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1.13 OSCB Protocol for a Co-ordinated Response to Serious/Fatal Safeguarding Cases

OSCB Inter-agency Safeguarding Procedures should be followed, but this protocol provides additional information to help with these cases.


This chapter was updated in July 2015 when contact details in Section 6, Escalation Process were amended and updated.


  1. This Protocol should be used for Planning S47 (Child Protection) Investigations in Cases of
  2. Aims
  3. First Presentation/Notification of Serious Case (during normal business hours and out-of-hours)
  4. Strategy Meeting: Specific Considerations for Serious Cases
  5. During Course of Investigation
  6. Escalation Process

1. This Protocol should be used for Planning S47 (Child Protection) Investigations in Cases of

  • Seriously/fatally injured child;
  • Serious sexual assault in young child;
  • Complex/exceptional safeguarding cases.

NB In defining ‘serious injury’ the age and developmental stage of the child needs to be considered alongside the severity of the injury

It should be noted that problems with case management are more likely to occur out of hours. This protocol should be adopted as soon as a serious case is reported to Oxfordshire social care, police or health, whether it is during normal hours of business or in the evening or weekend/holidays.

Problems can also occur when a seriously or fatally injured child from an external authority is transferred into Oxfordshire on admission to the children’s hospital. This protocol should be followed by Oxfordshire professionals in regular and close liaison with the child’s home local authority (LA).

2. Aims

  • To create a framework within which social workers, doctors and police officers support each other in their joint and separate responsibilities to assess, manage and review children’s safeguarding and medical needs; and to investigate crime, if the circumstances are considered suspicious;
  • To improve working together and reduce the likelihood of conflict amongst agencies;
  • To improve co-ordination in very complicated cases and, from the outset, clarify roles and responsibilities;
  • To provide information about escalation when problems occur.

3. First Presentation/Notification of Serious Case (during normal business hours and out-of-hours)

3.1 Initial Priorities for all Agencies:

  • Ensure safety of the child, including any boundaries on care and contact, overnight staying arrangements/restrictions for parents;
  • Ensure appropriate medical input for the child;
  • Ensure safety of other children and people, including any emergency placements and boundaries on care and contact by any relevant family members, as appropriate. Consider the use of written agreements;
  • Ensure all appropriate agencies are informed, including the LA in the child’s home area, if external to Oxfordshire;
  • In a fatal injury, police will initially manage the case as a homicide and will be actively seeking information at the earliest opportunity;
  • Immediate strategy discussion to agree how s47 investigation, risk assessment of siblings or other children and case- management should proceed, and to identify point of contact and communication route in each agency;
  • Ensure senior managers are informed;
  • Identify expected points of handover eg. from out-of-hours to daytime services;
  • Prior to the strategy meeting (see below) taking place, agree how, when and to whom the immediate actions will be fed back, so that all are clear on the outcomes and actions can be signed off as complete;
  • If professional is not an expert in safeguarding, then safeguarding advice must be sought from senior staff in own agency;
  • Ensure all actions and agreements are recorded in each agency.

3.2 Within 24 Hours

  • In cases of serious/fatal injury, it is crucial to hold the strategy meeting within the first 24 hours;
  • When a strategy meeting is held during the weekend or evening, it is important that the professionals involved have, or have sought advice from colleagues with, child protection experience;
  • The purpose of the meeting is to share information, ensure procedures are being followed, to plan exactly who is doing what and make clear records about assessment, interviews, agencies’ contacts (including any changes in key staff within each agency);
  • Ensure all information relating to the incident and child’s medical condition is collated and shared appropriately amongst agencies. This is critical in cases that start out-of-county where information gathering may be more difficult;
  • In the event of a child death, inform the child death overview manager Phone: 01865 231974, Mobile: 07733101867, Fax: 01865231981 who will initiate the rapid response process and begin the overview process (see OSCB Inter-agency safeguarding procedures).

