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OxfordshireSafeguarding Children Board Procedures Manual

Protocol for an Early Co-Ordinated Response to Serious Safeguarding Cases


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


This chapter was updated in June 2020 in order to link to a new chapter, Resolving Multi-Agency Disagreements and Escalation Policy.


  1. Use of Policy
  2. Aims
  3. First Presentation of Notification of the Serious Case
  4. Strategy Meeting: Specific Considerations for Serious Cases
  5. During the Investigation
  6. Escalation

1. Use of Policy

This protocol should be used for planning child protection (Section 47) investigations in cases of a:

  • Seriously injured child;
  • Seriously injured child who has died and where there may be other children at risk;
  • Child with a complex mental health presentation;
  • Serious sexual assault in young child;
  • Complex/exceptional safeguarding cases.

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 child is seriously injured or has died, is from an external authority and 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 an early response framework within which social workers, health practitioners 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 unexplained;
  • 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 of Notification of the Serious Case

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 and mental health 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, e.g. health, police and children's social care, including children's social care in the child's home area, if external to Oxfordshire. In the unexplained death of a child where the police attend, they will initially manage the incident as unexplained and will be actively seeking information at the earliest opportunity;
  • In respect of an investigation into Sudden Unexpected Death of an Infant / Sudden Unexpected Death of a Child the Child Death Review process will be initiated;
  • Children's Social Care to ensure an immediate strategy discussion takes place 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;
  • Thames Valley Police will appoint a Senior Investigating Officer (SIO) and Officer in the Case (OIC) at the earliest opportunity from the Child Abuse Investigation Unit (CAIU). If the death is a suspected homicide a Major Crime SIO may be appointed;
  • Identify expected points of handover e.g. 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 injury, or when a child has died and there are safeguarding concerns, 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 child protection experience or have sought advice from colleagues;
  • 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, refer to the Child Death Review Processes (2021) to initiate the overview process.

4. Strategy Meeting: Specific Considerations for Serious Cases

4.1 Attendees:

  • Where relevant the child's consultant or delegated representative of sufficient status and experience e.g. senior registrar;
  • Emergency Duty Team Manager 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 - senior representative of the criminal investigation team e.g. SIO or OIC;
  • Senior nurse for safeguarding children or, if unavailable, ward sister/senior nurse for an admitted child for Oxfordshire University Hospital and Oxford Health NHS Foundation Trust;
  • Professional from the child's education setting (nursery, school or college);
  • Consider inviting or providing facilities to phone in to the meeting for:
    • Ambulance Service;
    • Health visitor / GP/ School Nurse / CAMHS representative;
    • Lead doctor for safeguarding;
    • Any other key practitioners involved with the child.

4.2 Agenda:

Immediate safety of children
  1. Check that the necessary Police unique reference number (URN) has been created to manage ongoing safeguarding issues, and that it has been shared amongst agencies;
  2. 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;
  3. Review immediate safety arrangements for the injured child, their sibling(s) or, other relevant children. Consider whether the placements of siblings/other children are safe, appropriate and sustainable;
  4. Consider whether parents/carers/ children need (independent) interpreters or other services due to disability or ill health that will enable them to participate fully in the investigation;
  5. Consider/review written agreements with parents and carers on boundaries of contact and care;
  6. Consider whether hospital security needs to be briefed and if additional police resources are required.
Injuries / Health
  1. Share a detailed description of the injuries or other health presentations from the child's consultant;
  2. Share expert opinions of what has happened to the child;
  3. Share medical information to support or negate criminality;
  4. Review body maps and photos;
  5. Provide full medical information available from referring hospital and what investigations have been done there;
  6. Share and record the parents/carers' accounts of what has happened taking account of inconsistencies or changing explanations?
  7. Share information on the presentation of child on admission: consider whether timely and if there are signs of neglect or old injuries;
  8. Review and discuss any existing health condition(s) which might have caused the child to bruise or fracture more easily;
  9. Establish which tests/scans have been completed and which are outstanding and whether referrals have been made;
  10. Discuss any plans for discharge;
  11. Agree the timescale for written medical reports to be available and how these will be shared (within 3 working days, maximum).
Siblings and associated children
  1. Make arrangements for medical examinations, where indicated;
  2. Consider whether any follow up or further examinations are required;
  3. Gather any relevant information re their health/previous injuries;
  4. Consider whether they may be witnesses and how any spontaneous disclosures will be handled;
  5. Make arrangements for assessment interviews, where indicated.
Police / Legal
  1. Provide a briefing on the status of any criminal investigations;
  2. Ensure the necessary checks have been undertaken on all carers and household members, including the NICHE crime recording database and police databases;
  3. Plan the progress of the joint investigation under Section 47 including any joint interviews;
  4. 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;
  5. Interviews with parents/carers/child(ren): All practitioners 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;
  6. Agree appropriate deployments of staff at critical times e.g. arrest of suspects and impact on care of children;
  7. Review the use of police powers in respect of children e.g. whether the child/siblings are subject to police protection;
  8. Consider the need for emergency orders. If parents are cooperative and not undermining/threatening the child's safety then discuss Interim Care Order (ICO) application with Local Authority solicitor and area service manager;
  9. All agencies must be mindful that the police may be treating parents/guardians as suspects;
  10. In the case of a child death, agree with the police the arrangements for the parents/family to spend time with the child's body which must be supervised.
  1. 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
  1. Ensure consistency and continuity of staff;
  2. Clarify who will do what;
  3. Review resources and identify additional requests to be made within agencies;
  4. Agree timescales for action;
  5. Ensure there is a shared record and action plan of the strategy meeting:
    1. Ensure that documentation is detailed and clear important;
    2. Consider the need for a review strategy meeting Children's Social Care should follow procedure for notifying Ofsted of serious childcare incidents, see Child Safeguarding Practice Reviews Procedure.
Children's Social Care responsibilities with respect to Placements
  1. Ensure that appropriate children's social care procedures have been followed on kinship placements;
  2. Identify which social care colleagues will undertake any viability assessments/checks required;
  3. Consider whether a placement outside the family should be used. Agree who will request this.
Media / Confidentiality
  • 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 and inform Communications teams where appropriate;
  • Consider need for a security pass to be set up for communication between agencies.
Cases that have transferred into Oxfordshire
  • 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 local authorities 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 the 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.

Joint working

  • 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 support 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;
  • Consider seeking additional expert opinion.

6. Escalation

If disagreements or concerns about interagency working or actions occur, then escalation should happen, as per the Resolving Multi-Agency Disagreements and Escalation Policy

  • 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.