Fabricated or Induced Illness and Nutrition: What a Dietetic Expert Can, and Cannot, Say

In cases of fabricated or induced illness, and in the wider category of perplexing presentations, nutrition is frequently the presenting feature. A child whose reported intake does not match the documented growth, a feeding history that cannot be reconciled with the clinical findings, or dietary restriction said to be medically necessary where the records do not support it. Where nutrition sits at the centre of the concern, a dietitian may be instructed to assist the court.

As an HCPC-registered dietitian, I am instructed in matters where the nutritional dimension is material. FII and perplexing presentation cases are among the most sensitive an expert can be asked to address, and they are also among the easiest to get wrong, because the temptation to reach beyond the evidence and beyond one's discipline is strongest precisely where the stakes are highest. The value of a dietetic opinion in these cases lies as much in the discipline of its boundaries as in its findings.

The framework these cases are assessed against

Concerns about fabricated or induced illness and perplexing presentations are assessed within an established safeguarding framework, set out in the Royal College of Paediatrics and Child Health guidance Perplexing Presentations (PP) and Fabricated or Induced Illness (FII) in Children (RCPCH, March 2021) and, in England, the statutory safeguarding framework of Working Together to Safeguard Children (2023) and the Children Act 1989. That framework is a medical and safeguarding one. It is not a dietetic standard, and a dietitian does not apply it. What the dietitian applies is the recognised standard for nutritional assessment: whether a child's reported intake, growth trajectory and nutritional findings are internally consistent, whether any dietary restriction in place is clinically warranted, and whether the nutritional record supports the clinical picture as presented.

The distinction matters from the first page of the report. The dietitian contributes one component of the wider picture. The safeguarding determination, and the diagnosis of fabricated or induced illness itself, belong elsewhere.

The forum determines the standard, and the standard must be stated

This is the point on which these cases most often go wrong, and it is the reason they demand particular care. FII and safeguarding concerns can be litigated in more than one forum. In family proceedings, the standard is the balance of probabilities. The same underlying facts can also give rise to criminal proceedings, most often a charge of cruelty to a child under section 1 of the Children and Young Persons Act 1933, where the standard is proof beyond reasonable doubt and the expert speaks to nutritional findings and standards, never to guilt. They may also give rise to regulatory proceedings before a professional regulator, where the regulator's own standard governs. For the Health and Care Professions Council and most UK health regulators, that standard is now the balance of probabilities, so the expert confirms the standard for the specific body rather than assuming it.

A competent expert states the governing standard for the instructed forum explicitly, and applies that standard and no other. Civil probability language must never be carried into a criminal matter, and an opinion written for one forum cannot be reused in another without revision. An expert who has not identified the forum, or who has not stated the standard, has not yet done the work the court needs.

What inadequate or unsafe opinion looks like

In one recurring class of case, the difficulty is not the underlying concern but the expert evidence built on top of it. A dietitian opines that a parent fabricated a child's symptoms, which is a question of intent the dietitian cannot answer. A report conflates the severity of a nutritional finding with deliberate causation, when severity is observable and intent is for the court. An opinion drifts into the diagnosis of FII itself, which is a medical and safeguarding determination outside dietetic competence. Each of these is an overreach, and each tends to be exposed, rightly, under cross-examination.

The safe opinion does the opposite. It establishes the nutritional facts on the records, assesses whether the documented intake and growth are internally consistent and whether any restriction was clinically warranted, states the standard for the forum, and stops at the edge of the discipline.

Independent dietetic expert evidence in fabricated or induced illness cases turns on the documentary record.

The records that carry the weight

A dietetic opinion in these cases is built on the documentary record before it is built on anything else. Growth charts and weight trajectories over time, feeding and intake records, dietetic and medical correspondence, the basis on which any dietary restriction was instituted, and the consistency between what was reported and what was measured. The absence of a record where one should exist is itself a finding. The factual establishment is the load-bearing work, and an opinion that leads with conclusion before it has done that work is unsafe.

What a dietitian must not address

In these cases more than any other, scope discipline is the measure of a credible expert. A dietitian does not opine on a parent's or carer's state of mind, intent or culpability. A dietitian does not make the diagnosis of fabricated or induced illness, which is a medical and safeguarding determination. A dietitian does not address the psychiatric or psychological questions that often run alongside these matters, nor the medical management of the child, where those belong to the relevant experts. Where such a question arises, the report names the discipline that owns it and defers. Naming the boundary is not a weakness in the opinion. It is what makes the opinion safe to rely on.

Practical guidance for instructing solicitors

Records to obtain include: the full growth and weight record over time; all feeding and dietary intake records; the documented clinical basis for any dietary restriction; and the dietetic and medical correspondence that shows what was reported, what was measured, and how the two were reconciled.

Key instruction questions to put to a dietetic expert: Is the child's reported intake consistent with the documented growth and nutritional findings? Was any dietary restriction clinically warranted on the records? And, critically, what is the forum and the standard of proof, so the opinion is framed correctly from the outset? An expert who asks you that last question before accepting the instruction is the expert you want.

Independent dietitian expert witness

I provide independent expert witness opinion in clinical nutrition, prepared to the standard required by the instructed forum and within a clearly defined scope, on both claimant and defendant instructions. To discuss whether dietetic evidence is the right call for a matter in front of you, the route in is at rickmillerdietitian.co.uk/dietitian-expert-witness.