1.7.4 Critical Incident Reporting

 

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Volume 1: Agency Standards
Chapter 7: Service Administration
Section 4: Critical Incident Reporting
Approved: 2005/10/10
Last revised: 2015/10/15

 

This section pertains to reporting the critical incident of a child who was in the care of or received services from a mandated child and family services agency, or whose parent or guardian received services from an agency, at any time within one (1) year before the critical incident occurred.

Serious injury is defined in the Critical Incident Reporting Regulation, in relation to a critical incident, as a physical injury that could result in permanent disability or death of a child. Where ever possible the nature and prognosis of the disability should be determined by a medical professional. 

 

Standards
Policy
Legislation

Standards

Standards in this section pertain to the following activities required of care providers and agencies.

Reporting to agency – timeframes and information reported to the agency at the time of the incident.

Reporting to Director and Authorities – timeframes and information reported to the Director of Child and Family Services (director) and child and family services authorities (authorities).

Internal Agency Reviews – internal reviews carried out by agencies on learning of the critical incident to a child known to or in care of the agency.

External Investigations and Reviews – expectations placed on agencies and authorities with respect to investigations and reviews conducted by the police, Director of Child and Family Services, Children’s Advocate and others.

Reporting to Agency

Time Limit – A person who is aware of a critical incident must report it within one (1) hour of learning that a child

  • Has died; or
  • Is receiving medical care as a result of a critical incident

Contents of Report - This initial report from: foster parents; a person who provides care for a child at the family residence that is designated as a place of safety; and/or  volunteers providing work or services to agencies or authorities should be made using the Critical Incident Report form, if possible. If not, then the report can be made orally to the agency involved and should include as much of the known information as possible.  This includes:

  • the child’s name;
  • the child’s date of birth or age;
  • whether the child was in the care of an agency at the time of the critical incident, or within one year before the critical incident occurred, because the child
  • had been apprehended as a child in need of protection under section 21 or 22 of the Act;
  • Was the subject of a Voluntary Placement Agreement under section 14 of the Act;
  • was the subject of a voluntary surrender of guardianship agreement under section 16 of the Act, or;
  • was the subject of a supervisory, temporary or permanent order under section 38 of the Act;
  • the date, time and place of the critical incident;
  • a description of the critical incident.

Reporting to Director and Authorities

Reporting Agency – Unless another agency agrees to report the critical incident, the agency that was supervising a child in care or providing services to the family of a child not in care reports the critical incident. If a child was returned to the care of his or her family and the family file was closed within the one year period before the critical incident, the agency that closed the case is responsible for reporting the critical incident.

An agency reporting on a closed case/intake must provide information regarding the relationship between the agency and the family, services provided and how the reporting agency was informed of the critical incident and by whom.
Both written and verbal reports made to an agency must be recorded in the Intake Module by the agency.  It is incumbent upon the receiving agency to ensure the completeness of the report.

Reporting Critical Incidents – The reporting agency notifies its mandating authority and the director within one hour of learning that a critical incident has occurred.  If the information is received in the evening or on a weekend, the report must be made by 10:00 A.M. the next working day. This agency report may be via fax or e-mail on the Critical Incident Report form for agencies and must include:

  • name, birth date and legal status of the child;
  • names and addresses of the child’s parents or guardians;
  • name of the placing or guardian agency if different than the reporting agency;
  • names of workers and supervisors assigned to the child and the child’s family;
  • how the reporting agency was informed of the critical incident of the child and by whom;
  • known circumstances surrounding the critical incident including date, time, place, and unusual circumstances;
  • any information suggesting the child may have died or been critically injured as a result of abuse;
  • any risk to the safety of other children in the home and if applicable, action taken to decrease risk;
  • whether the child was receiving service from an agency, other than services under clause 2(c) or 2(d) under the Critical Incident Reporting Regulation;
  • whether the child was receiving services from an agency, at the time of the critical incident, or within one year before the critical incident occurred;
  • whether the child’s parent or guardian was receiving services from an agency within one year before the critical incident occurred to the child;
  • a summary of agency involvement with the child and the child's family;
  • persons notified by the agency, such as police, parents, guardian agency;
  • any other action taken.

Additional Information on Critical Incident– Within 48 hours of the initial report, the reporting agency provides any additional information on the critical incident to the director and its mandating authority including:

  • any updates on information given in the critical incident report;
  • information obtained to date from an investigation by the agency or the police;
  • anticipated action by the reporting agency;
  • in the case of death, whether an autopsy has been or will be performed;
  • whether charges under the Criminal Code (Canada) have been laid or are anticipated.

Notifying Parent or Next of Kin – On learning of the critical incident of a child in care, the reporting agency or, when applicable and agreed to by both parties, the placing or guardian agency, notifies the child’s parent or next of kin as soon as reasonably possible, preferably within 24 hours on learning of the critical incident to a child in its care.

