Official Statistics

Serious incident notifications from local authority children's services 2017 to 2018: main findings

Updated 21 September 2020

This release covers the period between 1 April 2017 and 31 March 2018 and contains data on notifiable incidents involving children aged under 18 years.

Notifiable incidents are those that involve death or serious harm to a child where abuse or neglect is known or suspected, and also deaths of children in care and children in regulated settings.

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 has decreased since last year.

Between 1 April 2017 and 31 March 2018, Ofsted received 384 serious incident notifications. This was an 11% decrease on the number of notifications in 2016 to 2017 (433) but returning to the level of previous years.

The number of child deaths notified to Ofsted has remained similar to the previous year but the number of suicides has increased.

Between 1 April 2017 and 31 March 2018, 209 cases of child deaths were notified compared with 211 in the previous year. There was an increase in the number of suicides reported to Ofsted from 35 in 2016 to 2017 to 46 in 2017 to 2018.

The number of serious harm incidents notified to Ofsted has decreased since last year.

Between 1 April 2017 and 31 March 2018, Ofsted received 175 serious harm notifications. This was a 21% decrease on the number of serious harm notifications in 2016 to 2017 (222).

1. Introduction

Under the 2015 statutory guidance Working together to safeguard children (pdf) local authorities were required to notify Ofsted about incidents that met 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)
• a child in a regulated setting or service has died (including cases where abuse or neglect is not known or suspected)

The guidance, including the above notification criteria, was updated in July 2018. However, it does not apply to this year’s statistical release as it does not cover the time period the statistical release covers.

There are approximately 12 million children in England. In 2017 to 2018, Ofsted received notification of 384 serious incidents that met the criteria in statutory guidance, relating to 435 children. This equates to 0.004% of the total child population in England. The latest Department for Education data shows that as at 31 March 2017, there were approximately 51,000 children who were subject to a child protection plan (CPP). Ofsted received notifications for 48 children who were on a CPP at the time of the incident. This equates to 0.094% of the total CPP population in England.

The number of notifications does not equate to the number of incidents that may have occurred within that time period. In each reporting year, a number of notifications are about incidents that occurred before the reporting period. The proportion of notifications received in 2017 to 2018 that related to historical incidents was the lowest in the last 4 years (55, or 14% of all notifications). In comparison, in 2014 to 2015 26% of all notifications received during that year (101 out of 385) related to incidents that happened before 1 April 2014.

2. Notifications

Of the 384 incidents notified to Ofsted in 2017 to 2018, 209 (54%) related to child deaths compared with 211 (49%) in the previous year. A further 175 (46%) related to serious harm compared with 222 (51%) the previous year. The fall in the total number of notifications is mostly attributable to the 21% reduction in the number of notifications about incidents of serious harm.

The overall number of notifications received in 2017 to 2018 returned to the level of previous years, after last year’s high figure. There was an 11% decrease on the number of notifications in 2016 to 2017 (433).

Figure 1: Number of serious incident notifications, from 2014 to 2018

As with last year, 33% (125) of the incidents notified to Ofsted in 2017 to 2018 were about children under the age of one. Of these incidents, 43% (54) were categorised as a ‘non-accidental injury by a parent or carer’ or ‘killing by a parent or carer’. It returned to the same proportion as in 2014 to 2015 from higher levels in 2015 to 2016 and 2016 to 2017.

Figure 2: The proportion of notifications received in 2017 to 2018 by the age range of children

Of all notifications received in 2017 to 2018, 200 (52%) were about boys and 184 (48%) were about girls. These were the same proportions as last year, and continue the last 2 years’ pattern. This was also broadly in line with the general population of children in England as 2017 ONS data estimates that 51% of children were boys and 49% were girls.

