N.B. While most of these recommendations can be implemented, others are State and country specific, and their implementation or use depends on legislation enacted in individual States and Countries.

INGREDIENTS

Before considering, or formulating an accusation of MSbP, a doctor need(s):

• access to all relevant information contained within medical records/files. This must involve going beyond the discharge summaries, or pre-prepared medical summaries to the actual records and GP records and notes. (see Flynn and D*** case)
• time to listen carefully to the parent(s), to read the medical records properly and time to evaluate the information on file.
• time to explain to, and educate parent(s)/guardian(s) in a way that makes sense to the them as individuals.
• to consider that the parents/mothers have often been in receipt of conflicting and contradictory information from other staff and other well meaning parents.
• education about MSbP that goes beyond that provided by text books.

They need education in:

• determining alternative explanations e.g. parental anxiety, parental lack of knowledge,
• The role of the medical system in creating the situation, which has prompted, suspicions of MSbP, eg multiple medical referrals for second opinions by doctors, lack of holistic care and lack of knowledge or incompetence of the medical practitioner, and
• information as to the rarity of this type of abuse.
• commitment to keeping the family together, whilst helping to assure the safety of the child(ren) .
• knowledge of resources available to assist families and to keep them together as a family unit.
• To consider that professional colleagues may have a vested interest in notifying children as having MSbP.
• To consider that an accusation of MSbp could be reprisal for making a complaint,
• the desire to cover up medical mismanagement,
• or 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 – The family to have direct access to one nominated person who is accessible, approachable, sensitive, empathetic, knowledgeable and trustworthy
• clear guidelines on detecting actual harm which do not pathologise or ‘profile’ the parent(s)/guardian(s).
• be able to present the evidence both for, and against, an accusation of MSbP
• be able to say what would cause the accusing doctor to change her/his mind
• to 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
• CPU should be independent of hospitals otherwise there is a conflict of interest. Alternatively, the CPU should be disbanded and the resources redirected to DoCS.
• If CPU’s are retained, the doctors need to have formal training in criminal medical investigations and the legal rights of parents and children. The rationale for this, is that these medically defined child abuse cases can result in criminal charges.
• The child’s medical consultant(s) is/are to write the referrals to consultants providing second opinions to ensure the referral information is accurate, complete, informative and not misleading (see D*** case)
• to recognise that children need
• protection from harm from medical personnel i.e. medical abuse
• consistency of medical personnel
• a parent(s)/guardian(s) that loves and cares 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 the illness has been fabricated.
• the least intrusive investigation/treatment as possible
• to assume his/her legal, ethical responsibility and duty-of care to the child by :
• fully documenting any concerns that the doctor may have, including tests performed and how the diagnosis of MsBP was arrived at, and organic illness ruled out. (see Flynn case and absence of documentation in file)
• immediately notifying the Department of Community Services (DoCS) of the suspicion of MSbP which is recognised as a form of child abuse as is required of doctors under section (2A) and (4) of the Childrens (Care and Protection) 1987 Act.
• Immediately notifying the allegation of child abuse to the hospital’s Child Protection Unit (CPU) (if available).
• not notifying, or making reference to a suspicion of child abuse in a child’s medical records, or reporting a suspicion of child abuse to the CPU as their own view WHEN IT IS THE SUSPICION OR OPINION OF A THIRD PARTY. This gives DoCS the opinion that there are a number of doctors who share the same view and who are all involved in the notification.
• reporting all false, misleading, inaccurate, incomplete and contradictory information that has been provided to DoCS in respect of a notification of a child-at- risk, to DoCS. They have a responsibility to do so under section 119 of the Childrens (Care and Protection) 1987 Act.
• Ensuring the removal of any potential additional sources of harm from the parent(s)/guardian(s) e.g needles, syringes and medications (see the Flynn and D*** cases)
• No doctor is to be allowed to contradict the expert opinion(s) of another, unless the doctor has personally examined or assessed the child or/and mother themselves and is qualified to do so. (e.g. D*** case).
• be able to clearly outline how they have arrived at their suspicions/confirmation of MSbP.
• be able to indicate what behaviors in general that the parent(s)/guardian(s) exhibit which would contradict an allegation of MSbP e.g. what is normal behaviour under these circumstances (ref: Dr Eric Mart see F.R.A.M.E’s library list)
• be able to indicate what guidelines they are using to investigate/confirm a suspected case of medically defined child abuse.
• consider and document what possible alternative explanations exist for the child’s condition/medical illness that does not pathologise the parent(s)/guardian(s).
• consider what is the scientific, documented evidence for the suspicion/identification 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 (ref: F.R.A.M.E’s library list)
• consider alternative explanations that include: parental anxiety, misinformation and the role of the medical system in creating the conditions for the development of the disorder
• parental anxiety re: sick child.

