By Andy Bilson and Taliah Drayak
The term fabricated or induced illness (FII) was introduced in 2002 to replace the discredited idea of Munchausen syndrome by proxy (MSbP).The label was meant to bring clarity and help professionals protect children. Instead, it has spread confusion, widened suspicion and caused serious harm.
In recent months, The Sunday Times has published a series of articles by Emily Dugan exposing the devastating impact of FII investigations on families.
It told the story of Ella, who was separated from her mother for eight months and placed with untrained carers who failed to meet her complex needs. It also described the case of Melody, whose mother watched her die in pain after medication was withdrawn during an FII investigation.
Recent surveys (Clements & Aiello, 2023; Ferguson & Hollingsworth, 2024) highlight many more such cases. These are not abstract tragedies - they are direct, preventable outcomes of acting on flawed guidance.
This illustrates what parents, campaigners and practitioners have been warning of for years: the evidence base for FII is weak, its application disproportionate and its consequences catastrophic.
An open letter signed on behalf of organisations and by parents, professionals and academics has now called for FII to be retired as a safeguarding category altogether.
A weak evidence base
When the Department for Education withdrew its 2008 guidance on FII in 2021, it left the Royal College of Paediatrics and Child Health (RCPCH) as the main source of advice.The RCPCH’s 2021 guidance openly acknowledges that all research on FII derives from the much-criticised MSbP literature.
Our own review found only four case studies on FII published since 2002, with no other empirical studies.
According to Glaser (2020), a leading proponent of FII, identification rests on “alerting signs”, ranging from parents seeking multiple medical opinions to children having unusual or fluctuating symptoms.
Yet in a previous paper, she and her fellow author admitted these signs were never systematically evaluated (Glaser & Davis, 2019), and there is no fixed list, “as others are added periodically” (Glaser 2020 p5).
This lack of rigour would be concerning in any area of safeguarding; in something as sensitive as parent-child relationships, it is indefensible.
The myth of 'high mortality rates'
Central to the FII narrative are claims of very high death and harm rates. Training courses and guidance, including from the Royal College of Psychiatrists, often cite mortality figures of 6-8% and similar rates of long-term morbidity.But these numbers are not epidemiological facts. They come from two flawed sources:
- Literature reviews of case reports. These counted deaths across published case studies and divided them by the number of children described, to produce “mortality rates”. One review, for example, reported 27 deaths among 354 cases over 50 years worldwide. This was presented as a 7.6% mortality rate, despite being based on publication patterns rather than population data.
- A 1990s survey of paediatricians (McClure et al 1996). This reported eight deaths among 128 cases of poisoning, suffocation or MSbP, though only one of the deaths was linked to an MSbP case. Among other concerning aspects of this survey (Bilson and Talia, 2025), a supposed 6% “death rate” continues to be attributed to FII.
A British Journal of Social Work review covering 2010–2021 identified 13 international child deaths attributed to FII across nine papers, also with none in the UK (Bilson & Talia, 2025).
What child safeguarding reviews show
If FII is as lethal as claimed, we would expect serious case reviews (SCRs) - which were mandatory whenever a child died and abuse or neglect were suspected - or local child safeguarding practice reviews (LCSPRs), which replaced SCRs in 2018, to reflect this.However, our review of SCRs and LCSPRs in England from 2010 to 2021 found no child deaths caused by fabricated or induced illness.
Extending the search to 2025 uncovered only one case where the label was considered: a father who murdered two children and attempted to kill a third, also poisoning his partner. His actions bore none of the features of FII as defined by the RCPCH, such as repeated presentations to health professionals.
This case aside, there were no child deaths from FII in England across 15 years of reviews.
As for serious harm, four SCRs/LCSPRs between 2010 and 2021 identified FII as a factor. Only one involved clear induction of illness (giving prescription drugs) and the child recovered quickly. In every case, better adherence to medical protocols and investigation of concerns could have prevented harm, without resorting to FII suspicion.
How parents are stereotyped and judged
The MSbP literature not only exaggerated risks but also misidentified cases, embedding damaging stereotypes of supposed perpetrators. These stereotypes - that perpetrators were mainly mothers, sometimes with medical knowledge, estranged partners or unusually close ties to clinicians - depicted parents as manipulative, deceitful and attention-seeking.Although current guidance avoids the most judgmental language, these stereotypes persist in the “alerting signs".
Parents who seek further medical opinions or investigations, resist reassurance or report unusual symptoms are flagged as suspicious. Yet these behaviours are precisely what we expect from carers of children with rare, complex or undiagnosed conditions.
Parents who do not accept reassurance that medically unexplained symptoms - occurring in up to 30% of children (Geist et al, 2008) - are psychosocial in origin and continue to display these understandable behaviours fall under suspicion of FII.
The danger is twofold: parents legitimately advocating for their child risk being labelled as abusers, and once suspicion is raised, all their actions are reinterpreted through a lens of deceit.
As Mr Justice Poole found in the case of BR & Ors (Three Families: Fabricated or Induced Illness: Findings of Fact) [2023] EWFC: “A belief that FII has occurred… may cause witnesses to re-interpret past events in a way that hinders the court.”
Corroding trust between families and professionals
As The Sunday Times investigation has revealed, the consequences are devastating: children removed without evidence, denial of treatment and mothers dismissed as liars rather than advocates.We are aware of several mothers who have died by suicide following FII suspicions - a hidden toll of this approach.
Beyond individual cases, the climate of suspicion corrodes trust between parents and professionals.