As in previous years, in 2017 to 2018 the majority of notified incidents (277 or 72%) were for children who were White, and 21% (79) related to children from minority ethnic groups. This mirrors the general child population in England. ^{[footnote 1]}

3. Child deaths

There were 209 child deaths reported to Ofsted in 2017 to 2018 that met the ‘Working together’ criteria. These have been categorised in the tables below according to information provided by the relevant local authority at the time of notification about the nature of the incident. Because incidents should be notified to Ofsted within 5 days of occurring, information available to the local authority at this stage about the cause of a child’s death is often limited. There is no requirement in guidance for local authorities to update Ofsted about the cause of a child’s death once they have established it. Consequently, the information held by Ofsted about the cause of death may not be accurate. Where the local authority has given Ofsted further information, for example about post-mortem or criminal investigations, it is included in the tables below.

All information in this release about child deaths should be treated with caution because our knowledge is based on incomplete data. There are also some deaths that remain unexplained or for which the cause of death is not known, or for which it has not been possible for the agencies investigating the death to find out all the circumstances.

As stated previously, the figures for child deaths may not all relate to deaths that occurred during the relevant period. This statistical release includes 19 notifications of child death that occurred before 1 April 2017.

Table 1: Cause of death for serious incident notifications, from 2014 to 2018 ^{[footnote 2]}

Cause of death	2014-15	2015-16	2016-17	2017-18
Accidents	31	18	16	20
Dangerous behaviour (incl. substance misuse)	5	2	4	4
Killing/non-accidental injury by parent or carer	39	19	34	28
Killing/non-accidental injury by unrelated person	12	8	13	17
Natural causes (incl. life limiting disability and illness)	31	42	49	39
Neglect	5	8	9	9
Suicide	29	26	35	46
Unknown or unascertained	38	48	51	46
Total	190	171	211	209

In 2017 to 2018, Ofsted was notified of 209 deaths of children, a small decrease on the 211 notified deaths in the previous year. The figures contained in Table 1 show that the overall numbers and split by causes of death remain broadly similar to the previous years. There has been an increase in both the number of notifications about ‘accidents’, and in ‘killing or non-accidental injury by unrelated person’, but there is no long-term trend. However, there has been a substantial increase in reported suicides over the last 2 years from 26 in 2015 to 2016 to 46 in 2017 to 2018.

As in previous years, the age group that had the largest number of notifications was under ones (77 or 37%).

Table 2: Cause of death for serious incident notifications for children aged under one, from 2014 to 2018 ^{[footnote 3]}

Cause of death	2014-15	2015-16	2016-17	2017-18
Accidents	12	7	5	10
Killing/non-accidental injury by parent or carer	14	9	17	15
Killing/non-accidental injury by unrelated person	0	1	0	0
Natural causes (incl. life limiting disability and illness)	15	13	14	16
Neglect	4	5	6	6
Unknown or unascertained	21	29	32	30
Total	66	64	74	77

The split by the causes of death for this age group is broadly in line with the previous year.

In 2017 to 2018 Ofsted received 94 notifications of child deaths for children aged 11 years old or older. Nearly half (46 of 94) of these were reported as suicides. Twenty-four of these children were girls and 22 were boys. Eight of the children were in care at the time of the incident. The number and percentage of child deaths by suicide are higher than in the previous 3 years. ^{[footnote 4]}

Of the 209 incident notifications of child death submitted to Ofsted, 112 (54%) related to boys and 97 (46%) related to girls. This is slightly different to the picture in the last 2 years when 41% of child death notifications related to girls and 58 to 59% to boys, but it is the same as the picture in 2014 to 2015. ^{[footnote 5]}

The majority of child deaths notified to Ofsted during 2017 to 2018 were for White children (148 or 71%) and 22% (46) were for children from minority ethnic groups, similar to the national figures.

Twenty-two of the 209 reported child deaths (11%) were of children who were subject to a CPP, in line with the previous year. Nineteen percent (40 out of 209) of reported deaths were for children in care. Just over a half of these children (23 out of 40) were reported to have died from ‘natural causes’. Most of these children were in the care of a local authority as a result of their complex and life-limiting disabilities.

The remaining 17 child deaths of children in care were due to ‘suicide’ (8); ‘non-accidental injury by an unrelated person’ (2); ‘accidents’, ‘dangerous behaviour’, and ‘non-accidental injury by parent or carer’ (one each); and for 4 of them the reason was ‘unknown or unascertained’. The proportion of deaths of children in care compared to all child deaths notified to Ofsted is similar to the picture in the previous 2 years.

