Chapter 7 – Child death review processes |
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UPDATE:
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Contents
Involvement of parents and family members (for all child deaths)
The Regulations relating to child deaths
Supply of information about child deaths by registrars
Duty and powers of coroners to share information
Duty and powers of Medical Examiners (MEs) to share information
Definition of an unexpected death of a child
Definition of preventable child deaths
LSCB responsibilities for the child death review processes
Procedures to be followed by the local Child Death Overview Panel (for all child deaths)
The process to be followed by Child Death Overview Panels (for all child deaths)
Roles and responsibilities when responding rapidly to an unexpected death of a child
Processes for a rapid response from professionals to all unexpected deaths of children (0–18 years)
Use of child death information to prevent future deaths
Introduction |
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| 7.1 | This chapter sets out the processes to be followed when a child dies in the Local Safeguarding Children Board (LSCB) area(s) covered by a Child Death Overview Panel. There are two interrelated processes for reviewing child deaths (either of which can trigger a Serious Case Review (SCR) – see Chapter 8): |
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| 7.2 | A sub-committee of the LSCB(s) known as the Child Death Overview Panel (CDOP) should be responsible for reviewing the available information on all child deaths, and should be accountable to the LSCB Chair. The disclosure of information about a deceased child is to enable the LSCB to carry out its statutory functions relating to child deaths. The LSCB should use the aggregated findings from all child deaths, collected according to the nationally agreed minimum data set to inform local strategic planning on how best to safeguard and promote the welfare of the children in their area. |
| 7.3 | Guidance in this chapter relates to the deaths of all children and young people from birth (excluding those deaths set out in paragraph 7.1b above) up to the age of 18 years. Implementation of some parts of the guidance will therefore need to take into account the needs of different age groups. |
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| 7.4 | Each death of a child is a tragedy for his or her family (including any siblings), and subsequent enquiries/investigations should keep an appropriate balance between forensic and medical requirements and the family’s need for support. A minority of unexpected deaths are the consequence of abuse or neglect or are found to have abuse or neglect as an associated factor. In all cases, enquiries should seek to understand the reasons for the child’s death, address the possible needs of other children in the household, the needs of all family members, and also consider any lessons to be learnt about how best to safeguard and promote children’s welfare in the future. |
| 7.5 | Families should be treated with sensitivity, discretion and respect at all times, and professionals should approach their enquiries with an open mind. |
| 7.6 | Chronic illness, disability and life limiting conditions account for a large proportion of child deaths. Whilst it is to be expected that children with life limiting or life threatening conditions (LL/LT conditions) will die prematurely young, it is not always easy to predict when, or in what manner they will die. Professionals responding to the death of a child with a LL/LT condition should ensure that their response to these families is appropriate and supportive, does not cause any unnecessary distress at a time when they are dealing with the tragic but anticipated, natural death of their child, and that their child’s expected death can be dignified and peaceful. End of life care plans may be in place and therefore families, where appropriate, should be supported, to choose where their child’s body is cared for after death for example a children’s hospice. The lives of children with LL/LT conditions are as valued and important as those of any other children, and hence the unexpected, death of a child with LL/LT conditions should be managed as for any other unexpected death so as to determine the cause of death and any contributory factors (see paragraphs 7.58–7.59). This is both out of respect for the child and family, and to fulfil any statutory requirements. |
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| 7.7 | It is vitally important that LSCBs establish mechanisms for appropriately informing and involving parents and other family members (Parents includes carers where appropriate, and family members includes siblings where appropriate) in both the child death overview and the rapid response processes (see paragraphs 7.4–7.12, 7.36, 7.50, 7.57–7.62, 7.73–7.75 and 7.91–7.92). (A leaflet which can be given to parents, carers and family members to explain the child death review process is available to order from DCSF Publications, Tel: 0845 60 222 60, please quote reference: 00180-2010LEF-EN) |
| 7.8 | Parents and family members should be informed that their child’s death will be reviewed, and often have significant information and questions to contribute to the review process. |
| 7.9 | Parents and family members should be assured that the objective of the child death review process is to learn lessons in order to improve the health, safety and well being of children and ultimately, hopefully, to prevent further such child deaths. The process is not about culpability or blame. |
| 7.10 | The LSCB, acting through the CDOP should agree what information is to be shared with parents and family members and ensure that a professional known to the family conveys to them agreed information in a sensitive and timely manner. Decisions on information sharing (i.e. what information is shared, with whom, and why) must be recorded in each agency’s records. It is not appropriate however, for parents to attend the CDOP meeting as this is a meeting for professionals to discuss not only the individual case but also wider public health issues. Parents should however be encouraged to contribute any comments or questions they might have to the review of their child’s death. |
| 7.11 | Parents should be informed that all cases will be anonymised prior to discussion by the CDOP, information gathered will be stored securely and only anonymised data will be collated at a regional or national level. Parents should also be made aware that the CDOP will make recommendations and report on the lessons learned to the LSCB. The LSCB produces an annual report which is a public document, but it will not contain any personal information that could identify an individual child or their family. |
| 7.12 | CDOPs should ensure that whenever necessary, arrangements are made for the family to have the opportunity to meet with relevant professionals, for example a professional known to the family before their child died, a paediatrician or a police officer to help answer their questions. |