1. To alleviate anxiety a parent may need:
1. reassurance re: the child’s illness and the prognosis for recovery
2. clear, complete and concise information, in a way that they understand, about illness – prognosis and management., hospital procedures., major and minor signs and symptoms., about possible/probable prognosis and management., and the risks/benefits of proposed treatment/investigative techniques. (see D*** case history and the hose pipe analogy)
3. time to discuss hopes/fears etc with empathetic and sympathetic and involved medical personnel
4. consistency of medical personnel
5. peer support – parents who have been through similar experiences
6. respite care
7. personal counseling around what it is like being a parent of a chronically ill child
8. ongoing access to all medical records
9. 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.
10. health education, in a way that they understand.
11. Parenting classes
12. access to all medical records
13. time from, and the involvement of medical staff to correct misunderstanding in parental knowledge base
14. the recognition that a lot of parental knowledge is derived from other parents whose children may have had similar treatment for differing medical complaints

1. to consider the role of the medical system in creating the situation which has led to
2. the suspicions of MSbP e.g. errors in medical records, referral processes, attitudes of

3. medical personnel, medical negligence, incompetence etc…. To offset this, the doctor needs to recognise that:

4. there is a need for the doctor to listen to the child’s parent(s)/guardian(s) when recording the child’s illnesses/medical conditions, even if there is a past history of child abuse.
5. The child needs to be free from the possibility of a vexatious, malicious, and false notification of child abuse.
6. To be free from doctors deliberately providing false information to DoCS in respect of a notification, even though the doctor may think it is in the best interests of the child in the future.

1. information about his/her responsibility under the:

1. Childrens (Care and Protection) 1987 Act.

1. the NSW Department of Health’s ‘Principles and Minimum Standards for the development of health service codes of conduct’ circular 98/79
2. NSW Medical Practice Act

1. Ensure the accuracy of medical reports, information, and medical summaries that are provided to DoCS in respect of the notification, and in the child’s medical file(s).

1. The doctors must 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 (See D*** and F**** case). The Director of the CPU should ensure that this has occurred.
2. 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 (see D*** and F**** case)
3. Written or verbal opinions from third parties should not be presented as being shared opinions, or as being the doctor’s own opinion, when they are the views of others.
4. Doctors must include any information that may contradict or conflict with the allegation of MSbP.
5. Doctors must indicate on any documents submitted to DoCS if the document has been altered from the original document, especially when 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 (see Dr A’s summary which was reviewed by Dr B ref: Flynn case).
6. 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 referred to in medical reports to DoCS that gives the impression that they are aware of, and involved in, the notification process (see reference to Prof. **** in the Notification Intake Summary and during the protection planning meetings when she was unaware of the notification to DoCS in the Flynn case)
7. No one must falsify, delete or remove any information from the child’s medical files/reports (see D*** and Flynn case).
8. All doctors should be made aware of the purpose of DoCS’s initiated protection planning meetings. These are:

9.  

10. the sharing and provision of accurate, complete, relevant and non-misleading information about the medical management of the child and the reasons for suspicion/identification of MSbP.
11. the ensuring the identification of all staff who have been involved in the child’s care to date, the chronological history of their involvement, and the care they have provided for the child.
12. Facilitating the involvement of all of the people who have been involved in the child’s care at all protection planning meetings.