4. Strategy Meeting: Specific Considerations for Serious Cases

4.1 Attendees:

  • Child’s consultant or delegated representative of sufficient status and experience eg senior registrar;
  • EDT child care social worker if out of hours;
  • Team manager and social worker of the assessment team investigating the case;
  • Team manager/senior practitioner of the child’s home LA team if external to Oxfordshire;
  • Police – representative from PVP (Protecting Vulnerable People) team;
  • Police - senior rep of criminal investigation team eg SIO (senior investigating officer) or OIC (Officer in the Case);
  • Lead OUH nurse for safeguarding or, if unavailable, ward sister/senior nurse for an admitted child.

Consider inviting:

  • Ambulance Service or at least have phone contact/request their patient care record;
  • Health visitor /GP;
  • Lead doctor for safeguarding;
  • Any other key professionals involved with the child.

4.2 Agenda:

Immediate safety of children

  • Check that the necessary police URN (unique reference number) has been created to manage ongoing safeguarding issues, and that it has been shared amongst agencies;
  • Where other children/siblings relevant to the case are living at different addresses, additional URNs may be necessary. However, ensure that relevant URNs can be linked together;
  • Review immediate safety arrangements for injured child, sibling(s), other relevant children. Consider whether the placements of siblings/other children are safe, appropriate and sustainable;
  • Consider whether parents/carers/children need interpreters or other services due to disability/ill health that will enable them to participate fully in the investigation;
  • Consider/review written agreements with parents and carers on boundaries of contact and care;
  • Consider whether hospital security needs to be briefed and if additional police resources are required.


  • Share a detailed description of the injuries from the child’s consultant;
  • Share expert opinions of what has happened to the child;
  • Share medical information to support or negate criminality;
  • Review body maps and photos;
  • Provide full medical information available from referring hospital and what investigations have been done there;
  • Share and record the parents/carers’ accounts of what has happened. Are they inconsistent or changing explanations? Review the parents’ demeanour; their behaviour on ward; their interactions with the child and with staff;
  • Share information on the presentation of child on admission: consider whether timely and signs of neglect or old injuries;
  • Review and discuss any existing health condition(s) which might have caused the child to bruise or fracture more easily;
  • Establish which tests/scans have been completed and which are outstanding and whether referrals have been made;
  • Discuss any plans for discharge;
  • Agree the timescale for written medical reports to be available and how these will be shared (within 3 working days, maximum).


  • Make arrangements for medical examinations;
  • Consider whether any follow up or further exams are required;
  • Gather any relevant information re their health/previous injuries;
  • Consider whether they may be witnesses and how any spontaneous disclosures will be handled;
  • Make arrangements for assessment interviews.


  • Provide a briefing on the status of any criminal investigations;
  • Ensure the necessary checks have been undertaken on all carers and household members, including the CEDAR crime recording database and the PNC (police national computer);
  • Plan the progress of the joint investigation including the joint interview strategy;
  • Agree what information is to be shared (including with families), how this is to be communicated, by whom, and how confidentiality is to be managed so that police, social workers and hospital can fulfil their responsibilities;
  • Interviews with parents/child(ren). Social workers, nurses and doctors need to ensure that their discussions with the parents/child(ren) do not jeopardise early evidence by making suggestions about how the injuries may have been caused. Record all interviews and exchanges;
  • Agree appropriate deployments of staff at critical times eg arrest of suspects and impact on care of children;
  • Review the use of police powers in respect of children eg whether the child/siblings are subject to police protection;
  • Consider the need for emergency orders. If parents are cooperative and not undermining/threatening the child’s safety then discuss ICO (Interim Care Order) application with LA solicitor and area service manager;
  • Following the death of the child, agree with the police the arrangements for the parents to spend time with the child's body which must be supervised


With reference to all agencies’ records, consider the family history and parental risk factors relevant to the investigation, assessment of risk and care proceedings.