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| 7.13 | One of the LSCB functions, set out in Regulation 6 of the Local Safeguarding Children Boards Regulations 2006, in relation to the deaths of any children normally resident in their area is as follows: |
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| 7.14 | As explained in Chapter 3, the child death review functions became compulsory on 1 April 2008 |
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| 7.15 | Registrars of Births and Deaths are required by the Children and Young Persons Act 2008 to supply LSCBs with information which they have about the deaths: |
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| Registrars must also notify LSCBs if they issue a Certificate of No Liability to Register where it appears that the deceased was or may have been under the age of 18 at the time of death. | |
| 7.16 | Registrars are required to send the information to the appropriate LSCB no later than seven days from the date of registration, the date of making the correction/ update or the date of issuing the certificate of no liability as appropriate. (The appropriate LSCB is the Board established by the children’s services authority in England within whose area is situated the sub-district for which the register is kept). These requirements only apply in respect of deaths occurring on or after 1 April 2009. |
| 7.17 | In order to support these new responsibilities, it is a statutory requirement for each LSCB to make arrangements for the receipt of notifications from registrars and to publih these arrangements. In order to carry out this responsibility LSCBs are therefore required to notify the Department for Children, Schools and Families of the name and email address for the Child Death Overview designated person (hereafter referred to as the ‘designated person’) in each LSCB to whom child death notifications should be sent. This information is published by the Department on the Every Child Matters website - see the list of people designated by the Child Death Overview Panel to receive notifications of child death information. |
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| 7.18 | The Coroners Rules 1984 as amended by the Coroners (Amendment) Rules 2008 place a duty on coroners to inform the LSCB, for the area in which the child died, of the fact of an inquest or post mortem. It also gives coroners powers to share information with LSCBs for the purposes of carrying out their functions, which include reviewing child deaths and undertaking SCRs. Where there is more than one LSCB in a coroner’s area, arrangements should be made between the coroner and the LSCBs as to which LSCB should be informed of the coroner’s decisions. |
| 7.19 | On receipt of an initial report of a death of a child, the LSCB or LSCBs with an interest in this information should inform the coroner of the address(es) (including email address(es)) to which future information should be supplied. If any information comes to the attention of an LSCB which it believes should be drawn to the attention of the relevant coroner, then the LSCB should consider supplying it to the coroner as a matter of urgency. See further guidance on the Ministry of Justice website. |
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| 7.20 | In taking forward the proposed improvements to the process of death certification, the Department of Health will ensure that appropriate interfaces are established with these functions now being delivered by LSCBs. It is anticipated that under the Coroners and Justice Act 2009, MEs will be required to share information with LSCBs about child deaths that are not investigated by a coroner. |
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| 7.21 | In this guidance an unexpected death is defined as the death of an infant or child (less than 18 years old) which: |
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| 7.22 | The designated paediatrician responsible for unexpected deaths in childhood (see paragraph 7.29) should be consulted where professionals are uncertain about whether the death is unexpected. If in doubt, the processes for unexpected child deaths should be followed until the available evidence enables a different decision to be made. |
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| 7.23 | For the purpose of producing aggregate national data, this guidance defines preventable child deaths as those in which modifiable factors may have contributed to the death. These factors are defined as those which, by means of nationally or locally achievable interventions, could be modified to reduce the risk of future child deaths. |
| 7.24 | In reviewing the death of each child, the CDOP should consider modifiable factors, for example in the family and environment, parenting capacity or service provision, and consider what action could be taken locally and what action could be taken at a regional or national level. |
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| 7.25 | The CDOP should undertake an overview of all child deaths (excluding those deaths set out in paragraph 7.1b) up to the age of 18 years in the LSCB area(s) covered by the CDOP. This is a paper based review, based on information available from those who were involved in the care of the child, both before and immediately after the death, and other sources including, perhaps, the coroner. The panel should: |
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| 7.26 | Neighbouring LSCBs may decide to share a CDOP, depending on the local configuration of services and population served (experience shows that panels responsible for reviewing deaths from a total population greater than 500,000 gain experience more quickly, and review a sufficiently large number of deaths to be better able to identify significant recurrent contributory factors). In this situation LSCBs should agree lines of accountability with the CDOP in accordance with this guidance. |
| 7.27 | The CDOP has a permanent core membership drawn from the key organisations represented on the LSCB (see paragraph 3.70); although not all core members are necessarily involved in discussing all cases. The Panel should include a professional from public health as well as child health. Other members may be co-opted, either as permanent members to reflect the characteristics of the local population (for example, a representative of a large local ethnic or religious community), to provide a perspective from the independent or voluntary sector, or to contribute to the discussion of certain types of death when they occur (for example, fire fighters for house fires). The Panel will be chaired by the LSCB Chair or his or her representative, who will be a member of the LSCB. The Panel Chair should not be involved in providing direct services to children and families in the area. |
