• With the exception of Peter Willis Residence (see Enhanced Serious Occurrences), any serious injury to a client or a staff which occurs while participating in a service that requires off-site medical/dental attention or hospitalization.  This includes:
  

• any injury caused by the Agency,
• a serious accidental injury received while in attendance at a service or in receiving service from the Agency, and,
• an injury to a client which is non-accidental, including self-inflicted, or unexplained.
• Any alleged abuse or mistreatment of a client which occurs while participating in a service, e.g. allegations of abuse against staff, foster parents or other foster family members, volunteers, temporary caregivers, police/court staff while clients are in custody, drivers providing client transportation.  This category does not include reports of historical abuse divulged by the client that did not occur while the client was participating in service.
• With the exception of Peter Willis Residence (see Enhanced Serious Occurrences), any situation where a client is missing and the Agency considers the matter to be serious.  
• Any complaint concerning the operational, physical or safety standards of the service that is considered by the Agency to be of a serious nature, including any report of adverse water quality, reports of lead exceedence, hazardous/dangerous substances (poisons, flammables), medication error (not resulting in medical treatment), missing or stolen files, neighbour complaint about noise or physical appearance of the property (only where municipal authorities are involved), etc.
• Any complaint made by or about a client, or any other Serious Occurrence concerning a client, that is considered by the Agency to be of a serious nature.  This includes police involvement with a client (client charged by police, serious assault by clients against staff, peers or community member, serious assault by a non-caregiver against a client, e.g., friend, another client, stranger, hospitalization (excluding regularly occurring doctors visits related to an ongoing medical problem e.g., pneumonia, suicidal ideation, drug or alcohol overdose, medical ailment, inappropriate disciplinary techniques (excessive, non-sanctioned) and complaints arising from sexual contact between clients.
• In addition to the above, the following would be a SOR for Peter Willis Residence new serious charges that may prompt media attention, peer on peer assaults, serious contraband (weapons), transfers to secure custody (Sec. 88 - Administrative Bump Ups),  hunger strike, improper detainment/release.

The Serious Occurrence Initial Notification includes the following information:

Serious Occurrence Initial Notification

Roy Walsh, Varency Home and Youth Resource Centre - The Serious Occurrence Initial Notification report is to be faxed to 1-905-521-7621.

The fax cover sheet will outline the name of the staff reporting the Serious Occurence, the Agency name and phone number, the date and time.

If further information is required, a Ministry representative will call the residence.

In any situation where a client is missing and a Serious Occurence Initial Notification report has previously been filed, the Ministry is to be advised regardless of the date/time via phone or email message, of the client's return to the facility. Staff are to submit by email, the notification to the Serious Occurence email account at HNR.SO@css.gov.on.ca.

Peter Willis Residence - Serious Occurence Initial Notification Reports are to be faxed within 24 hours to the Western Regional Office 1-519-858-8745 and the Information Management Unit in North Bay 1-705-494-3009.

If a Serious Occurrence needs to be reported on the weekend (Friday at 5:00 p.m. – Monday at 8:30 a.m.), or on a statutory holiday, the Manager or delegate will telephone the On-Call Ministry mailbox at 1-905-521-7433.

Enhanced Serious Occurrences

Enhanced Serious Occurrences are defined as events involving heightened risk to a client, the Agency and the Ministry of Children and Youth Services.

For the Youth Resource Centre and Roy Walsh and Varency Homes, Enhanced Serious Occurrences are to be reported using the Enhanced Serious Occurrence Reporting (ESOR) form within three (3) hours.

For Peter Willis Residence, Enhanced Serious Occurrences are to be reported using a Serious Occurrence Initial Notification Form within (1) hour.

