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1.4.1 Action to be Taken in the event of the Death of or Serious Injury to a Child or Other Critical Incidents

SCOPE OF THIS CHAPTER

This chapter outlines the steps to be taken in the event of the suspicious death of/serious injury to a child living in the community or the death of/serious injury to any Looked After child. In addition the chapter looks at responses to other critical incidents which might also lead to a Serious Case Review, Individual Management Review or Local Management Report (YOS). These steps are in addition to the carrying out of child protection procedures, as appropriate, in relation to any surviving children.

AMENDMENT

This chapter was updated in September 2017 in line with the requirement to notify Ofsted of any serious childcare incident using the Ofsted Notification Form for Serious Childcare Incidents.


Contents

  1. Introduction
  2. Death or Serious Injury of a Child in the Community
  3. Death or Serious Injury of a Looked After Child
  4. Other Serious Child Care Incidents within Children's Social Care
  5. Serious Incidents within the Youth Offending Service
  6. Needs of Social Worker/Team/Manager/Carer


1. Introduction

Working Together to Safeguard Children 2015 outlines that a Serious Case Review must be carried out by the Southwark Safeguarding Children Board under the following circumstances:

  1. Abuse or neglect of a child is known or suspected; and
  2. Either:
    1. The child has died; or
    2. The child has been seriously harmed and there is a cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together.

The SSCB has a local Learning and Improvement Framework which covers the full range of reviews and audits to drive improvements to safeguarding and promoting the welfare of children.

OFSTED (LA Circular (2007)) 25 outlines the circumstances where Local authorities should notify Ofsted of serious incidents involving children which:

  • Are serious enough that they may lead to a Serious Case Review (including “where a child has sustained a potentially life-threatening injury through abuse or neglect, serious sexual abuse, or sustained serious and permanent impairment of health or development through abuse or neglect” - Working Together paragraph 8.6); or
  • Involve a child death and will automatically lead to a Serious Case Review (“when a child dies (including death by suicide) and abuse or neglect is known or suspected to be a factor in the child’s death” - Working Together paragraph 8.5); or
  • Should be bought to the attention of Ofsted and the Government because of concern about professional practice or implications for Government policy; or
  • Raise issues about a council’s professional practice that may need to be considered further in the context of performance assessment; or
  • Have attracted or are likely to attract media attention.

If the above cases give rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children, they may also be considered as meriting a Serious Case Review or an Internal Management Review.

Within the Youth Justice Board (YJB) guidance, the Youth Offending Service should notify the YJB in the event of the following:

Safeguarding

  • The death of a young person in secure accommodation or under escort;
  • The death or attempted suicide of a young person who is being supervised in the community by a Youth Offending Team (YOT) or by another project that the YJB supports including prevention programmes;
  • Where a young person under the supervision of the YOT is the victim of any of the offences listed below.

Public Protection

A serious incident occurs if while under the supervision of the YOT, a young person is charged with one or any of the following offences:

  • Murder, attempted murder or manslaughter;
  • Rape;
  • Torture;
  • Kidnapping;
  • False imprisonment;
  • Firearms offences.


2. Death or Serious Injury of a Child in the Community

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

The child’s social worker or, if unallocated, the duty worker receiving the information will:

  1. Immediately inform their line 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 social worker’s line manager will:

Immediately inform their Head of Service and the Head of Quality Assurance by telephone and provide follow up information in writing as soon as possible afterwards.

The Head of Quality Assurance will:

  1. Inform the Director Children’s Social Care;
  2. Ascertain as full details as possible from the Police and any other source;
  3. Request their administrative staff to check the Mosaic records on the child and family and print out any information held;
  4. Collect any paper files held on the child and family and secure them in the correct office location;
  5. Arrange through the administrative staff how to inform the other relevant agencies about the death/serious injury and remind them to secure their files;
  6. Arrange, in consultation with the Director Children’s Social Care, an emergency meeting of the Serious Case Review (SCR) Sub-Group of the Southwark Safeguarding Children Board to consider the circumstances of the death/serious injury and the commissioning of a Serious Case Review;
  7. Inform Ofsted using the Notification Form for Serious Childcare Incidents.

The report to Ofsted is submitted online and the contents entered must be reviewed by the Designated Manager before it is submitted. The form requires a range of information and is set out clearly in sections. A copy of the completed form should be saved in Carestore within the child’s electronic file.

In urgent situations, Director of Children’s Services should telephone Ofsted on 0300 123 1231 and then complete the form.

An emergency Serious Case Review Sub-Group meeting must be held within 72 hours of notification of the death/serious injury of the child and should decide whether a Serious Case Review is appropriate under Working Together 2015 procedures. If the Independent Chair is not present, s/he must ratify any decision made. The agenda for the meeting will cover:
  • Sharing of knowledge about the situation so far; reports from individual agencies;
  • Discussion regarding need for Serious Case Review;
  • If a Serious Case Review is required, the commissioning of the Review through the Serious Case Review Sub-Group and the setting of dates;
  • Arrangements for press/media liaison and ratification of joint SSCB press statement if necessary;
  • Consideration of staff/public counselling needs and commissioning of the same from the Southwark Safeguarding Children Board’s Treatment Sub-Committee;
  • Consideration of the need for follow-up meetings and if so, the setting of dates.

When a Serious Case Review is required, a Serious Case Review Panel will be set up, chaired by an independent person. The process will be guided by Chapter 4 of Working Together 2013.