| 7.28 | Within each organisation represented on the LSCB, a senior person with relevant expertise should be identified as having responsibility for advising on the implementation of the local procedures on responding to child deaths. Each organisation should expect to be involved in a child death review at some time. |
| 7.29 | Each PCT should ensure that the LSCB, acting through the CDOP, has access to a consultant paediatrician whose designated role is to provide advice on: |
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| The designated paediatrician for unexpected deaths in childhood may provide advice to more than one PCT, and is likely to be a member of the local CDOP. This is a separate role to the designated doctor for child protection, but does not necessarily need to be filled by a different person. These responsibilities should be recognised in the job plan agreed between the consultant and his or her employer. | |
| 7.30 | The CDOP should have a clear relationship and agreed channels of communication with the local coronial service. |
| 7.31 | The LSCB should ensure that appropriate single and inter-agency training (see Chapter 4) is made available to ensure successful implementation of these processes. LSCB partner agencies should ensure that relevant staff have access to this training. (Responding when a child dies – a multi-agency training resource to support LSCBs in implementing the child death review processes have been published to support the training of staff at all levels.) |
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| 7.32 | In order for LSCBs to fulfil their child death reviewing responsibilities, the LSCB should be informed of all deaths of children normally resident in its geographical area. The LSCB Chair should decide who will be the designated person to whom the death notification and other data on each death should be sent. (A list of people designated by the Child Death Overview Panel to receive notifications of child death information is available at the DCSF website). The Chair of the CDOP is responsible for ensuring that this process operates effectively. |
| 7.33 | Deaths should be notified by the professional confirming the fact of the child’s death. For unexpected deaths, this will be at the same time as they inform the coroner and the person designated by the LSCB to be notified of all children’s deaths in the area in which the death occurred. If this is not the area in which the child is normally resident, the designated person should inform their opposite number in the area where the child normally resides. (A list of people designated by the Child Death Overview Panel to receive notifications of child death information is available at the DCSF website). |
| 7.34 | In these situations, it should be decided on a case-by-case basis which Panel should take responsibility for gathering the necessary information for a Panel’s consideration. In some cases this may be done jointly. Where partner agencies in more than one LSCB area have known about or have had contact with the child, the LSCB for the area in which the child was normally resident at the time of death should take lead responsibility for conducting the child death review. Any other LSCBs that have an interest or whose local agencies have had involvement in the case should co-operate as partners in jointly planning and undertaking the child death review. In the case of a looked after child, the LSCB for the area of the local authority looking after the child should exercise lead responsibility for conducting the child death review, involving other LSCBs with an interest or whose local agencies have had involvement as appropriate. The Registrar has a duty to send a notification of each child’s death to the LSCB (see paragraphs 7.15–7.17), and this provides a check to ensure that all child deaths have been notified to the designated person in each LSCB. (A list of people designated by the Child Death Overview Panel to receive notifications of child death information is available at the DCSF website). Any professional (or member of the public) hearing of a local child death in circumstances that mean it may not yet be known about (for example, a death occurring abroad) can inform the designated person in the LSCB. |
| 7.35 | Section 32 of the Children and Young Persons Act 2008 gives the Registrar General a power to share child death information with the Secretary of State. However information about children who die abroad may not reach the Registrar General for some time after the death has occurred. Therefore, LSCBs should continue to utilise other sources, such as professional contacts or the media, to inform the CDOP with information about the death of a child who is normally resident in England and who dies abroad. |
| 7.36 | The functions of the CDOP include: |
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| 7.37 | Any person notifying the designated person in the LSCB (A list of people designated by the Child Death Overview Panel to receive notifications of child death information is available at the DCSF website) of the death of a child should provide as much detail as is known to them in relation to the child and family and the circumstances of the death. They should inform the designated person of any professionals known to be involved with the child or family. Form A – The notification of the death of a child – is available at the Department for Education website. |
| 7.38 | Following notification of the death of a child, the designated person should seek to establish which agencies and professionals have been involved with the child or family either prior to or at the time of death. A lead professional should be nominated in each agency to assist with this. Form B – Agency report form (and any relevant supplementary Form B’s), is available at the Department for Education website. Form B should be sent out to the lead professional in each agency and to any professionals known to be involved. If the death was either an early or a late neonatal death, the standard CMACE Perinatal Mortality Surveillance form should continue to be completed as normal and a copy should be sent to both the regional CMACE office and the relevant LSCB Child Death Overview designated person. This CMACE form is in addition to Form B2 having to be completed by the relevant professionals. |
| 7.39 | Professionals receiving an agency report form (Form B) should retrieve any relevant case records for the child or other family members to complete any information known to them or their organisation and return the form to the designated person within the requested time frame using a secure means of transfer. Normally this should be within three weeks of notification, although there will be circumstances where, because of ongoing medical or police investigations information may not be available for a longer period. It may be appropriate for the lead professional in each agency to collate information from all involved professionals within their agency. |
