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1.6.1 Death or Serious Injury to a Child (Including Children Managed by Social Workers or Lead Professionals)

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 child in care (Looked After).

These steps are in addition to the carrying out of the Local Safeguarding Children Board Procedures in relation to the need to hold a Multi-Agency Concise Review / Serious Case Review and the work of the Child Death Overview Panel.

NOTE: Local Authority Circular (2007) 25 requires local authorities to statutorily notify Ofsted of serious childcare incidents. Serious incidents involving children are defined as:
  • Are incidents serious enough that may lead to a serious case review; or
  • Involve a child death and will lead automatically to a serious case review; or
  • Should be brought 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.

Deaths of all children looked-after by the local authority and serious harm to children living in children’s homes are also reportable incidents under the arrangements of LAC (2007) 25.

AMENDMENT

This chapter was updated in February 2016.


Contents

  1. Death of or Serious Injury to a Child in the Community
  2. Death of or Serious Injury to a Child in Care
  3. Needs of Social Worker / Team / Manager / Carer


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

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

1.1

The child's social worker or lead professional or, if unallocated, the duty worker receiving the information will:

  1. Immediately inform his or her 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.
1.2 The line manager will immediately inform the Head of Service in Social Work (another Head of Service within Children’s Services in their absence) by telephone and provide follow up information in writing as soon as possible afterwards. Lead professionals will report in the same way to the Service Leader, Early Years and Early Help through the CAF Team.
1.3

The Head of Service in Social Work and / or the  Service Leader, Early Years and Early Help will:

  1. Inform the Director of Children's Services and Head of Safeguarding who will notify council leaders and elected members as necessary;
  2. Ascertain as full details as possible from the Police and any other source;
  3. Request his or her 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 at his or her office and arrange for the record on Protocol to be locked down;
  5. Arrange through his or her administrative staff to inform the other relevant agencies about the death/serious injury and remind them to secure their files;
  6. Arrange to consider the circumstances of the death/serious injury, in accordance with the Pan Lancashire Policy and Procedures for Safeguarding Children Manual, including the need to hold a Case Review;
  7. Ensure there is a referral to the Child Death Overview Panel;

  8. Inform Ofsted, where applicable using the Notification Form for Serious Childcare Incidents (Ofsted will in turn notify the Department for Education who may contact the DCS (usually the officer who submits the form on behalf of the DCS) and /or the Head of Safeguarding/Safeguarding Development Manager for more information); and
  9. Inform the Clinical Commissioning Group (The Designated Nurse for Safeguarding and where applicable the Named Nurse for Looked After Children) who will on behalf of local health partners inform the Area NHS England Team, who in turn will inform the Care Quality Commission.
1.4

The Ofsted serious incident notification report will include the following information and must be approved by the Head of Service in Social Work and / or the Service Leader, Early Years and Early Help before it is sent:

