Need to Know/Notifications of Significant Events

1. Internal Notifications

1.1 Introduction

This procedure aims to be as comprehensive as possible but will inevitably omit some circumstances. If you are in any doubt about the need for reporting to the Director, consult with your immediate manager.

All Need to Know Reports must be copied to relevant line managers for the matter and other senior managers must be copied in as judged appropriate.

The Director will decide whether Members or the Chief Executive need to be informed.

1.2 Circumstances which Require a Director Briefing

The Director needs to be briefed by the relevant Service Manager in the following circumstances:

Service Users

• Death or serious injury to any service user – adult or child – in particular:
• Death on a local authority premises, or when a local authority member of staff is present;
• Death in situations where the death is unusual or expected/unexpected;
• Death or serious injury of child in care or subject to a Child Protection Plan, including circumstances where death or serious injury were narrowly avoided;
• Death or serious injury of any child who is an open case to Children's Services;
• Serious accidents or injuries which occur in unusual or unexpected circumstances. Particularly, if these occur in the presence of a member of staff. If death is the likely outcome in these circumstances the Chief Executive should also be informed;
• Involvement in violent incidents, whilst on local authority premises, in the company of local authority staff, or where there are serious implications for staff working with that person;
• Cases of serious communicable diseases in school or residential premises;
• Missing children: Missing for over 24 hours, where the child is Looked After, subject to a Child Protection Plan or otherwise vulnerable;
• Any media coverage relating to service users where that may impact on the Council.

Staff

• Allegations of gross misconduct;
• Unexpected death or serious injury;
• Significant accidents or injuries at work. (This is in addition to the standard health and safety procedures that should be followed for all accidents);
• Involvement in violent incidents;
• Allegations of arrests or convictions for criminal offences;
• Any media coverage relating to members of staff where that may impact on the Council.

Service Premises and Schools

• Serious of significant damage resulting from floods, accidental fire etc.
• Significant vandalism or burglary;
• Any incidence of arson.

Controversies

• Matters of public debate or anxiety;
• Major complaints implicating the service;
• Matters likely to attract local or national interest;
• Any matter which has, or is likely to attract the attention of the media, Members of the Council or Members of Parliament.

Significant Legal Proceedings

• Proceedings likely to attract public/or media interest. This will include criminal trials resulting from child protection proceedings;
• With potentially high or policy implications;
• Inquests.

This list is not exhaustive and other categories of incidents may also fall within the definition of a serious incident. Managers will need to ensure that consideration is given to other serious incidents that do not fall within this procedure and use their judgment in discussion with senior managers as to whether the incident needs to be reported in line with this procedure.

1.3 Format for Initial Briefing – All Cases

In the circumstances described above, the first line manager responsible for the case is responsible for drafting the briefing report. Where possible, the relevant senior manager should also be advised and consulted and contribute to the briefing. However, reports must not be delayed if they are not available.

The briefing should be e-mailed using the Need to Know / Serious Incident form (attached at Appendix A: Need to Know/Serious Incident Notification (Internal)). It must be copied to the relevant line managers responsible for the case or the matter. Where agreed as appropriate, the form should be sent to the DfE and the DSCP (see Section 2, External Notifications - Statutory Notifications to Ofsted, Other External Bodies and the Darlington Safeguarding Children Board).

The purpose of this proforma is to alert the Director to the incident or and to provide the information needed to form an initial opinion on what, if any, action is required on behalf of the service.

The purpose of the proforma is not expected to be a full report. Such a report will be requested at a later date if it is required.

The briefing should include details of the following:

• Name of the adult/child subject of the notification;
• Details of the Incident or issue;
• Background to the Authority's involvement i.e. period of time, reason for involvement, names of staff involved;
• Details of child's legal status if they are looked after, and registration category if they have a Child Protection Plan, ethnicity and religion etc.
• Current situation;
• Manager's comment on situation (including risk analysis) and recommendation for action;
• Lines to Take;
• Further Action;
• Next Update;
• Date of notification to Ofsted;
• Date of Notification to the Secretary of State at the Department for Education (DfE);
• Outcome of discussion as to whether the case meets the criteria for notification to the DSCP Business Manager; and
• Date of Notification to the DSCP Business Manager.

When to update the initial briefing

As a situation develops it will be necessary to provide regular updates to the Corporate Director. Updates should be provided whenever there has been a significant change in the situation.

For missing children or vulnerable adults, a weekly report is required.

N.B. Arrangements must also be made to update Ofsted and the DfE where relevant. This must be discussed and agreed with the Head of Service prior to any information being shared.

Completion/resolution

When a situation has been resolved, please advise the Director of this with a brief report indicating reasons for resolution (e.g. missing child has returned) and identifying any learning points which can be picked up within the wider organisation.

For serious incidents there will be a formal debriefing meeting where learning points can be identified.

2. External Notifications - Statutory Notifications to Ofsted, other External Bodies and the Darlington Safeguarding Children Partnership

2.1 Notifications – All Children

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.