1. The physician who asserts a suspicion/accusation of MSbP must be able to provide substantive evidence in the form of a statutory declaration. They must substantiate this evidence from the medical files to DoCS within four working days. In particular, the doctor should be able to provide evidence that an illness in a child has been INDUCED or FABRICATED by the parent(s)/guardian and that such an act has been to obtain the attention of the physician for him/herself e.g. parent seen deliberately injecting air into IV line. The doctor’s evidence must be able to show that the mother is receiving personal gratification or attention for themselves from a health practitioner for the child’s illness to warrant the suspicion/accusation of MSbP.
2. Doctors should not be able to ‘substantiate’ medically defined forms of child abuse. This should be the role of a proposed DoCS funded and run medical investigation unit. Therefore doctors should not be able to confirm the existence of the disorder, or write about the suspicion of any form of medically defined child abuse in the child’s medical file(s).
3. No doctor should be able to refer to any medically defined child abuse in the child’s medical file(s) until after the case has been fully investigated by DoCS and the case has been substantiated by DoCS.

1. Ensuring the existence of checks and balances in the hospital system.

1. Must ensure that the parent(s)/guardian(s) and DoCS have been informed of the allegation of MSbP.
2. The physician who asserts an accusation of MSbP is to be compelled to provide prima face evidence that an illness in a child has been INDUCED or FABRICATED by the parent(s)/guardian(s), and to provide evidence 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 her own faecal material into the child’s intravenous line. The evidence must show that the mother is receiving personal gratification, or attention from a health practitioner for the child’s illness to warrant the diagnosis of MSbP.

1. Hospital must provide/facilitate immediate individual and family counseling for child/parents on the formation of the accusation, and prior to the notification (if possible) and if the parents are willing/interested in receiving counseling.
2. Must immediately ensure that DoCS has been notified.
3. The identification of this disorder is to be coded, and on a yearly basis audited by the facility. If CPU’s are retained, the Director of the CPU is to personally report to the Director of the proposed medical investigation unit (see under DoCS). As you would expect, MSbP is an extremely rare disorder and auditing will give the true prevalence of the disorder in this particular institution/specialty.
4. The parent(s)/guardian(s) are to be allowed to take their child for a second medical opinion to a specialist of their choice. Access to second opinions are to be free of threat and those providing a second opinion are not to be informed of the suspicion/accusation of MSbP. Several cases that we are aware of, once they were able to seek a second opinion, had the accusation of MSbP disproved and were treated for an organic illness.
5. The person who has been accused of having MSbP should have the automatic right to a second opinion on the formation of the accusation and the second opinion should examine whether the criteria and guidelines set by Professor Meadow in 1994 have been followed.

1. Following the suspicion/accusation of MSbP, the hospital must appoint a doctor who is blind to the differential diagnosis of MSbP. This doctor is to prepare a complete medical summary of the child’s medical care to date. This summary must be done in consultation with all past and present treating doctors and allied health staff. The summary should be compiled using the full medical, child protection, and administration file(s), and any disparity between the discharge summaries and admission notes must be noted. The summary should then be sent to DoCS and any current treating doctors. The parents should be consulted, prior to the completion of the medical summary to check for the accuracy of the summary. Parents must be able to highlight inaccuracies in the medical summary to DoCS.
2. The parents or the child’s/parent’s advocate must then be allowed to organise an external review of the child’s medical care to date, with an independent paediatrician of the parents choice. Alternatively, an external review is to be facilitated by the Director of the medical investigation unit. It is important that this review is conducted to detect any medical mismanagement, or deviation from the acceptable standard. This independent paediatrician must remain unknown to the current or past treating health practitioners of the child, and this review is to conducted PRIOR to any notification to DOCS if at all possible.
3. The review may have to occur after the notification if the child is in immediate danger, but should be done as part of the notification, and prior to the case going to the children’s care court.

