2.3.7 Serious Incident Notifications

CONTACTS

Contact details for various managers/agencies referred to in this Chapter are contained in Appendix 2: Key Contacts

RELATED CHAPTERS

London Child Protection Procedures, Section 19, Serious Case Reviews is a copy of Working Together to Safeguard Children, Chapter 8.

AMENDMENT

This chapter was updated in October 2011, a new Appendix 3: Need to Know - Informing the Divisional Director about serious issues.

Introduction
Definition of a Serious Incident
Notifications
Role of the Local Safeguarding Board
Application of Serious Incident Procedure
Relationship with Other Procedures
Responsibility for Notification and Decision Making
Briefing
Other Action to be Considered

Appendix 1: Serious Childcare Incident Notification Flowchart

Appendix 2: Key Contacts

Appendix 3: Need to Know - Informing the Divisional Director about Serious Issues

1. Introduction

This document sets out guidance and responsibilities for the notification of serious incidents to senior officers and members: it is not an operational procedure and should be read alongside the relevant legislation, regulations and internal and corporate procedures as they apply to specific responsibilities and settings within the Children and Young People’s Service (CYPS), including schools.

Nothing in this document should be interpreted as bypassing any normally applicable procedure. All managers are responsible for ensuring that staff are aware of those that are relevant within the service area.

The term ‘incident’ refers both to a specific event as well as to a set of circumstances that may have taken place over time, but cause serious concern to come to light.

2. Definition of a Serious Incident

Seriousness of an Incident Relates to:

The extent of the harm suffered by the child or other persons involved

The degree of CYPS involvement directly in the incident or with the parties involved in the incident, as well as any previous involvement.

The extent to which the incident or circumstances could reasonably have been foreseen or averted.

The consequences of the incident for those directly concerned, for the service and for the Council generally.

Whether there are any issues of misjudgment, lack of competence or failure to follow procedures or other causes for public concern on the part of Lambeth officers or those acting on their behalf.

Additional relevant factors include:

The degree of interest likely to be attracted: from partner agencies; within CYPS and more widely among senior officers and elected members; the media and general public.

The degree of urgency in making a response on behalf of the service will also be a factor.

3. Notifications

Certain situations as indicated below must be reported to OFSTED or the Youth Justice Board: all of these will fall within the definition of ‘serious incident’. Additionally, the Government Office for London Children’s Services Advisor should be informed of serious incidents. It is not possible to give an exhaustive set of examples, however; those given below indicate the type of situation in which awareness and judgement by staff at all levels is needed to determine whether this procedure should be triggered. Divisional Directors are responsible for making a clear recommendation to the Executive Director on the basis of the available facts.

Serious Case Review by the Local Safeguarding Board Required

A child dies or sustains a potentially life-threatening injury or serious and permanent impairment of health and development through abuse or neglect;
A child has been subjected to particularly serious sexual abuse;
A parent has been murdered and a homicide review is being initiated;
A child has been killed by a parent with a mental illness;
The case gives rise to concerns about inter-agency working to protect children from harm.

Working Together to Safeguard Children 2010

Notification to Ofsted as a Serious Childcare Incident

All situations requiring a Serious Case Review, plus:
Death of a Looked After Child;
Death or serious harm to a child in a Children’s Home;
Conduct of a member of staff which has implications for the safety of children.

Notification of serious childcare incident

Notification to the Youth Justice Board

Death;
Attempted suicide;
Specified serious offences

Of young persons under the supervision of the Youth Offending Team:
See Serious Incidents: Guidance on serious incident reporting procedures.

Notification to Ofsted by Registered Day Care Providers

Death or serious injury to a child;
A serious breach of registration requirements;
Serious misconduct by staff;
Other circumstances which impact on the provider’s ability to offer safe care to children.

Incidents in schools which have a child protection element must be reported to the Schools Safeguarding Officer. Where an allegation against a member of school staff is an aspect of the incident guidance can be found at Joint Guidance on Allegations against School Staff

Other circumstances which would clearly fall within the definition of a serious incident would include:

A serious incident of malicious damage or intrusion to premises in which a Lambeth service is being provided, resulting in actual or likely harm;
Any accidental occurrence causing death or serious injury to children using a CYPS service;
Abduction or disappearance of a looked after child;
Serious misconduct committed by children or young people under the supervision or in the care of CYPS, which causes harm or loss to others;
Collusion by staff with serious misconduct by children or young people who are under the supervision or in the care of CYPS;
Misconduct or malpractice by staff or contractors which affects public confidence in the service.