Examples of Enhanced Serious Occurrences include:

• Situations that affect clients and/or staff that may draw public and media attention that involve the use of emergency services such as fire, ambulance or police.
• Any disaster on the premises where a service is provided, that interferes with daily routines, (i.e. the incident is a lockdown relating to a serious incident occurring, the incident is an outbreak of a serious contagious disease or virus, such as C. Difficile or SARS, the incident caused major damage to a service provider’s location and will significantly disrupt the delivery of services.
• Any death of a client or staff which occurs while participating in a service, including clients receiving community-based support services that are funded or licensed by the Ministry.  (i.e. suspicious circumstances or negligence could be perceived to have contributed to the death).  
• (Refer to Regs Appendix 2 Emergency Response Policy).
• A serious injury to a client (i.e. the injury is currently life threatening.  Suspicious circumstances or negligence could be perceived to have contributed to the cause of injury).
• Any alleged abuse or mistreatment of a client (i.e. the incident is an allegation of sexual or physical abuse against staff by a client where the media has become involved).
• With the exception of Peter Willis Residence - Missing client (i.e. the client’s age or mental capacity makes him/her especially vulnerable, a crime is suspected to have occurred in conjunction with the client going missing, the service provider contacted the police and an amber alert or a similar public awareness tactic is planned).  Note – do not report incidents in this category if the incident has already been resolved).
• Any major disturbances, such as riots or hostage taking incidents.
• A complaint about the service provider (i.e. the individual or group who has complained has contacted the media, a staff member has been arrested for a serious crime that may have affected clients, the complaint is about a topic that is often covered in the media).
• With the exception of Peter Willis Residence - A complaint made by or about a client and any other serious occurrences. (i.e. the incident involves serious criminal activity on the part of the client).
• Physical Restraints – (i.e. service provider applied a physical restraint and resulted in life threatening injury).

For Peter Willis Residence the following are additional examples of Enhanced Serious Occurrences:

• Any situation where a client is missing (e.g. Unlawfully at Large or Escaped Lawful Custody).
• Any media report referencing a justice client or a youth justice funded service.
• Any disasters that result in evacuation/removal of a client from a facility.
• Stand-offs, bomb threats, serious/aggravated assaults and assaults on staff by clients.
• Any serious injury to a client or a staff which occurs while participating in a service.

The Manager will determine if the occurrence will be reported using the enhanced protocol.  If the Manager cannot be reached staff must call the Service Director.

The Manager will advise the Service Director and/or Executive Director. 

Roy Walsh, Varency and Youth Resource Centre – Preferred notification will be by fax or telephone if fax is not available.  Email can be used if fax or telephone is not available.

Weekdays/Evenings/Overnight (from Sunday 9:00 p.m. to Friday 5:00 p.m.).  Enhanced Serious Occurrences may be faxed to (905) 521-7621 or emailed to hnr.so@gov.on.ca.

On weekends and government holidays ONLY (from Friday 5:00 p.m. to Sunday 9:00 p.m.).  Enhanced Serious Occurrences may be faxed to 1-866-262-8881.  If you do not have access to a fax machine, the enhanced Serious Occurrence may be reported by phone to 1-877-444-0424.

When providing a telephone report, the service provider must ensure that the following information is given:

• Caller’s name and contact number,
• Service provider's name and site location,
• Client’s first name and last initial,
• Date of birth and age,
• Date and time of the incident,
• And briefly outline what happened.

 Peter Willis Residence - One Hour Verbal and Written Notification.  All Enhanced Serious Occurrence issues noted above require immediate telephone notification followed by a completed Serious Occurrence Initial Notification Report which is faxed within one hour to the Ministry of Children and Youth Services - Western Regional office 1-519-858-8745 and the Information Management Unit in North Bay 1-705-494-3009.

During regular business hours – (8:30 a.m. to 4:30 p.m.), the Manager or delegate will telephone the Ministry of Children and Youth Services - Western Regional Office at 1-519-858-2774, ext. 2681. A message is to be left identifying St. Leonard’s Community Services, Peter Willis Residence, the phone number, the date and time and a brief description of the Enhanced Serious Occurrence.  If further information is required, a representative from the Ministry of Children and Youth Services will contact the Peter Willis Residence.

After business hours - 4:30 p.m. to 8:30 a.m., weekends and statutory holidays staff are to telephone the Ministry of Children and Youth Services - Western Region Provincial Director On-Call pager number 1-519-435-3186.  Staff will be prompted to key in the Peter Willis Residence phone number beginning with the digits 88.

Serious Occurrence Inquiry/Update Report(s)

A  Serious Occurrence Inquiry/Update Report may be submitted in lieu of an Initial Notification Report if done so within twenty-four hours of the occurrence and all necessary action has been taken and documented. 

