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Part 1 Serious Incident Notifications
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- 2. This presentation isfor safeguarding children professionals, panel members of case review groups and those interested in the review process for a serious safeguarding incidents. We will be looking at the full cycle of the decision making process for serious safeguarding incidents: • identification and notification, • rapid review, and • local child safeguarding practice reviews. There will be an opportunity to look at the barriers and challenges, and reflect on practice within your partnership. Finally, we will look at completing the review cycle with ideas for embedding learning and service improvement, and providing assurance of the impact of reviews and in improving outcomes for children and young people. At the end of this presentation you will have a comprehensive understanding of the purpose and practice of reviews within the legislation and statutory guidance. 02
- 3. 03 Statutory background • The ChildrenAct 2004 • The Children and Social Work Act 2017 • Working Together to Safeguarding Children 2018
- 4. 04 The Children andSocial Work Act 2017 defines a serious child safeguarding case as one in which: 16(a) abuse or neglect of a child is known or suspected by a local authority or another person exercising functions in relation to children, and 16(b) the child has died or been seriously harmed; “serious harm” includes serious or long-term impairment of mental health or intellectual, emotional, social or behavioural development.” WTG 2018 states that 'When making decisions, judgment should be exercised in cases where impairment is likely to be long-term, even if this is not immediately certain. Even if a child recovers, including from a one-off incident, serious harm may still have occurred.'
- 5. 05 CSWA 2017 14Events to be notified to the Panel amended the Children Act 2004, 16 C Events to be notified to the Panel (1)Where a local authority in England knows or suspects that a child has been abused or neglected, the local authority must notify the Child Safeguarding Practice Review Panel if— (a)the child dies or is seriously harmed in the local authority’s area, or (b)while normally resident in the local authority’s area, the child dies or is seriously harmed outside England. (2)A local authority in England must have regard to any guidance given by the Secretary of State in connection with their functions under this section. (3)In this section “serious harm” has the meaning given by section 16B(9).” Responsibilities of the local authority: Duty to Notify
- 6. 06 managers. • Not havinga robust system in place for managing and escalating cases that meet the criteria for SIN, • Capacity of staff to review and register incidents. • Dispute's between agencies on where the criteria is met. • Insufficient information to make a judgement. • Not having a clear pathway for external referrals. Serious Incident Notifications SINs: common practice issues
- 7. • To identifyserious safeguarding cases that raised complex issues of were of national importance including perennial issues which form barriers to effective practice. • To review or undertake Child Safeguarding Practice Reviews. • To identify improvements made by safeguarding partners. • May request information for the purpose of discharging its' functions - have an authority to enforce. • Quality assurance of reviews and reviewers. • Sharing learning across the child protection and safeguarding system. • Promote child centered practice, championing the voice of children, families and communities. • Use of evidence to drive system improvement and learning , encourage learning and sharing of best practice. • Culture for excellence. . www.gov.uk/government/organisations/child-safeguarding-practice-review-panel 07
- 8. 08 Child Safeguarding Practice Review Panel guidance forsafeguarding partners September 2022 SIN Findings
- 9. 09 • “serious child safeguardingcases” means cases in which— • (a) • abuse or neglect of a child is known or suspected by a local authority or another person exercising functions in relation to children, and • (b) • the child has died or been seriously harmed; • “serious harm” includes serious or long-term impairment of mental health or intellectual, emotional, social or behavioural development.” Abuse or neglect is interpreted by the panel as meaning that there is sufficient reason to suspect that abuse or neglect was present and contributed to death or serious harm. Criteria is met if the act/incident itself is abusive - i'e murder by a parent or carer even if there is no other pre-existing evidence. Local authorities do not need to wait until a case is proven to notify, use the rapid review process to explore the strength of possible abuse/neglect. Notification is recommended where there has been a recent or current concern and there has been an unexplained death or suicide. Abuse or neglect can be a cause or contributory factor. If there is sufficient concern to trigger a section 47, care proceedings or criminal investigation then this would suggest sufficient indication that neglect, or abuse is suspected. Is it a serious child safeguarding case (a) abuse or neglect is known or suspected
- 10. 10 • “serious child safeguardingcases” means cases in which— • (a) • abuse or neglect of a child is known or suspected by a local authority or another person exercising functions in relation to children, and • (b) • the child has died or been seriously harmed; • “serious harm” includes serious or long-term impairment of mental health or intellectual, emotional, social or behavioural development.” Partners should consider the persistence and severity of the injury within the context of wider neglect or abuse. Other forms of abuse should be considered in terms of persistence and repetition, partners should consider how this may have impacted on the child's development and wellbeing. Long term psychological harm - and may supersede consideration of longevity and persistence of abuse in determining serious harm. Child has life changing injury or long-term impairment resulting from injury, an injury that is life threatening. i.e. the child required resuscitation or intensive care. Isolated bruises or limb fracture would not normally meet the threshold for serious unless other injuries were present. Is it a serious child safeguarding case (b) was it serious harm?