Families become fearful of seeking help, even in emergencies. We have heard from siblings of children at the heart of an FII investigation that this catastrophically impacts on their trust in professionals and their willingness to seek care for their own health needs.
For parents of disabled or neurodivergent children, already navigating long diagnostic journeys and service gaps, the additional risk of being accused creates unbearable pressure.
This is not safeguarding. It is systemic harm.
Why change needs to happen
In a very small number of cases, illness may be fabricated or induced by a parent or carer.These are extremely rare and should be treated either as criminal matters or mental health concerns, using established safeguarding, forensic or psychiatric pathways. They do not require a vague and misapplied label like FII.
The evidence from serious case reviews and local child safeguarding practice reviews is clear: there have been no child deaths from FII in 15 years in England, and only a handful of cases of serious harm.
In contrast, hundreds of families report lasting trauma following misidentification of FII: delayed treatment, forced separation, exclusion from services and fear of approaching professionals again.
This imbalance shows why change is essential.
The campaign to end FII as a safeguarding label
In response, parents, practitioners and academics have launched a campaign to end the use of FII as a safeguarding label. Their open letter calls for:- Immediate withdrawal of the FII label and associated guidance. The main bodies that should withdraw guidance are the RCPCH, the Royal College of Psychiatrists, the Royal College of GPs, the NHS, the National Institute of Health and Care Excellence (NICE) and, in particular, safeguarding partnerships, in relation to their child protection procedures.
- Creation of evidence-based safeguarding frameworks co-produced with disabled people and parent carers. This would centre families’ expertise, ensure child- and family-focused practice and be grounded in the social model of disability. It would prioritise listening to children in accessible ways, provide transparency and procedural safeguards at every stage and make reasonable adjustments so assessments are supportive rather than punitive.
- Professional training promoting collaborative, family-centred practice and disability awareness. Assessors would be trained in disability awareness, trauma-informed practice and human rights, with a presumption that parents are usually best placed to judge their child’s wellbeing. Such a framework would focus on meeting needs and reducing barriers, rather than relying on vague, untested labels like FII.
- Review by regulatory bodies, including the General Medical Council, Care Quality Commission and the Health and Care Professions Council, of any guidance legitimising the use of FII.
- Judicial caution in accepting FII cases without rigorous scrutiny of evidence and expert testimony. The FII label is not useful and should not be used in a court context and evidence based on the outdated MSbP and associated literature and stereotypes should not be accepted. Where a case focuses on induction or fabrication of an illness, there needs to be rigorous scrutiny of evidence and expert testimony to avoid the reliance on stereotypes and alerting signs and to identify and challenge “reinterpretation of past events”.
Rebuilding safeguarding on firmer and fairer ground
For more than two decades, FII has cast a long and damaging shadow over safeguarding.Built on outdated research, inflated mortality claims and untested “alerting signs,” it has fostered a culture of suspicion that harms families rather than protecting children. Instead of building understanding and trust in the most intimate of settings - children’s hospitals and schools - FII has removed the most necessary components for professionals to work together with families to protect children.
Community Care readers know the importance of balancing vigilance with proportionality. The time has come to retire FII as a category, focus on actual evidence of harm and rebuild safeguarding on firmer, fairer ground.
As the open letter campaign insists, ending the use of FII is both an ethical necessity and a legal imperative. Children deserve protection - but families also deserve justice.
Andy Bilson is emeritus professor of social work at the University of Central Lancashire, where his research focuses on children’s rights, parent advocacy and reform of child protection systems. He is co-chair of the Parents, Families and Allies Network, which aims to promote greater parental participation in child protection.
Taliah Drayak is a children and families advocate, writer and researcher. She is a research fellow at the University of Cambridge and co-founder of the Parents, Families and Allies Network. She is a care experienced mother and has personal experience of a false accusation of FII
References
Abdurrachid N & Marques JG (2022) ‘Munchausen syndrome by proxy (MSBP): a review regarding perpetrators of factitious disorder imposed on another (FDIA)’ CNS spectrums, 27(1), 16-26.Bilson A & Talia A (2025) ‘Fabricated or induced illness in England: Examining mortality and serious harm’ The British Journal of Social Work, bcaf089.
Bilson A, Talia A, Drayak T, Margaret M, Smith S & Spence, M (2025). ‘Fabricated or induced illness: the controversial history, missing evidence base and iatrogenic harm’ In Clements L and Aiello A, Understanding Parent Blame (pp 76-97) Policy Press
Clements L & Aiello AL (2023) The prevalence and impact of allegations of Fabricated or Induced Illness (FII) Cerebra Legal Entitlements and Problem-solving Programme, University of Leeds
Ferguson L & Hollingsworth D (2024) Autism and Parental Blame Project: Blamed Instead of Helped West Midlands Association of Directors of Adult Social Services
Geist R, Weinstein M, Walker L & Campo JV. ‘Medically unexplained symptoms in young people: the doctor's dilemma’ Paediatrics & Child Health 13, no. 6 (2008): 487-491
Glaser D & Davis P (2019) ‘For debate: Forty years of fabricated or induced illness (FII): Where next for paediatricians? Paper 2: Management of perplexing presentations including FII’ Archives of disease in childhood, 104(1), 7-11
Glaser D (2020) ‘Fabricated or induced illness: From “Munchausen by proxy” to child and family-oriented action’ Child abuse & neglect, 108, 104649
McClure RJ, Davis PM, Meadow SR & Sibert JR (1996) ‘Epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation’ Archives of disease in childhood, 75(1), 57-61
RCPCH (2021) Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in Children: RCPCH Guidance
