Discuss a perplexing presentation with the safeguarding team — OSCE

Candidate instructions

You are the paediatric registrar. You have looked after a two-year-old admitted for the fourth time this year with apnoea that nobody on the ward has witnessed. Between his mother's reports he feeds, plays, and grows normally, and his objective findings are normal — yet his mother, a former enrolled nurse, is pressing for a central line and a gastrostomy. You suspect a perplexing presentation with fabricated-or-induced-illness alerting features. You have ten minutes with the designated doctor for child protection to present the case concisely and agree the plan. Establish the alerting features, the differential including a genuine rare disease, the immediate safety and observation plan, the multi-agency information-gathering, the sibling assessment, and what must not happen — never confronting the suspected caregiver alone. [1]

Encounter

Safeguarding lead: "Tell me about the child and what is concerning you." [1]

Registrar: "A two-year-old boy, fourth admission this year for apnoea. The concern is the gap: every episode is described vividly by his mother, a former enrolled nurse, but no nurse or doctor has ever witnessed one, and between her reports he feeds, plays, and grows completely normally with normal saturations and normal baseline tests. She is now pressing for a central line and a gastrostomy. I think this is a perplexing presentation with several RCPCH alerting features for fabricated or induced illness, and I want to plan before I do anything further." [1]

Safeguarding lead: "Which alerting features specifically, and what have you excluded?" [3]

Registrar: "Symptoms reported by the caregiver but never observed by staff; symptoms that resolve when she is absent; a presentation that does not fit any recognised disease pattern; objective findings consistently normal between reports; and a caregiver unusually willing to consent to invasive procedures who moves between clinicians. I have excluded the common medical causes of apnoea with a focused, objective workup, but I have paused further invasive testing — I do not want to deepen iatrogenic harm by chasing a fabricated symptom. I have not excluded every rare disease, and I would hold that uncertainty with subspecialty input rather than label him prematurely." [3]

Safeguarding lead: "What is your immediate plan for his safety?" [1]

Registrar: "Keep him admitted for observation and plan a period of separation from his mother to test whether the apnoea resolves when she is not present — separation with resolution is both diagnostic and protective. I will not confront or accuse her alone or at the bedside, because premature confrontation risks escalation, flight, or evidence destruction. I will brief the ward staff on the observation plan and who has access, and ensure he is not discharged to her unsupervised care while we complete the assessment." [1]

Safeguarding lead: "How will you bring the records together, and what about the family?" [2]

Registrar: "The pattern only emerges when the fragmented records are brought together, so I will request every hospital, GP, pharmacy, and school record, and contact the other clinicians he has seen. I will not interview the mother alone before a strategy meeting. We need to assess his siblings — he has a six-month-old sister, and siblings of an index child are at elevated risk and may already be harmed, so I will arrange her assessment through child protection as part of this response. Then I would convene a strategy meeting with social care, police, nursing, and pharmacy to decide perplexing presentation versus confirmed FII and to coordinate any forensic testing." [2] [4]

Safeguarding lead: "And the principle you want me to hold from here?" [1]

Registrar: "Two things. First, the child-centred definition — this is about harm to the child, not about proving the mother has any psychiatric label, and I do not need that diagnosis to make him safe. Second, the safeguarding response is the treatment: pause the iatrogenic harm, separate and observe, gather the multi-agency record, and never confront her alone. We own a long-term plan afterwards, because recurrence and harm to siblings are well documented — I will not close the file after a single intervention." [1] [4]

Marking domains

• Clinical reasoning (30%): identifies the alerting features and the core finding (the gap between reported and witnessed), holds the differential including a genuine rare disease, and frames this as a perplexing presentation rather than a premature FII diagnosis. [3]
• Safeguarding plan (30%): separation and observation, halting iatrogenic harm, multi-agency record-gathering, strategy meeting, and never confronting the suspected caregiver alone. [1]
• Safety and family (20%): ensures the child is not discharged to unsupervised care, and mandates sibling assessment as part of the initial response. [4]
• Conceptual clarity (10%): articulates the child-centred definition and that the safeguarding response — not further investigation — is the treatment. [2]
• Communication and global (10%): concise, structured handover to the safeguarding lead, invites the plan to be owned jointly, documents appropriately. [1]