3.1 Death of, or Serious Injury to, a Child in the Community or a Child in Care

The child's social worker 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
3. Ensure that the Single Point of Contact for Child Deaths (SPOC) has received a notification of the death so that the Child Death Overview Process can be initiated.

The unit/Service Manager will:

1. Inform the Head of Children's Services
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
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 Bexley Local Safeguarding Children Board Procedures/London Child Protection Procedures, including the need to hold a Serious Case Review

The Head of Service will inform the Deputy Director who will be responsible for ensuring that a Serious Child Care Incident Notification is made to Ofsted as required and the Chairs of the LSCB and Serious Case Review Panel are informed.  The decision to hold a Serious case Review is made by the Chair of the LSCB based on a recommendation by the Chair of the Standing SCR Panel.

The Notification to Ofsted should be made on the relevant form that can be found on the Ofsted website.

Notifications should be made within 2 weeks of the incident coming to the notice of the Local Authority. Ofsted will then prepare a briefing for the Department of Education. Any decision to initiate a Serious Case Review will be notified to Ofsted in accordance with guidance by the Deputy Director

All child deaths are reviewed by the Child Death Overview Panel (CDOP) in conjunction with any other enquiries or investigations such as those undertaken by the Police and the Coroner. If a child or his family were known to Children Social Care prior to the death the Social Worker will be required to complete a Form B that will be issued by the Single Point of Contact for Child Deaths. CDOP considers the preventability of the death and whether there is any trend information or any lessons to be learnt by agencies or if there is a need for a public awareness campaign.

Where it is decided that a Serious Case Review (SCR) is to be held, the Unit Manager, in consultation with the Head of Children's Services will determine the most appropriate person to carry out the Individual Management Review (IMR) of the case within Children's Services. This person must be independent of the line management of the case and must have had no involvement in the case. The person completing the IMR should not come from within the Unit or the Service. The person undertaking the review will produce an IMR that addresses the Scope and Terms of Reference as set down by the Serious Case Review Panel and make a detailed Chronology of what is contained in the records. They will conduct interviews with members of staff where necessary and critically analyse the social work practice as set down in the Bexley LSCB Procedures for Serious Case Reviews and the framework in those procedures must be used. The objective is to establish whether the correct procedures were followed, whether professional judgments were sound and consider 'why' any mistakes or failings were made. The reviewer should draw conclusions and make recommendations for future action as a result of any lessons learned that may include changes in procedures, practice or training. The reviewer may also identify any issues arising for other agencies, which would be brought to the attention of the SCR Panel but, the reviewer cannot make recommendations on behalf of any other agency. Prior to presenting the review report to the appointed Serious Case Review Panel, the author should consult with the Head of Children's Services. The review must be concluded within the timescale agreed for the SCR. The reviewer will join the Author's Group for the SCR to discuss common issues and inter-agency concerns.

The recommendations of the Individual Management Review report should be reported to the Senior Management Team of Children Social Care and be signed off by the Deputy Director. The IMR will form part of the complete SCR and will be considered by the SCR Panel and the Overview Report Author. The recommendations in the IMR may be included in the recommendations of the SCR Overview Report. The IMR will be submitted to Ofsted as part of the SCR for evaluation. All actions single agency and multi-agency will be included in the SCR Action Plan and the progress of that Action Plan will be monitored by the Standing SCR Panel and the LSCB. The recommendations should also be fed back to all relevant staff by the Service Manager or his/her nominee

If a decision is made not to hold a Serious Case Review by the Chair of the Bexley Local Safeguarding Children Board, this will be notified to Ofsted in accordance with the Bexley Local Safeguarding Children Board Procedures/London Child Protection Procedures.  However, the Standing SCR panel or the Unit Manager, in consultation with the Head of Children's Services, may still decide that there are issues arising from the case which justify holding a single agency internal management review in order to learn lessons.

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.
8. Ensure that the Single Point of Contact for Child Deaths (SPOC) has received a notification of the death so that the Child Death Overview Process can be initiated

The line manager will:

1. Immediately inform the Unit/Service Manager 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.

The Unit/Service Manager will:

1. Inform the Head of Children's Services
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. Consult the Head of Children's Services 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 Safeguarding Manager, appropriate meetings under the Bexley Local Safeguarding Children Board Procedures/London Child Protection Procedures, including the need to hold a Serious Case Review
7. Inform Ofsted as in 1.5 above and the Department for Education.

The report to the Department for Education 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 was 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).

All child deaths are reviewed by the Child Death Overview Panel (CDOP) in conjunction with any other enquiries or investigations such as those undertaken by the Police and the Coroner. If a child  or his family were known to Children Social Care prior to the death the Social Worker will be required to complete a Form B that will be issued by the Single Point of Contact for Child Deaths. CDOP considers the preventability of the death and whether there is any trend information or any lessons to be learnt by agencies or if there is a need for public awareness campaign.

In the event of a Serious Case Review or a single agency internal management review being required, the steps outlined in Section 3, Needs of Social Worker/Team/Manager/Carer below should be followed.