Evidence Search Completed by Frances Sim..Date

Document Type: Policy Document Title: Infant and Child Abduction Policy Scope: Maternity, Neonatal, Peadiatric, A&E, Outpatient s and Community Services Author / Title: Dan Willis, Local Security Management Specialist (LSMS) Replaces: Version 1, Baby Abduction Policy, M76 Validated By: Health and Safety Committee Ratified By: Procedural Documents and Information Leaflet Group Chairman s Action Review dates may alter if any significant changes are made Unique Identifier: CORP/POL/020 Version Number: 2 Status: Ratified Classification: Organisational Responsibility: Security Head of Department: Anna Smith, Health and Safety Manager Date: 23/12/2014 Date: 11/12/2014 Review Date: 01/12/2017 Which Principles of the NHS Constitution Apply? Please list from principles 1-7 which apply 1,3,4,5,6,7 Which Staff Pledges of the NHS Constitution Apply? Please list from staff pledges 1-7 which apply 1,2,3,45,6,7 Does this document meet the requirements of the Equality Act 2010 in relation to Race, Religion and Belief, Age, Disability, Gender, Sexual Orientation, Gender Identity, Pregnancy & Maternity, Marriage and Civil Partnership, Carers, Human Rights and Social Economic Deprivation discrimination? Yes Document for Public Display: Yes Evidence Search Completed by Frances Sim..Date 22.2.15. To be completed by Library and Knowledge Services Staff

CONTENTS Page 1 SUMMARY 3 2 PURPOSE 3 3 SCOPE 3 4 POLICY 3 4.1 Duties 3 4.2 Other Stakeholders 4 4.3 Risk Management Process 5 4.4 Staff Awareness 6 4.5 Information for Expectant Mothers, Patients, Parents, Guardians 6 and Visitors 4.6 Parental Discharge against Medical Advice 7 4.7 Physical Security Measures 7 4.8 Access Control and Staff Identification 7 4.9 Testing of the Policy 7 5 ATTACHMENTS 8 6 OTHER RELEVANT / ASSOCIATED DOCUMENTS 8 7 SUPPORTING REFERENCES / EVIDENCE BASED 9 DOCUMENTS 8 DEFINITIONS / GLOSSARY OF TERMS 9 9 CONSULTATION WITH STAFF AND PATIENTS 9 10 DISTRIBUTION PLAN 9 11 TRAINING 9 12 AMENDMENT HISTORY 9 Appendix 1 Action To Be Taken Upon The Discovery Of A Child Abduction 10 Appendix 2 Equality & Diversity Impact Assessment Tool 11 Page 2 of 11

1. SUMMARY This policy is designed to ensure that maternity, neonatal and paediatric services are delivered in an environment that is properly safe and secure which minimises the risk of security incidents affecting babies and children as well as their parents/guardians, in line with the requirements of NHS Protect. The aim of this policy and outline the organisations strategic approach to security in maternity, neonatal and paediatric services. 2. PURPOSE This policy stipulates the mandatory arrangements for dealing with Child Abductions The policy will assist the trust in meeting its legal responsibilities set out in Secretary of State Directions, commissioning contracts and relevant legislatio 3. SCOPE This policy should apply to all areas in which NHS care is provided to women and children, including Accident and Emergency, outpatients departments, community services, etc. While it may be most relevant in practice to maternity, neonatal and paediatric units, its scope extends beyond these settings. 4. POLICY 4.1 Duties 4.1.1 Chief Executive Shall have overall responsibility for the implementation of this policy and shall have overall accountability for the management of health & safety and security and will delegate responsibility to the Security Managing Director to ensure that adequate and appropriate resources are made available to ensure that the security managing director duties are completed as per their role 4.1.2 Security Managing Director The Security Management Director (SMD) will lead and communicate at Executive Board level on security management in the organisation, including specific arrangements for security in maternity, neonatal and paediatric services. This will assist the board in meeting its responsibilities under Secretary of State Directions and standard NHS contracts, and allow full consideration of NHS Protect guidance. Final responsibility for security management matters remains with the SMD and the Chief Executive. 4.1.3 Local Security Management Specialists The LSMS takes forward security management work locally in accordance with national standards, reporting directly to the SMD. The LSMS will work with key colleagues to promote security and identify, assess and Page 3 of 11