4. Role of the Local Safeguarding Board

The Local Safeguarding Board and its predecessor has had a longstanding role in reviewing cases through its Case Review Sub-Committee, particularly where abuse has gone undetected or has continued after a child protection plan has been developed, or where there have been difficulties in effective inter-agency partnership.

The Local Safeguarding Board has an additional statutory responsibility to review the circumstances of all unexpected child deaths within the area. (Chapter 7 Working Together)

Referral to the Case Review Sub-Committee is through the Divisional Directors Social Care or Community Learning. The Assistant Director, Safeguarding is additionally available for consultation regarding any matter concerning child protection.

There may however be circumstances which are less clear cut, for example a 'near miss'. Application of this procedure calls for professional judgement, sound awareness of roles and responsibilities within the Council and alertness to the need to protect users and staff and also the reputation of the Council. A consideration which could be used as a benchmark in judging these situations is:

Schools will have additional accountabilities dependant upon their status and will need to report serious incidents to the Board of Governors, diocesan authorities or other relevant bodies as appropriate.

5. Application of Serious Incident Procedure

The procedure applies to a serious incident:

Involving a child, young person or any other person where Lambeth CYPS has direct or indirect legal responsibilities or clear professional obligation, regardless of where and how the incident occurs. Examples include children in care, children and young people receiving a direct service from Children’s Social Care or the Youth Offending Team or young adults receiving a service under the Leaving Care Act.

Involving a child or young person or other person who is taking part in activities provided, commissioned by or in association with CYPS. Examples include children attending a Lambeth school, youth centre, day care facility, Children’s Centre, play centre or school holiday facility.

Involving any child or young person either permanently or temporarily resident in Lambeth, whether or not known to CYPS who suffers death, serious injury or other serious harm due to the actions or oversight of a parent; carer or other adult; or that of other children or young people.

Involving persons either directly employed by CYPS or in any way contracted to or providing services on behalf of CYPS which may affect the safety of children or which may otherwise compromise the service. In addition to Lambeth officers this includes: volunteers, trainees, students on placement; foster carers, prospective adopters and the employees of children’s homes, day care settings boarding schools, adventure centres, transport contractors; or any other provider of services to children on behalf of CYPS

6. Relationship with Other Procedures

All procedures relevant to the setting and service area which are applicable to the situation continue to apply e.g. a child protection issue will always require a strategy meeting and Section 47 enquiry.

These include, as appropriate:

London Child Protection Procedures (including Managing allegations of abuse made against people who work with children);
Working Together to Safeguard Children;
Recording procedures, relevant to the service area;
Youth Offending Team procedures and relevant National Standards Serious Incidents: Guidance on Serious Incident Reporting Procedures;
Looked after Children – including Missing from Care Procedure and Private Fostering Procedure;
Nurseries and Childminding Regulations Framework for the Regulation of Childminding and Day Care;
Corporate and local Risk Assessment Procedures as they apply both to standard management responsibilities and to the need for subsequent re-evaluation. Risk management- Manager's Toolkit (to follow);
Corporate and local Human Resources Procedures, where there are conduct, performance or staff welfare issues. Discipline Standards (to follow);
Professional bodies who may need to be informed e.g. General Teaching Council, and General Social Care Council;
Contracting Procedures where a contracted service is involved.

7. Responsibility for Notification and Decision Making

See Appendix 3: Need to Know - Informing the Divisional Director about Serious Issues

All Heads of Service or equivalent senior operational managers including Head Teachers are responsible for maintaining an oversight of key areas of risk within their service and for ensuring that all staff are aware of issues and circumstances that need to be referred for their attention. All notifications should be cleared through normal line management channels.

There may be a conflict between speed of notification to the Divisional Director; against the time needed to make all necessary enquiries. The Head of Service is responsible for making a judgement on this: some circumstances including those mentioned in sections above will need to be notified at the earliest possible point however vague the details are. There will be other situations where it is necessary to gather more information in order to make a useful judgement as to the level of seriousness.