| 7.40 | Once all agency report forms are received by the designated person, the information should be collated onto a single Form B, anonymised and entered into a suitable database. The national agreed data set should be kept securely and separately from any identifiable data. The CDOP is likely to receive information that is personal data, including sensitive personal data, within the meaning of the Data Protection Act 1998 (DPA) for the purposes of child death reviews. CDOPs should be mindful of their obligations under the DPA when processing that information. |
| 7.41 | Prior to each panel meeting, anonymised, collated Form B’s should be sent to all panel members in sufficient time to allow them to read all the material in preparation for the meeting. Panel members may wish for supplementary material (for example, individual case records, autopsy reports, scene photographs) to be made available at the panel meeting, but consideration should be given to its appropriateness for the meeting and issues of confidentiality. This information should be sent to the designated person before the meeting. |
| 7.42 | The CDOP should review each case brought before it to consider any factors contributing to the death, its classification of the death, and any lessons to be learnt from this death or from patterns of similar deaths in the area. Form C – the case review form (available at the Department for Education website) may be used to facilitate this discussion and provides a template for local and national data collection. These forms should remain anonymous with a unique identifier but no identifiable information. For each death, the panel should classify the cause of death, make a decision as to the preventability of the death, identify any modifiable factors, and consider any recommendations that may be made about actions which could be taken to prevent such deaths in the future and to whom these recommendations should be addressed. |
| 7.43 | If the CDOP is unable to classify the death, or adequately review it from the information available, a decision should be made as to whether and what further information could be obtained to assist the panel. Where appropriate, the case should be rescheduled for discussion at a subsequent meeting. Where it is recognised that no further learning is likely, even with further information, the final review of the case should not be delayed. |
| 7.44 | Panels should consider whether groups of similar deaths (for example, all road traffic deaths, sudden unexpected death in infancy (SUDI), or deaths of children with life limiting conditions) should be discussed at designated panel meetings. In addition to standing panel members, specialists in relation to the type of death being discussed could be invited. |
| 7.45 | When reviewing neonatal deaths, these deaths should be discussed by the CDOP with appropriate representation of the professionals involved in this specialist area for example, midwifery, obstetrics, neonatal care. The process should focus on learning lessons from the deaths, and should use the minimum national data set when collecting information. |
| 7.46 | Any recommendations made by the CDOP should be directed at interventions that could help to prevent future child deaths, or improve the safety and welfare of children in the local area or further afield. The panel will not normally make direct recommendations in respect to individual case management. Recommendations should be few in number and should be carefully thought through to be Specific, Measurable, Achievable, Relevant and Timely. |
| 7.47 | Recommendations should be submitted to the LSCB or any other relevant body identified by the CDOP. The LSCB should make arrangements for following up on the recommendations to ensure that appropriate actions are taken. |
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| 7.48 | The paragraphs below set out the roles of the various professionals for enquiring into and evaluating all unexpected child deaths (see paragraph 7.21 for a definition of unexpected child death). Information from this process should be considered by members of the CDOP which has responsibility for reviewing the deaths of all children normally resident in their area. |
| 7.49 | When a child dies unexpectedly, several investigative processes may be instigated, particularly when abuse or neglect is a factor. This guidance intends that the relevant professionals and organisations work together in a co-ordinated way, in order to minimize duplication and ensure that the lessons learnt contribute to safeguarding and promoting the welfare of children in the future. |
| 7.50 | It is intended that those professionals involved (before and/or after the death) with a child who dies unexpectedly should come together to respond to the child’s death. This means that some roles may require an on-call rota for responding to unexpected child deaths in their area. The work of the team convened in response to each child’s death should be co-ordinated, usually, by a local designated paediatrician responsible for unexpected deaths in childhood. LSCBs may choose to designate particular professionals to be standing members of a team because of their roles and particular expertise. The professionals who come together as a team will carry out their normal functions – for example, as a paediatrician, GP, nurse, health visitor, midwife, mental health professional, substance misuse worker, social worker, Youth Offending Team worker, probation or police officer in response to the unexpected death of a child in accordance with this guidance. They should also work according to a protocol agreed with the local coronial service. Other professionals known to the family from specialist agencies should be accessed on a case by case basis to support the core team; i.e. hospice support workers, children’s community nurses. The joint responsibilities of these professionals include: |
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| 7.51 | Where there is an ongoing criminal investigation, the Senior Investigating Officer and the Crown Prosecution Service must be consulted as to what it is appropriate for the professionals involved in reviewing a child’s death to be doing, and what actions to take in order not to prejudice any criminal proceedings. Where a death of a young person occurs in custody, local agencies must co-operate with the Prisons and Probation Ombudsman. |
| 7.52 | Where a child dies unexpectedly, all registered providers of healthcare services are obliged to notify the Care Quality Commission, but may discharge this duty by notifying the National Patient Safety Agency (NHS providers) or the Care Quality Commission, as set out in Regulation 16 of the Care Quality Commission (Registration) Regulations 2009 (See ‘Outcome 18 – Notification of death’ in Guidance about Compliance Essential Standards of Quality and Safety, CQC, 2009). NHS organisations should also follow locally agreed procedures for reporting and handling serious untoward and/or patient safety incidents.). The results of these investigations should be made available to the CDOP in order to allow the information to be included in the Panel’s discussions. |