Incidents should be reported where the local authority knows or suspects that a child has been abused or neglected and:

• The child dies (including suspected suicide) or is seriously harmed in the local authority's area;
• While normally resident in the local authority's area, the child dies or is seriously harmed outside England.

The process for reporting a serious incident to the Panel are set out on GOV.UK.

Local authorities should continue to use Ofsted's current Notification Form for Serious Childcare Incidents to notify the Panel until a new system for the Panel goes live. Notifications made through this route will go to the Panel, Ofsted and the DfE.

The local authority must also notify the Secretary of State and Ofsted where a looked after child has died, whether or not abuse or neglect is known or suspected.

All serious child care incidents must be notified to Ofsted and the DfE immediately, this should be done following discussion with senior managers within children's social care. In appropriate cases the Safeguarding Children Partnership (DSCP) must be notified via the Partnership Business Manager.

Police involvement does not mean the Police have been informed of an incident; rather involvement implies that they are actively doing something concerning the incident, for example making an arrest or taking witness statements.

It is the responsibility of the Service Manager to make sure the notifications below are completed in a timely manner.

For the purposes of statutory notifications to Ofsted, DfE and the DSCP a serious incident includes:

• Death of a child (including suspected suicide) where abuse or neglect is known or suspected;
• Serious injury to a child where abuse or neglect is known or suspected;
• Death of a looked after child;
• Death of a child in a regulated setting (i.e. care home, registered early years, child minders, or out of school childcare provision);
• The unexpected or avoidable death of a child in receipt of services from Darlington Borough Council;
• The death of a child subject to a child in need or child protection plan;
• An incident that is serious enough that it may lead to a Child Safeguarding Practice Review under DSCP procedures;
• An incident likely to result in significant media attention (e.g. a serious allegation against a professional);
• Any case which indicates organised or large scale abuse, which has resulted in the DSCP Organised and Complex Abuse procedures being invoked;
• Where a child has suffered serious harm as a result of a worker (employed by DBC) failing to follow procedures;
• Where a registered provider (residential or early years) is closed following enforcement action by Ofsted;
• A child being the victim or perpetrator of a serious assault;
• A serious incident of self harm;
• Serious concerns over a child's missing behaviour, such as where you consider the child to be at grave risk due to their age or vulnerability or where they have been missing for a considerable period of time and their whereabouts are unknown (Please note - Ofsted do not need to routinely know about children going missing, even if the Police are called out to help look for them. However, this information should always be shared with the placing authority).

A serious illness or accident would include matters such as fractured bones, when a child loses consciousness or situations that require admittance to hospital for more than 24 hours. Ofsted do not need to be notified about injuries such as sprains, strains or falls that have happened in the course of regular childhood experiences. This is the case even if the child is taken to the local accident and emergency department to have the injury checked out, unless it results in the child being admitted to hospital for more than 24 hours. If the injury has been sustained as part of a wider incident, for example a restraint or during a child running away, it may be appropriate to notify Ofsted. However Ofsted do not need to know if a child becomes ill and is not admitted to hospital.

Self-harm incidents that result in minor or superficial injuries do not need to be reported to Ofsted. However, homes should have in place a system for notifying responsible authorities of any serious concerns about the emotional or mental health of a child to the extent that a mental health assessment would be requested under the Mental Health Act 1983.

3. Children Placed with Independent Fostering Agencies

Regulation 36 and Schedule 7 of the Fostering Services Regulations 2011 set out the arrangements for notifications in relation to specified events.

Click here to view the Schedule 7 Events and Notifications table.

Independent Fostering Agencies should use the online notification form to notify Ofsted of a specified event. Any member of staff can complete the notification form, but the manager or proprietor is responsible for ensuring notifications are made. To complete the form you will need your URN (Unique Reference Number), and full postal address and details of the incident and those involved.

Independent Fostering Agencies should have a system in place to ensure notifications are made within 24 hours and that a written record of actions and outcomes is kept. In urgent situations, particularly where there is likely to be media interest in the incident, Ofsted can be contacted by telephone (0300 123 1231).

Whenever there is a serious injury or safeguarding concern, the Independent Fostering Agency should also notify the placing/responsible authority and, where the placement is located in a different local authority to the placing/responsible authority, the area authority should also be notified, (particularly where there may be a need for ensuring appropriate enquiries are made under Section 47 Children Act 1989).

Note also that the National Minimum Standards (NMS 29.3) requires notification to the responsible authorities, (the Responsible Local Authority and Integrated Care Board), of any serious concerns about the emotional or mental health of a child, such that a mental health assessment would be requested under the Mental Health Act 1983.

4. Children Placed in Children's Homes

See: Tell Ofsted about an Incident - Online Forms and Guidance.

Regulation 40 (safeguarding notifications) of the Children's Homes (England) Regulations 2015 sets out the arrangements for notifications by the registered person in relation to serious incidents which should be shared with Ofsted. The intention is that Ofsted should only be notified of the most serious incidents.

