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Derby CityChildren's Social Care Procedures

1.1.8 Serious Incident Policy

Contents

  1. Purpose
  2. Scope
  3. Guiding Principles
  4. Serious Incident Reporting Procedures
    1. Introduction
    2. Definition of a Serious Incident
    3. Procedure
  5. Appendix A: Definition of a Serious Incident
  6. Appendix B: Serious Incident Procedure Stages
  7. Appendix C: Children Placed in Foster Care
  8. Appendix D: Children Placed in Children's Homes

1. Purpose

The purpose of this policy is to ensure that there is a systematic process for reporting, managing and learning from serious incidents. The aim is to ensure that all serious incidents are reported to an appropriate senior manager in a timely manner, to ensure that lessons are learned and that risks are managed.

The policy sets out a positive, non-punitive approach to the reporting of serious incidents, and is one element of a proactive framework for risk management, reputation management and quality assurance.

2. Scope

Please note that whenever an incident meets the criteria set out in Working Together to Safeguard Children (March 2015), and either:

  • 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);
  • A child in a regulated setting or service has died (including cases where abuse or neglect is NOT known or suspected).

Then staff MUST refer to the procedure on Death of or Serious Injury to a Child.

This policy applies to serious incidents, as defined below, which occur within Derby City Council.

The policy is separate from the Major Incident Policy/Emergency Planning arrangements and it does not replace any other policies where the Council has a legal responsibility to report a serious incident, for example, incidents which must be reported to the Health and Safety Executive (HSE), deaths which should be reported to the Coroner or actions under the Safeguarding Children or Safeguarding Adults procedures.

This is not a fully comprehensive list. The Serious Incident reporting system is NOT a substitute for taking the action required under other policies.

3. Guiding Principles

The context of this policy is a commitment by the Council to reduce serious incidents and promote a culture of openness and learning. The policy is designed to promote a non-punitive approach, and uses a risk based diagnostic of serious incidents to reduce the risk of incidents occurring in the future and to support staff in their learning and development.

A "Near Miss" - an event that has the potential to be a serious incident is included within the scope of this policy to increase the opportunity for learning and reduce the possibility of an actual serious incident occurring.

The overriding principle of this policy is that the first priority is to ensure safe practices and every opportunity is taken to learn lessons from incidents which occur. Action under the Disciplinary procedures will only be considered where there has been wilful negligence, professional misconduct or beach of law.

The policy will ensure that senior managers and Elected Members are made aware of Serious Incidents quickly so that action can be taken, if necessary, to protect the reputation of the Council and its employees.

4. Serious Incident Reporting Procedures

4.1 Introduction

This procedure is to be followed when a serious incident occurs. A rapid response in terms of dealing with the immediate issues, communicating the nature of the incident to senior managers and completing a diagnostic are required. The procedure details the stages and timescales to be followed and includes a definition of a serious incident.

4.2 Definition of a Serious Incident

A Serious Incident in the context of this procedure is defined as a situation which may seriously harm staff, people who use the service, or others, and/or involve financial irregularities. It includes serious damage to Council premises which may disrupt the delivery of services and serious breaches of confidentiality. Guidance about what should be included is contained in Appendix A: Definition of a Serious Incident. If there is uncertainty about if an incident should be categorised as serious then a report should be made. The responsibility for this decision if there is any doubt about whether a report should be made rests with the Head of Service.

In deciding if an incident should be defined as "serious" under this procedure consideration should be given to how likely it is to produce legal, media or other interest, which if not properly managed may result in further damage or harm to those involved or damage to the Council's reputation. An incident which may in itself not be thought of as serious, may be defined as such because of the possibility of attracting media attention.

4.3 Procedure

The stages of the procedure, individual accountability and timescales to be followed are summarised in the Table in Appendix B: Serious Incident Procedure Stages.

The Council has a legal responsibility to report certain serious incidents under other relevant polices, for example the Adult Protection policy. This procedure is not a substitute for action required under other procedures or legal requirements.

Immediate Response

The first priority of the person in closest proximity to the serious incident is to respond to the immediate needs of the individual(s) involved and to re-establish a safe environment. If necessary the emergency services should be contacted, the environment made safe and appropriate steps taken to maintain a safe environment and protect the physical and emotional well being of all those who have been involved. No aspect of the procedure should detract from this primary duty. The person responsible for these actions is the most senior person immediately available. Assistance should be sought from other members of staff if possible and necessary.

Initial Discussion

After these initial responses have been concluded, the most senior member of staff available, having evaluated the information available from the staff directly involved, will decided how serious the incident was. If the incident is "catastrophic" then as soon as practicable a phone call should be made to the Chief Executive's Office or relevant Strategic Director's office and a verbal report made on what has happened and the action taken. A serious incident notification form should be completed and returned as soon as possible, but within one working day. "Catastrophic" includes death or serious injury to a service user, member of staff or member of the public, serious damage to Council property, immediate, significant disruption to a Council service or immediate inquiries from the press with regard to the incident.

If it is decided that the incident is serious, then a serious incident notification form should be completed as above. The form should be sent to the Chief Executive or relevant Strategic Director, the relevant service Director and the Head of Service. The report should be brief, factual but include all the relevant information available. Personal opinions or conjecture about any aspect of the incident should not be included.

