The document provides guidance on serious safeguarding incident notifications. It discusses the identification and notification process, as well as rapid reviews and local child safeguarding practice reviews. Key points covered include statutory requirements, criteria for serious incidents, common issues in practice, and tips for improving the decision making process.

1. SERIOUS
SAFEGUARDING
INCIDENT
NOTIFICATIONS
01
Training Presentation
Final June 2023

2. This presentation is for safeguarding children professionals, panel members of case
review groups and those interested in the review process for a serious safeguarding
incidents.
We will be looking at the full cycle of the decision making process for serious
safeguarding incidents:
• identification and notification,
• rapid review, and
• local child safeguarding practice reviews.
There will be an opportunity to look at the barriers and challenges, and reflect on
practice within your partnership.
Finally, we will look at completing the review cycle with ideas for embedding
learning and service improvement, and providing assurance of the impact of reviews
and in improving outcomes for children and young people.
At the end of this presentation you will have a comprehensive understanding of the
purpose and practice of reviews within the legislation and statutory guidance.
02

3. 03
Statutory
background
• The Children Act 2004
• The Children and Social
Work Act 2017
• Working Together to
Safeguarding Children
2018

4. 04
The Children and Social Work Act 2017 defines a serious
child safeguarding case as one in which:
16(a) abuse or neglect of a child is known or suspected by a local
authority or another person exercising functions in relation to children,
and
16(b) the child has died or been seriously harmed;
“serious harm” includes serious or long-term impairment of mental
health or intellectual, emotional, social or behavioural development.”
WTG 2018 states that 'When making decisions, judgment should be
exercised in cases where impairment is likely to be long-term, even if
this is not immediately certain. Even if a child recovers, including from
a one-off incident, serious harm may still have occurred.'

5. 05
CSWA 2017 14 Events to be notified to the Panel amended
the Children Act 2004, 16 C Events to be notified to the Panel
(1)Where a local authority in England knows or suspects that a child has
been abused or neglected, the local authority must notify the Child
Safeguarding Practice Review Panel if—
(a)the child dies or is seriously harmed in the local authority’s area, or
(b)while normally resident in the local authority’s area, the child dies or is
seriously harmed outside England.
(2)A local authority in England must have regard to any guidance given by
the Secretary of State in connection with their functions under this section.
(3)In this section “serious harm” has the meaning given by section 16B(9).”
Responsibilities of the local authority:
Duty to Notify

6. 06
managers.
• Not having a
robust system in
place for
managing and
escalating cases
that meet the
criteria for SIN,
• Capacity of staff
to review and
register incidents.
• Dispute's
between
agencies on
where the criteria
is met.
• Insufficient
information to
make a
judgement.
• Not having a clear
pathway for
external referrals.
Serious
Incident
Notifications
SINs: common
practice issues

7. • To identify serious safeguarding cases that raised complex issues of
were of national importance including perennial issues which form
barriers to effective practice.
• To review or undertake Child Safeguarding Practice Reviews.
• To identify improvements made by safeguarding partners.
• May request information for the purpose of discharging its'
functions - have an authority to enforce.
• Quality assurance of reviews and reviewers.
• Sharing learning across the child protection and safeguarding
system.
• Promote child centered practice, championing the voice of
children, families and communities.
• Use of evidence to drive system improvement and learning ,
encourage learning and sharing of best practice.
• Culture for excellence.
.
www.gov.uk/government/organisations/child-safeguarding-practice-review-panel
07

8. 08
Child
Safeguarding
Practice Review
Panel guidance
for safeguarding
partners
September 2022
SIN Findings

9. 09
• “serious child
safeguarding cases” means
cases in which—
• (a)
• abuse or neglect of a child
is known or suspected by
a local authority or
another person exercising
functions in relation to
children, and
• (b)
• the child has died or been
seriously harmed;
• “serious harm” includes
serious or long-term
impairment of mental
health or intellectual,
emotional, social or
behavioural
development.”
Abuse or neglect is interpreted by the panel as meaning that there is
sufficient reason to suspect that abuse or neglect was present and
contributed to death or serious harm.
Criteria is met if the act/incident itself is abusive - i'e murder by a parent
or carer even if there is no other pre-existing evidence.
Local authorities do not need to wait until a case is proven to notify, use
the rapid review process to explore the strength of possible
abuse/neglect.
Notification is recommended where there has been a recent or current
concern and there has been an unexplained death or suicide.
Abuse or neglect can be a cause or contributory factor.
If there is sufficient concern to trigger a section 47, care proceedings or
criminal investigation then this would suggest sufficient indication that
neglect, or abuse is suspected.
Is it a serious child safeguarding case (a)
abuse or neglect is known or suspected

10. 10
• “serious child
safeguarding cases” means
cases in which—
• (a)
• abuse or neglect of a child
is known or suspected by
a local authority or
another person exercising
functions in relation to
children, and
• (b)
• the child has died or been
seriously harmed;
• “serious harm” includes
serious or long-term
impairment of mental
health or intellectual,
emotional, social or
behavioural
development.”
Partners should consider the persistence and severity of the injury within
the context of wider neglect or abuse.
Other forms of abuse should be considered in terms of persistence and
repetition, partners should consider how this may have impacted on the
child's development and wellbeing.
Long term psychological harm - and may supersede consideration of
longevity and persistence of abuse in determining serious harm.
Child has life changing injury or long-term impairment resulting from
injury, an injury that is life threatening. i.e. the child required resuscitation
or intensive care.
Isolated bruises or limb fracture would not normally meet the threshold
for serious unless other injuries were present.
Is it a serious child safeguarding case
(b) was it serious harm?

