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Fabricated/Induced Illness

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Presentation on theme: "Fabricated/Induced Illness"— Presentation transcript:

1 Fabricated/Induced Illness
“Significant harm which is caused to a child by the actions of a parent or other carer who deliberately fabricate symptoms in a child which would not otherwise be present.” Safeguarding Children in whom Illness may be fabricated or Induced (DOH 2008)

2 Spectrum of behaviour Fabrication – signs and symptoms past medical history Falsification – hospital charts and records; specimens of body fluids; letters and documentation Induction – by a variety of means

3 Assessment of F.I.I. At the point of “dawning” practitioners should consult a Named Nurse/Doctor without delay for advice. The child must be made safe whilst the investigation is ongoing. Suspicions should not be discussed widely. The parent/family must not be informed. When, in discussion with the Named Professional, it is thought that there is some foundation to suspect the abuse, a referral must be made to Children’s Social Care

4 Emotional Abuse “Emotional abuse is the persistent emotional ill-treatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development. …Some level of emotional abuse is involved in all types of maltreatment of a child, though it may occur alone.” WTSC 2013 Emotional Abuse is very damaging, children who suffer emotional abuse often end up in our mental health services either as children or when they become adults It is recognised that if a child is the subject of any of the other three types of abuse there is an emotionally abusive element to that abuse also. Observing and documenting parents interactions with their children is helpful, particularly where there may be concerns about attachment.

5 Conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. May include not giving child opportunities to express their views, deliberately silencing them or ‘making fun’ of what they say or how they communicate. May feature age or developmentally inappropriate expectations. Overprotection and limitation of exploration and learning or preventing the child participating in normal social interaction. Seeing/hearing ill treatment of another. Serious bullying (including cyber-bullying) causing children to feel frightened or in danger. May involve exploitation or corruption.

6 Sexual Abuse “Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening” Physical contact, including penetrative (e.g. rape or buggery) or non-penetrative acts. Involving children in looking at, or in the production of, pornographic material. Watching sexual activities. Encouraging children to behave in sexually inappropriate ways. Grooming a child in preparation for abuse. WTSC 2013 The sexual Offences Act of 2003 provides us with greater opportunities to protect children from Sexual Abuse __ Grooming for the purposes of Sexual Abuse __Abuse of positions of trust, particularly to protect children who are 16 or 17yrs __Abuse in the name of prostitution __Child sex tourism etc

7 Definition of CSE: 2009 Guidance
“Sexual exploitation of children and young people under 18 involves exploitative situations, contexts and relationships where young people (or a third person or persons) receive ‘something’ (e.g. food, accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as a result of them performing, and/or another or others performing on them, sexual activities. Child sexual exploitation can occur through the use of technology without the child’s immediate recognition; for example being persuaded to post sexual images on the Internet/mobile phones without immediate payment or gain. In all cases, those exploiting the child/young person have power over them by virtue of their age, gender, intellect, physical strength and/or economic or other resources. Violence, coercion and intimidation are common, involvement in exploitative relationships being characterised in the main by the child or young person’s limited availability of choice resulting from their social/economic and/or emotional vulnerability. 2009 Guidance Separated out into 4 characteristic elements: Involves some form of payment or reward for sexual services. Can happen without child being aware. Always involves a power imbalance. Characterised by child’s limited choice.

8 Signs of possible CSE: 2009 Guidance
Going missing for periods of time or regularly coming home late; Regularly missing school/not taking part in education; Appearing with unexplained gifts or new possessions; Associating with other young people involved in CSE; Having older boyfriends or girlfriends; Suffering from sexually transmitted infections; Mood swings or changes in emotional wellbeing; Drug and alcohol misuse; Displaying inappropriate sexualised behaviour. 2009 Guidance

9 Neglect Neglect is the persistent failure to meet a child’s basic, physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance misuse. Once a child is born, neglect may involve a parent or carer failing to: provide adequate food, clothing and shelter; protect a child from physical and emotional harm or danger; ensure adequate supervision; ensure access to appropriate medical care or treatment. WTSC 2013 Neglect has long term effects on children and in some cases it can be fatal Good documentation is essential for building a picture and identifying Neglect as early as possible Chronologies can be very useful to clearly see patterns of missed appointments, A/E attendances etc

10 Indicators of Neglect Dirty clothes/skin/nails/odour;
Chronic infestation; Hair matted or thin; Chronic nappy rash; Infected sores (especially in skin folds); A long history of illness, accidents, ingestions and repeated hospital admission; Delay in presentation to health professionals.

