5.1.8 Incidents

1. Definition of Incident

The following are defined as incidents, but this list is not exhaustive. Any similar occurrences can be defined as an incident by a Manager, and recorded as such.

Where reference procedures are provided, they apply to chapters within this manual. It is recommended that users read these chapters for clarification of what constitutes an Incident in each case; users may click on the title.

00 = No Chapter reference

2. Notifications

If an Incident occurs, the manager/senior on duty/supervisor of the unit in which the incident occurred must be notified as soon as practicable but at the latest within 24 hours.

The child's social worker must also be informed within 24 hours or as soon as practicable afterwards and an agreement reached with the social worker about whether it is necessary to inform the child's parent(s). If so, it should be agreed who should undertake this task.

Where Incidents are serious, Designated Managers within the authority and, in some circumstances, in other agencies, must be notified.

Assistant Directors are to be alerted about any significant incident. 

Managers need to use professional judgement about what constitutes a significant incident but some examples are:

• The death or serious injury of a child where abuse or deliberate injury is suspected.  Notification to be completed whether the child is supported in any way by Lincolnshire County Council Children's services or is previously unknown;
• Serious illness of a child currently supported in any way by Lincolnshire County Council Children's services. Notification to be completed;
• Looked after children or those subject to CP or CIN plan where missing is a serious concern.  This may be that the child is missing and their location unknown or that they are known to be with someone who may pose a risk. Notification to be completed;
• Serious incident concerning a member of staff:

Accident involving death or injury.

Alleged involvement in criminal activity.

• Major failure or incident (alleged or evidenced) involving inter agency working;
• Incident likely to generate any media interest.

Please refer to the Assistant Director Notification of Serious Incident form in Local Resources/Forms - AD Notification.

3. Incident Recording

Which records must be completed

The following records should be completed after an Incident:

When to complete the records

Unless stated differently in procedures contained in this manual, records pertaining to incidents must be completed within 24 hours.

However, it is advisable that staff/carers do not complete records immediately after an incident, but wait until they can calmly recollect what happened.

If an incident leads to, or is followed by, the absence of the person responsible for completing records due to leave, sickness, rostered rest days, it is normally reasonable to expect that person to complete the records before leaving. If exceptional circumstances, such as hospitalisation, prevent this from happening, the manager/senior on duty/supervisor must arrange for the records to be completed as accurately as possible in another way.

Before completing records, it may be helpful to talk to others involved to help recollect events, but staff/carers should avoid having suggestions put to them that are inaccurate or inconsistent with what they did or observed.

Who should complete the records

The staff member most significantly involved should complete the records, after consulting other staff concerned; except where there is any risk that a Complaint, child protection or criminal investigation will be made. In such a case, each person involved must write his or her own record. Separate records must also be completed if there is significant difference or dispute between staff on what occurred.

Guidance on completion of incident records

1. Write down what happened in chronological order, preferably stating the time each event occurred;
2. Don't express opinions and don't make assumptions about what happened;
3. If you are writing the report on behalf of others make sure you check and report their versions, not what you think they said or did;
4. Differences of opinion, recollection or knowledge must be accurately recorded;
5. Avoid using jargon or professional terms unless you are confident that readers will understand them;
6. Don't use generalisations such as "aggressive", "verbal" or "offensive"; use plain English, write down exactly what was said or done, and by whom;
7. Always use full names. If the common name for a person is an alias or nickname, always put the person's full name in brackets the first time you use the alias;
8. Always indicate, in brackets, the status of the person named (e.g. Foster Carer, RSW, Child);
9. State clearly what diversionary tactics or Strategies were used, and by whom; also state the impact or changes the tactics brought about;
10. If Physical Intervention was used, state the name of the technique used; if the technique has no name, describe the intervention rather than saying "He was held or restrained";
11. Also state who used the intervention, the duration it was used and what was said and done during the intervention until the child was released;
12. If more than one intervention was used, state the order they were used in - and why it was necessary to escalate or reduce the intervention;
13. If there are particular techniques used give their technical names and say in what order they were used;
14. The child should be asked to contribute to the report(s) where they have the capability to do so; as part of this process, the child should also be offered an interview. If requested, if there is a significant difference between staff and child versions or a complaint is made, an independent person must offer support to the child and obtain his/her views/comments;
15. Complete all sections. Don't leave sections blank or any significant spaces. If you have nothing to report in a section, either draw a line through it, put N/A or (for example, in the section on injuries) "No Injuries". Alternatively strike a line through the space;
16. Always sign and date the record and make sure other staff/carers sign to say they agree with the record before you pass it to the manager.

If you have any concerns about your own or other people's actions or decisions you must discuss them with the manager as soon after the incident as possible. If you feel uncomfortable or uneasy about returning to work also talk to a manager.

4. Manager/Supervisor Responsibilities

Prevention of Incidents

1. Managers must ensure staff/carers are familiar with relevant procedures; using creative and interesting methods to bring procedures to their attention, discussing them in supervision sessions and meetings, undertaking training etc.
2. If procedures appear to require updating or amendment, including the way in which incidents are recorded, the matter must be followed up with line management;
3. Staff/carers are required to do all they can to contact managers if they anticipate an incident or immediately afterwards if they did not. If, for whatever reason, managers are not likely to be available, they should ensure suitable contact arrangements are in place, that a colleague has been identified to provide cover or that staff/carers understand the levels of their delegated authority;
4. If managers anticipate that an incident may occur, they must plan to reduce or prevent the risks, and they must inform staff/carers;
5. If staff/carers inform managers that they suspect or anticipate an Incident, they must be taken seriously and provided with appropriate levels of support, guidance and direction to manage situations safely;
6. If managers anticipate a serious incident that may require intervention by the Police or other emergency services, consult or inform those agencies;
7. Also consult relevant social workers;
8. Keep accurate records of your contacts, conversations, decisions and actions.