4. Serious harm

Ofsted received 175 notifications of incidents involving serious harm to a child. This related to 223 children. In some cases, where the incident involved harm to more than one child, the notification form only provided information about the first child identified. All data in this release is based on single notifiable incidents and the information is only about 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. Local authorities are not required to update Ofsted with new information.

The data in the table below represents Ofsted’s understanding based on the notifications and any subsequent updates we may have received.

Table 3: Cause of serious harm for serious incident notifications, from 2014 to 2018

Cause of serious harm	2014-15	2015-16	2016-17	2017-18
Accidents	3	4	8	5
Neglect by parent or carer	25	26	23	30
Non-accidental injury by parent or carer	55	75	82	65
Non-accidental injury by unrelated person	6	14	9	16
Other (incl. unknown or unascertained)	24	29	30	12
Self-harm/dangerous behaviour	8	12	16	3
Sexual abuse by family member	13	10	10	27
Sexual abuse/child sexual exploitation by unrelated person	61	38	44	17
Total	195	208	222	175

There has been a 21% decrease in the number of serious harm notifications notified to Ofsted since last year, from 222 in 2016 to 2017 to 175 in 2017 to 2018.

As in the previous 2 years, the most frequent cause of serious harm was ‘non-accidental injury by a parent or carer’. Incidents in this category have decreased for the first time in 3 years (65 notifications compared with 82 in 2016 to 2017) although the percentage remains the same as last year at 37%. Of this type of incident, as with last year, the majority affected children aged 5 or under (58 or 89%), of whom 30 were girls and 28 were boys. Six of these children in 2017 to 2018 were in care and 8 were subject to a CPP at the time of the incident.

The next largest category of serious harm was incidents of ‘neglect by a parent or carer’ (30 notifications or 17%). This differs from last year when the second largest category was ‘sexual abuse or child sexual exploitation by an unrelated person’ (20%). Around two thirds of these incidents of neglect (19 or 63%) affected children aged 10 or under, of whom 11 were girls and 8 were boys.

This year, for the category of ‘sexual abuse by a family member’, Ofsted have also included notifications where the child was sexually abused by a carer. However, this does not fully account for the increase in notifications in this category. There were 27 notifications of ‘sexual abuse by a family member’, compared with 10 in 2016 to 2017. There were also 17 notifications of ‘sexual abuse or child sexual exploitation by an unrelated person’, compared with 44 in 2016 to 2017.

The highest number of serious harm notifications related to children aged under one (48 or 27%). This is similar to the previous 2 years. The below table shows the split by main cause of serious harm.

Table 4: Cause of serious harm for serious incident notifications for children aged under one, from 2014 to 2018

Cause of serious harm	2014-15	2015-16	2016-17	2017-18
Accidents	0	2	1	0
Neglect by parent or carer	5	1	4	3
Non-accidental injury by parent or carer	35	51	62	39
Non-accidental injury by unrelated person	1	1	1	0
Other (incl. unknown or unascertained)	8	4	3	6
Total	49	59	71	48

Of all serious harm notifications, 87 (50%) were about girls and 88 (50%) about boys. There is no real trend in the year-on-year data. ^{[footnote 6]}

The majority of serious harm notifications were about White children (129 or 74%). Children from minority ethnic groups accounted for 19% (33). This is broadly in line with child population figures in England.

Of all children who suffered serious harm, 26 (15%) were the subject of a CPP and 44 (25%) were in care of a local authority at the time of the serious incident. Both these figures are proportionally in line with last year. Four children were both in care and subject to a CPP at the time of the notification.

5. Serious case reviews

During the period 2017 to 2018 every local authority had a Local Safeguarding Children Board (LSCB) that was responsible for deciding whether or not to initiate a Serious Case Review (SCR) in response to an incident. This decision should normally be made within one month of notification of the incident. ^{[footnote 7]}

For 105 (27%) of the 384 incidents notified to Ofsted, the relevant LSCB told Ofsted that it had decided to initiate an SCR. LSCBs notified Ofsted of 107 (28%) decisions not to initiate an SCR. For the remaining 172 (45%) cases, Ofsted received no information from the relevant LSCB about whether or not it had decided to conduct an SCR. Ofsted’s data about SCRs is therefore incomplete.