11 NICE Guidance (2009) Listen and observe Seek an explanation
Record what is observed and heard and why this is a concern Either consider, suspect or exclude child maltreatment Record actions taken and the outcome

12 CG89 When to suspect child maltreatment: quick reference guide
Available at: <http://guidance.nice.org.uk/CG89/QuickRefGuide/pdf/English>

13 6. Managing Disclosures

14 Dealing with disclosure
Listen carefully and take it seriously Reassure children they are right to tell Negotiate getting help and obtain help quickly Do not jump to conclusions Ask open questions Do not make promises you cannot keep – in particular, never promise confidentiality Do not make the child repeat what he or she has said to another member of staff Children rarely lie about abuse and it will have taken a great deal of courage to disclose. Remember all those feelings we identified in the exercise earlier. 14

15 Adults who disclose abuse in childhood
In addition to previous slide – Try to ascertain if the perpetrator may still pose a risk to children. If so, you have a responsibility to protect those children Encourage and support the adult in disclosing as much information as they are willing and refer the child/ren to Social Care Services Provide information about services Ask adult to consider a formal disclosure to the Police

16 7. Case Scenarios

17 Scenario 1 It is your last patient on Friday afternoon before a Bank Holiday. Whilst carrying an examination on a 6 week old baby boy you notice what appears to be a fading bruise on his forehead and another on his left cheek. You draw these to the attention of his mother who says that she does not know how they were caused, but thinks he might bruise easily. She thinks he may have hit himself with a toy. Are these marks significant. What action will you take in the short term? YES!! AGE OF CHILD – PRE MOBILE; MUM DOESN’T KNOW CAUSE NEED TO ASK MUM HOW THINGS ARE GENERALLY AT HOME; CHECK RECORDS OF ANY SIBLINGS, AND BOTH PARENTS – WHAT IS THEIR HISTORY? REFER TO CSC OR EDT DEPENDING ON TIME OF DAY

18 Scenario 1 cont. You discuss the child with the Paediatric SpR on call and agree to send the child to CAU. The mother explains that she needs to collect the other children from their granny’s and she’ll take him up as soon as she has done so. After you have made the referral whose responsibility is it to ensure they arrive at the hospital? YOU ARE RESPONSIBLE FOR ENSURING THAT THE CHILD ATTENDS HOSPITAL.

19 Scenario 2 You are asked by the Health Visitor to examine a 3 year old child who has a badly infected toe. Mother reports that the child injured his toe two to three weeks previously, and for the last five to six days it has been red and inflamed and obviously causing the child some distress. The mother apologises for the state of the child, who is dressed in dirty clothes, and all exposed areas are also covered in dirt. She says he had been playing outside when the Health Visitor visited and insisted he was taken to the doctor. cont… DELAYED PRESENTATION CHIDL IN PAIN FOR 5-6 DAYS ? NEGLECT – ARE CLOTHES APPROPRIATE FOR TIME OF YEAR? WAS THE THREE YEAR OLD BEING WATCHED WHILST PLAYING OUTSIDE? BY WHOM? APPROPRIATE CARER?

20 Scenario 2 cont. Mother is seven months pregnant, looks tired and unwell and has a fading bruise on her left cheek. You note she has an older child aged 5 who is at school. Discuss the issues raised by this scenario and prioritise your actions. PREGNANCY INCREASES LIKELYHOOD OF DOMESTIC ABUSE HOW ARE THINGS AT HOME GENERALLY? WHAT DOES HV KNOW ABOUT FAMILY? WHAT DOES SCHOOL NURSE KNOW ABOUT 5 YEAR OLD? WHAT IS HISTORY OF SIBLINGS & PARENTS? NEED TO FIND OUT MORE – CONCERNS = POSS DA, POSS NEGELCT

21 Scenario 3 The receptionist witnesses a mother of two young children aged 3 and 5 hitting them across the head in the waiting room of your surgery. The children had been very noisy and disruptive in the waiting room whilst waiting to see the doctor. What should the receptionist do? What should the doctor/nurse do? RECEPTIONIST – INFORM THE GP/NURSE WHO IS GOING TO SEE THE FAMILY & RECORD EXACTLY WHAT SHE SAW, SIGNING, DATING & TIMING THE RECORDING NURSE/GP – DISCUSS WITH MUM DANGERS OF HITTING CHILDREN’S HEADS; CHECK CHILDREN OVER; ASK MUM HOW LIFE IS IN GENERAL FOR HER; SEE IF SHE WOULD ACCEPT HELP FROM MULTI-AGENCY TEAM; DISCUSS WITH HV & SCHOOL NURSE; COMPLETE A CAF IF NO FURTHER CONCERNS & IF MUM ACCEPTS REFER TO INTEGRATED SERVICES TEAM AT CSC.

