Definitions of Notifiable Incidents and Seriously Harmed
Last updated 18/05/2017
A notifiable incident is an incident involving the care of a child which meets any of the following criteria:
- A child has died (including cases of suspected suicide), and abuse or neglect is known or suspected;
- A child has been “seriously harmed” and abuse or neglect is known or suspected;
- A Looked After Child has died (including cases where abuse or neglect is not known or suspected); or
- A child in a regulated setting or service has died (including cases where abuse or neglect is not known or suspected.
‘Seriously harmed’ in the context of the above 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:
- A potentially life-threatening injury;
- Serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development.
This definition is not exhaustive. In addition, even if a child recovers, this does not mean that serious harm cannot have occurred.
Responsibilities of Organisations when Notifiable Incidents Occur
Where a serious childcare incident occurs which meets the definition of a ‘notifiable incident’ as outlined above the first step for any organisation is to ensure it takes appropriate action to ensure the immediate safety of the child or minimise the impact of any serious harm.
In all circumstances staff should consult with their Safeguarding Lead. The organisation should have its own internal processes to ensure that:
- Where a child has suffered serious harm, the organisation will make a referral into the MASH;
- The organisation’s Safeguarding Lead is informed of the incidents and agrees with a Senior Manager within the organisation that the criteria have been met;
- Where the child has died, the organisation notifies the Child Death Overview Panel of the death using the agreed procedure, and where the child has died unexpectedly, the organisation follows the SUDIC procedure Merseyside Joint Agency Protocol: Sudden Unexpected Death in Childhood (SUDiC).
Responsibility of the Local Authority
In accordance with Working Together to Safeguard Children (2015), Sefton Council is required to report any incident that meets the criteria of a ‘notifiable incident’ to Ofsted and Sefton LSCB promptly, and within five working days of becoming aware that the incident has occurred.
The decision to notify Ofsted about an incident will be made by the Head of Children’s Social Care in consultation with the Director of Children’s Services who will inform the Corporate Safeguarding Manager. The notification will be made within the 5 day timescale by the Safeguarding Unit using the Ofsted ’Notification of Serious Childcare Incident’ online form. This form is available here: Ofsted Online: Notification of serious childcare incident.
Responsibility of the Sefton Local Safeguarding Children Board
In accordance with the Sefton LSCB Learning and Improvement Framework the Practice Review Panel sub group will identify whether the case meets the threshold for a Serious Case Review or whether another form of learning review would be useful. This decision must be ratified with by the Chair of the LSCB and the LSCB Business Manager will consult with the National Panel of Independent Experts. Further information can be obtained from the links below:
For the avoidance of doubt, if an incident meets the criteria for a Serious Case Review (see below) then it will also meet the criteria for a notifiable incident. There will, however, be notifiable incidents that do not proceed through to Serious Case Review. If a decision is made to conduct a serious case review the LSCB Manager will inform Ofsted that a review will take place.
Publication of Reports
All reviews of cases meeting the SCR criteria will result in a report which is published and readily accessible on the LSCB’s website for a minimum of 12 months. Thereafter the report will be made available on request. This is important to support national sharing of lessons learnt and good practice in writing and publishing SCRs.
From the very start of the SCR the fact that the report will be published will be taken into consideration. SCR reports will be written in such a way that publication will not be likely to harm the welfare of any children or vulnerable adults involved in the case.
Final SCR reports will:
- Provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence;
- Be written in plain English and in a way that can be easily understood by professionals and the public alike; and
- Be suitable for publication without needing to be amended or redacted.
LSCB will publish, either as part of the SCR report or in a separate document, information about: actions which have already been taken in response to the review findings; the impact these actions have had on improving services; and what more will be done.
When compiling and preparing to publish reports, LSCB will consider carefully how best to manage the impact of publication on children, family members and others affected by the case. LSCB will comply with the Data Protection Act 1998 in relation to SCRs, including when compiling or publishing the report, and will comply also with any other restrictions on publication of information, such as court orders. The timing of publication will have due regard to the impact on any ongoing legal proceedings, including any inquest.
