Observation of the medical practitioner's legal responsibility to the child

As Msbp is a form of child abuse, medical practitioners should immediately notify the child to the Department of Community Services (DoCS) as is required of medical practitioners under section (2A) and (4) of the Children (Care and Protection) 1987 Act.

Immediately refer the child to the hospital’s Child Protection Unit (CPU) (if available). 

Health Practitioners must not: 1) make reference to a suspicion/ confirmation of Msbp to a third person., 2) document the suspicion/ confirmation of Msbp in the child’s clinical file., 3) report a suspicion/ confirmation of Msbp to the hospital's CPU or 4) notify the child as suffering from Msbp when this is the SUSPICION/ OPINION/ VIEW OF A THIRD PARTY. This a) clouds the issue, b) confuses the origin of the suspicion/allegation/confirmation of Msbp and c) conveys the impression to DoCS that there are a number of doctors who share the same opinion and are involved in the notification. 

If a doctor becomes aware that false, misleading, inaccurate, incomplete and contradictory information has been provided to DoCS in respect of a child-at- risk notification or during the child protection planning meetings, the doctor has a clear legal, moral and ethical obligation to inform DoCS. 

Documentation

In order to meet the criteria for Msbp: 

The physician should be required to provide a written statement which outlines the rationale for the suspicion or confirmation of Msbp. In particular, the doctor should be able to provide evidence that the illness or medical condition in the child has been INDUCED or FABRICATED by the parent(s)/guardian and be able to provide evidence or a justification that such an act by an adult has been to obtain the attention of the physician for him/herself e.g. Parent seen deliberately injecting air into IV line. The evidence must be able to show that the mother is receiving personal gratification from the act, or is deriving attention from a health practitioner for the child’s illness to warrant an allegation of Msbp as stated in Meadows' guidelines. 

The doctor should (and should be required to do so): 

• be able to clearly outline how they have arrived at their suspicions  or confirmation of Msbp

• be able to indicate what behaviours that the parent/mother are exhibiting that are not indicative of Msbp

• be able to indicate what guidelines they are using to confirm /investigate a suspected case of Msbp

• be able to consider what possible alternative explanations exist for the child’s presenting condition/medical illness that do not pathologise the mother

• be able to the scientific, documented evidence for their differential or actual confirmation of Msbp 

• be asked to explain how this case of Msbp has been clinically evaluated (does it meet the criteria for clinical validity 
  outlined by Kendell – Kendell, R.E. 1989 ‘Clinical Validity, Psychological Medicine’ 19 (1) February pp 45-55) 

Possible alternative explanations that doctors need to consider before considering an allegation or confirming a case of Msbp: 

Parental anxiety regarding the sick child. 

To alleviate anxiety a parent may need reassurance re: the child’s illness and the prognosis for recovery clear information about illness – prognosis and management  clear information about hospital procedures and risks/benefits of treatment/investigative techniques time to discuss hopes/fears etc with involved medical personnel consistency of medical personnel peer support – parents who have been through similar experiences respite care personal counseling around what it is like being a parent of a chronically ill child 
ongoing access to all medical records recognition that they may have been given false information from other staff and other parents during their time on
the ward with their sick children. 

Parental lack of knowledge. 

To ensure parental knowledge, a parent may need:

• clear ,complete and concise information, in a way that they understand, about illness – prognosis and management

• clear, complete and concise information ,in a way that they understand, about hospital procedures 

• clear, complete and concise information information, in a way that they understand, about major and minor symptoms 

• parenting classes 

• health education, in a way that they understand. 

• access to all medical records 

• time from medical staff to correct misunderstanding in parental knowledge base 

• the recognition that a lot of parental knowledge is derived from other parents whose children may have had similar treatment for differing medical complaints

to consider the role of the medical system in creating the situation which has led to the suspicions of Msbp e.g.errors in medical records, referral processes, attitudes of medical personnel, etc. 

Before considering, formulating or confirming a differential or actual ‘diagnosis’ of Msbp a doctor needs: 

• access to all relevant information contained within medical records/files. This may involve going beyond the discharge/summaries, or pre-prepared medical summaries to the actual records and GP records and notes. 

• time to listen carefully to mothers and to read the records and to evaluate the information on file. 

• time to explain to, and educate parents/mothers in a way that makes sense to the parents/mother. 