Notifications to Ofsted should be made by using the online notification form. Any member of staff can complete the notification form, but the manager or proprietor is responsible for ensuring notifications are made. You will need your URN (Unique Reference Number), full postal address and details of the incident and those involved when completing the form.

In urgent situations, particularly where there is likely to be media interest in the incident, Ofsted can be contacted by telephone (0300 123 1231).

[1] "relevant person" means any person, body or organisation that the registered person considers to be relevant in relation to the care, protection or safeguarding of a particular child in all the circumstances.

Additional Notifications

The Children's Homes Regulations also require notifications to be made to Ofsted, the placing authority and other relevant persons in the following circumstances:

1. A serious incident requiring Police involvement occurs in relation to a child which the registered person considers to be serious. Police involvement means the Police are actively doing something concerning the incident, for example making an arrest or taking witness statements; and
2. There is any other incident relating to a child which the registered person considers to be serious.

The Oxford English Dictionary defines 'serious' as: 'significant or worrying because of possible danger or risk; not slight or negligible'.

The line between what is serious, and what is not, can be blurred and is always a matter of judgement. Deciding whether an incident is 'serious' and warrants notification to Ofsted will depend on many factors, including the age of the child, the frequency of the incident(s), the nature of any injuries sustained, any additional needs the child has and the context of the home. In some instances the cumulative effect of frequent incidents may make a notification appropriate even if  the individual event would not warrant this.

Incidents which are likely to be considered serious, and thus warrant notification to Ofsted as well as the placing authority, include:

• A child being the victim or perpetrator of a serious assault;
• A serious incident of self harm;
• A serious illness or accident;
• Serious concerns over a child's missing behaviour, such as where you consider the child to be at grave risk due to their age or vulnerability, where they have been missing for a considerable period of time and their whereabouts are unknown, or there is a pattern of repeated absence (Please note - Ofsted do not need to routinely know about children going missing, even if the Police are called out to help look for them. However, this information should always be shared with the placing authority).

A serious illness or accident would include matters such as fractured bones, when a child loses consciousness or situations that require admittance to hospital for more than 24 hours. Ofsted do not need to be notified about injuries such as sprains, strains or falls that have happened in the course of regular childhood experiences. This is the case even if the child is taken to the local accident and emergency department to have the injury checked out, unless it results in the child being admitted to hospital for more than 24 hours. If the injury has been sustained as part of a wider incident, for example a restraint or during a child running away, it may be appropriate to notify Ofsted. However Ofsted do not need to know if a child becomes ill and is not admitted to hospital.

Self-harm incidents that result in minor or superficial injuries do not need to be reported to Ofsted. However, homes should have in place a system for notifying responsible authorities of any serious concerns about the emotional or mental health of a child to the extent that a mental health assessment would be requested under the Mental Health Act 1983. Ofsted should be notified if a child living in the home requires a Mental Health Assessment.

This is not an exhaustive list, and each case must be assessed individually taking into account any patterns of behaviour or unusual behaviour that may indicate an increased risk to the child.

Sharing Information with the Placing Authority

Regardless of whether Ofsted are notified, the home must always share any concerns about the child or their behaviour with the placing authority, in order to safeguard the child and promote their welfare.

Quality of Notifications

Notifications should not just be a chronology of events. The notification should include a brief summary of the event, the actions taken by staff and managers at the time, and further actions planned to reduce the likelihood of a similar incident occurring again.

Registered managers and providers are responsible for the quality of the reports completed by their staff.

As part of the inspection process, Ofsted will discuss incidents to gain a shared understanding of what happened and the actions staff took to address the situation.

This conversation will be wider than the process of notifying (or not notifying) Ofsted, and will focus on your response to any incidents in terms of safeguarding practice and outcomes for children.

Sending Updates to Ofsted

Ofsted do not need to be sent updates in relation to any notifications made, unless there is a significant development. Even if Ofsted are not updated, it will be appropriate to share updates with the placing authority and other relevant persons.

There may be occasions when an inspector will ask for an update following a serious incident because this would be helpful in understanding what has happened and the action that you have taken. In these situations, the inspector is likely to ask for additional information directly by e-mail rather than through a series of further notifications.

Learning from Notifications

It is important that managers and providers consider the wider implications of incidents which have led to notifications. The notification should not be seen as the end of the process, rather the circumstances of the incident should be reviewed and any implications for safeguarding or outcomes for children identified. Wherever possible, actions should be planned to reduce the likelihood of similar incidents occurring again. Inspectors will ask for information on learning from notifications during subsequent inspections.

5. Accidents or Infectious Diseases - Notifying the Health and Safety Executive (HSE)

Where a child, visitor or member of staff is involved in a serious accident in the home, the HSE should be informed. The outbreak of any infectious disease (which in the opinion of a registered medical practitioner is sufficiently serious to be so notified) should also be reported.

See HSE website for forms to report incidents to the HSE.

For more information, see HSE – Reporting of Injuries, Diseases and Dangerous Occurrences.

Appendix A: Need to Know/Serious Incident Notification (Internal)

Click here to view Appendix A: Need to Know/Serious Incident Notification (Internal).