LSCB will send copies of all SCR reports, including any action taken as a result of the findings of the SCR, to Ofsted, DfE and the national panel of independent experts at least seven working days before publication.
If LSCB considers that an SCR report will not be published, it will inform DfE and the national panel. The national panel will provide advice to the LSCB. The LSCB will provide all relevant information to the panel on request, to inform its deliberations. In cases where an LSCB is challenged by the panel to change its original decision about publication, the LSCB will inform Ofsted, DfE and the national panel of their final decision.
Criteria for a Serious Case Review
A Serious Case is one where:
- Abuse or neglect of a child is known or suspected; and
- Either –
- The child has died; or
- The child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.
Whether to undertake a serious case or other review is agreed or not, the LSCB Business Manager will inform the referrer and the Practice Review Panel of the outcome.
If the decision is made that the threshold for a Serious Case Review has not been met, other types of reviews may be considered to support LSCB learning. Sefton LSCB Reflective Review Procedure.
Serious Case Review checklist
Decisions whether to initiate an SCR
The LSCB for the area in which the child is normally resident should decide whether an incident notified to them meets the criteria for an SCR. This decision should normally be made within one month of notification of the incident. The final decision rests with the Chair of the LSCB. The Chair may seek peer challenge from another LSCB Chair when considering this decision and also at other stages in the SCR process.
The LSCB should let Ofsted, DfE and the national panel of independent experts know their decision within five working days of the Chair’s decision.
If the LSCB decides not to initiate an SCR, their decision will be subject to scrutiny by the national panel. The LSCB should provide sufficient information to the panel on request to inform its deliberations and the LSCB Chair or the Chair’s representative should be prepared to attend in person to give evidence to the panel. In cases where an LSCB is challenged by the national panel to change its original decision, the LSCB should inform Ofsted, DfE and the national panel of the final outcome.
The LSCB must appoint one or more suitable individuals to lead the SCR who have demonstrated that they are qualified to conduct reviews using the approach set out in this guidance. The lead reviewer should be independent of the LSCB and the organisations involved in the case. The LSCB should provide the national panel of independent experts with the name(s) of the individual(s) they appoint to conduct the SCR. The LSCB should consider carefully any advice from the independent expert panel about appointment of reviewers.
Engagement of organisations
The LSCB should ensure that there is appropriate representation in the review process of professionals and organisations who were involved with the child and family. The priority should be to engage organisations in a way which will ensure that important factors in the case can be identified and appropriate action taken to make improvements. The LSCB may decide as part of the SCR to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review.
Timescale for SCR completion
The LSCB should aim for completion of an SCR within six months of initiating it. If this is not possible (for example, because of potential prejudice to related court proceedings), every effort should be made while the SCR is in progress to: (i) capture points from the case about improvements needed; and (ii) take corrective action to implement improvements and disseminate learning.
Agreeing improvement action
The LSCB should oversee the process of agreeing with partners what action they need to take in light of the SCR findings, establish timescales for action to be taken, agree success criteria and assess the impact of the actions.
Methodology for Learning and Improvement
Working Together 2015 does not prescribe any particular methodology to use in such continuous learning, except that whatever model is used it must be consistent with the following 5 principles:
- Recognises the complex circumstances in which professionals work together to safeguard children;
- Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;
- Seeks to understand practice from the viewpoint of the individuals and organisations; involved at the time rather than using hindsight;
- Transparency about the way data is collected and analysed; and
- Makes use of relevant research and case evidence to inform the findings.
Whilst Working Together stops short of advocating any specific method the systems methodology as recommended by Professor Munro (The Munro Review of Child Protection: Final Report: A Child Centred System) is cited as an example of a model that is consistent with these principles.
See: Sefton LSCB Learning & Improvement Framework (LIF)