Chapter 7 : Section 18

Critical Incidents

Procedures

Critical Incidents

Critical incidents include but are not limited to:

• a fatality or near fatality of a child due to alleged abuse, abandonment or neglect; and

• any other situation designated by Department Administration as a critical incident.

Notification

Child Abuse Hotline: Within two hours of identifying a situation as a critical incident, the Hotline Program Manager or designee will notify the agency administration through the regional High Profile distribution email. See Critical Incidents Field Guide.

Local Office Level: Within two hours of identifying a situation as a critical incident, the DCS Program Manager will notify the Program Administrator or designee of the situation.

Region Office Level: Within two hours of identifying a situation as a critical incident, the Program Administrator or designee will notify the Assistant Director of Field Operations, Assistant Director of Office of Accountability, and Safety Analysis Review Team (SART) by telephone and email.

Depending on the urgency of the situation, the first notification may be made via email or verbally (in person or by phone).

The Office of Child Welfare Investigations Manager, DCS Specialist or designee will immediately notify SART by email at SART@azdcs.gov when there is any change in the circumstances following a critical incident, including:

• an admission, criminal arrest, indictment, charge or conviction against a parent, guardian or custodian for causing the child injury;

• DR number and local police department contact information;

• a medical professional makes a determination of the causation of the critical incident due to abuse or neglect; or

• any information determined by the medical examiner regarding the cause of death.

Safety Analysis Review Team (SART)

The SART is responsible for tracking, reviewing, and coordinating the Multi-Disciplinary Team (MDT) review of all critical incidents, and if needed, a subsequent Systemic Critical Incident Review (SCIR). A SCIR begins when the Intake Unit notifies the SART of a critical incident. A Safety Analyst (SA) completes a records review of Guardian and, if needed, relevant hard file documentation and refers the case to the DCS MDT for review. The DCS MDT includes, but is not limited to, the following DCS employees or their designee:

• DCS Safety Analysis Review Team;

• Hotline/Intake Manager;

• Practice Improvement Manager;

• Fidelity and Practice Consultation Manager;

• Safety Practice Advisor;

• DCS General Counsel;

• Office of Child Welfare Investigation Manager;

• DCS Policy Manager;

• DCS CHP representative;

• Learning and Development Administrator;

• Supervision Coach Program Supervisor; and

• Office of Prevention representative.

The DCS MDT also includes the following community participants:

• a licensed pediatrician who has professional experience relating to child abuse and neglect;

• a peace officer who has experience investigating child abuse and neglect fatalities and near fatalities;

• a practicing social worker;

• a behavioral health practitioner; and

• an attorney with past professional experience representing children in child abuse and neglect cases.

Determining the Need for a SCIR

The MDT, in consultation with agency counsel, determines which cases will receive a SCIR. A case is eligible for a SCIR if one or more of the following is present:

• a child was in DCS custody at the time of the critical incident and an allegation of abuse or neglect generated a report;

• the critical incident occurred when the case was open;

• DCS was involved with the child, the family, or the perpetrator within the three years preceding the date of the critical incident; or

• Department Administration requests a review of a case.

If the MDT recommends a SCIR of an eligible case, a SA completes an in-depth review of the hard file and relevant medical information, and conducts debriefings with DCS personnel and other parties.

All debriefings are voluntary . DCS employees may decline the entire debriefing process or decline to answer an individual question during the process. If the DCS employee declines to participate in the SCIR, the SCIR will continue with the other participants.

Initiating and Conducting the SCIR

The SA will initiate the SCIR process by identifying the personnel to participate in the debriefing and complete the following steps:

• notify the relevent Program Administrator prior to scheduling the debriefing; and

• schedule the debriefings for those willing to participate.

Identified personnel may include but are not limited to the following persons:

• Investigative Specialist of the fatality/near fatality;

• Investigative Specialist(s) on prior reports within three years of the fatality/near fatality;

• Investigative Supervisor(s);

• On-going/In-home Specialist, if applicable; and

• Other involved parties, when deemed appropriate.

All SCIRs include the following steps:

• The SA requests debriefings via email, providing the specific case identifying information and the Participant Guide Information, which explains the debriefing process.

• During the debriefing, the SA leads the participant(s) through the timeline of the case, emphasizing the circumstances surrounding the reported event, addressing findings, and seeking to understand relevant issues and systemic influences (e.g., knowledge, system constraints, and environmental cues) that led to the decisions made at the time of their involvement.

• The SA provides information to the DCS employees about how to access the Employee Assistance Program.

• After the Debriefing, the SART sends out a SCIR Participant Survey to the debriefing participants to collect feedback and gather data on perceptions of the experience. Participation in the survey is voluntary.

• Upon completion of the debriefings, the SA updates the Summary Analysis Review and schedules the Mapping Team Review.

• The Mapping Review Team will analyze the systemic influences that may have influenced the case decision-making.

• The SA completes the Summary Analysis Review Tool, which aggregates the data collected and provides underlying systemic themes.

After the SA completes the SCIR, the SART presents the aggregate data to the DCS MDT to develop recommendations for the DCS leadership.

Documentation

Effective Date: September 14, 2024

Revision History: July 02, 2018, March 11, 2020, February 1, 2021