- 11. 11 • CLA • oneoff incidents • suicide • SUDI • extrafamilial harm Is it a safeguarding incident? Neglect. -adverse impacts most likely when neglect is persistent rather than one off in the context of an otherwise good environment: Questions to ask when making a decision whether to notify: • Was the action of the parent or carer neglectful in itself? • Was the outcome death or serious harm? • Was the neglect cumulative? • Was it willful? All deaths are notifiable but do not require a rapid review unless abuse or neglect is suspected or known - that relates to the incident rather than the background to becoming looked after. Where a looked after child has experienced recent abuse or neglect, or criminal or sexual exploitation, that is linked to the death or serious harm, then a SIN should be made wtih view to a rapid review. Children Looked After Neglect
- 12. 12 Cases are normallyreviewed through the Child Death Review process and would not require a notification unless it is a Child Looked After or: • neglect has directly contributed to death - severe persistent • neglect- evidence of dangerous sleeping environments. The Panel advises that partners should refer to 'Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm' 2020 to make a judgment as to whether a review would contribute to additional learning. Most cases sit within the Child Death Review process except where abuse or neglect is considered to have directly contributed to the death - trigger factors include intrafamilial, extra-familial and child exploitation. Sudden Unexpected Death in Infancy SUDI Suicide
- 13. 13 • Extra-familial harm- Hard to Escape 2020 consideration should be given to this report before progressing to CSPR • Incident should be considered as notifiable where there is a a direct relationship between the actions/omissions of an adult/carer/or person in position of power or trust in relation to the child, and the death or incident of serious harm. • Where the actions of the adult constitute CSE or CE with caring responsibilities would be a sin • If there is no evidence that the death or serious harm was caused by or related to adult coercion or exploitation or abuse or neglect then it is likely to fit the definition of extrafamilial violence. This would also apply to cases where there is child on child harm without evidence of adult involvement/neglect or abuse. Safeguarding or extrafamilial violence?
- 14. 14 Tips for good practice • Triumviratedecision making . • Clear process in place for partners to escalate cases for SIN • All SINS should be rapid reviews unless it is a notifiable incident for a child looked after without safeguarding concerns. All rapid reviews should be SINS • Clear policy for resolving disputes over notification utilizing independent scrutineer. • Sufficient capacity to review serious child safeguarding incidents - by trained staff with access to the appropriate level of information and sufficient senior management oversight. • Clarity over SIN process and partnership referral process - often using the same terminology. • Failsafe to meet 5 days notification deadline from becoming aware of incident to SIN. • Senior safeguarding partners have clear role and responsibilities for the decision-making process - where there is delegation there is a clear line of accountability. • Audit SIN referrals that have not made the criteria for notification • Look at levels of senior management alerts to SIN levels - training as required.
- 15. 15 Workshop In small groupsI would like you to discuss: • Whether the decision making for the serious safeguarding incidents was clear, timely and in line with local procedures, statutory guidance and National Panel Guidance. • Whether you can you identify any areas of strength or weakness in your local practice. You will need: • Your current operational guidance, pathway and or and forms for Serious Safeguarding Incidents • Anonymised examples of serious safeguarding incidents recently referred.
- 16. WORK SHOP 16 You may wishto consider: • Whether there is a clear pathway for reporting incidents that may meet the criteria for SIN from internal and external safeguarding professionals • Whether there is a clearly named individual or point of contact for this to happen • Whether there is sufficient management oversight of decision making, both within the LA and the partnership. • Whether the current dispute resolution process sufficiently cover disputes over SIN's . • If there is sufficient training, guidance and advice for decision makers. • If there is room for more triumverate decision making in the decision to notify. • Whether referrals and notifications are timely, if not why not? • Whether decision makers and those submitting SINs have sufficient access to information to support decision making.
- 17. 18 Recommended reading and references •Child Safeguarding Practice Review Panel guidance for safeguarding partners September 2022 • Working Together to Safeguard Children A guide to inter-agency working to safeguard and promote the welfare of children July 2018 • Children and Social Work Act 2017 • Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm Final report July 2020 • It was hard to escape Safeguarding children at risk from criminal exploitation 2020 • Children Act 2004 • www.gov.uk/guidance/report-a-serious-child-safeguarding-incident