• to consider that the parents/mothers have often been in receipt of conflicting and contradictory information from other staff and other well meaning parents. 

• to have been in receipt of education about MSbP that goes beyond that provided by text books. They need education in:
  1) determining alternative explanations e.g. parental anxiety, parental lack of knowledge, 2) the role of the medical system in creating the situation which has prompted suspicions of MSbP and 3) information as to the rarity of this type of abuse. 

• commitment to keeping family together, unless direct harm has been detected 

• knowledge of resources available to keep families together 
  consider that professional colleagues may have a vested interest in notifying children as having MSbP. 

• To consider that a differential diagnosis for MSbP could be reprisal for making a complaint, the desire to cover up medical mismanagement, the desire of some doctors to carve themselves a niche as being an expert in MSbP as without MSbP cases there cannot be experts in this disorder. 

A coordinated response – one nominated person who is accessible, approachable, knowledgeable and trustworthy clear guidelines on detecting actual harm which does not pathologise or profile the mother be able to present the evidence both for and against a diagnosis of MSbP be able to say what would cause the ‘diagnosing’ doctor to change her/his mind consult with all practitioners involved in child’s care or referred to in medical reports. Dissenting opinion to be noted, and the reason for the dissenting opinion to be provided to DoCS. This has relevance for the doctors employed by the
CPU’s. 
Not allowed to contradict expert opinion(s) unless they have examined or assessed the child or/and mother themselves. 
The child’s medical consultants are to write the referrals to consultants providing second opinions to ensure the referral
information is accurate, complete, informative and not misleading 

A doctor needs to recognise that children need: 

• protection from harm from medical personnel. 

• consistency of medical personnel 

• parents/guardians that love and care for them. 

• the treatment and investigation of all presenting illnesses. There needs to be a recognition that children who have suffered from MSbP in the past do and can become sick. There is to be no withdrawal of treatment on the suspicion that all the illness has been fabricated. 

• the least intrusive investigation/treatment as possible. 

• Doctors to listen to the child’s parents’/guardians when reporting illnesses/medical conditions even if there is a past history of child abuse. 

• To be free from vexatious, malicious, and false notifications of child abuse. 

• To be free from doctors lying and providing false information to DoCS in respect of a notification, even though thedoctor may think it is in the best interests of the child in the future. 

A doctor needs information about his/her responsibility under the: 

Childrens (Care and protection) 1987 Act. the NSW Department of Health’s ‘Principles and Minimum Standards for the development of health service codes of conduct’ circular 98/79 

Ensure the accuracy of medical reports to DoCS, in medical summaries and in the child’s medical records. 

Doctors must ensure that they comply with Section 119 of the Children’s (Care and Protection) 1987 Act by ensuring
that any medical reports that they provide to DoCS in respect of the notification, or to the reviewer appointed by DoCS,
are accurate, complete, informative, and not misleading in ‘a material particular’. They also have a duty to clearly indicate
to DoCS when information provided by a third person in respect of a notification is false, misleading, inaccurate,
contradictory and incomplete. 
Doctors should ensure that they indicate in their reports when they are referring to: a) second hand reports of events, b)
hearsay or c) summarising the views of another practitioner when they are not their own views. 
Opinions from third parties should not be presented as being shared opinions, or as being the doctor’s own opinion when this is not the case. 
Doctors must include any information that may contradict or conflict with the the assumption of MSbP. 
Doctors must indicate on any documents submitted to DoCS if the document has been altered from the original document, especially when it the document has been reviewed by a third person. The reviewer should indicate which
points s/he disagrees with and indicate where they have made amendments or additions to the original document. 

Doctors should ensure they do not give DoCS the impression that doctors who have seen the child, and who are unaware of the notification, are not referred to in medical reports to DoCS that gives the impression that they are aware of, and involved in, the notification process. Doctors must not falsify, or delete any information from the child’s medical files/reports. 

Involvement in protection planning meetings: 
All doctors should be aware of the purpose of DoCS’s initiated protection planning meetings. These are: 

the sharing and provision of accurate, complete, relevant and non-misleading information about the medical management of the child and the reasons for the differential or/and actual diagnosis of MSbP of the child. 

Doctors should ensure that DoCS are aware of all medical staff involved in the child’s care to date, the history of their involvement, and that the involvement of all people who have been involved in the child’s care is facilitated in all
protection planning meetings.