  • 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 or any siblings were subject to 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 case review;
  • Policy and practice issues raised and intended local authority action (to follow later if necessary).
1.5 Where it appears that the LSCB thresholds to hold a Case Review may be met, the Head of Service in Social Work and / or the Service Leader, Early Years and Early Help, in discussion with the DCS, will submit the LSCB’s SCR Referral form and determine the most appropriate person to be part of the LSCB’s SCR Case Consideration Panel and Review Group from Children's Services. This case review must be conducted in accordance with the expectations that are set out in Chapter 4: Learning and Improvement Framework, Working Together to Safeguard Children 2015 and the Pan Lancashire Policy and Procedures for Safeguarding Children Manual. This will include the preparation of a Significant Practice Episodes (SPE), Chronology of what is contained in the records, providing contact details of all the departmental staff involved in the child’s case to the LSCB and the case review’s Lead Reviewer(s) so that it can be determined which staff will be involved in the Case Group, and nominated Review Group and Case Group members attending all the relevant meetings for the case review. From the SPE chronology, discussions at the Case Group or discussions at the Review Group further evidence of records may be requested and agreed to be provided to inform the case review; staff must ensure the information is supplied securely.
1.6 The case review findings and action plan should be reported to the Senior Management Team of Children's Services, together with a report of any follow-up action. The findings and action plan should also be fed back to all staff by the Head of Service in Social Work and / or the Service Leader, Early Years and Early Help or their nominee. Dissemination of the learning from the case review so that improvements to practice can be made must be as important as taking part in the case review.
1.7 If a decision is made not to hold a Case Review by the Chair of the Local Safeguarding Children Board, this will be notified to the Department for Education and Ofsted in accordance with the Pan Lancashire Policy and Procedures for Safeguarding Children Manual. However, the LSCB, Head of Service in Social Work and / or the Service Leader, Early Years and Early Help, may still decide that there are issues arising from the case which justify an internal management review. The Head of Service in Social Work and / or the Service Leader, Early Years and Early Help in discussion with the DCS will determine the methodology to be used to conduct an internal management review.
1.8 All child deaths are reviewed by the Child Death Overview Panel to help identify any patterns or safety concerns in the deaths. All services have a responsibility to report all deaths to the LSCB through the CDOP Co-ordinator in accordance with the Pan Lancashire Policy and Procedures for Safeguarding Children Manual. Where a child concerned has been provided with services, the LSCB will request information to assist in the review of the death that will be undertaken by CDOP. For deaths classed as an ‘unexpected death’ additional work with the Sudden Unexpected Death of a Child Service will be required in accordance with the Pan Lancashire Policy and Procedures for Safeguarding Children Manual.


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

Where information comes to notice of the death of or serious injury to a child in care, the following tasks are required.

2.1

The child's social worker will:

  1. Immediately inform his or her 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 line 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. 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 arrangements for the child's funeral / hospital visits.
2.2

The line manager will:

  1. Immediately inform the Head of Service, Permanence (another Head of Service within Children’s Services in their absence) 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.
2.3

The Head of Service, Permanence will:

  1. Inform the DCS, who will come to a decision about whether to notify Council  leaders and elected members. The Head of Safeguarding will also be informed;

  2. Ensure that the parents' wishes concerning the funeral are discussed (by the social worker or the 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. Come to a decision about the need for an internal management review of the case and if so, the appropriate person to conduct the review;
  4. Where a review is to be conducted, collect any files held on the child and family and secure them at his or her office;
  5. 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;
  6. Arrange, in consultation with the Head of Safeguarding/Safeguarding Development Manager, appropriate meetings under the Pan Lancashire Policy and Procedures for Safeguarding Children Manual, including the need to hold a Case Review;
  7. Ensure there is a referral to the Child Death Overview Panel;
  8. Inform the Secretary of State for Education;
  9. Inform Ofsted using the Notification Form for Serious Childcare Incidents; and
  10. Inform the Clinical Commissioning Group (The Designated Nurse for Safeguarding and where applicable the Named Nurse for Looked After Children) who will on behalf of local health partners inform the Area NHS England Team, who in turn will inform the Care Quality Commission.
2.4

The report to the Department for Education and Ofsted will include the following information in the order shown:

  • Local authority;
  • Child's name;
  • Parents' names and support being offered to them;
  • 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 or siblings were subject to 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, including type of placement;
  • Local authority duties in respect of the child;
  • Intention of the local authority to hold an independent management review;
  • Policy and practice issues raised and intended local authority action (to follow later if necessary).

In the event of a LSCB Case Review and / or internal management review being required, the steps outlined in Section 1, Death of or Serious Injury of a Child in the Community and Section 3, Needs of Social Worker / Team / Manager / Carer should be followed.


3. Needs of Social Worker / Team / 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 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 Case 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 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;
  • Further information on supporting workers can be accessed from the Pan Lancashire Policy and Procedures for Safeguarding Children Manual, Support for Staff Following the Death of a Child Procedure.

End