1. This review must be conducted by the paediatrician in consultation with specialists from the field(s) of medicine from whence the differential diagnosis has arisen e.g. if a gastro-enterologist has proposed MSbP, the paediatrician must consult with a consultant from that field. This may involve the paediatrician contacting one or more specialists (see D*** case). The review must be conducted using the full medical, child protection, and administration file(s) and any disparity between the medical summary, discharge summaries and admission notes must be noted. This review should be funded by the Child Protection Unit (CPU). The reviewer should note any deviation from the accepted standard of medical care for that specialty
2. If the allegation of MSbP is found to be unsubstantiated, all reference to this disorder is to be removed from the child’s file(s). The file should be destroyed or locked away, not to be accessed for the child’s general medical care. This is to try and ensure that the child’s future health care is not prejudiced by this unsubstantiated allegation.
3. If a complaint is made that a doctor has provided false and misleading information to DoCS in respect of the notification, the hospital must immediately suspend the doctor from any further involvement in child protection matters pending a full investigation of the matter. As part of this investigation, the Area Health Authority must access the child’s medical file(s), appoint the medical superintendent to investigate (and be accountably) and have him/her randomly review other cases the doctor has been involved in. If this allegation is found to be substantiated, the hospital must refer the matter to the proposed Director of the medical investigation unit in DoCS and arrange for the doctor to be interviewed and be asked to explain the findings of the investigation team. If the doctor cannot provide a satisfactory explanation, the hospital must act to suspend the doctor and refer the matter to the HCCC for investigation.

Building in checks and balances into the Dept. of Community Services (DOC’s) policies and procedures.

1. Establish a centralised medical investigation unit to investigate notifications of medically defined forms of child abuse (e.g. MSbP, Chronic fatigue/ME, atypical anorexia nervosa, multiple chemical sensitivities, children who are developmentally delayed).

2. Employ experienced investigation officers with paediatric investigation skills to staff the unit.
3. Provide the child/parents with an advocate who is accessible and reliable and has demonstrated a commitment to social justice, procedural fairness and the protection of children and their families.
4. Acculturate them with the idea that the doctors that notify children to DoCS are not necessarily the doctors that have been looking after the child, or are ‘experts’ in the particular field that they are notifying in (see D***).
5. Educate officers that doctors may have an ulterior motive for making the notification eg medical malpractice. Also not all doctors are honest or honourable, eg Dr McBride, Dr Shipman
6. Trust the parents, especially the mothers, and check on everything they tell you, including speaking to other people that the family refers you to.
7. Speak to all of the doctors that have treated the child and obtain written reports from all of them.
8. Do not accept unverified second hand reports or reports that contain hearsay. Always check with the original source and ensure that what is written is a true and accurate reflection of what they said.
9. The auditing of this disorder will give the Director of the unit an idea of the reported prevalence of this disorder in each hospital by specialty. This can then be compared with the incidence/prevalence in other facilities and be reported by the Director in DoCS’s annual report (?).
10. Fully resource this unit, especially as it may need to organise second opinions and obtain medico-legal reports.
11. Appoint a ‘Director’ to head the unit that has a strong commitment to the protection of children, has a proven track record in advocacy and the support of women and children, has health experience (but who is not a doctor), and will accept a salary that is lower than is commiserate with the title. You want the right person.
12. Wait for the number of these notifications to rise. Some doctors will see this as a direct challenge to their authority within the health system, and they will increase the number of such notifications until they realise that DOCS is serious about investigating these notifications. Once the doctor’s realise that DOCS is serious about investigating, and will hold them responsible for the information they provide to DOCS, we predict that there will be a very rapid decline in such notifications. So saving the Department and the NSW taxpayer hundreds of thousands of dollars.
13. Maintain a child abuse notification register that monitors who notifies, which hospital specialty notifies, and who has been the child’s treating physician(s). Audit these on a yearly basis.
14. Code the disorders to monitor the prevalence of such notifications.
15. Empathise the need for the thoroughness of investigations rather than the need for file closures.
16. The identification of MSbP should be coded, along with the hospital and the specialty from where the diagnosis first originated.
17. The incidence/prevalence of this diagnosis should be audited on a yearly basis. This is only possible with the coding of the disorder.
18. DoCS must compile a full assessment form (to be designed)
19. The Director should ensure that the unit obtains all relevant medical information including information retained by general practitioners or held by other government bodies such as the HCCC (see Flynn case).
20. Suspend, then hold DOCS’s officials accountable for major breaches in DOCS’s policies and procedures and poor investigations.
21. Post details of the child’s presenting complaint, and details of the child’s medical management on a specially designed DoCS controlled web page and as reports in popular doctor’s focussed magazines. Advertise the web page in popular doctor’s magazines and invite comments/ and the involvement of other practitioners in the identification of a possible organic basis for the child’s illness/presenting condition. Provide this feedback to the current treating medical team and the child’s parent(s)/guardian(s). The child’s name, specific location, and any other identifying factors must be confounded to protect the identity of the child and family.
22. If the case is substantiated by the investigator in the medical investigation unit, the case is then to be reviewed by a three member committee which is comprised of I) the Director of the unit, ii) a consumer representative, and a children’s lawyer from a community legal centre.
23. Don’t cut corners, the costs to this child, and other children of doing so is just far too high.

