Notification of Serious Events

1. Notifications of Serious Events

This procedure summarises who must be notified of serious events in relation to Looked After children placed in the Home.  The registered person must ensure that notifications of all significant events that relate to the welfare and protection of children living in the Home are made to the appropriate authorities, and must take the necessary action following the incident to ensure that the child's needs are met and that they are safe and protected.

See also: Leadership and Management Procedure, which includes information on notifying Ofsted about:

• Absence from the Home for a continuous period of 28 days or more, of the person in day-to-day charge of the Home;
• Changes in relation to the registered provider;
• The registered provider, manager or responsible individual being convicted of any criminal offence.

The Home's registered manager and the placing authority must always be notified of any serious event. Notifications of a child's death should always be made 'without delay'.

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 without delay. The intention is that Ofsted should only be notified of the most serious incidents.

The registered person should have a system in place so that all serious events are notified, within 24 hours, to the appropriate people. The system should cover the action that should be followed if the event arises at the weekend or on a public holiday. Notification must include details of the action taken by the Home's staff in response to the event.

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. When making the notification you will need your URN (Unique Reference Number), full postal address and details of the incident and those involved.

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

Caption:

Serious Event	Who to notify
Death of a Child.	Ofsted; The placing authority; The Secretary of State (if the Secretary of State is not the placing authority); The local authority in whose area the Home is located (if that local authority is not the placing authority); The Integrated Care Board (ICB) 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"); Any other relevant person [1].
Referral of a person working in the home pursuant to section 35 (Regulated activity providers: duty to refer) of the Safeguarding Vulnerable Groups Act 2006.	Ofsted; Any other relevant person.
Allegation of abuse against the home or a person working there.	Ofsted; The placing authority; The local authority designated officer (LADO) for the area where the Home is located; Any other relevant person.
A child is involved in or subject to or suspected of being involved in child sexual exploitation.	Ofsted; The placing authority; The Police; Any other relevant person.
A Child Protection Enquiry involving a child is instigated or concludes.	Ofsted; The placing authority; The local authority in whose area the Home is located (if different to the placing authority) which will have responsibility for ensuring appropriate enquiries are made under Section 47 of the Children Act 1989; Any other relevant person.

[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.

Secure children's homes must also tell Ofsted if a child:

• Goes missing from the Home or while away with an escort;
• Has a serious accident in the Home or while away with an escort;
• Makes or receives unauthorised contact with someone that their plan states they should not be in contact with.

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; and
2. There is any other incident relating to a child which the registered person considers to be serious.

‘Police involvement' does not mean simply that police have been informed of an incident, but that the police are actively doing something concerning the incident, for example making an arrest or taking witness statements. Ofsted do not need to be notified, for example, that police have been informed that a child has gone missing, even if the police are helping staff look for the child.

Guidance on Chapter 5 of the Regulations – Policies, Records, Complaints and Notifications and What Ofsted means by a Serious Incident provide examples of incidents that are likely to be considered serious affecting the welfare of a child (and thus warrant notification to Ofsted as well as the placing authority):

• A child being the victim or perpetrator of a serious assault;
• A serious illness or accident;
• A serious incident of self-harm;
• Serious concerns over a child's missing behaviour, such as where the child is considered  to be at grave risk due to 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, the Home 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.

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. This includes considering the frequency of incidents and judging whether their cumulative effect makes notification appropriate even if in isolation each event would not warrant this.

It is for the registered person to judge whether the incident is sufficiently serious to make formal notifications and, if it is, which other relevant persons may be notified, for example, the police, probation service, health professionals, the local authority for the area the Home is located in (if this is not the child's placing authority) and others involved with the care or protection of the child.

The Home's record of the event must include a description of the action taken and the outcome of any resulting investigation.

Sharing Information with the Placing Authority

Following a notifiable event under regulation 40 the Home should contact the placing authority to discuss the need for further action. 

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

The notification must include details of:

1. The incident;
2. Who else has been notified; and
3. Outcomes and future actions.

Quality of Notifications

Notifications should not just be a chronology of events. The notification should include a brief summary of the event, the other persons, bodies or organisations (if any) who or which have been notified, 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 the Home's 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 though Ofsted are not updated, it may be appropriate to share updates with the placing authority and other relevant persons.

Ofsted will discuss incidents as part of the inspection process with aim of understanding the incident and actions taken by staff as a result and further actions planned to reduce the likelihood of a similar incident occurring again.

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 taken. In these situations, the inspector is likely to ask for additional information to be sent directly by e-mail rather than through a series of further notifications.

There is no legal requirement to keep notifying Ofsted as a case progresses.

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.

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

Also see the Recording and Reporting of Accidents Procedure.

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.