11. 11
• CLA
• one off incidents
• suicide
• SUDI
• extrafamilial harm
Is it a
safeguarding
incident?
Neglect. -adverse impacts most likely when neglect is persistent
rather than one off in the context of an otherwise good environment:
Questions to ask when making a decision whether to notify:
• Was the action of the parent or carer neglectful in itself?
• Was the outcome death or serious harm?
• Was the neglect cumulative?
• Was it willful?
All deaths are notifiable but do not require a rapid review unless
abuse or neglect is suspected or known - that relates to the incident
rather than the background to becoming looked after.
Where a looked after child has experienced recent abuse or neglect,
or criminal or sexual exploitation, that is linked to the death or
serious harm, then a SIN should be made wtih view to a rapid review.
Children Looked After
Neglect

12. 12
Cases are normally reviewed through the Child Death Review process and
would not require a notification unless it is a Child Looked After or:
• neglect has directly contributed to death - severe persistent
• neglect- evidence of dangerous sleeping environments.
The Panel advises that partners should refer to 'Out of routine: A review of
sudden unexpected death in infancy (SUDI) in families where the children are
considered at risk of significant harm' 2020 to make a judgment as to
whether a review would contribute to additional learning.
Most cases sit within the Child Death Review process except where abuse or
neglect is considered to have directly contributed to the death - trigger
factors include intrafamilial, extra-familial and child exploitation.
Sudden Unexpected Death in Infancy SUDI
Suicide

13. 13
• Extra-familial harm - Hard to Escape 2020
consideration should be given to this report
before progressing to CSPR
• Incident should be considered as notifiable
where there is a a direct relationship between
the actions/omissions of an adult/carer/or
person in position of power or trust in relation
to the child, and the death or incident of
serious harm.
• Where the actions of the adult constitute CSE
or CE with caring responsibilities would be a sin
• If there is no evidence that the death or serious
harm was caused by or related to adult
coercion or exploitation or abuse or neglect
then it is likely to fit the definition of
extrafamilial violence. This would also apply to
cases where there is child on child harm
without evidence of adult involvement/neglect
or abuse.
Safeguarding or
extrafamilial
violence?

14. 14
Tips for
good
practice
• Triumvirate decision making .
• Clear process in place for partners to escalate cases for SIN
• All SINS should be rapid reviews unless it is a notifiable incident for a child
looked after without safeguarding concerns. All rapid reviews should be SINS
• Clear policy for resolving disputes over notification utilizing independent
scrutineer.
• Sufficient capacity to review serious child safeguarding incidents - by trained
staff with access to the appropriate level of information and sufficient senior
management oversight.
• Clarity over SIN process and partnership referral process - often using the same
terminology.
• Failsafe to meet 5 days notification deadline from becoming aware of incident
to SIN.
• Senior safeguarding partners have clear role and responsibilities for the
decision-making process - where there is delegation there is a clear line of
accountability.
• Audit SIN referrals that have not made the criteria for notification
• Look at levels of senior management alerts to SIN levels - training as required.

15. 15
Workshop
In small groups I would like you to
discuss:
• Whether the decision making for
the serious safeguarding incidents
was clear, timely and in line with
local procedures, statutory
guidance and National Panel
Guidance.
• Whether you can you identify any
areas of strength or weakness in
your local practice.
You will need:
• Your current
operational
guidance, pathway
and or and forms
for Serious
Safeguarding
Incidents
• Anonymised
examples of
serious
safeguarding
incidents recently
referred.

16. WORK
SHOP
16
You may wish to consider:
• Whether there is a clear pathway for reporting incidents that
may meet the criteria for SIN from internal and external
safeguarding professionals
• Whether there is a clearly named individual or point of contact
for this to happen
• Whether there is sufficient management oversight of decision
making, both within the LA and the partnership.
• Whether the current dispute resolution process sufficiently
cover disputes over SIN's .
• If there is sufficient training, guidance and advice for decision
makers.
• If there is room for more triumverate decision making in the
decision to notify.
• Whether referrals and notifications are timely, if not why not?
• Whether decision makers and those submitting SINs have
sufficient access to information to support decision making.

17. 18
Recommended reading and
references
• Child Safeguarding Practice Review Panel guidance for safeguarding
partners September 2022
• Working Together to Safeguard Children A guide to inter-agency
working to safeguard and promote the welfare of children July 2018
• Children and Social Work Act 2017
• Out of routine: A review of sudden unexpected death in infancy
(SUDI) in families where the children are considered at risk of
significant harm Final report July 2020
• It was hard to escape Safeguarding children at risk from criminal
exploitation 2020
• Children Act 2004
• www.gov.uk/guidance/report-a-serious-child-safeguarding-incident