manage security risks in maternity, neonatal and paediatric services. The LSMS will also contribute to the effective response to security breaches in these services. 4.1.4 Departmental Managers and Heads of Department It is the role of departmental managers and heads of department in all areas providing maternity, neonatal or paediatric services in relation to the security of those services, including how they liaise with the LSMS and other relevant staff. In line with the scope of this policy, this includes managers in all areas where expectant mothers, neonates and children are treated, not just those in maternity and children s units. Their responsibilities should include ensuring that (the list is not exhaustive): staff having a strong awareness of security risks, and a good understanding of the policies and procedures in place to address them staff are fully trained to discharge their security-related responsibilities expectant mothers, patients, parents, guardians and visitors are informed of their responsibilities in preventing security incidents, and aware of relevant policies and procedures 4.1.5 Staff Working in Maternity, Neonatal and Paediatric Services All staff working in maternity, neonatal and paediatric services have a primary responsibility to familiarise themselves with relevant security policies and procedures, and to ensure that they are consistently applied within a strong pro-security culture. Their role also includes informing expectant mothers, patients, parents, guardians and visitors of their responsibilities in preventing security breaches, and making them aware of relevant policies and procedures. 4.1.6 Human Resources Human resources staff are responsible for pre-employment checks and making sure that no staff start both permanent and Bank and Agency without the relevant checks and screening. They will inform both the LSMS and Departmental Managers of any mitigating factors that need to be considered before allowing a new member of staff on to the wards and units. 4.2 Other Stakeholders 4.2.1 Local Police NHS Protect has national agreements with the Association of Chief Police Officers and the Crown Prosecution Service (CPS) to facilitate communication, information sharing and joint working between the police and LSMSs operationally at the local level. The LSMS and the police will work together locally to promote security in maternity, neonatal and paediatric services and respond effectively to any security incidents and breaches. 4.2.2 Multi-Agency Public Protection Arrangements (MAPPA) Responsible Authority The Multi-Agency Public Protection Arrangements (MAPPA) is a set of statutory arrangements to assess and manage the risk posed by certain sexual and violent offenders. They bring together the Police, Probation and Prison Services into what is known as the MAPPA Responsible Authority for each MAPPA Area. Page 4 of 11

A number of other agencies are under a duty to co-operate with the Responsible Authority, including NHS organisations. The MAPPA will assess and manage the security risks posed by certain offenders in relation to maternity, neonatal and paediatric services. The Named Nurse for safeguarding will be the Trust representative for MAPPA. 4.2.3 Local Safeguarding Children Board The trust co-operates with the local authority in the establishment and operation of the Local Safeguarding Children Board (LSCB) and, as statutory partner, shares responsibility for the effective discharge of its functions in safeguarding and promoting the welfare of children. 4.2.4 In-house and Private Security Contractor Firms In-house and contracted security staff should be adequately trained and be made aware of the relevant security practices and procedures relating to the Abduction Policy. Contracted Security Officers should have Security Industry Authority licence for Manned Guarding and a DBS check 4.3 Risk Management Process The Paediatric services have a risk assessment which takes into account the potential for Child abduction which moulds the security arrangements for the protection of this vulnerable group of patients. The Trusts LSMS and SMD will offer advice and guidance to the Paediatric Services on the management of these risks and offer advice where needed. Staff within Paediatric services should familiarise themselves with the Trusts Secure Environment Policy and how the Trusts Risk Management Strategy applies to the running of the service. 4.3.1 Security Review The Trusts LSMSs will regularly review security arrangements on maternity, neonatal and paediatric services. This would include, among other things, a security risk assessment, along with an evaluation of existing physical security measures and of policies and procedures currently in place. This review will involve the Governance Lead for WACS and relevant DGM s 4.3.2 Measures to Manage, Control and Mitigate Security Risks: General Once security risks are identified and assessed, the Trust will ensure that appropriate measures are in place to manage, control and mitigate these risks. This can be done by building on existing measures, by developing new ones, or both, depending on local circumstances. Available measures include policies and procedures as well as physical security measures. The Trust will ensure that the measures in place to address security risks in maternity, neonatal and paediatric services are strongly integrated with relevant measures in place across the organisation and at department/ward level. Page 5 of 11

