Significant Incidents - Death of or Serious Harm to a Child in Need, Looked After or Care Leaver Up to and Including the Age of 24

1. What is a Serious Incident?

A significant incident is any incident involving the care of a child, which meets the principles set out below.

Local authorities in England must notify the national Child Safeguarding Practice Review Panel (the Panel) within 5 working days of becoming aware of a serious incident.

Serious incidents which should be reported are those where the local authority knows or suspects that a child has been abused or neglected and:

• A child has died (including cases of suspected suicide), and abuse or neglect is known or suspected;
• Child seriously harmed in the local authority area. Seriously harmed includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following:
  • Potentially life-threatening injury;
  • Serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development. A child missing from home or service provision;
  • Accident/incident notifiable to the Health and Safety Executive;
  • Significant impact of a provision of a service, e.g. children’s home registration changes;
  • A high-profile case in Court/Coroner’s Court;
  • A prosecution;
  • Issues/incident that is likely to attract media attention.

This list is not exhaustive, there may be other incidents which are considered as significant events. In addition, even if a child recovers, this does not mean that serious harm cannot have occurred (Working Together to Safeguard Children)

Regulated setting and services include: Childcare on domestic premises; Childcare on non-domestic premises; Home childcarer; Childminder; Children’s Homes (including secure children’s homes); Adoption Support Agencies; Voluntary Adoption Agencies; Independent Fostering Agencies; Residential Family Centres and Holiday Scheme for Disabled Children.

2. Notification of a Significant Incident: Notification Pathway

Where there has been a significant incident to a child living in the community, the following tasks are required.

• Starting Point (New referrals);
• Allocated / Duty worker;
• Out of Hours Team (new referrals outside of working hours, contacts on open cases).
• The worker receiving the information will immediately inform the team manager;
• Appropriate Child Protection Procedures in conjunction with our partners from health, police and any other agency involved should be followed in response to the significant event, to ensure that safeguards are in place for the child or surviving siblings in child death circumstances;
• Team manager will immediately inform the Head of Service who will notify senior managers. (The Head of Service and senior manager will consider during this conversation who else needs to have immediate notification);
• Senior Managers need to be regularly updated of the progress of the incident/investigation via the Head of Service.

3. Significant Incident Briefing to Senior Managers

Senior managers need to give consideration at the earliest opportunity to the threshold criteria for notifying the Child Safeguarding Practice Review Panel, the Safeguarding Children Partnership and Partners and other departments. The Head of Service notifying the senior manager will complete the Significant Incident briefing form.

4. Death of/or Serious Injury of a Child in the Community

Where information is received about the suspicious death of/or serious injury to a child, living in the community, the following tasks are required:

The child’s allocated worker or, if unallocated, the Duty Worker receiving the information will:

1. Immediately inform their Team Manager;
2. Obtain as much information as possible on the circumstances surrounding the cause of death/serious injury and pass this to the line manager.

The Team Manager will immediately inform the Head of Service, Service Director of Early Help and Safeguarding for Children’s Services by telephone and provide follow up information in writing as soon as possible afterwards.

The Service Director will undertake the following as may be required:

1. Inform the Executive Director, who will notify Local Authority members as necessary;
2. Ascertain as full details as possible from the police and any other source;
3. Request their administrative staff to check children’s services records on the child and family and print out any information held;
4. Collect any files held on the child and family and secure them in the correct office location;
5. Arrange through their administrative staff how to inform the other relevant agencies about the death/serious injury and remind them to secure their files;
6. Liaise with the Safeguarding Children Partnership Manager;
7. Notify the child Safeguarding Practice Review Panel if the criteria are met.

5. Death of or Serious Injury to a Child in Care

Where information is received regarding the death of or serious hear to a child in care, the following tasks are required:

The allocated/duty worker will:

1. Immediately inform their Team Manager;
2. Notify the parent(s) immediately and in person if possible;
3. In the event of a child’s death, discuss with the parent(s) and reach agreement with regarding the funeral (in the event of a sudden, unexplained deaths the arrangements for the funeral may need to be delayed);
4. In the event of a serious injury to the child, arrange with the parent(s) to visit the child in hospital;
5. Obtain as much information as possible on the circumstances surrounding the cause of death/serious injury and pass this to their line manager; and
6. Discuss with the line manager any necessary expenditure including reasonable travel expenses to assist the family with attending the funeral or visiting the child in hospital where it appears there is financial hardship;
7. Where the child was in a long-term foster placement, discuss with the line manager any possible conflict between the carers and the parents regarding arrangement for the child’s funeral.

The team manager will:

1. the team manager will immediately inform the Head of Service, the Services Director for Early Help and Safeguarding by telephone and provide follow up information in writing as soon as possible;
2. Advise Legal Services initially by telephone, then confirm details in writing; and
3. Contact the Insurance Section of the Finance Department initially by telephone and then in writing.

