It can be very difficult to confirm a suspected case of fabricated or induced illness (FII).
Healthcare professionals will naturally assume that a parent or carer will always act in the best interests of a child in their care, unless there's compelling evidence to suggest otherwise.
If a healthcare professional suspects FII, they'll usually refer the case to a community paediatrician.
A senior paediatrician will examine the medical evidence to determine whether there's a clinical explanation for the child's symptoms. They may also seek further specialist advice and arrange further testing.
If the senior paediatrician also suspects FII, they'll put together a detailed record of all the available information related to the child's medical history. This is called a chronology.
They'll also contact the local authority's child protection team (CPT) to inform them that concerns have been raised about the child's safety and that an investigation is under way.
CPTs are teams consisting of a number of different professionals. They're employed by local authorities responsible for protecting children from abuse and neglect.
Other agencies involved with the child's welfare, such as their school or social services, may be contacted in case they have information that's relevant to the chronology, such as the child being absent from school.
The full chronology is a critical part of the assessment process. Once complete, the information will be presented to the CPT and the police. The CPT, police and medical staff meet to discuss the best way to proceed with the case.
Covert (secret) video surveillance may be used to collect evidence that can help to confirm a suspected case of FII.
However, only the police have the legal authority to carry out covert video surveillance, which may be used if there's no other way of obtaining information to explain the child's symptoms. This is rare in practice.
If the child is thought to be at immediate risk of physical harm, social services will remove them from the care of the parent or carer. The child may be placed in the care of another relative or in foster care by social services.
In many cases of suspected FII, the child is already in hospital. They'll be moved to a safe place inside the hospital so that their medical assessment can continue. Alternatively, the carer may be banned from the child's ward.
A child will be taken into care in almost all cases involving physical harm, and in around half of cases where the mother is only fabricating, not inducing, symptoms of illness.
As the child is commonly at risk of significant physical or mental harm, a child protection plan is drawn up. This plan takes into account the child's health and safety needs, as well as their educational or social needs. For example, the child may have been deprived of regular education because their parent or carer kept them away from school.
As part of the child protection plan, the parent or carer may be asked to have a psychiatric assessment or family therapy. If they refuse to comply with the child protection plan, the child may be removed from their care.
If the police decide that there's sufficient evidence to bring criminal charges, they'll begin to investigate the case.
The Royal College of Paediatrics and Child Health has published information and guidance about the protection of children in cases of FII (see below).