In all settings the senior member of staff on duty at the time of the incident is responsible for notifying their Head of Service. If a Head of Service becomes aware of any situation which either clearly is or which may be a serious incident they are responsible for collating full written details and for passing these to their Divisional Director through the appropriate management line.

The Divisional Director should decide, on the basis of available information and with advice from colleagues as necessary, whether it is necessary and appropriate to brief the Executive Director; whether to inform the Press office; to consider whether and when external notifications should be made (Section 3, Notifications); to determine what further information they require, and in general to decide what further action should be taken.

Where the relevant Divisional Director is unavailable the matter should be referred to another Divisional Director or to the Executive Director.

The Executive Director or their deputy will decide whether the Lead Member for Children and Young People, the Chief Executive and any other person should be notified; and will also generally review action taken and that planned.

The Assistant Director, Safeguarding is available for consultation and advice in any situation where there is uncertainty regarding the seriousness of the incident or concerns.

8. Briefing

The format for briefing will vary according to the nature of the incident: it may be necessary to provide updates in the light of further information as this emerges. A briefing must be in writing and should be concise and centre on what is known, avoiding surmise or speculation. It will normally need to include:

Details of the significant individuals involved in the incident and of roles played by them i.e. John Smith Youth Worker, based at Acacia Avenue Children’s Centre;
Children’s full details: names, dates of birth, next of kin, legal status, school or other facility attended and whether they have any medical condition or other special need;
There should be a brief summary of the incident: exact location, what happened, when, and who was involved; including, as far as possible both antecedents and outcome;
Where any further information is awaited e.g. medical or police reports this should be stated;
Any relevant background history should be summarised briefly, accurately and non-judgementally;
Any views or issues raised by those either directly concerned in the incident or by others, including parents;
A summary of action taken so far and of that planned, including statutory notifications, decisions of strategy or other meetings;
A summary of implications for CYPS and for Lambeth and any recommendations which may be appropriate.

9. Other Action to be Considered

The Divisional Director should also consider alongside the appropriate Assistant Director whenever a serious incident is notified to them:

Consultation with other people who have Parental Responsibility for the child or children concerned;
Whether there is a need for human resources advice regarding conduct or competency issues?
Whether records need to be secured to prevent access or tampering?
Whether there is a need for legal advice on any aspect of the situation?
Which staff and inter-agency partners will need to be briefed and how this will be done?
Whether insurers need to be informed?
Who should be the lead officer and point of contact i.e. depending on seriousness or complexity the Divisional Director, Assistant Director or Head of Service?

The Head of Service or equivalent must consider how best to provide support to those directly affected by a serious incident, including any children directly or indirectly involved, parents and other family members as well as any staff members.

Incidents occurring or coming to light outside normal hours: any potentially serious incident which occurs or comes to notice outside of normal working hours should be notified to the Emergency Duty Team within Children’s Social Care in order that any child protection or other safeguarding issues can be considered and legal and the Divisional Director informed. In extreme circumstances it may be necessary to liaise with the Council’s Civil Emergency Section.

Contact with the media. No Lambeth officer should provide information to any branch of the media unless specifically authorised to do so. Heads of Service should remind their staff of this whenever a serious incident has occurred.

Relationship with other public authorities: Where the incident occurred within the area of another local authority; at a hospital, police station or any other institution; where it took place in a multi-disciplinary setting or where any other public body is otherwise involved it is essential to establish liaison with the body’s key managers and, as appropriate communications department at the earliest possible stage.

Initial enquiries should be made and liaison established by the Head of Service. The appropriate managerial level for this will depend upon circumstances and should be agreed by the Divisional Director.