| 7.53 | The Youth Justice Board for England and Wales (YJB) requires Youth Offending Teams (YOTs) to report and undertake local reviews of youth offending practice in cases where a child or young person has either died or attempted suicide whilst under supervision or within three months of the expiry of supervision. Where a child has died, the Local Management Review undertaken by the YOT in relation to the death should feed into the child death processes initiated by the CDOP. |
| 7.54 | If it is thought, at any time, that the criteria for a SCR might apply (see paragraphs 8.9–8.12), the Chair of the LSCB should be contacted and the SCR procedures set out in Chapter 8 should be followed. If a SCR is initiated, the CDOP will not be able to conclude the child death reviewing process until after the SCR Executive Summary has been published. Similarly, the child death reviewing process will not be able to be completed if the CDOP is awaiting the outcomes of criminal proceedings and/or an inquest. This should not, however, prevent lessons from being learned and from being acted upon in a timely manner. |
| 7.55 | If, during the enquiries, concerns are expressed in relation to the needs of surviving children in the family, discussions should take place with local authority children’s social care. It may be decided that it is appropriate to initiate an initial assessment using the Framework for the Assessment of Children in Need and their Families (2000)136. If concerns are raised at any stage about the possibility of surviving children in the household being abused or neglected, the inter-agency procedures set out in Chapter 5 in this guidance should be followed. Local authority children’s social care has lead responsibility for safeguarding and promoting the welfare of children. The police will be the lead agency for any criminal investigation. The police must be informed immediately that there is a suspicion of a crime, to ensure that the evidence is properly secured and that any further interviews with family members and other relevant people accord with the requirements of the Police and Criminal Evidence Act 1984. |
| 7.56 | When a child dies unexpectedly and no doctor is able to issue a medical certificate of the cause of death, the child’s death must be reported to the coroner. Agencies and professionals contributing to the processes described in this chapter should co-operate with their local coroner to ensure the inquest is able to proceed appropriately. The process of the rapid response can greatly assist the coroner in gathering information to inform the inquest, whilst providing ongoing support to the family. Any information pertaining to the death arising from the rapid response, including the outcome of a final local case discussion should be passed to the coroner. The CDOP members may attend an inquest at the discretion of HM Coroner and ask questions as a ‘properly interested person’; there may be issues identified through the inquest that the CDOP would then be able to review to identify any wider public health concerns. |
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| See: Resources to assist in the conduct of a rapid response to an unexpected child death | |
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| 7.57 | Where a child has died in, or been taken to, a hospital their parents/carers should be allocated a member of the hospital staff to remain with and support them throughout the process. The parents should normally be given the opportunity to hold and spend time with their baby or child. During this time the allocated member of staff should maintain a discreet presence. |
| 7.58 | Children dying at home or in a hospice or other setting who have been undergoing end of life care will not usually be considered to have died unexpectedly, and a rapid response to such deaths is rarely indicated. |
| 7.59 | When a child with a known life limiting and or life threatening condition dies in a manner or at a time that was not anticipated, the rapid response team should liaise closely and promptly with a member of the medical, palliative or end of life care team who knows the child and family, to jointly determine how best to respond to that child’s death. This should include consideration of whether the child’s body should be transferred to a hospital or hospice, and whether any investigations or inquiries are required. Where an end of life plan has been agreed by the end of life care team and is in place, this should be followed unless there are pressing reasons not to do so. For example, the coroner decides where the child’s body may be taken and this decision may be different to what was set out in the family’s prepared plan. The presence of a community children’s nurse on call as part of the rapid response team could facilitate the process of communication and fact-finding. |
| 7.60 | Within the local rapid response procedures there should be provision for an identified professional to provide support to the family where their child has died and has not been taken to a hospital. |
| 7.61 | Where a child is living in England but their parents live abroad, careful consideration should be given to how best to contact and support the bereaved family members. |
| 7.62 | Parents/carers should be kept up-to-date with information about their child’s death and the involvement of each professional, unless such sharing of information would jeopardise police investigations or other criminal justice processes. |
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| 7.63 | The type of response to each child’s unexpected death will depend to a certain extent on the age of the child, but there are some key elements that underpin all subsequent work. Supplementary information is required for making enquiries into, for example deaths of infants, those deaths in hospital that are the result of trauma, and suicides. |
| 7.64 | Once the death of a child has been referred to the coroner and s/he has accepted it, the coroner has jurisdiction over the body and all that pertains to it. Coroners must therefore be consulted over the local implementation of national guidance and protocols, and should be asked to give general approval for the measures agreed to reduce the need to obtain specific approval on each occasion. |
| 7.65 | A multi-professional approach is required to ensure collaboration among all involved, which may include ambulance staff, A&E department staff, coroners’ officers, police, GPs, health visitors, school nurses, community children’s nurses, midwives, paediatricians, palliative or end of life care staff, mental health professionals, substance misuse workers, hospital bereavement staff, voluntary agencies, coroners, pathologists, forensic medical examiners, local authority children’s social care, YOTs, probation, schools, prison staff where a child has died in custody and any others who may find themselves with a contribution to make in individual cases (for example, fire fighters or faith leaders). |