1. Retain mandatory notifications and prosecute anyone who does not adhere to this provision in the Act. This will ensure that doctors continue to notify and do not simply retain an informal notification system by writing the ‘diagnosis’ or allegation in the child’s medical records so compromising the future health of the child at the hospital or elsewhere.

1. Suspend doctors who are suspected of having provided DoCS with false, contradictory, misleading, and inaccurate information in respect of child at risk notifications (see Dr Southall in the U.K). If a preliminary investigation confirms their unreliability, prohibit their further involvement in child protection matters pending a full investigation that must involve other cases that the doctor has been involved in. Prosecute doctors who have knowingly (and consistently?) provided false and misleading information to DoCS in respect of notifications.
2. Maintenance of DoCS records. Each DoCS centre must keep a postal log of all correspondence received in relation to each DoCS case. This log is to be maintained by an administration assistant and is to be audited on a three monthly basis. Before child care matters are to be brought before the court, or F.O.I applications processed, the file, as well as the centre’s log, are to be checked to make sure all of the information is presented to court or included in the F.O.I application (See Flynn and D*** case).
3. In accordance with DoCS commitment to transparency in all ‘decision making’, the child’s parent(s)/guardian(s) or legal representative/ advocate should have immediate access to all information contained on their child’s DoCS’s file, except for the name of the notifier. This is to enable the parents/guardians or advocate to:

1. Test the reliability, validity and the completeness of the information supplied in respect of the notification.
2. Supply additional relevant information
3. Challenge false, inaccurate, and misleading information
4. Ensure the accountability of all those supplying the information.

1. If the allegation of MSbP is unsubstantiated, all efforts should be made by DoCS to contact the school, neighbours and whoever else was told about the abuse, or the alleged abuse, so that the family does not continue to be the victim of a false allegation of MSbP.

2.  

3. The purpose of DoCS’s protection planning meetings should be:

4.  

5. To facilitate the sharing and provision of accurate, complete, relevant and non-misleading information about the medical management of the child and the reasons for the identification of MSbP as a possibility/probability.
6. To facilitate the involvement of all of the people involved in medical care to date. Information as to the scope of their involvement, time frames should be freely available.
7. All stakeholder’s in actual case to attend all protection planning meetings held in respect of the notification. To include: parents & advocate, all past and present treating health practitioners (to include allied health staff LMO(s) and all consultants involved in child’s care to date, Principal of school, Child (if over 12?).....
8. Written statements to be provided by the medical practitioner re: MSbP diagnosis to be available to all parties, prior to any meetings in order that the information in the statement can be examined by all parties.
9. Facilitate the involvement of anyone who could challenge, or contradict the ‘evidence’ provided by the doctors during protection planning meetings. At these meetings openly consider all of the information contained on the department’s file and record any supporting/dissenting opinion.
10. Minutes of protection planning meetings to be taken and signed by all attendees as to the accuracy of the content of the meeting.

