not had any clinical involvement. 

The SSCP FAST Resolution process policy should be used if concerns remain.

 7.2 The Surrey FaST Resolution Process

5.6 Communicating outcomes with parents:

The consensus should be shared with the parents at a meeting by the responsible Consultant, they will be supported by a member of the Safeguarding Children Team or another Consultant.

The child’s genuine issues or concerns (not diagnoses) should be acknowledged and it should be clear to the parents that a diagnosis may/may not have implications for the child’s functioning.

The current consensus should be shared. It should be acknowledged that this may differ from what they have previously been told and may differ from their views or beliefs

The Health and Education Rehabilitation Plan (HERP) (Appendix B should be completed with the family and child (if sufficiently mature). This should be discussed and shared with the GP by the Paediatrician. The plan should be led by Health usually as the lead agency but may also involve Education and possibly Children’s services. Consideration should be given to what support the family may require to help them work alongside the professionals and this may include psychological support and / or a referral to Children’s services for additional support.

Psychological support should aim to:

• Help the child to adjust to a better state of health, by using coping strategies for symptoms with a cognitive behavioural approach. The child might also need support for the loss of gains associated with being a sick child
• Help the child and the family, including the siblings, to construct an account which explains the evolution of the child’s difficulties as well as the improvement in the child. This needs to be truthful and may be distressing to the child who will need support
• Explore the parent’s motivations, including: anxiety, compassion, beliefs, fulfilment of needs, and the implications and likely changes for the parent when the child’s state of health is improved, and the child is functioning optimally. This will require helping the parent to adjust to having a well or better child
• Consider the need for referral of the parent by the GP to adult mental health services. This is in order for both the parent and professionals to better understand the nature of the parent’s actions, any mental health diagnoses, motivations, prognosis and likely capacity to change, indication of treatment to effect change and who is likely to provide treatment
• The paediatrician should not discharge the child from their care until there is evidence that rehabilitation is proceeding.
• Where the child has been identified as suffering actual of likely harm as a result of FII, the Paediatrician needs to determine as a result of this discussion whether the parents recognise the harm and are able to change their views and beliefs.

If the Paediatrician has concerns that the parents do not accept the consensus opinion, or they feel they have insufficient information to determine the risk of harm then a consultation and referral to the Local Authority should be considered at this point to enable a multi- agency discussion with the parent’s consent. No additional review by an alternative Paediatrician will be offered

• What to include in a Health and Education Rehabilitation plan (HERP) (Appendix B):

• Clear timescales and intended outcomes for all actions.
• Responsible clinicians, clarify all professionals roles, including the GP and the role of the social worker if involved
• Considerations of any safeguards including alerts on systems to notify professions of repeated attendance, for example frequent presentations to ED
• Rationalisation and co-ordination of the child’s care
• Re-establishment of optimal education
• Is psychological support required for the child/parents?
• Review of the plan against improvement of the child’s functioning

If the child is on a CPP or CIN plan the HERP plan should be embedded in the child’s social care plan which will be reviewed by the allocated social worker. However, the responsibility of reviewing the HERP will be led by the health Lead Professional alongside education and social care.

It is important that the HERP is reviewed regularly by the lead health professional with the family until the outcomes are all completed, and the child is able to function at optimal health and any previous alerting signs are no longer apparent.  

6. Referral

When a possible explanation for the signs and symptoms is that they may have been fabricated or induced by a carer and as a consequence the child’s health or development is or is likely to be impaired, a referral should be made to the Surrey Children's Services in accordance with the Contacts and Referrals Procedure. 

If the parents disagree with the consensus feedback and the Health and Education Rehabilitation plan (HERP – Appendix B), then a referral should be made to Surrey Children’s services on basis that the child’s functioning and/or development is being impaired, and any harm caused has become significant.  The nature of the harm should be made clear, i.e. Physical, emotional, neglect and the impairment on the child’s health or development. The referral should state;

• Any verified diagnosis and functional implications of the diagnosis(es) for the child
• The nature of the concerns
• Detail all independent observations, all medical services involved, and the consensus professional views about child’s state of health.
• Information about what has been provided to carers and their response.
• Full description of the harm to the child (and siblings).

A full chronology will be required but may not be required immediately and may delay the referral and place the child at increased risk.

A chronology (Appendix D) should include the following information:

• Source of the entry
• What actually happened/ or was observed by whom/what was said
• The analysis.

Whilst professionals should in general, discuss any concerns with the family and, where possible, seek agreement to making referrals to Surrey Children's Services, this should only be done where such discussion and agreement-seeking will not place a child at increased risk of significant harm or jeopardize a criminal investigation.

If the child is at imminent risk of significant harm, then the police should be contacted by 999. Any suspected case of fabricated or induced illness may also involve the commission of a crime and the Police will take responsibility for deciding whether to initiate a criminal investigation.

7. Initial Consideration of Referral

As with all other referrals, Surrey Children's Services should decide within one working day what response is necessary.

Whilst Surrey Children's Services has lead responsibility for action to safeguard and promote the child’s welfare, the decision should be taken in consultation with the Responsible Paediatric Consultant who is responsible for the child’s health care and the Police

This decision-making process must agree what action needs to be taken, by whom and within what timeframe.

All decisions about what information is shared with parents should be taken jointly, bearing in mind the safety of the child.

The possible outcome of referrals is the same as for any other referrals (see the Contacts and Referrals Procedure).

If emergency action is the required response, e.g. if a child’s life is in danger through poisoning or toxic substances being introduced into the child’s blood stream, an immediate Strategy Meeting should take place, where possible, between Surrey Children's Services, Police, Health and other agencies as appropriate. The Responsible Paediatrician should be invited to the Strategy meeting where possible. Decisions about possible immediate action to protect the child should be kept under constant review. A police protection may be required.

If the referral is declined as not reaching the threshold for Children’s social care involvement, then every effort should be made to understand each other’s professional opinions. Named and Designated Health professionals’ advice should be sought. The SSCP FAST Resolution process policy should be used if concerns remain. 7.2 The Surrey FaST Resolution Process

8. Strategy Meetings and S47

If there is reasonable cause to suspect the child is suffering, or likely to suffer significant harm, Surrey Children's Services should convene and chair a Strategy Meeting involving all the key professionals.

Please refer to 4.8 Strategy Discussions and Section 47 Enquiries

Wherever possible, prior to the Strategy Meeting, each agency should provide a written chronology of significant events indicating Perplexing Presentation, Suspected Fabricated or Induced illness concerns they have had with the child and family.  A more detailed chronology may be requested from all agencies to provide the best possible information for the decision-making process.

It may be necessary to have more than one Strategy Meeting. This is likely where the child’s circumstances are very complex and a number of discussions are required to consider whether and, if relevant, when to initiate a Section 47 Enquiry and/or a Police investigation.

Any evidence gathered by the Police should be available to other relevant professionals, to inform discussions about the child’s welfare and contribute to the Section 47 Enquiry and Assessment.

9. Pre-birth Consideration

Please refer to 5.20 Pre-birth Child Protection Procedure

Appendices

Appendix A - Definitions

Appendix B - Health and Education Rehabilitation Plan Template

Appendix C - RCPCH Summary diagram

Appendix D - Blank chronology

Definitions