Within seven (7) business days of the Serious Occurrence Initial Notification Report, a Serious Occurrence Inquiry/Update Report(s) must be completed.  The document will detail what had happened, the client’s current status and all new developments since the submission of the Serious Occurrence Initial Notification Report.

1. The Serious Occurrence Inquiry/Update Report(s) will be completed by the Manager or delegate (person designated by the Agency).  The purpose of the inquiry is to gather information regarding the actual or alleged occurrence(s).
2. The Serious Occurrence Inquiry/Update Report(s) will identify any client involved by first name and last initial only.  Any other party should be referenced in non-identifying terms as possible (i.e. First and last initials only, staff “A”, staff “B”, etc).  The report will include as many of the following details as possible at this time:

• Description of the occurrence,
• Client’s allegation (if applicable),
• Date, time, place where it occurred,
• Time occurrence reported,
• Reason for the occurrence (if known),
• People involved,
• Action taken,
• Current status,
• Parties notified (See Step # 5),
• Further action recommended – specific to immediate situation; and/or related to potential underlying factors (e.g. Review of internal policy/procedure, review of program or treatment/action plan for client, staff training need, modification to physical plant, etc.).
• If on the basis of the inquiry there is reason to suspect that a client has been abused (and/or in need of protection, in the case of a child), the designated person will ensure immediate contact with the Children’s Aid Society and police as appropriate.  Refer to Client Service Policy 10-120 Child Abuse.

3. Upon completion, the Serious Occurrence Inquiry/Update Report(s) will be forwarded to the Administration office (Executive Director and the Service Director) within five (5) business days.  The report will be reviewed, signed and faxed to the Ministry. 
4. Once the Serious Occurrence Inquiry/Update Report(s) has been faxed, it will be returned to the residence for filing.  The fax activity report will be attached so staff can verify that it has been sent.  All Serious Occurrence Initial Notification Reports and the Serious Occurrence Inquiry/Update Report(s) must be copied and placed in the client’s file.
5. The following people will be verbally advised and faxed a copy of the Serious Occurrence Initial Notification and Serious Occurrence Inquiry/Update Report(s):

• CAS Worker (if applicable) - if the worker cannot be reached directly, a voicemail message is to be left. 
• CAS On-Call staff must be contacted during evening and weekend hours.
• Probation Officer (if applicable) – if the Probation Officer cannot be reached directly, a voicemail message is to be left.
• In cases where the client has been referred from a non-CAS agency, that Agency’s case manager must be informed.
• Parent(s) (if applicable), providing the Serious Occurrence does not involve them.

The primary focus of the Serious Occurrence Inquiry/Update Report(s) is to record the Agency’s actions from an accountability perspective (i.e. were the actions taken appropriate, complete, consistent with legislation/policy, etc.)

The Agency is to always submit the Serious Occurrence Inquiry/Update Report(s) within the 7 day period, even if staff have incomplete information and/or actions that have yet to be completed.  In such cases, an explanation should be included, along with a clear indication that a supplementary follow-up report to the Ministry office will be forthcoming. 

For Peter Willis Residence Serious Occurrence Inquiry/Update Report(s) are to be forwarded to the Ministry as information becomes available.

Upon a review of the Serious Occurrence Inquiry/Update Report(s), the Ministry office may request additional information or a further review, by the Agency, of the serious occurrence.  The Agency is then expected to submit any related follow-up or outcomes report(s) to the Ministry office, in accordance with approved timelines.  If required, the Ministry may also initiate its own or other Ministry review.

Serious Occurrence Reviews and Analysis

Serious Occurrences are reviewed quarterly by each department with a view to preventing future occurrences and to ensure quality of service.  These reviews are documented by Service Directors in staff meeting minutes or Case Management Minutes.

Serious Occurrences are included in the Service Directors’ Board Reports, which are reviewed and summarized by the Program Committee for presentation at the next scheduled Board of Directors’ Meeting.

A quarterly summary of all serious occurrences and follow up responses, prepared by the Program Committee are presented to the Board of Directors at the next regularly scheduled meeting for action. (See also HR – Staff Security 6-710)

An Annual Report is completed and forwarded to the Ministry and will indicate any patterns and suggested training needs.  The Ministry may also identify possible issues or action that require follow-up by the Agency.  If follow-up action is required or requested, the Agency is required to submit an outcome report to the Ministry once all required action has been taken.