Official Statistics

Serious incident notifications from local authority children's services 2015 to 2016 - key findings

Published 27 October 2016

This release contains:

• data on notifiable incidents involving the care of children aged under 18 years
• notifiable incidents are those involving death or serious harm to a child where abuse or neglect is known or suspected, and also deaths of children looked after and children in regulated settings
• data is for the period between 1 April 2015 and 31 March 2016
• the analysis is based on information provided to Ofsted by local authorities at the time of notification and in any further updates received from local authorities and Local Safeguarding Children Boards
• the data is experimental, because the statistics do not yet meet the rigorous quality standards of National Statistics

The number of serious incidents notified to Ofsted was almost the same as last year.

From 1 April 2015 to 31 March 2016 Ofsted received 379 incident notifications. This was a 2% decrease on the number of incidents between 2014 to 2015 (385).

The number of child deaths notified to Ofsted has fallen.

From 1 April 2015 to 31 March 2016, 171 cases of child deaths were notified, compared with 190 in the previous year. This was a 10% decrease from the previous year.

The number of child deaths notified from killing or non-accidental injury by a parent or carer has fallen.

In the period 1 April 2015 to 31 March 2016 the number of notifications of child deaths from killing or non-accidental injury by a parent or carer has dropped to 11% compared with 21% between 2014 to 2015.

Key findings

Notifications

Under the statutory guidance ‘Working together to safeguard children’ local authorities should notify Ofsted of incidents meeting the following criteria:

• a child has died (including cases of suspected suicide), and abuse or neglect is known or suspected
• a child has been seriously harmed and abuse or neglect is known or suspected
• a looked after child has died (including cases where abuse or neglect is not known or suspected) or a child in a regulated setting or service has died (including cases where abuse or neglect is not known or suspected)

Ofsted received notification of 379 incidents between 1 April 2015 to 31 March 2016, that met the criteria in statutory guidance. This was only a 2% decrease in the number from the previous year (385), but 27% higher than 2013 to 2014 when 298 incidents were notified, suggesting that the number of notifications may have plateaued.

The number of notifications during 1 April 2015 to 31 March 2016 does not necessarily equate to the number of incidents that have occurred within that time period. Some notifications relate to incidents which occurred before 1 April 2015, but about which Ofsted was not notified until after 1 April 2015.

Over the period of three years there has been a shift in balance between incident notifications of child deaths and serious harm. Incidents notified relating to child death have reduced from the previous year, while those relating to serious harm have increased. Of all incidents notified in the period, 45% (171) related to child deaths compared with 49% in the previous year, and 55% during 2013 to 2014.

Of the 379 incident notifications, 211 (56%) related to boys and 168 (44%) related to girls. This is very different compared with 2014 to 2015 when 182 (47%) related to boys and 202 (53%) related to girls.

Children under the age of one year were the subjects of 32% (123) of all incidents reported during 2015 to 2016. Just over two fifths of these incidents (51 or 41%) had, as primary cause, non-accidental injury by parent or carer, which was the most common cause for this age group. This is a very similar picture compared with 2014 to 2015, when children under the age of one year were the subjects of 30% (115) of notifications and non-accidental injury by parent or carer of incident was also 30%, although relating to fewer incidents (35).

There were 158 (42%) incidents of all types reported on young people aged 11 years or older during 2015 to 2016. This is similar to the proportion of incidents affecting this age group in the previous year (43%). Just over a fifth of incidents affecting this age group between 2015 to 2016 related to sexual abuse or child sexual exploitation by an unrelated person. There were more notifications in this category for girls (28) than for boys (5).

During 2015 to 2016, the majority of incidents notified, 274 (72%) were of children who were white. Census data shows that, across England, 79%^{[footnote 1]} of children are white. Some 84 (22%) notified incidents related to children from a black or minority ethnic (BME) background (England 22%).^{[footnote 2]} The picture was similar compared with 2014 to 2015. There continues to be non-reporting of ethnicity information with 21 (6%) during 2015 to 2016 and 39 (10%) in the previous year.

One third of incidents involving BME children (28 or 33%) were reported with a cause of ‘unknown or unascertained’. In contrast, around one sixth of incidents (46 or 17%) involving white children were reported with this classification. In part, this is because such classification is most often used for those under one, where cause of death is less likely to be known than it is for older children. While there are proportionately more notifications for very young white children than young BME children, this only partly explains the difference.

Child deaths

During 2015 to 2016, Ofsted was notified of 171 deaths of children under the Working Together criteria. These have been categorised, below, according to information provided by the relevant local authority at the time of notification about the nature of the incident. Because incidents are notified to Ofsted within 5 days of occurring, information available to the local authority about the cause of a child’s death is often limited.

There is no requirement in guidance for local authorities to provide further updates to Ofsted about the cause of a child’s death once it becomes known. Consequently, the information held by Ofsted about the cause of death may not be accurate. Where further information has been provided to Ofsted by the local authority, for example about post-mortem or criminal investigations, Ofsted has used this information to inform the data in the tables below.

