Agenda item

Notification of Serious Incidents Review


The Head of Democratic Services submitted a report introducing an issue which had been brought to the attention of the Chair in respect of the processes supporting the Notification of Serious Incidents.


In introducing the item, the Chair advised that he had been made aware that there had been some instances where differing views were evident within the Leeds Safeguarding Children Partnership in relation to whether or not to categorise a case as a notifiable Serious Incident. Arising from that, a local review of notification arrangements had commenced in December 2021 with a report due to be considered by the Partnership at the end of March. The Chair expressed his view that the current review of notification arrangements, and the background to it, should reasonably have been brought to the attention of the Children and Families Scrutiny Board at an earlier stage; and because of the seriousness of the issue, he had requested this issue be considered as a matter of urgency at this meeting.


The following were in attendance for this item:

·  Councillor Fiona Venner - Executive Member for Adult and Children’s Social Care and Health Partnerships

·  Sal Tariq - Director of Children and Families

·  Julie Longworth - Deputy Director of Children and Families

·  Rebecca Roberts - Section Head, Social Care Legal and legal adviser to the Safeguarding Partnership Board

·  Jasvinder Sanghera CBE – Independent Chair of the Leeds Safeguarding Children Partnership


The Section Head, Social Care Legal and legal adviser to the Safeguarding Partnership Board, provided an overview of the framework introduced by the provisions of the Children Act 2004 and amended by the Children and Social Work Act 2017 to support the delivery of multi-agency services to protect and safeguard children. The Board received information on the establishment of the Child Safeguarding Practice Review Panel (the national panel) and the framework for reporting serious incidents commonly referred to as Notifications. It was highlighted that the duty to report serious incidents to the national panel falls to the local authority in which the child or young person resides.


The Board was provided with the timeframe for actions to be taken following the notification of a Serious Incident and an overview of those actions, culminating in the partners determining whether or not the information/learning gathered is sufficient to implement and learn from, or whether further learning is required, perhaps in the context of a Child Safeguarding Practice Review (CSPR). 


Members additionally noted the following:

·  The criteria taken into consideration by partners when determining whether a CSPR is appropriate, as contained in The Child Safeguarding Practice Review and Relevant Agency (England) Regulations 2018, part 11.

·  Since the new arrangements were established in September 2019, Leeds had made 6 notifications involving suspected abuse or neglect, and one notification which did not.

·  The LSCP is undertaking 3 CSPRs (including one where no notification was made) and the Review and Advisory sub group of the LSCP is currently overseeing 10 other cases where the criteria for a notification was not deemed to have been met, but learning could still be gathered.


The Chair of the Leeds Safeguarding Children Partnership provided an overview of the remit of her role as the Independent Chair and explained to the Board that in August 2021, she had raised initial concerns regarding the existing notification processes.  Linked to this, she highlighted that although the Partnership is tasked with working collaboratively and to share information, she felt that the framework requiring the local authority to make notifications of serious incidents in some way may hamper collective decision making when identifying cases where serious harm had occurred.  It was highlighted that one case had particularly reinforced her concern and led to her also seeking advice from the Chair of the Child Safeguarding Practice Review Panel, Annie Hudson, as well as commissioning a local review of the notification arrangements.


At this point, the Chair indicated his wish for the Board to be able to discuss specifics related to this issue and acknowledged that those discussions may touch upon a current or recent Serious Incident case. As such the Chair requested, and the Board agreed, to holding those discussions in private, in order to maintain the confidentiality of any such cases.  The public interest in maintaining confidentiality in relation to any Serious Incident case which may be discussed outweighed the public interest in holding the discussions in public.


RESOLVED – Under the provisions of Access to Information Procedure Rules 10.4 (1) and (2) the Board entered into private session.


At the conclusion of discussions held in private, the meeting resumed in open session and discussed the following matters:

·  The role of the Review and Advisory Group in considering cases of most serious harm and its focus on the impact of harm and long-term harm on children and young people.

·  There had been two cases where differing views were evident within the LSCP on whether or not to categorise a case as a notifiable Serious Incident and where the local authority had not made a notification.

·  The local review being undertaken provided an opportunity for partners to share their own individual processes supporting the notifications made to the LSCP, highlighting the importance of sharing the rationales and pre-notification discussions.

·  The role and powers of the Independent Chair and her concern that she was not aware of the number of cases considered by partners but not presented to the LSCP for discussion.

·  The view of the Chair of national panel of Leeds’ notification history.

·  Whether reputational damage could be a factor in a decision not to make a notification.

·  The use of retrospective notifications should new evidence come to light, which would prompt a Rapid Review and instigate learning.


The Executive Member for Adult and Children’s Social Care and Health Partnerships provided the Board with assurance of the commitment of the Directorate to the safety and wellbeing of children and young people and advised that the Notification and Rapid Review process was just one of a number of ways to support learning after an incident or serious case.


The Executive Member highlighted that as Leeds provided good Children’s Services, the local authority made less notifications than other authorities, and in light of the disagreement between partners, a review of processes had been implemented with input requested from the National Panel.


The Director of Children and Families confirmed that consultation with other local authorities was undertaken when considering Notifications and advised of the other learning opportunities, aside from Serious Case Reviews. The Director also offered his apologies that this matter had not previously been drawn to the attention of the Chair.


The Board also heard from the Deputy Director of Children and Families who confirmed that following discussions in 2021, a Notifications framework was developed whereby the Independent Chair was made aware of a case in the first instance, followed by partners and after discussions, if it was felt that the criteria was not met, a written rationale was provided.


Discussions covered the following matters:

·  Concern that under existing internal processes, there will be a number of cases which had not been brought to the attention of the LSCP Review and Advisory Group.

·  Support for the request made by the Chair of the LSCP to receive the rationale for the decision made by Childrens Services not to pursue a notification in respect of a specific 2021 case.

·  The role of the resolution process in strategy discussions with partners and whether a similar solution would be appropriate for Notification discussions in the event that partners had differing views.

·  Whether a representation should be made to the Minister to review that part of the legislation which vests the Notification process only to local authorities.

·  The structure of Safeguarding Children Partnerships within neighbouring authorities.


In conclusion the Chair reiterated that he had not previously been aware of concerns relating to the Notification process and noted the offer to bring back the findings of the local review work, which is due to be concluded in March, for the Scrutiny Board’s consideration.



a)  To note the content of the report and discussions on the information presented during the meeting.

b)  That once available, the findings of the local review work are brought back to the Scrutiny Board for consideration and that all partner members of the Leeds Safeguarding Children Partnership who are party to the Notification process are invited to contribute to the Board’s consideration of the review findings.

c)  To thank the Independent Chair of the Leeds Safeguarding Children Partnership for her participation in the meeting.


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