Each of the services should ensure that they have an effective Local Lockdown policy which has been practiced with staff members including bank staff. And that there has been physical testing of this policy. 4.4 Staff Awareness It is crucial that there is a high level of security awareness among all staff to minimising the risk of security incidents and breaches occurring. It is also a prerequisite for the effective functioning of other preventative measures. All staff working at the Trust should have a challenge culture this should be particularly rigid within the maternity, neonatal and paediatric services. Where all unknown persons should be required to identify themselves. Staff must be aware of their right and responsibility to challenge, when it is safe to do so, anyone who appears to be trying to gain, or to have gained, unauthorised access to a ward/department All staff should be regularly reminded of their responsibility around security during 121 and PDP sessions and any internal training. Managers should ensure as many staff as possible are able to take part in the testing of both the Local Lockdown Policy and the Child Abduction Policy staff who were unable to attend this training should be talked through the process with Management staff. 4.4.1 All Staff All Staff should be aware of the Child abduction policy and aware of how it affects the day to day running of the ward/department they should also take part in the active testing of the Child Abduction Policy and ensure that they are aware of the Local Lockdown policy 4.4.2 Staff Involved in the Delivery of Maternity, Neonatal and Paediatric Services The staff who are involved in the delivery of Maternity, Neonatal and Paediatric Services are to be aware of the content of this policy and should actively support this policy Staff will take part in testing of this policy and should take an active role in providing constructive feedback on the processes and making sure that it is as effective as possible. Staff Involved in these services should ALWAYS report security concerns and any information they become aware of which could affect the safety of the users of the services 4.5 Information for Expectant Mothers, Patients, Parents, Guardians and Visitors Expectant mothers, parents, guardians and visitors have a critical role to play in preventing security breaches in maternity, neonatal and paediatric services and should be made aware of their responsibilities in respect to the Child Abduction Policy and Local Lockdown Policy. Staff on the relevant ward/department will provided information to them about security and about their responsibilities in relation to it. Included in this should be a discussion around challenge culture, in which all are aware of their right and responsibility to challenge anyone who appears to be trying to gain, or to have gained, unauthorised access to a ward/department Page 6 of 11

Information should be given to children receiving care and in particular how they are made aware of the need to tell a responsible adult or member of staff about any suspicious incidents. This should be done by parents or guardians if possible; otherwise a member of staff should speak to the child adopting an appropriate style of communication. 4.6 Parental Discharge against Medical Advice Should parents wish to remove their child against medical advice, escalation should be made to the following: Safeguarding Nurse / Midwife Clinical Lead Senior Matron Senior Manager On call (Out of Hours) The senior manager on call (out of hours) / Clinical Lead / Senior Matron are to contact the Police to inform them of the abduction 4.7 Physical Security Measures In order to deter and prevent security incidents the Trust uses physical security measures such as locked doors with swipes and access that can be controlled by staff. There are also CCTV cameras and security officers on the site to further increase security. However, physical security measures alone are not enough: they must be supported by effective policies and procedures which are adhered to by all staff working within a strong prosecurity culture. 4.8 Access Control and Staff Identification All wards and departments that provide maternity, neonatal and paediatric services will have secured access control points which allow the staff working in that area to come and go using their swipe cards but that can be controlled for patients and visitors and any staff who would not normally work in this area included in this is temporary workers such as bank staff. Assurance is sought from human resources about pre-employment checks before health body IDs are issued to staff; Staff should outline visiting hours to patients and then ensure that these times are monitored closely as this is the most vulnerable time for wards and departments. The Ward/Department Manager should work alongside the Trusts LSMS to put measures in place to control and regulate access when systems are broken or malfunctioning, and when emergency door release mechanisms are activated (whether because of a genuine emergency or inappropriately). 4.9 Testing of the Policy There is a need to do a physical test on this policy on a 12 month basis to ensure that the procedures work correctly and that the staff have had the ability to test the procedures and understand how they work. Page 7 of 11