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| 7.66 | Children who die suddenly and unexpectedly at home or in the community should normally be taken to an A&E department rather than a mortuary, and resuscitation should always be initiated unless clearly inappropriate. Resuscitation, once commenced, should be continued according to the UK Resuscitation Guidelines (2005) until an experienced doctor (usually the consultant paediatrician on call) has made a decision that it is appropriate to stop further efforts. There may be some situations where it is inappropriate for a child to be transferred to a hospital (for example, if the circumstances of the death require the body to remain at the scene for forensic examination). |
| 7.67 | As noted above, children who die at home or in a hospice or other setting in which they have been in receipt of planned end of life care will not normally be considered to have died unexpectedly, and therefore should not usually be moved to a hospital A&E department. Parents whose children die at home in such circumstances may wish their child to remain at home, or be taken to a hospice cool room. This death will be subject to local coronial guidelines if the doctor is unable to issue a Medical Certificate of the Cause of Death. |
| 7.68 | As soon as practicable (i.e. as a response to an emergency) after arrival at a hospital, the baby or child should be examined by the consultant paediatrician on call (in some cases this might be together with a consultant in emergency medicine or, for some young people over 16 years of age, the consultant in emergency medicine may be more appropriate than a paediatrician). A detailed and careful history of events leading up to and following the discovery of the child’s collapse should be taken from the parents/carers. This should begin the process of collecting a nationally agreed data set139. The purpose of obtaining high-quality information at this stage is to understand the cause of the death when appropriate and to identify anything suspicious about it. The paediatrician should carefully document the history and examination findings in the hospital notes. This should include a full account of any resuscitation and any interventions or investigations carried out. The use of a structured proforma may assist with documenting the history, but this should always include a narrative account by the carer of the events leading to the death. The examination findings, including any post mortem changes should be documented on a body chart. Templates for recording the history and examination are available on the Department for Education website. |
| 7.69 | Where the cause of death or factors contributing to it is uncertain, investigative samples should be taken immediately on arrival and after the death is confirmed. In order to be compliant with the Human Tissue Act 2004 (HTA Act), the removal of these investigative samples must take place on Human Tissue Authority licensed premises with the authorisation of the coroner (or, where the coroner is not involved, the consent of a parent) (Further information can be found at the Human Tissue Authority website). These samples need to be agreed in advance with the coroner (see paragraph 7.64) and should include the standard set for SUDI (Royal College of Pathologists and Royal College of Paediatrics and Child Health, 2004) and standard sets for other types of death presentation as they are developed. The removal of tissue without such coronial authorisation or consent under the Human Tissue Act 2004 would be unlawful. Consideration should always be given to undertaking a full skeletal survey and, when appropriate, it should be made before the autopsy starts as this may significantly alter the required investigations. |
| 7.70 | When the baby or child is pronounced dead, the consultant clinician should inform the parents, having first reviewed all the available information. S/he should explain future police and coroner involvement, including the coroner’s authority to order a post mortem examination. This may involve taking particular tissue blocks and slides to ascertain the cause of death (see paragraph 7.69 above). Consent from those with parental responsibility for the child is required for tissue to be retained beyond the period required by the coroner (for example, for use in research or for possible future review). |
| 7.71 | The consultant clinician who has seen the child should inform the designated paediatrician with responsibility for unexpected deaths in childhood immediately after the coroner is informed. |
| 7.72 | The same processes apply to a child who is admitted to a hospital ward and subsequently dies unexpectedly in hospital. |
| 7.73 | In most circumstances following the unexpected death of a child, it will be appropriate to allow the parents to spend time with and hold their child. This should be facilitated by the hospital staff and rapid response team, with a quiet, designated area provided for the family to be with their child. In most circumstances it will be appropriate for a nurse or other professional to maintain a discreet presence at all times. In most situations the parents will have already handled their child after the death, and allowing them to hold their child will not in any way interfere with the investigation into the cause of death. |
| 7.74 | Support should be offered to the family, including where available, a bereavement counsellor, hospital chaplain or other faith leader. The hospital team should offer to contact any relatives or friends to support the parents at this time. The parents should be allowed to spend as much time as they wish with the child and any examination of the child or further investigations should where possible be carried out in a manner that causes least disruption to the family. Unless there are clear reasons not to (this matter should be discussed with the senior investigating police officer first), mementos such as a photograph, lock of hair, or hand and footprints should be offered to the family. |
| 7.75 | Before the parents leave the hospital, or in the case of a child who is not transferred to hospital, before the professionals leave the home, the parents should be provided with contact details for the lead professionals (consultant paediatrician, senior investigating police officer or coroners officer), and the details of who they should contact for information on the progress of any investigation or if they wish to visit the hospital to see their child. Following this immediate response, parents should be kept informed of the whereabouts of their child and any planned moves. |