Further Reports to Director – Upon receiving additional information regarding the critical incident, the reporting agency or authority forwards the information to the director. Such information includes:

  • in the case of a deceased child, the results of an autopsy as to the cause of death;
  • the results of any medical examinations as to the cause of the critical incident;
  • the results of agency investigations;
  • the results of any police investigations including the laying of criminal charges;
  • any further actions indicated or planned by the agency.

Internal Agency Reviews

Internal Agency Review Objectives – On learning of the critical incident of a child known to or in the care of the agency, the executive or regional director consults with the mandating Authority with respect to the urgency and scope of the review and if required will immediately initiate an internal review of the events and circumstances leading to the child’s critical injury or death  in order to:

  • obtain detailed information on the circumstances leading to the critical incident;
  • identify applicable agency programs and services;
  • determine whether applicable programs and services were involved;
  • assess the actions and decisions of any workers or supervisors involved in providing services to the child or the child’s family;
  • determine whether staff followed applicable policies and procedures including provincial standards;
  • reassign case management responsibilities when indicated;
  • determine if additional staff training is required;
  • take appropriate disciplinary action when indicated.

Completion of Internal Agency Review – Within 30 days from the date the critical incident of a child is first reported to the agency and it has been determined that an internal agency review is required, the executive or regional director completes the internal agency review and forwards a copy of the agency’s report to:

  • the agency’s board of directors or departmental head, as the case may be;
  • the agency’s mandating authority.

External Investigations and Reviews

Facilitating Investigations and Reviews – An agency and its mandating authority assist and cooperate fully with the police, Director of Child and Family Services, Children’s Advocate or Ombudsman regarding any investigation or review of the critical incident to a child.

Policy

Agencies are required to report the critical incident of a child to their mandating Authority and the Director of Child and Family Services (the director) in accordance with the standards in this section. As a general rule, the reporting agency is the agency that was supervising a child in care or providing services to the family of a child not in care. If more than one agency was involved, the director may require both agencies to report.

The mandating authority and the director require this information in order to:

  • advise the minister of the circumstances leading to the critical incident of a child;
  • conduct a review of the actions of an agency in collaboration with the appropriate child and family services authorities,
  • assist the Children’s Advocate in conducting a review under section 8.2.3 of The Child and Family Services Act, and;
  • assist the Ombudsman in any investigations or reviews undertaken by that office.

Legislation

The Child and Family Services Act
The Child and Family Services Authorities Act

Critical Incident Reporting Regulation

Authority and Departmental Reviews

Section 21 of The Child and Family Services Authorities Act specifies that authorities may also advise the minister. 

Section 8.2.2 of The Child and Family Services Act requires the director upon receiving a critical incident report, to review the matter and as needed and determined by the director, investigate the incident further.  The director may make any recommendations about the incident to the minister that the director considers necessary or advisable.

Sections 23 – 27 (inclusive) of the Child and Family Services Authorities Regulation make it clear that CFS Authorities also have the power to investigate under The Child and Family Services Act. Section 51 of the Child and Family Services Authorities Regulation gives authorities the same power as the director to solicit, accept and review reports under clause 4(2)(e) of The Child and Family Services Act and clause 5(3)(c) of The Adoption Act. Subsection 30(2) transfers the power of the director to authorities to require agencies to provide reports under clause 7(1)(n) of The Child and Family Services Act.

However, the director may also request reports from authorities and agencies on behalf of the minister. Under section 25, of the Child and Family Services Authorities Act, the minister may give directions to an authority to direct agencies for the purpose of achieving provincial objectives and priorities, providing guidelines for authorities to follow, and coordinating the work of authorities with that of government and others.

Children’s Advocate Reviews

The Children’s Advocate Enhanced Mandate Act (Various Acts Amended), SM. 2007, c. 14, amended The Child and Family Services Act and The Fatality Inquiries Act.

The Children’s Advocate is responsible under section 8.2.3 of The Child and Family Services Act for reviewing services provided by an agency following the death of a child who was in the care of, or received services from, a child and family services agency, or whose parent or guardian received services from an agency within one year before the critical incident. The Chief Medical Examiner no longer has this responsibility.

Upon learning that a child has died in Manitoba, the Chief Medical Examiner is responsible under section 10 of The Fatality Inquires Act to notify the Children’s Advocate of the death and provide a copy of the medical examiner’s report and final autopsy report if 8.2.3 of The Child and Family Services Act applies.

 

Critical Incident Reporting Regulation

The Critical Incident Reporting Regulation 154/2015 outlines definitions, contents of critical incident reports, time limits and manner of reporting.