     

1. Audit the unit for their thoroughness of the investigations.
2. Thoroughly investigate client’s complaints, even if they reveal illegal and very real and flagrant breaches in DOCS’s practices.
3. Provide parents with free and complete access to the child’s departmental file, except the name of the notifier. This will partly ensure the accuracy of the information on file.
4. As more cases are investigated by F.R.A.M.E, we may have additional contributions to make. Ensure that this contribution is considered/acted upon.
5. Involve a member of F.R.A.M.E as a consumer representative to DoCS.
6. Ensure that all mothers/parents who are accused of these types of child abuse are referred to F.R.A.M.E who will be conducting/facilitating support meetings and will be organising group and individual counseling for all parents.

The Judicial System

1. Have a member of FRAME invited to give inservices to magistrates/judges on MSbP and related forms of ‘medically defined/constructed‘ child abuse.
2. Ensure that magistrates/judges have complete access to all of the department’s investigation notes and medico-legal reports
3. Appoint an experienced lawyer, who has medico-legal or health related experience is to the case. Ensure that the family and the advocate adequately brief the lawyer and ensure that the lawyer is interested in the subject matter, is briefed properly, and has had the time to prepare the case properly. This will ensure that the child is properly represented. (see D*** case)
4. Schedule enough court time for the defense to call the notifying doctors as witnesses, and to call other doctors as witnesses. This will enable the magistrate/judge to give a considered opinion, even if it may not be the right judgement.
5. Make provision in the Childrens (Care and Protection) 1987 Act that allows for ‘evidence’ that is presented in child’s courts to be able to be used by the mother’s/parent’s lawyers in other court cases, when that evidence is shown to have been deliberately false, misleading, contradictory and inaccurate in a ‘material particular’.
6. Parents are to retain the right to choose which medical practitioners treat their child and can veto the department’s choice of medical practitioners.
7. Rules of evidence to apply in children’s care courts and the courts to be open to the public. Closed courts simply permit the further abuse of parent(s) and their children by allowing certain magistrates to openly abuse defendants in court.
8. In order for the court to make a temporary care order, the magistrate has to sight prima facie evidence that supports the allegation.
9. If a temporary care order is made, the parent(s)/guardian(s) are to retain visitation rights and supervised access visits.
10. Magistrates are to be educated in medically defined disorders and to be guided into only make temporary care orders in severe cases.
11. Do not make a judgement that the child is retained in the care of the notifying doctors. The dangers of such a decision are obvious and should not need spelling out. The child should always have a right to a second, third, fourth….. opinion. This judgement only protects the doctors, not the child.
12. Allow free access to children’s court transcripts and retain these transcripts until the child is 22 years of age.
13. Have woman/parents (defendants) given free access to community legal aid funding for appeals. DoCS should provide this extra funding. It will be cheaper in the long run and will help to ensure that children have access to justice.

Minimise the advantages for notifying or accusing doctors

1. Ensure that medico-legal reports are accurate, complete, are not misleading and do not contain contradictions.
2. Have the notifying doctor(s) and/or treating doctors explain their position.

1. The disorder has the potential to facilitate blame shifting, to conceal cases of medical mismanagement and medical negligence. With the existence of MSbP, doctors are able to conveniently shift the blame onto mothers and hold them responsible for the medical mistreatment of the child.
2. Do not accord ‘expert’ status to any notifying doctors (they will endeavor to do that themselves).
3. Make it very clear to the doctors that DoCS will be implementing very real changes and that they will be enforceable.
4. Have frequently notifying doctors justify their position from the scientific literature and have their work open up for peer scrutiny by the Medical Board of NSW and colleges of paediatrics, and the college representing the specialty from where the case arose.
5. DIRECTIONS

1. These are the basic ingredients that are needed for a cake of substance. There may need to be additional ingredients to take into consideration regional variations, but to subtract any of the basic ingredients will produce an inferior cake and are to be avoided.

1. Make this a national cake which may require legislative changes to regional recipes and VIOLA.

Another ‘unsubstantiated’ case of child abuse…?

 

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