Notification of Serious Events

This procedure summarises who must be notified of serious events in relation to Looked After Children placed in children’s homes.

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’.

In the case of events other than the death of a child, a more proportionate approach should be taken and, before making a notification to Ofsted, sufficient time should be taken to collect any further information required in order to determine whether the incident is in fact serious enough to warrant a notification to Ofsted.

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 of the home 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 Events

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 children’s home is located (if different to 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; The placing authority; 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 children's 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.}

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 illness or accident;
• 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 age or vulnerability, where they have been missing for a considerable period of time and their whereabouts are unknown or where there is a pattern of repeated absence. (Please note - Ofsted do not need to routinely know about children going missing from the home, 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 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 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 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, though 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 that you have taken. In these situations, the inspector is likely to ask for additional information to be sent directly by email 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 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.

If any of the following people are convicted of a criminal offence, they must notify Ofsted in writing without delay giving details of the date and place of the conviction, the offence and the penalty imposed:

• The Registered Provider;
• The Registered Manager;
• The Responsible Individual;
• If the Registered Provider is an organisation, any director of that organisation;
• If the Registered Provider is a partnership, any partner in that partnership.

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.