22 Scenario 4 The Practice Nurse is told by a patient that a man that she knows is a sex offender has moved in to live with her next door neighbour who has three young children. What should the GP/Practice Nurse do? YOU HAVE THE ADDRESS OF THE MAN – DOES PATIENT KNOW MAN’S NAME? IS HE YOUR PATIENT? IF SO YOU HAVE INFORMATION THAT YOU MAY NEED. CONTACT POLICE VULNERABLE PEOPLES UNIT TO SHARE THESE CONCERNS – THEY SHOULD KNOW OF THE MAN IF HE IS A REGISTERED SEX OFFENDER. CONTACT CSC – CHILDREN MAY BE AT RISK OF SEXUAL ABUSE & AN ASSESSMENT IS NEEDED (NB: CSC MAY ALREADY KNOW OF THE MAN)

23 Scenario 5 GP is contacted by telephone. The caller says she works for Children’s services and needs some information about a family where a child may be at risk. She says that she will require photocopies of the child’s notes and that a colleague will drop into the practice in the morning to collect the copied notes. What is your response? HOW DO YOU KNOW SHE WORKS FOR CSC? RING BACK VIA A SWITCH BOARD NUMBER. ASK WHAT EVIDENCE THERE IS THAT CHILD MAY BE AT RISK SHARE INFORMATION IN PROPORTION TO NEED – YOU MUST LOOK AT ALL FAMILY MEMBER RECORDS & SHARE WHAT IS RELEVANT SHE CANNOT HAVE COPIES OF CHILD’S NOTES PRODUCE A WRITTEN REPORT OF RELEVANT INFORMATION WITHIN CHILD’S RECORDS & RECORDS OF OTHER MEMBERS OF THE HOUSEHOLD ASK HER IF THE THERE WILL BE A STRATEGY MEETING & THAT YOU MAY NEED TO ATTEND/SEND INFORMATION TO THAT MEETING.

24 Scenario 6 Sam is 14. He has a life limiting condition and the family understand that he is unlikely to reach adult life. The family call the medical centre first thing in the morning , leaving a message to tell you that Sam died in the night. What should you do? Who should you inform? SUPPORT THE FAMILY! GENRALLY WE WOULD ADVISE A HOME VISIT. RECORD INFORMATION – IN ALL FAMILY MEMBERS RECORDS ENSURE OTHER PROFESSIONALS WORKING WITH SAM/FAMILY ARE AWARE CHECK BEREAVEMENT COUNSELLING IS AVAILABLE FOR FAMILY INFORM CDOP COORDINATOR VIA SAFEGUARDING CHILDREN BOARD UNIT.

25 Scenario 7 Mrs. Roberts brings her granddaughter, 14 year old Alice, to see you. She is requesting contraception for Alice. Alice is a physically mature girl who is home educated. She is polite and quiet in clinic and appears to be content playing with a Barbie doll. Mrs Roberts is concerned that Alice is a little immature. She feels Alice would be safer on the pill. IS ALICE FRASER COMPETENT? DOES ALICE WANT TO GO ON THE PILL? IS ALICE SEXUALLY ACTIVE? DOES ALICE UNDERSTAND RISK OF GOING ON PILL, AND RISKS OF SEXUAL ACTIVITY? ALICE SEEMS QUITE IMMATURE – BARBIE, GRANDMOTHER’S OPINION – BE AWARE WHY DOES GRANDMOTHER THINK SHE WOULD BE SAFER ON THE PILL? DOES GRANDMOTHER HAVE PR? IF NOT, AND ALICE IS NOT FRASER COMPETENT, SHE WOULD NEED TO BE SEEN WITH SOMEONE WITH PR – MOTHER OR FATHER. WOULD SEXUAL HEALTH SERVICE BE BETTER ABLE TO SUPPORT & ADVISE? WOULD THEY GO? CAN SCHOOL NURSE OFFER ADVICE & SUPPORT?