3. Death or Serious Injury of a Looked After Child

Where information comes to notice of the death of a Looked After Child, the following tasks are required.

The child’s social worker will:

  1. Immediately inform their line 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 regarding the arrangements for the funeral (in the event of sudden, unexplained deaths 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 manager any necessary expenditure including reasonable travel expenses to assist the family in attending the funeral or visiting the child in hospital where it appears there is financial hardship;
  7. Discuss with the manager and plan for any possible conflicts between foster carers/adopters and birth parents in this process.

The social worker’s line manager will:

  1. Immediately inform the Head of Service and the Head of Quality Assurance by telephone and provide follow up information in writing as soon as possible afterwards;
  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 Head of Quality Assurance will:

  1. Inform the Director Children’s Social care;
  2. Consult the Director about the need for an internal management review of the case and if so, the appropriate person to conduct the review;
  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. Where appropriate, arrange, in consultation with the Director, Children’s Social Care, an emergency meeting of the Serious Case Review Sub-Group of the Southwark Safeguarding Children Board (SSCB) to consider the circumstances of the death/serious injury and the commissioning of a Serious Case Review;
  6. Inform the Department for Education and OFSTED.

The report to the Department for Education and OFSTED (using OFSTED’s proforma) will include the following information in the order shown:

  • Local Authority;
  • Child’s Name;
  • Parents’ names;
  • Date of Birth;
  • Date of Death/Serious Injury;
  • Child’s Legal Status;
  • Child’s ethnicity, religion, language, disability;
  • Cause of Death as on Death Certificate;
  • Dates if any when child was the subject of a Child Protection Plan;
  • The date and findings of the Post Mortem, Inquest and any criminal proceedings initiated. It may be necessary to notify these details at a later date;
  • Brief details of the case;
  • Local authority duties in respect of the child;
  • Intention of the local authority to hold an independent review or inquiry;
  • Policy and practice issues raised and intended local authority action (to follow later if necessary).

In the event of a Serious Case Review and/or internal management review being required, the steps outlined in Section 2, Death or Serious Injury of a Child in the Community should be followed.


4. Other Serious Child Care Incidents within Children's Social Care

Apart from the situations outlined in Section 2, Death or Serious Injury of a Child in the Community and Section 3, Death or Serious Injury of a Looked After Child, the following instances should be regarded as serious child care incidents:

  • A parent is murdered and a domestic homicide review is being initiated under the Domestic Violence, Crime and Victims Act 2004; or
  • A child has been seriously harmed following a violent assault perpetrated by another child;
  • A child known to Southwark commits a murder;
  • A child known to Southwark commits suicide;
  • Serious concern about the professional practice of a worker in the council.

In the event of one of the above instances coming to light, a worker should immediately inform their line manager. The local Head of Service and Head of Quality Assurance should be informed immediately and any appropriate documentation secured.

A decision will be made with the Director Children’s Social Care as to whether the incident merits:

  • A notification to be made to OFSTED;
  • A meeting of the Serious Case Review Sub-Group to be convened;
  • A management review.


5. Serious Incidents within the Youth Offending Service

In all cases the YJB Guidance on serious incident reporting procedures (2007) should be followed.

If a serious incident occurs in the community, the YJB should be informed within 24 hours of the serious incident coming to the attention of the YOT. Initial notification of the incident should be sent via secure e mail to YJBSeriousincidents@yjb.gov.uk.cjsm.net and copied to the relevant YJB head of region. A member of the Serious Incidents team will then:

  • Confirm receipt of the notification by email;
  • Advise the YOT manager of the 20 day deadline for submission of a Local management Report on the incident to the head of region;
  • Alert the YJB media team who will liaise with the Ministry of Justice and/or Home Office press officers and the local authority press office.

If the serious incident occurs in a secure accommodation or under escort, the manager of the service will report the incident as soon as possible using existing reporting procedures. The YOT should then liaise with the YJB as above and agree if a Local management review should be completed and by whom.

In addition a Serious Incident in the YOT should always be notified to the Business Manager for Social Work Improvement and Quality Assurance. Following discussion with the Assistant Director for Children’s Services, it may be thought appropriate to consider the case within the Serious Case Review Sub-Group.

Whenever a Serious Incident is reported to the YJB a Local Management Report (LMR) must be completed and submitted to the YJB within 20 working days.

The LMR should be completed by a practitioner of or above the grade of operational manager and who has no direct involvement in the management of the case and should always be countersigned by a YOT manager. It should contain:

  • An analysis of the events surrounding the offence, death or attempted suicide;
  • A chronology of the young person’s time under the care or supervision of the YOT and/or secure establishment;
  • Documentary and supporting evidence;
  • Recommendations for local operational practice and/or training.

In some cases a Serious Case Review may be considered necessary in addition to an LMR. In these situations the LMR will substitute for the Individual Management Review for the YOT.


6. Needs of Social Worker/Team/Manager/Carer

During the implementation of these procedures consideration must be given to the needs of those staff involved in the cases. The impact of a child death or a serious incident on social worker/team/manager/carer needs to be addressed in terms of:

  • The need for counselling for those involved;
  • The manner in which 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 Case Review or Local Management Review;
  • 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 de-briefings whilst observing confidentiality. This must be discussed with the Designated Manager (Death of a Looked After Child);
  • The need to acknowledge that a child death or serious incident can have a serious impact on the functioning of any Team both in terms of the emotional impact on team members and the possibility of an increased workload. There may need to be agreed strategies to manage this.

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