As stated previously, the figures for child deaths may not all relate to deaths which occurred during the relevant period. Child deaths in this statistical release relate to those notified to Ofsted during the period 1 April 2015 to 31 March 2016.

Table 1: Priority cause of death for deaths notified to Ofsted between 1 April 2015 and 31 March 2016

Priority Cause	Number	Percentage
Unknown or unascertained	48	28
Natural causes (incl. life limiting disability and illness)	42	25
Dangerous behaviour[footnote 3] (incl. substance misuse)	28	16
Killing/non-accidental injury by parent or carer	19	11
Accidents (including possible overlay)	18	11
Killing/non-accidental injury by unrelated person	8	5
Neglect	8	5
Total	171	100

The number of notified child deaths caused by killing/non accidental injury by a parent or carer has fallen during 2015 to 2016: there were 19 cases (11% of the total deaths) compared with 39 (21%) in 2014 to 2015.

Of the 171 reported child deaths, 29 (17%) were of children who were subject to a child protection plan. Almost half, 14 (48%) of these were cases where the cause of death was unknown or unascertained, with a further 10 (35%) who died through natural causes such as a life limiting disability or illness.

Of the 42 children who were reported as dying from natural causes, 18 were children looked after, equating to 43% of the total. This figure was the same as the previous year of 18, but the proportion was higher (58%).

The largest age group was children aged under one (64 or 37%), similar to the picture in 2014 to 2015 (66 or 35%). Twenty nine (45%) children in this age group died with cause of death unknown or unascertained, compared with 21 (32%) the previous year. A further 13 (20%) children in this age group are reported to have died of natural causes, such as life limiting disabilities or illness, similar to the previous year (15 or 23%).

Of the 70 notified deaths of young people aged 11 years or older between 2015 to 2016, or 41% of the total deaths reported, over one third died as a result of suicide (26 or 37%). Fifteen of these children were boys and 11 were girls. Two of the children were looked after by the local authority at the time of the incident. The numbers and percentages were very similar compared with 2014 to 2015, where there were 29 deaths by suicide in this age group (38% of 72). One difference was a slightly higher number of girls (15) than boys (14).

All information with respect to child deaths should be treated with caution, because our knowledge is based on incomplete data. There may be still ongoing post mortems or criminal investigations, where the details may not be known to Ofsted. There are also some deaths, for example that remain unexplained or where the cause of death is not known, or it has not been possible for the agencies investigating the death to fully ascertain the circumstances.

Serious harm

From 1 April 2015 to 31 March 2016, Ofsted received 208 notifications of incidents involving serious harm to a child. In some cases, the incident involved harm to more than one child, but the notification form only provided information about the first child identified. All data in this report is based on single notifiable incidents and the information is only on the first child identified on the incident form.

At the time of a notification being made to Ofsted, the local authority may not have had full information about the serious incident. It is not a requirement for a local authority to update Ofsted of any new information. Where information has become available subsequent to the notification being made, such as criminal convictions or further information from the local authority, Ofsted has used this to inform the data in the table below.

Table 2: Priority cause of serious harm for incidents notified to Ofsted between 1 April 2015 and 31 March 2016

Priority Cause	Number	Percentage
Non-accidental injury by parent or carer	75	36
Sexual abuse/CSE by unrelated person	38	18
Other (incl. unknown or unascertained)	29	14
Neglect by parent or carer	26	13
Non-accidental injury by unrelated person	14	7
Self-harm/Dangerous behaviour	12	6
Sexual abuse by family member	10	5
Accidents	4	2
Total	208	100

The most frequent overall cause of serious harm was non-accidental injury by a parent or carer. This affected 75 (36%) children. The majority of incidents of this type affected children aged under 5 (68), of whom 48 were boys and 20 were girls.

The next highest category was incidents of sexual abuse or child sexual exploitation by an unrelated person (38 children). The majority of these incidents (33 or 87%) affected children aged 11 years or older, of whom 28 were girls and five were boys. Of these 38 young people, 17 (45%) were looked after by the local authority at the time of the incident and one young person was subject to a child protection plan at the time of the incident. No young person was subject to both.

Of all children who suffered some form of serious harm, 28 (13%) were the subject of a child protection plan at the time of the serious incident and 47 (23%) were looked after by a local authority at the time of the serious incident. Three children who suffered non-accidental injury by a parent or carer were both subject to a child protection plan and looked after at the time of the incident.

Of the incidents notified between 2015 to 2016 concerning serious harm, 110 (53%) were boys and 98 (47%) girls. In contrast, there were 114 (59%) girls between 2014 to 2015 and 80 (41%) boys.

The age group with the highest number of serious harm incidents was children aged under one year (59 or 28%). The vast majority of these children sustained non-accidental injuries by a parent or carer (51 or 86%). This is very different from the picture during 2014 to 2015, where the largest single age group was 11 to 15 year olds (71 or 36%) of whom 46 (65%) suffered sexual abuse or child sexual exploitation by an unrelated person.