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| 7.76 | Where a child is not taken immediately to A&E, the professional confirming the fact of death should inform the designated paediatrician with responsibility for unexpected deaths in childhood at the same time as the coroner is informed. |
| 7.77 | The police will be involved and may decide that it is not appropriate to move the child’s body. This may typically occur if there are clear signs that lead to suspicion. In most cases, however, it is expected that the child’s body will already have been held or moved by the carer and, therefore, removal to A&E will not normally jeopardize an investigation. |
| 7.78 | The professional confirming the fact of death should consult the designated paediatrician with responsibility for unexpected deaths in childhood, who will ensure that relevant professionals (i.e. the coroner, the police and local authority children’s social care) are informed of the death. This task may be undertaken by a person on behalf of the designated paediatrician. Contact may be required with more than one local authority if the child died away from home (see paragraphs 7.33–7.34 for more information about what should happen when a child who is normally resident within a LSCB area dies outside the area, including abroad). Any relevant information identified by local authority children’s social care should be shared promptly with the police and on-call paediatrician. The health visitor or school nurse and GP should also be promptly informed as a matter of routine and relevant information should be shared. |
| 7.79 | The professional confirming the fact of death should consult the designated paediatrician with responsibility for unexpected deaths in childhood, who will ensure that relevant professionals (i.e. the coroner, the police and local authority children’s social care) are informed of the death. This task may be undertaken by a person on behalf of the designated paediatrician. Contact may be required with more than one local authority if the child died away from home (see paragraphs 7.33–7.34 for more information about what should happen when a child who is normally resident within a LSCB area dies outside the area, including abroad). Any relevant information identified by local authority children’s social care should be shared promptly with the police and on-call paediatrician. The health visitor or school nurse and GP should also be promptly informed as a matter of routine and relevant information should be shared. |
| 7.80 | For all unexpected deaths of children (including those not seen in A&E) urgent contact should be made with any other agencies who know or are involved with the child (including CAMHS, school or early years provider) to inform them of the child’s death and to obtain information on the history of the child, the family and other members of the household. If a young person is under the supervision of a YOT, the YOT should also be approached. |
| 7.81 | The police will begin an investigation into the sudden or unexpected death of a child on behalf of the coroner. They will carry this out in accordance with relevant Association of Chief Police Officers guidelines. |
| 7.82 | When a baby or older child dies unexpectedly in a non-hospital setting, the senior investigating police officer and senior healthcare professional should make a decision about whether a visit to the place where the child died should be undertaken. This should almost always take place for infants who die unexpectedly (see paragraph 5.1 in the Kennedy Report) (Sudden Unexpected Death in Infancy: a multi-agency protocol for care and investigation. The report of a working party convened by the Royal Colleges of Pathologists and the Royal College of Paediatrics and Child Health (2004). London: RCPath.). As well as deciding if the visit should take place, it should be decided how soon (within 24 hours) and who should attend. It is likely to be a senior investigating police officer and a healthcare professional (experienced in responding to unexpected child deaths (this will most commonly be a paediatrician or specialist nurse) who will visit, talk with the parents and evaluate the environment where the child died. They may make this visit together, or they may visit separately and then confer (details should be included in the local child death review protocol). After this visit the senior investigating police officer, visiting health care professional, GP, health visitor or school nurse and children’s social care representative should review whether there is any additional information that could raise concerns about the possibility of abuse or neglect having contributed to the child’s death. If there are concerns about surviving children in the household, the procedures set out in Chapter 5 should be followed. If there are grounds for considering initiating a SCR, the process set out in Chapter 8 should be followed. |
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| 7.83 | If s/he deems it necessary (and in almost all cases of an unexpected child death it will be), the coroner will order a post mortem examination to be carried out as soon as possible by the most appropriate pathologist available (this may be a paediatric pathologist, forensic pathologist or both) who will perform the examination according to the guidelines and protocols laid down by The Royal College of Pathologists. The designated paediatrician should collate information collected by those involved in responding to the child’s death and share it with the pathologist conducting the post mortem examination in order to inform this process. Where the death may be unnatural, or the cause of death has not yet been determined, the coroner will in due course hold an inquest. |
| 7.84 | All information collected relating to the circumstances of the death – including a review of all relevant medical, social and educational records – must be included in a report for the coroner prepared jointly by the lead professionals in each agency. This report should be delivered to the coroner within 28 days of the death, unless some of the crucial information is not yet available. |
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| 7.85 | The results of the post mortem examination belong to the coroner. In most cases it is possible for these to be discussed by the paediatrician and pathologist, together with the senior investigating police officer, as soon as possible, and the coroner should be informed immediately of the initial results. At this stage, the LSCB child death core data set should be updated and, if necessary, previous information corrected to enable this change to be audited. If the initial post mortem findings or findings from the child’s history suggest evidence of abuse or neglect as a possible cause of death, the police and local authority children’s social care should be informed immediately, and the SCR processes in Chapter 8 of this guidance should be followed. If there are concerns about surviving children living in the household, the procedures set out in Chapter 5 should be followed with respect to these children. |
