1.7.4 Critical Incident Reporting

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. Wherever possible a medical professional should determine the nature and prognosis of the disability.

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.

To clarify further - Under the Child and Family Services Act and Critical Incident Regulations, Critical Incident Reports are only required if the incident occurs before the age of 18. The Manitoba Advocate for Children and Youth Act however gives the Manitoba Advocate jurisdiction to review critical incidents or death of a child or youth up to the age of 21. If there is a death or critical incident of an

• 18 year old who was a child in care or whose family was involved with CFS in the previous year or
• 18 – 21 year old on an Agreement with Young Adult

an authority (agency) has a duty to report to MACY and reporting to the branch, while not required, is best practice.

• Legislation

  Authority and Departmental Reviews

  Section 8.21 of The Child and Family Services Act (the 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 – 25 (inclusive) of the Child and Family Services Authorities Regulation make it clear that CFS authorities also have the power to investigate under the Act. Section 27 of the Child and Family Services Authorities Regulation gives authorities the same power as the director to solicit and review reports under clause 4(2)(e) of the Act.

  Manitoba Advocate for Children and Youth Reviews

  The Manitoba Advocate for Children and Youth (MACY) is responsible under section 11(1)(c) of the Advocate for Children and Youth Act to review, investigate and report on serious injuries and deaths of children and young adults. Part 4 of the Act outlines that MACY has jurisdiction to review a serious injury or death of a child who was receiving or whose family was receiving a reviewable service (includes child and family services) at the time or in the year before the injury or death. MACY also has the jurisdiction to review a serious injury or death of a young adult who was receiving services under subsection 50(2) of the Act at any time within one year before the death or serious injury occurred.

  Upon learning that a child has died in Manitoba, the Chief Medical Examiner is responsible under section 10 of The Fatality Inquiries Act to notify the MACY of the death and provide a copy of the medical examiner’s report and final autopsy report if MACY has jurisdiction under Part 4 of The Advocate for Children and Youth Act.

  Critical Incident Reporting Regulation

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

• Policy

  Agencies are required to report the critical incident involving a child to their mandating authority and the director in accordance with the standards in this section. 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 MACY in conducting a review under Part 4 of The Advocate for Children and Youth Act
  • assist the Manitoba Ombudsman in any investigations or reviews undertaken by that office

• Standards

  Reporting to Agency

  1. 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
  2. Contents of Report - This initial report 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 or receiving services 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 the repealed section 14 of the Act;
  • was the subject of a Voluntary Care Agreement under section 13.4 of the Act;
  • was the subject of a voluntary surrender of guardianship agreement under section 16 of the Act
  • was the subject of a supervisory, temporary or permanent order under section 38 of the Act
  • was receiving services under a family service file
  • the date, time and place of the critical incident
  • description of the critical incident

  Reporting to Director and Authorities

  3. Reporting Agency - 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 their family and the family file was closed within one year of 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.

  4. 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
  5. 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
  6. 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.
  7. 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

  8. Internal Agency Review Objectives - On learning of the critical incident of a child known to or in the care of the agency, the agency consults with the mandating Authority with respect to the urgency and scope of the review. If required, the agency 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 and their involvement
  • 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
  9. Completion of Internal Agency Review - Within 6 months of the date an agency and authority have determined an internal agency review (IAR) is required, the agency completes the IAR and forwards a copy of the their report to:
  • the agency’s board of directors or departmental head
  • the agency’s mandating authority

  If the IAR is not completed within 6 months, the agency consults the authority and the two agree on how much additional time is required.

  External Investigations and Reviews

  10. Facilitating Investigations and Reviews – An agency and its mandating authority assist and cooperate fully with the police, the director, MACY or the Manitoba Ombudsman regarding any investigation or review of the critical incident to a child or young adult (as per MACY’s legislation only).

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