Serious case reviews

The Local Safeguarding Children Board (LSCB) in a local authority area has the responsibility for deciding whether or not to initiate a serious case review in response to an incident.

For 134 (35%) of the 379 incidents notified to Ofsted between 2015 to 2016, the relevant LSCB notified Ofsted that they had decided to initiate a serious case review. This compares with 43% in the previous year, and 48% between 2013 to 2014.

The pattern of notifications to Ofsted suggests that there has been a considerable reduction in the number and proportion of serious case reviews that relate to cases of child death. Of the 134 serious case reviews initiated and notified to Ofsted between 2015 to 2016, 60 (45%) were initiated in response to the death of a child, compared with 90 (54%) in the previous year. The number of serious case reviews that were initiated concerning an incident of serious harm to a child has reduced slightly from 76 between 2014 to 2015 to 74 between 2015 to 2016.

Of the 134 serious case reviews:

• 22 (16%) were initiated where a child was subject to a child protection plan at the time of the incident and 10 (7%) were initiated where a child was looked after by the local authority at the time of the incident
• 33 (25%) were initiated following incidents of non-accidental injury by a parent or carer and 17 (13%) followed incidents concerning neglect by a parent or carer
• 45 (34%) were for children who were aged less than one year old and 36 (27%) were for young people aged between 11 and 15 years old

The majority of serious case reviews, (104 or 78%) were for children who were White. The triennial analysis of serious case reviews published by the Department for Education found that 79% of the children who were at the centre of serious case reviews from 2011 to 2014 were White.^{[footnote 4]}:

Revisions to previous release

This is the first release of the data for the period 1 April 2015 to 31 March 2016.

Notes

Requirement for local authorities to notify Ofsted

The criteria for notifiable incidents are set out in Working together to safeguard children, page 74, paragraph 13 onwards.

1. A notifiable incident is an incident involving the care of a child which meets any of the following criteria:

• a child has died (including cases of suspected suicide), and abuse or neglect is known or suspected
• a child has been seriously harmed and abuse or neglect is known or suspected
• a looked after child has died (including cases where abuse or neglect is not known or suspected) or a child in a regulated setting or service has died (including cases where abuse or neglect is not known or suspected)

1. The local authority should report any incident that meets the above criteria to Ofsted and the relevant LSCB or LSCBs promptly, and within five working days of becoming aware that the incident has occurred.
2. For the avoidance of doubt, if an incident meets the criteria for a Serious Case Review (see below) then it will also meet the criteria for a notifiable incident (above). There will, however, be notifiable incidents that do not proceed through to Serious Case Review.
3. Contact details and notification forms for notifying incidents to Ofsted are available on Ofsted’s website.

Serious case reviews

Working together to safeguard children says on page 78:

Decisions whether to initiate an SCR

The LSCB for the area in which the child is normally resident should decide whether an incident notified to them meets the criteria for an SCR. This decision should normally be made within one month of notification of the incident. The final decision rests with the Chair of the LSCB. The Chair may seek peer challenge from another LSCB Chair when considering this decision and also at other stages in the SCR process. The LSCB should let Ofsted, DfE and the national panel of independent experts know their decision within five working days of the Chair’s decision.

Methodology

Due to concerns about confidentiality, a decision has been made not to publish the underlying dataset for the Serious Incident Notifications SFR this year. Not publishing the underlying data allows us to provide users with a rich and detailed analysis of the data while minimising the risk of identification of individuals from the dataset. If you are a researcher with a need to access the underlying data please contact socialcaredata@ofsted.gov.uk.

The data in the release is from serious incident notifications received by Ofsted between 1 April 2015 and 31 March 2016.

From 1 April 2015 to 31 March 2016, Ofsted was notified of 396 incidents by local authorities using the online form on www.gov.uk.^{[footnote 5]}: Out of these notifications, 17 did not meet the criteria in the statutory guidance so have not been counted in the data in this statistical release.

The numbers of incident notifications received during the time period covered in this statistical release are not necessarily the number of incidents which have occurred during 1 April 2015 and 31 March 2016, where some notifiable incidents relate to those which occurred before 1 April 2015, and where Ofsted was not notified until after this date.

If you have any comments or feedback on this publication, please contact the Social Care Data Team on 03000 130020 or socialcaredata@ofsted.gov.uk

1. England child ethnicity information is taken from the ONS 2011 census: https://www.nomisweb.co.uk/census/2011/dc2101ew ↩

2. More than 100% due to rounding. (England 78.5% and BME 21.5%) ↩

3. The term ‘dangerous behaviour’ has been used to signify actions by a child or young person which put them at risk of injury or death, including suspected suicides ↩

4. Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016: https://www.gov.uk/government/publications/analysis-of-serious-case-reviews-2011-to-2014 ↩

5. https://www.gov.uk/government/publications/notify-ofsted-of-serious-childcare-incident-form-for-local-authorities ↩