Professional Roles and Responsibilities

  • Clarify who will do what. NB consistency of staff is important;
  • Review resources and identify additional requests to be made within agencies;
  • Agree timescales, including arrangements for reviewing the strategy meeting;
  • Ensure there is a shared record and action plan of the strategy meeting: careful and detailed documentation is important.


  • Ensure that appropriate children’s social care procedures have been completed on kinship placements;
  • Identify which Social Care colleagues will undertake any viability assessments/checks required;
  • Consider whether a LA foster carer should be used. Agree who will request this.


  • Agree a strategy for managing enquiries to the ward and visitors to the child, including permissions and checking of ID for professionals and foster carers;
  • In high profile cases it is useful to remind staff about confidentiality for the child/family, including paper and electronic records;
  • Agree points of contact for media enquiries in each agency.

Cases that have transferred into the County

  • An appropriate representative from the child’s home local authority should attend the strategy meeting;
  • Strategy meetings should be held in the hospital whilst the child remains a patient and both LAs should be represented;
  • Information should be shared across the two authorities and with other agencies. Agree how this will be managed;
  • Agree what is expected of the two social work teams involved;
  • Identify any relevant police, health or education points of contact in the child’s home area;
  • Address any difficulties between agencies urgently to avoid delay in investigation.

5. During Course of Investigation

Review strategy discussions/meetings

  • Update and share information regularly amongst all agencies. In complex cases, one or more review Strategy Discussions or meetings may be necessary to plan the stages of an investigation and future actions.

Inter-agency risk assessment

  • Professionals working on the different parts of an investigation should confer and assess risk together, before drawing conclusions or giving findings of investigations to parents/family members/potential witnesses;
  • Professionals should make every effort to substantiate their judgements and be prepared to challenge each other if evidence is unclear, or opinions appear to lack foundation;
  • Ensure agencies continue to be clear about each other’s roles and responsibilities so that individuals enable both the assessment of risk and the criminal investigation;
  • Ensure that social workers and health professionals continue to share with the police information that assists in building the case and fulfils court disclosure if a person is charged.

6. Escalation Process

If disagreements or concerns about interagency working or actions occur, then escalation should happen.

  • Each service should take their concerns to their own manager/seniors first;
  • There should be discussion with the equivalent level manager in the other agency. In Health, this would be the paediatric consultant for the child;
  • If unresolved, additional advice/support should be obtained from.
Agency In-hours (Mon-Thurs 8.30-5.00 Fri 8.30-4.00) Contact details

Out-of-hours (eves and w’ends)

Contact details
Children’s Social Care Area social care manager
Nth: Karen Palmer
Ctrl: Penny Browne/Sue Lingard
Sth: Elaine Wade
Nth: 01865 816670
Ctrl: 01865 323048
Sth: 01865 897983
EDT Senior manager on-call Via EDT co-ordinator on 0800 833408

CAIU Led Investigation:

  • MASH Detective Sergeant;
  • PVP DCI or DI for county covering respective office (Oxfordshire currently DCI Katy Barrow-Grint).

Major Crime led Investigation

  • SIO or Deputy SIO;
  • Head of Major Crime Unit (Currently D/Supt Chris Ward).

Accessed via Call Centre:

Duty DI or if Major Crime Case: Duty SIO

Consultant paediatricians/named doctors for safeguarding:
Dr. Praveen Goyal
Dr. Clare Robertson

Named GPs:
Dr Meriel Raine
Dr Sarah Ledingham

Lead nurse for safeguarding:
Alison Chapman
Named Nurse for safeguarding:
Jackie Hucker

All via JR switchboard 01865 741166 – ask for them to be contacted by their mobile

Same as in-hours

Safeguarding Leads

This table is correct as at the date of this document.

  • See escalation protocol and leads for a wider range of agencies’ responsible senior managers and more detail on how to escalate;
  • The escalation protocol and leads is kept updated by OSCB business officer and circulated to all agencies’ frontline teams on a regular basis.