6. Notes

6.1 Requirement for local authorities to notify Ofsted

The criteria for notifiable incidents in this period were set out in the 2015 version of Working together to safeguard children (pdf), page 74, paragraph 13 onwards.

13). 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)
• a child in a regulated setting or service has died (including cases where abuse or neglect is not known or suspected)

14). The local authority should report any incident that meets the above criteria to Ofsted and the relevant LSCB or LSCBs promptly, and within 5 working days of becoming aware that the incident has occurred.

15). 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.

16). Contact details and notification forms for notifying incidents to Ofsted are available on Ofsted’s website.

6.2 Serious case reviews

Working together to safeguard children 2015 said 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 5 working days of the Chair’s decision.

7. Methodology

Due to concerns about confidentiality, we no longer publish the underlying dataset for the Serious Incident Notifications statistical release. This 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 2017 and 31 March 2018.

The process for notifying of serious incidents has changed. Since 29 June 2018 there has been a duty on LAs in England to notify the national Child Safeguarding Practice Review Panel within 5 working days of becoming aware of a serious incident. A new online system is being developed for notifications for the new Panel. This will replace the current process for notifying incidents to Ofsted. The notifications to the Panel will, however, be shared with Ofsted and the DfE. As a result, Ofsted is planning for this year’s release to be the last statistical release we produce covering this area.

From 1 April 2017 to 31 March 2018, Ofsted was notified of 396 incidents by local authorities using the online form on www.gov.uk. Out of these notifications, 12 did not meet the criteria in the statutory guidance so have not been counted in the data in this statistical release.

The figures for child deaths caused by ‘killing or non-accidental injury by a parent or carer’ also include notifications where the child was killed or fatally injured by another family member. Figures for child deaths by ‘killing or non-accidental injury by an unrelated person’ include cases where the injury was caused by a person living in the household who was not a family member (for example an adult in a relationship with a parent).

The figures for serious harm incidents of ‘sexual abuse by a family member’ also include notifications where the child was sexually abused by a carer.

The ethnicity has been left blank or was not declared for 7% of serious incident notifications received in 2017 to 2018. Also, for 46 child deaths (22%) the main cause was recorded as unknown or unascertained.

The number of serious case reviews notified to Ofsted might not equal the number of serious case reviews that have been commissioned in the period. Decisions to initiate serious case reviews are not always communicated promptly to Ofsted.

The number of incident notifications received during the time period covered in this statistical release does not necessarily equate to the number of incidents that occurred between 1 April 2017 and 31 March 2018. Some of the incidents that were notified in this period occurred before 1 April 2017.

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.

Acknowledgements

Thanks to the following for their contribution to this statistical release: Anna Otczyk, Klara Davies and Anne Gair.

1. The ethnicity has been left blank or was not declared for 7% of serious incident notifications. ↩

2. The category of ‘Accidents’ includes possible overlay. Overlaying describes the accidental death by smothering caused by a larger individual sleeping on top of a child when sharing a bed or sofa. ↩

3. The category of ‘Accidents’ includes possible overlay. Overlaying describes the accidental death by smothering caused by a larger individual sleeping on top of a child when sharing a bed or sofa. ↩

4. ONS has recently reported on the number of suicides in the UK registered in 2017. Suicides in the UK: 2017 registrations September 2018 - This reports on all deaths from intentional self-harm for persons aged 10 years and over, and deaths where the intent was undetermined for those aged 15 years and over ↩

5. In 2016 to 2017, the gender of one child was unknown/not reported, therefore the gender split for this year was 41% girls and 58% boys. ↩

6. Percentages are rounded which accounts for the difference in numbers but equal percentages. ↩

7. LSCBs and serious case reviews will be replaced by new multi-agency safeguarding arrangements and local and national child safeguarding practice reviews by September 2019. Details of the new arrangements are in the 2018 version of the DfE’s statutory guidance Working together to safeguard children ↩