Appendix 1: Serious Childcare Incident Notification Flowchart

Appendix 2: Key Contacts

Name	Position/ Agency	Contact number
Referral and Assessment	Social Care	0207 926 5555
Emergency Duty Team	Social Care	0207 926 1000
Press Office	Press Officer	0207 926 2841
Cllr Sally Prentice	Lead Member CYPS	0207 587 0160
Derrick Anderson	Chief Executive	0207 926 2941
Phyllis Dunipace	Executive Director CYPS	0207 926 9771
Ade Adetosoye	Divisional Director Social Care	0207 926 9787
Chris Ashton	Divisional Director Inclusion and Standards	0207 926 9950
John Readman	Divisional Director Community Learning	0207 926 9703
Doreen Redwood	Divisional Director Commissioning and Performance	0207 926 4794
Sandra Morrison	Divisional Director Change Management	0207 926 9705
Farrukh Akbar	Divisional Director Finance and Resources	0207 926 9774
Mike Pocock	Divisional Director Building schools for the future	0207 926 3220
Margaret Sutherland	Assistant Director Multi Agency Safeguarding, Quality Assurance and Service Development (Social Care)	0207 926 4526
Graham Griffin	Safeguarding Children Manager (Lead Officer for Schools)	0207 926 1643
Craig Stevenson	Family Support Service Co-ordinator- Staying Safe, Community Children’s Service	0207 926 9567
Serious Incident Notification	Ofsted	08456 40 40 40
Robert McCulloch- Graham	Children’s Services Advisor Government Office for London	0207 213 3259 07879 603659 Robert.graham@gol.gsi.gov.uk

Appendix 3: Need to Know - Informing the Divisional Director about Serious Issues

1. Background

It is important that senior managers are briefed at the right time about the right sorts of issues. There are 2 main reasons for this. Firstly, so that senior managers are aware of serious risks within the organisation and therefore that these risks are managed at the right operational level. Secondly, in well organised departments, senior managers are effectively briefed about important issues in advance so that they are well placed to respond to enquiries from councillors, the press, or partner agencies.

Sometimes it is a matter of fine judgement whether an issue is sufficiently serious to inform the Divisional Director, however there are a number of circumstances where the Divisional Director should always be informed. If in doubt discuss it with your line manager.

2. Issues which should always be reported to the Divisional Director:

The death of a child where abuse or neglected is suspected;
Death or serious injury to a Child Looked After;
Death or serious injury to a Child subject to a Child Protection Plan;
When a Child Looked After is missing for 48 hours or more;
When a child with a Child Protection Plan missing for 72 hours or more. This applies both to a child who goes missing alone, and a child who goes missing with their family, e.g. child removed from the country against the terms of the Child Protection Plan;
Cases where there is a reasonable suspicion of organised abuse. This can include ritual abuse, child trafficking, or network of abuse on the internet;
Serious incidents of violence against staff;
Death or serious injury to staff or service user through an accident at work;
Allegations of Gross Misconduct against staff;
Complex legal cases that might impact on the reputation of the local authority or complex JR cases (the principle Lawyer has delegated authority to report this directly to the Divisional Director).

3. Cases which must be reported to an Assistant director who will decide whether to notify the Divisional Director

Missing children who do not fall into the above category, but because of other factors - e.g age + vulnerability - are at serious risk of Significant Harm;
Children Looked After charged with a serious crime;
CLA removed from the UK jurisdiction in an unplanned way;
Cases where there is a change of significant media interest;
A child with a CP Plan made homeless (?)
A CLA or a child with a CP Plan out of Education for 3 months (?)
Serious concerns about practice within the department that have not been resolved by managers;
LADO cases where allegations of abuse against CYPS staff are substantiated or where it involves a high ranking member of staff - eg Headteacher.

4. Procedure

Cases under category (2) will need an immediate briefing for the Divisional Director. This would usually be completed by the social worker and / or Team Manager. it should consist of the following sections.

Basic information relating to the child, including the legal status;
What is the nature of the concern? Why does the director need to be informed?
Action being taken to deal with/the issue;
Date when an update is expected;
Who to contact for further details.

The briefing should be sent to the Head of Service with copies to the Assistant Director for any amendments. If there is no response by the end of the working day during which the concern arose, then it needs to be sent to the Divisional Director anyway, with copies to the HOS and the AD.

For cases under category (3) a full briefing need not be prepared, however the AD will need enough information to make the decision as to whether to inform the Divisional Director. If it is decided that the DD is to be briefed, then a full briefing will need to be prepared as for category 2 above.

If in doubt, discuss it with your line manager.

End