Immediate Management Responsibilities

When the manager is informed that an incident has occurred, the following tasks should be undertaken immediately:

• Co-operate with Police/emergency services if contacted; or consider whether the Police or other emergency services should be contacted;
• Check if anyone has been injured; ensure first aid or hospital treatment is appropriate;
• If Physical Intervention involving physical contact has been used upon a child, whether or not the child was injured, s/he must be given the opportunity to see a Registered Nurse or Medical Practitioner - and the outcome recorded;
• Check whether there is any damage; and that it is made safe or repaired;
• Listen to everyone involved, note what they have said, provide support and advice if necessary; but don't make judgements or take sides;
• Ensure that the child is given adequate opportunity to contribute to the reports and offered an interview;
• Establish whether people need to be separated, for example if there are complaints; and take what action is necessary;
• Ensure those involved are recording their recollections in detail in an All Incident Record. If any conflicts between those involved or potential complaints, ask each person to write a separate record. These records should normally be completed and passed to the manager within 24 hours of the incident. See When to Complete the Records;
• If there are complaints or any potential child protection issues, follow them up in line with appropriate complaints or Child Protection Procedures;
• Arrange for social worker, parents and others, including Designated Managers and others to be notified.

5. Management Reviews

Purpose of the Management Review

The purpose of the Management Review is to unpick the circumstances leading to the incident, the manner in which it was managed and the actions and decisions of all those involved - with a view to reducing or preventing future similar incidents.

In some situations it may be necessary to implement Disciplinary Procedures; this should only commence following discussion with Human Resources and relevant senior managers.

Everyone involved, staff and children alike, will have been affected, probably negatively; some may have been traumatised.

Seek to help people learn from what has happened.

Take a positive, developmental stance throughout, even if things could have been done differently.

Who should undertake the review?

The manager should undertake the review, unless directly involved or as required by a line manager.

Timescales

Under normal circumstances, the manager/supervisor must review the incident within the following timescales

Restraints:

Within 72 hours of the Restraint report being completed by staff.

All other Incidents:

Within 5 days of the Incident Report being completed by staff.

If there are Police, Child Protection or Complaints investigations, the review should be postponed until they are complete.

Gather Information

1. Don't make judgements early on. Don't take sides;
2. Start from the point of view of seeking to learn from what has happened;
3. Involve everyone, including the child where they are able to contribute, at all stages. Inform them of the anticipated timescales;
4. Listen, note, explore; try to identify the circumstances or behaviours which triggered the incident. Analyse the extent to which everyone adhered to procedures or recognised good practice; were people working effectively together, were they planning ahead, sharing information, doing what they could to anticipate and prevent the incident from occurring?
5. Read the records of the incident, clarify and challenge, if necessary, generalisations, assumptions, justifications etc. Unpick and simplify jargon;
6. If Restraint or other Physical Intervention was used, ensure staff/carers are able to demonstrate they applied it in keeping with procedures and guidance;
7. Did everyone appear to behave reasonably in the circumstances? To what extent was the child (or staff) set up by the actions of others; did anyone act in a way which provoked or increased the likelihood of the incident;
8. Look beyond that which is stated in the record of the incident; what hasn't been included which should have been in the circumstances;
9. If anyone was injured, check and note the outcome of any first aid or medical treatment offered/given. Where an injury occurred or there is the possibility of an injury, ensure there is a corresponding accident form;
10. If physical intervention was used upon a child, whether or not the child was injured, check and note the outcome of any first aid or medical treatment offered/given. Again, ensure there is a corresponding accident form;
11. Obtain views from everyone involved about whether the incident was managed as required by procedures or in line with recognised good practice;
12. Consult and keep your Line Manager informed if required to do so, if the review is complex or potentially controversial or if you need assistance/support.

Consider Information

1. Remain objective, stay positive and look for developmental outcomes;
2. Balance what actually happened against what was required by procedure, recognised good practice or in the light of staff experience, skills and knowledge;
3. Consider how the child acted in the light of his/her background, skills, and knowledge;
4. Consider your own interests and needs; look at the role you played; or should have played; be open to criticism;
5. Get help if you need it; consult your line manager, especially if policy or other decisions outside your brief are required;
6. Consider whether there are any training or other support mechanisms that ought to be put in place for staff - or for yourself. Is there a need for specialist help, support or counselling?
7. Consult the social worker; consider whether any changes are required to the child's Placement Plan; including new or amended expectations, strategies or interventions to help reduce or prevent the likelihood of a repeated incident. Is there a need for specialist or therapeutic help, support or counselling?
8. Come to a decision, which can be sustained - which can be put into practice;
9. Avoid 'punishing' or looking to blame. Seek outcomes that are encouraging and developmental.

If changes are required to the child's Placement Plan, the manager/supervisor must co-ordinate these changes; which may mean undertaking a Placement Review.

Debrief and Support

Make sure everyone is informed of the outcome, and is given the opportunity to make comment.

Having undertaken the management review, the Manager must ensure that all concerned do not have unresolved feelings, guilt or other concerns about their own behaviour or other people.

In some circumstances it may be necessary for the Manager to ask an independent consultant or counsellor to provide assistance; especially if there are indications of post-traumatic stress disorder.

The emphasis must be on everyone learning for the future - and reducing or preventing similar incidents from occurring.

It may also be appropriate for all concerned, including the child if it would be beneficial to meet and discuss what happened.

If there are procedural, policy or practice issues which individuals or whole teams can benefit from the Manager must follow them up.

The Manager must record the outcome on the Incident Record.