Strategy Meeting

Some serious incidents may require a response from more than one service in the Council. The Service Director receiving the initial report should consider if a Strategy Meeting is required. The purpose of this meeting is to share information and ensure that action taken by different services is co-ordinated. The timing of the meeting will be determined by a risk assessment completed by the Director.

Investigation

On receipt of the notification form, having considered if a Strategy Meeting is required, the service Director should nominate a manager to investigate the incident and provide a more detailed report on the circumstances of the incident and lessons to be learned. The Director will agree with the investigating officer a timescale for completing the report, based on an assessment of the nature of the incident but this will be no longer than 28 days. As part of the role, the Investigating Officer will ensure that appropriate de-briefing of staff and support arrangements are in place.

The report may include recommendations to minimise the risk of a similar incident occurring again and any opportunities there may be for learning across the Department or the Council.

Review and Feedback

On receipt of the investigating officer's report the Director will review the report and recommendations and agree a process for feeding back to staff if this is appropriate and a process for monitoring the implementation of any recommendations.

The Director will forward a copy of the investigation report to the Director of Transformation and Strategic Services highlighting any opportunities for learning in other areas of the Department or Council. If areas of urgent concern are identified this should be actioned immediately, but within 28 days.

Annual Review and Dissemination

The Director of Transformation and Strategic Services will collate the lessons learned from Serious Incident Reviews on an annual basis and identify any common themes. A report will be tabled on an annual basis at Chief Officer Group where dissemination of lessons learned will be agreed, for example, through the monthly team briefing, or if the range of learning opportunities justifies this, through a learning event for staff.

Appendix A: Definition of a Serious Incident

Click here to view Appendix A: Definition of a Serious Incident.

Appendix B: Serious Incident Procedure Stages

Stage Action Person Timescale

Immediate response

Respond to the immediate needs of individual and re-establish a safe environment, contacting emergency services if necessary.

Most senior member of staff immediately available.

Immediate.

Initial Discussion

Review immediate action and ensure all necessary steps have been taken is maintained safety.

Classify incident as catastrophic or serious.

Catastrophic - phone call to Chief Executive or Strategic Director's office then complete form.

Serious - complete serious incident notification form.

Person responsible for immediate response with a more senior manager.

Most senior person involved.

Within 2 hours of completion of immediate response.

As soon as practicable.

As soon as practicable.

If possible same working day.

Strategy meeting

Strategy meeting to be held if incident requires a response or actions from different Departments.

Service Director who received the original alert.

Dependent upon risk assessment of particular circumstances.

Investigation

Investigation into serious incident including lessons learned.

Service Director nominates Manager.

Input completed within 28 days.

Review

Service Director, Reviews investigation manager and confirms necessary actions have been taken.

 

With 28 days of completing investigation.

Feedback & Learning

1. Feedback if staff directly involved;

2. Investigation input with summary investigating any appointee ships/or wider learning to be forwarded to Director of Transformation and Strategic Services.

Service Director.

Depending on the issues - immediate is 28 days.

Annual Review

Collation of lessons learned from Serious incidents in the past 12 months.

Director of Transformation and Strategic Services.

Annual Report.

Dissemination

Learning disseminated through team briefing.

Director of Transformation and Strategic Services/all Managers.

Annually.

Appendix C: Children Placed in Foster Care

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 Schedule 7 Events and Notifications table.

Appendix D: Children Placed in Children's Homes

Regulation 30 and Schedule 5 of the Children's Homes Regulations 2001 (as amended) set out the arrangements for notifications in relation to specified events.

EVENT WHO TO NOTIFY

Death of a Resident.

Outside Agencies: 

Ofsted (National Business Unit: Tel 0300 123 1231)

The Health and Safety Executive

The Secretary of State for Children

The local authority in whose area the children's home is located (if that local authority is not the placing authority)

The Clinical Commissioning Group for the area in which the home is located

If the child was accommodated in a secure children's home, the Prisons and Probation Ombudsman for England and Wales ("the PPO"); and

Any other relevant person

Referral pursuant to section 35 of the Safeguarding Vulnerable Groups Act 2006 (as amended) of an individual working in the Home.

Outside Agencies: 

Ofsted (National Business Unit: Tel 0300 123 1231)

Involvement or suspected involvement of a Resident in sexual exploitation.

Outside Agencies:

Ofsted (National Business Unit: 0300 123 1231)

The Police

Any incident requiring police involvement occurs in relation to a child which the registered manager considers to be serious.

Outside Agencies:

Ofsted (National Business Unit: 0300 123 1231)

Any allegation of abuse against the home or a person working there.

Outside Agencies:

Ofsted (National Business Unit: 0300 123 1231)

Any other incident relating to a child which the registered manager considers to be serious.

Outside Agencies:

Ofsted (National Business Unit: 0300 123 1231)

Instigation and outcome of any Child Protection Enquiry involving a Resident.

Outside Agencies

Ofsted (National Business Unit: 0300 123 1231)

In addition, the following notifications should be made:

Outbreak of any infectious disease which in the opinion of a registered medical practitioner is sufficiently serious to be so notified.

Outside Agencies

The Health and Safety Executive

Serious illness or serious accident sustained by a Child or employee. This includes serious or persistent self harming or attempted suicide.

Outside Agencies:

The Health and Safety Executive

*If a medical practitioner considers it to be notifiable under RIDDOR

A child accommodated at the Home is absent or missing.

Placing authority (where relevant)

Police (in accordance with the Joint Runaway and Missing from Home or Care Protocol)