The Service Director will:

1. Inform the Executive Director of Children's Services, who will come to a decision about whether to notify local authority members;
2. Ensure that the parent’s wishes concerning the funeral are discussed (by the Social Worker or Team Manager), that any possible conflict with the wishes of the carers are also ascertained and addressed, and that any appropriate associated costs are met;
3. Where a review is to be conducted, collect any files held on the child and family and secure them at his or her office;
4. Arrange through his or her administrative staff to inform other relevant agencies about the death/serious injury and remind them to secure their files where a review is likely to be required;
5. Notify the Safeguarding Children Partnership;
6. Notify the child Safeguarding Practice Review Panel.

6. Death of a Care Leaver Up to and Including the Age of 24

Working Together to Safeguard Children provides that the local authority should also notify the Secretary of State for Education and Ofsted of the death of a care leaver up to and including the age of 24. This should be notified via the Child Safeguarding Online Notification System. The death of a care leaver does not require a rapid review or local child safeguarding practice review. However, safeguarding partners must consider whether the criteria for a serious incident have been met and respond accordingly, in the event the deceased care leaver was under the age of 18. If local partners think that learning can be gained from the death of a looked after child or care leaver in circumstances where those criteria do not apply, they may wish to undertake a local child safeguarding practice review.

7. Notification to the Child Safeguarding Practice Review Panel

Where a local authority knows or suspects that a child has been abused or neglected, the local authority must notify the Child Safeguarding Practice Review Panel if:

• The child dies or is seriously harmed in the local authority area;
• While normally resident in the local authority’s area, the child dies or is seriously harmed outside England.

For child in care, deaths must be reported to the Panel whether abuse or neglect is suspected.

The local authority must notify the Panel within 5 working days or becoming aware of the incident.

The Panel will share all notifications with Ofsted and the Department for Education.

It is crucial the practitioners alert team managers as the earliest opportunity to all events which could be considered as a significant incident.

The decision to notify Panel will be taken by a member of SMT (Senior Management Team)

See Derby and Derbyshire Safeguarding Children Partnership Procedures.

Out of hours communication strategy

On call social worker will alert the on call manager via telephone who will then contact the Head of Service Rachal Harrisson and the Head of Service for the area in which the child resides. The Head of Service will then contact Senior Managers.

The on call social worker will send a detailed email out to the relevant managers outlining the key areas for consideration and immediate action.

On call manager and the head of service should discuss key areas such as:

• Circumstances;
• Safety p;lans for other children if necessary;
• Potential media attention.

In some circumstances such as in cases of non-suspicious deaths the decision might be made not to contact head of service and senior managers until the following day however, this must be at 7.30am before the working day or at weekends before 9.00am, unless the case is likely to attract media coverage. In this case senior manager and heads of service need notification with immediate effect.

All telephone contact must be followed up by an email to the following senior managers:

Social Care

• Executive Director;
• Service Director for Early Help and Safeguarding;
• Assistant Director for Early Help and Safeguarding;
• Assistant Director for Specialist Services;
• Head of Child Protection;
• Head of Children in Care Provision (if the child/young person is a child in care);
• Team Manager for Children’s Out of Hours Team;
• Relevant locality head of service or head of service disabled children’s team.

Education

If a child is attending school, consider the age of the child and email:

• Service Director for Schools and Learning;
• Assistant Director Education Improvement (including Early Years);
• Assistant Director Learning Access and Inclusion;
• Principle Educational Psychologist;
• Children Protection Manager for Schools.

Communication/Press Office (where there is likely to be media interest)

Non-Suspicious Death

In the event of a non-suspicious death, you should email the following:

• Executive Director;
• Service Director for Early Help and Safeguarding;
• Assistant Director for Early Help and Safeguarding;
• Assistant Director for Specialist Services;
• Head of Child Protection;
• Head of Service Starting Point and/or where the child resides or hold case responsibility;
• Team Manager for Children’s Out of Hours Team;
• Relevant locality Head of Service or Head of service disabled children;
• Service Director for Schools and Learning;
• Assistant Director Education Improvement (including Early Years);
• Assistant Director Learning Access and Inclusion;
• Principle Educational Psychologist;
• Children Protection Manager for Schools.

8. Needs of Social Worker / Service / Managers / Carer

During the implementation of this procedure consideration must be given to the needs of those staff and carers involved in the case.

The impact of a child death on social worker/team/manager/carer needs to be addressed in terms of:

• The need for counselling for those involved;
• The ways such support is offered;
• The provision of access to legal and professional advice about the ongoing conduct of the case;
• The provision of a clear explanation of the process of a Serious Incident
• Support for staff in the event of Police investigation/interviews;
• The need to inform and keep informed any relevant Trades Unions;
• The need for team debriefing whilst observing confidentiality. This must be discussed with the Service Manager;
• The need to acknowledge that a child death can impact on the productivity of any team and its ability to function; and the need to agree strategies to manage workloads.