The Trust is aware that there needs to be specific parameters around the testing of this policy. The Trust will never test this policy using patient s children. A doll will be used to represent a child. In addition to this the staff will be given notice that testing will be happening and what week that will be happening in. All staff will be talked through what the physical test will involve and be spoken to regarding the test week and what Management staff will be expecting from them. Where possible the Local Police Constabulary s will be invited to take part in the exercises and informed of the trust intentions to run this kid of exercise. The trust feels that this is the most appropriate way to test this possible without causing undue stress to staff and patients yet give an accurate understanding of how a real life situation would arise and be escalated. This form of exercise would also test the resilience of the Trusts Lockdown Policy. 5. ATTACHMENTS Number Title 1 Action to be taken upon the Discovery of a child Abduction 2 Equality and Diversity Impact Assessment Tool 6. OTHER RELEVANT / ASSOCIATED DOCUMENTS Unique Identifier Title and web links from the document library Corp/Pol/062 Secure Environment Policy http://uhmb/cs/tpdl/documents/corp-pol-062.docx 7. SUPPORTING REFERENCES / EVIDENCE BASED DOCUMENTS References in full Number References 1 2 3 8. DEFINITIONS / GLOSSARY OF TERMS Abbreviation Definition or Term LSMS Local Security Management Specialist SMD Security Managing Director MAPPA Multi-Agency Public Protection Arrangements 9. CONSULTATION WITH STAFF AND PATIENTS Enter the names and job titles of staff and stakeholders that have contributed to the document Name Job Title Sascha Wells Deputy Director and Head of Midwifery, Gynaecology and Obstetrics Sharon Perkins Maternity Risk Manager Louise Jones Givernance Lead Womens and Childrens Page 8 of 11

10. DISTRIBUTION PLAN Dissemination lead: Previous document already being used? If yes, in what format and where? Proposed action to retrieve out-of-date copies of the document: To be disseminated to: Document Library Proposed actions to communicate the document contents to staff: LSMS Yes Baby abduction policy on Heratige Part of weekly news that this policy replaces the old policy Include in the UHMB Weekly News New documents uploaded to the Document Library 11. TRAINING Is training required to be given due to the introduction of this procedural document? Yes Action by Action required Implementation Date Ward Managers Ensure run through of policy so staff 2015 understand their responsibility LSMS To physically test the policy as per agreed time scales with divisional managers ongoing 12. AMENDMENT HISTORY Revision No. Date of Issue Page/Selection Changed Description of Change Review Date Page 9 of 11

Appendix 1 - Action to be taken upon the Discovery of a child Abduction Child Reported As Missing Child Reported as Missing Ward Manager To Put Ward on Lockdown Child Discovered Staff to carry out initial fast and thorough search of the Ward/Department Child Not Found Ward to be taken off lockdown and incident form to be completed Police on 999 Security on 2222 Site Lead In Hours SMOC Out of Hours Divisional LSMS Ward Manager to Contact Emergency Contacts in the Following Order Available security staff to assist with Searching of site and police requests - LSMS to contact NHS Protect and inform them of situation Ward Manager and staff to follow guidance from police and assist them in any enquiries and remain on Lockdown Site Lead / SMOC to inform Exec Team of Situation and keep them updated Comms. Team to prepare for potential Media interest Staff to follow guidance from the Police and senior staff whilst maintaining calm and a high level of Patient Care Upon Police and Site Lead /SMOC Approval Ward/Department to come off lockdown but remain on heightened security. All relevant personal will continue to assist the police with any lines of enquiries they may have. Page 10 of 11

Appendix 2: EQUALITY & DIVERSITY IMPACT ASSESSMENT TOOL Yes/No Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination are there any exceptions - valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 4a If so can the impact be avoided? N/A 4b 4c What alternative are there to achieving the policy/guidance without the impact? Can we reduce the impact by taking different action? N/A N/A If you have identified a potential discriminatory impact of this procedural document, please refer it to the HR Equality & Diversity Specialist, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact the HR Equality & Diversity Specialist, Extension 6242. Page 11 of 11