26 Scenario 8 Mother brings her 12 year old daughter to surgery. The 12 year old has disclosed to her that she has had sex two weeks previously. She will not disclose the identity of the other person and has refused to speak to the Police. What should you do, who would you take advice from and what advice would you give the mother? WILL DAUGHTER STATE AGE OF PERSON SHE HAD SEX WITH? AGE DIFFERENCE IS RELEVANT. WAS IT ‘CONSENSUAL’? I.E. DID ALICE WANT TO HAVE SEX WITH THIS PERSON? MIGHT NEED TO SEE ALICE ALONE (OR WITH NURSE PRESENT) OR BY FEMALE GP. ANY RISK OF PREGNANCY? CHLAMYDIA? SEXUALLY TRANSMITTED INFECTIONS? COULD THIS BE SEXUAL ABUSE? DOES CHILD NEED CP MEDICAL EXAMINATION? SEEK ADVICE FROM DESIGNATED DOCTOR/ NAMED DOCTOR ADVISE MOTHER TO BE KIND & SUPPORTIVE, TO LISTEN TO ALICE IF SHE WILL TALK AT ALL, TO OFFER RELEVANT & SENSITIVE ADVICE TO ALICE BE CLEAR WITH MOTHER THAT WITHIN THE LAW A CHILD OF 12 CANNOT CONSENT TO SEXUAL ACTIVITY. SEXUAL HEALTH DROP IN SERVICE? SCHOOL NURSE? BE AWARE THAT THIS IS POSSIBLY A CRIMINAL OFFENCE ON BEHALF OF THE PERSON SHE HAD SEX WITH.

27 Scenario 9 A baby is brought for routine immunisations by a woman who describes herself as his auntie. Should the immunisation be given? What are the issues that need to be considered? - NEED TO CHECK WITH AUNTIE THAT MOTHER IS AWARE THAT AUNTIE IS BRINING BABY OFFICIALLY, YOU SH9ULD HAVE MOTHER PRESENT AS SHE HAS PR DOES AUNTIE KNOW HEALTH HISTORY OF BABY, AND FAMILY HEALTH HISTORY? DO YOU HAVE ENOUGH INFORMAITON TO SAFELY PROCEED?

28 8. The Child Protection Process

29 CP PROCESS ROLE OF GP Identification of concerns Timely & detailed referral Referral to Social Care Sharing of proportionate information re children & parents/carers Assessment Strategy Meeting/ Discussion Attendance (if possible) - Submission of reports regarding all children &relevant information re parents/carers - Attendance (if possible) Initial Child Protection Conference Core Group Meetings to develop Child Protection Plan GPs unlikely to be member of Core Group Review Child Protection Conference/s until Plan no longer required Submission of reports regarding all children and relevant information re parents/carers

30 QUIZ - The Child Protection Conference System

31 9. And finally…

32 Framework for Safe Practice
i. Policies and Procedures iv. Inter-agency partners ii. Training iii. Access to advice and support Wyllie E., 2010

33 i) Policies & Procedures

34 Local Protocols and Guidance
North Yorkshire LSCB Procedures (supporting protocols including Pre-Birth Protocol) City of York LSCB Procedures NYLMC Child Protection Guidelines Practice Policy

35 ii) Training

36 Ongoing, NOT a one off! Over a three year period, professionals should receive refresher training equivalent to 1 – 1.5 PAs/sessions (for those at Level 3 core this equates to 0.5 PA per annum). Training, education and learning opportunities should be multi-disciplinary and inter-agency, and delivered internally and externally. It should include personal reflection and scenario-based discussion, drawing on case studies and lessons from research and audit. This should be appropriate to the speciality and roles of the participants. RCPCH (2010) Intercollegiate Document

37 iii) Access to Advice & Support

38 Lead GP for Safeguarding within practice
Named Doctor or on-call paediatrician Designated Doctor or Nurse - role is to provide advice, support and supervision (consulting your Designated professionals does not constitute a child protection referral). ‘Hypothetical’ discussion with Children’s Social Care or Police – no names Are contact numbers readily available?

39 iv) Inter-Agency Partners

40 Identify key individuals from your local partner agencies (Children’s Social Care; Protecting Vulnerable Person’s Unit; Women’s Refuge, etc.) Are local contact numbers readily available to all staff in the practice?

41 RCPCH Toolkit (2011) - Contents Aim of the Toolkit What is Safeguarding? Who is Responsible? Why is Safeguarding Necessary in General Practice? Barriers Barriers to Children Telling Monitoring and Reviewing Parental Responsibility Practice Policy and Procedure Working in Partnership with Parents Domestic Violence

42 Thank you and good luck!


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