Interpretation of videos

The observers cannot allow the child to be harmed. If they see something that may lead to an assault they wait only about 25 seconds before intervening. They do this on the assumption that if the action continued, the child would be harmed. This is open to interpretation and speculation. Actions that appeared to me to be innocent were interpreted as attempts to harm the child: a mother cuddling a fussing child into her breast; playing with the child by putting a hand over his face; brushing the teeth of an irritable child; or smacking a fractious child. Denial that she is harming the child is considered “typical” of Munchausen's syndrome by proxy. This makes it difficult for the parent to defend himself or herself.

If covert video surveillance is used only when a parent is strongly suspected of trying to harm a child, then it is being used specifically to catch or entrap the parent harming the child. If the suspicions are correct this puts the child in danger. This has resulted in a child being injured.

To keep the child in view of the cameras he is “confined” to (or very near to) a bed by 1.5 m leads attached to a physiological recorder. As the child should have been fully investigated before covert video surveillance, such recordings should not be needed. The restraint required to record for many hours is uncomfortable and restrictive and may make the child fractious. Moreover, if the doctors believe that the child is well they are deceiving the parent.

Reactions of parent and child in these conditions

As the purpose of the surveillance is to watch how the parent handles and cares for the child he or she has to stay with the child. In my experience the parent is constrained to stay in the cubicle with the child on the grounds that the physiological recorder may sound an alarm and may not be heard by the nurses.

• Download figure
• Open in new tab
• Download powerpoint

The parent is often told that the child has to be investigated for a serious problem—for example “acute life threatening events” or “low oxygen levels” or “apnoeic attacks.” This worries the parent, who may think that the child is seriously ill and at risk of dying. The parent's reaction to this anxiety and to the stress of being in a cubicle with the child all day adds further stress to the parent-child interaction. The artificial nature of the conditions in the cubicle create extra stress. Normal behaviour by the child or parent cannot be expected in these circumstances. Covert video recordings of the parent's behaviour are unlikely to represent how she behaves at other times.

Covert video surveillance lacks objective and independent statistical validation. There are no studies in which recordings of alleged cases and controls, in the same environment, have been evaluated blind to any history.

A letter in the BMJ stated that 32 of 34 children subjected to covert video surveillance were taken into care.2 This is despite the fact that several parents did not harm the child under video surveillance. If investigators decide to use covert video surveillance they should consider what they will do if they do not observe abuse. If the answer is that the child will still be taken into care then surveillance should be unnecessary.

Videos are recorded to obtain evidence that may be used in court. The whole recording should be exhibited to show how the parent cares for the child during the entire time, and suspicious episodes should not be shown out of context. Video material that does not show “abuse” should not be erased.3 Erasure could bias the evidence against the parent.

The paramount concern must be the welfare of the child, but those involved should carefully examine the practical and ethical problems of undertaking and interpreting covert video surveillance before they use it as part of their diagnostic armamentarium. Hopefully they will realise that it does not “provide certainty over the diagnosis.” 4

“Double effect” and care orders

Covert video surveillance should be used only with a minority of young children presenting with apparent life threatening events where the parent is strongly suspected of trying to harm the child. It is used to “entrap” the parent. It is recognised that this may potentially pose a risk of harm to the child, but it is a situation in which the principle of “double effect” applies—that is, when an act definable as good in terms of its object can achieve a good effect only at the risk or expense of causing incidental but unavoidable harm. Morley argues that if the child is going to be taken into care even if covert video surveillance does not prove abuse, then such surveillance is unnecessary. This oversimplifies the problem. The history itself may well be sufficient to obtain an emergency and often definitive care order. However, it should be recognised that although there may be enough grounds for legal proceedings, courts may decide to make only a supervision order or no order at all, unless an appreciable level of risk is shown and the child may be returned to his parents to face the same risk. Covert video surveillance can therefore provide valuable evidence for both care proceedings and criminal proceedings.

One of the principles of the Children Act is that where possible children should be brought up by their parents.3 This may be totally inappropriate if one parent is the perpetrator of the induced illness syndrome. However, if the parent has not been convicted of a criminal offence relating to the induced illness syndrome, or no conclusive evidence exists of the cause of harm to the child, then it may be very difficult to argue that the child should not be returned to his or her parents even though they may be strongly suspected of perpetrating child abuse. The needs of siblings and any future children are easier to deal with when there has been conclusive evidence or conviction through care or criminal proceedings, or both of these.

Morley describes a child being “confined” to the bed by attachment to a physiological monitor. In practice covert video surveillance is usually undertaken on babies, who spend much of their time anyway in bed. With appropriate technology, including wide angle cameras, considerable “freedom to roam” can be allowed. In the only reported large series of covert video surveillance, recordings lasted from 15 minutes to 15 days (median 29 hours).4 Morley also states that parents are told that the child has to be investigated for a “serious” problem and that this worries them. Innocent parents are already unbelievably worried, and we are indeed investigating a serious problem which has both a high mortality and significant morbidity. He also argues that there are no “control” recordings. It would be both unethical and probably unlawful to try to obtain such evidence on normal children and parents.

The pioneering work of Southall and his colleagues has been pivotal in raising both professional and some public awareness of the profound difficulties in this area.4 It has been argued that there is now a great deal more understanding, and indeed belief, that parents can and do try to obstruct their child's airway and that because of this the judiciary may be more willing to agree to make care orders on the basis of a suggestive history. However, criminal proceedings are much less likely to be successful in the absence of such evidence. We believe that in many circumstances the long term protection of the child requires the added support of criminal proceedings and conviction.

Inappropriate and “maverick” use of covert video surveillance must be avoided by using an agreed and rigorous protocol. Here again, Working Together—Under the Children Act 1989 is important.2 Early involvement of the police and social services in strategy and planning meetings is essential if children are to be protected. A rigorous protocol for covert video surveillance must be owned by all agencies involved.

Children have the right to protection from abuse and ill treatment. Covert video surveillance is an important tool to help professionals make the correct decision on behalf of children.