| 7.86 | In all cases, the designated paediatrician for unexpected child deaths or the paediatrician acting as his/her deputy should convene a further multi-agency discussion (usually on the telephone) very shortly after the initial post mortem results are available. This discussion usually takes place five to seven days after the death and should involve the pathologist, police, local authority children’s social care and the paediatrician, plus any other relevant healthcare professionals, to review any further information that has come to light and that may raise additional concerns about safeguarding issues. |
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| 7.87 | A case discussion meeting should be held as soon as the final post mortem result is available. The timing of this discussion varies according to the circumstances of the death. This may range from immediately after the initial post mortem examination to three-four months after the death. The type of professionals involved in this meeting depends on the age of the child. The meeting should include those who knew the child and family and those involved in investigating the death, for example, the GP, health visitor or school nurse, paediatrician(s), pathologist, senior investigating police officers and where appropriate, social workers. |
| 7.88 | The designated paediatrician with responsibility for unexpected deaths in childhood (or agreed deputy) should convene and chair this meeting. At this stage, the collection of the LSCB child death core data set should be completed and if necessary, previous information corrected to enable this change to the information to be audited. |
| 7.89 | The main purpose of the case discussion is to share information to identify the cause of death and/or those factors that may have contributed to the death, and then to plan future care for the family. Potential lessons to be learnt may also be identified by this process. Another purpose is to inform the inquest. |
| 7.90 | There should be an explicit discussion of the possibility of abuse or neglect either causing or contributing to the death. If no evidence is identified to suggest maltreatment, this should be documented as part of the minutes of the meeting. |
| 7.91 | At the case discussion, it should be agreed how detailed information about the cause of the child’s death will be shared, and by whom, with the parents, and who will offer the parents ongoing support. |
| 7.92 | The results of the post mortem examination, with the consent of HM Coroner, should be discussed with the parents at the earliest opportunity, except in those cases where abuse or neglect is suspected and/or the police are conducting a criminal investigation. In these situations, the paediatrician should discuss with local authority children’s social care, the police and the pathologist what information should be shared with the parents and when. This discussion with the parents is usually part of the role of the lead paediatrician involved in the investigation of the child’s death and she or he will, therefore, have responsibility for initiating and leading the meeting. A member of the primary healthcare team should attend this meeting whenever possible. |
| 7.93 | An agreed record of the case discussion meeting and all reports should be sent to the coroner, to take into consideration in the conduct of the inquest and, in the cause of death, notified to the Registrar of Births and Deaths. The record of the case discussions and the record of the core data set should also be made available to the relevant local CDOP. When a child dies away from their normal place of residence, a joint decision will need to be made by the rapid response team in the LSCB area in which the death occurred and the team in the child’s normal area of residence as to which team will lead the investigation and in which LSCB area the case review meeting should be held. On occasion separate meetings may be appropriate in both LSCB areas, but good communication between the teams is essential (see paragraphs 7.33–7.34). This information can then be analysed and decisions can be made about what actions should be taken by whom to prevent similar deaths in the future. |
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| 7.94 | When a child’s death is not regarded as ‘unexpected’, the team looking after the child may choose to organise a discussion of the case, since it is likely that important lessons can be learnt that might improve the care of other children. Such a discussion may be conducted using the same format as a professionals’ meeting, the output of which could be captured on the Analysis Proforma (Form C). Information from these discussions would provide the CDOP with evidence of good local practice and allow a wider engagement of professionals with the child death review process. |
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| 7.95 | Each Child Death Overview Panel should prepare an annual report of relevant information for the LSCB. This information should in turn inform the LSCB annual report (see paragraph 3.35). This information should include the total numbers of deaths reviewed, recommendations made by the panel about required future actions to prevent child deaths, and any further description of the deaths that the panel deems appropriate. It should also include a review of actions taken to implement the recommendations from the previous year’s report, and set out any such recommendations which have not yet been fully implemented which are to be carried forward. Appropriate care should be taken to ensure confidentiality of personal information and sensitivity to the bereaved families. Information which could lead to the identification of individual children or family members should not be included in the annual report. The LSCB annual report should serve as a powerful resource for driving public health measures to prevent child deaths and promote child health, safety and wellbeing. |
| 7.96 | The LSCB has responsibility for disseminating the lessons to be learned from the child death and other reviewing processes to all relevant organisations, ensures that relevant findings inform the Children and Young People’s Plan and acts on any recommendations to improve policy, professional practice and inter-agency working to safeguard and promote the welfare of children. The LSCB is also required to supply anonymised data on child deaths to the Department for Children, Schools and Families, so that the Department can commission research and publish nationally comparable analyses of these deaths. The primary aims of this research are to support a reduction in the incidence of children whose deaths can be prevented, to improve inter-agency working and to safeguard and promote the welfare of children. |
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